Since the 1980s, the United States has seen a gradual decline in the duration and intensity of treatment for traumatic brain injury (TBI). Largely a response to economic pressures, this trend has raised the question of whether shortened, less intensive TBI treatment adversely affects patient outcomes. A definitive answer may soon be found through a comparative study of TBI outcomes now being conducted at MossRehab and Hvidovre Hospital in Denmark.

As a cross-national comparison, the project sidesteps several confounding factors between case mix characteristics and treatment intensities that would be inevitable in an observational study conducted solely in the U.S. “In the United States, people receive more or less rehabilitation based on how impaired they are, but also on what type of insurance they have, which in turn depends on things like whether or not they’re employed,” said Tessa Hart, PhD, Principal Investigator of the Moss Traumatic Brain Injury Model System, of which this study is a part. “The factors that affect treatment intensity also affect outcomes, so you can’t isolate the effects of treatment alone. A cross-national study allows us to compare healthcare delivery systems that provide different intensities of treatment, but not because of factors that are directly related to outcomes.”

Denmark is ideal for comparison because, like the United States, it is a developed nation with cultural norms that emphasize returning to society after disability. “The difference is that Denmark, with a national healthcare system, offers significantly longer and more intensive rehabilitation to its TBI patients,” Dr. Hart said. “Our main hypothesis is that TBI patients with similar injuries will do better in Denmark. If this is true, our goal is to uncover which factors account for the difference.”

Over the next three-and-a-half years, investigators at MossRehab and Hvidovre, an urban hospital near Copenhagen, will compare patient outcomes at both six months and one-year post-TBI. A composite outcome score will roll together functional measures, including the FIM™, as well as measures of emotional well-being, quality of life and community integration. The investigators also plan to compare outpatient treatment data to see if such treatment compensates for the relative shortage of inpatient services found in the United States.

In their initial analysis, the investigators found that inpatient stays for TBI were 55% shorter at MossRehab than Hvidovre. Measurements of treatment intensity are underway to examine whether Denmark also offers more therapies per unit time. Discussions between the two sites has already revealed that clinicians at Hvidovre have lighter caseloads affording them more time for treatment planning, goal setting and team meetings. Furthermore, MossRehab spends considerable resources on communication with insurance companies, whereas Denmark’s single payer system avoids this expense.

“Everyone knows that inpatient rehab is shrinking in the United States,” Dr. Hart said. “Through this comparative study, we hope to be able to tell if that’s making a difference. And if it is, maybe we can help to swing the pendulum back at least part of the way to benefit patients and families affected by TBI.”