Lost in Transition: Long-term Follow-up in Traumatic Brain Injury Patients

Authors

Marco J Henriquez, Department of Surgery, Washington University in St. Louis School of Medicine
Danyi Wang, Department of Surgery, Washington University in St. Louis School of Medicine
Fabiana C Sanchez, Department of Surgery, Washington University in St. Louis School of Medicine
Ricardo A Fonseca, Department of Surgery, Washington University in St. Louis School of Medicine
Michael W. Alchaer, HCA HealthcareFollow
Leonardo J Diaz, Department of Surgery, Washington University in St. Louis School of Medicine
Amin Dehghan, Department of Surgery, Washington University in St. Louis School of Medicine
Grant V Bochicchio, Department of Surgery, Washington University in St. Louis School of Medicine
Lindsay M Kranker, Department of Surgery, Washington University in St. Louis School of Medicine
Douglas J E Schuerer, Department of Surgery, Washington University in St. Louis School of Medicine
Grace M Niziolek, Department of Surgery, Washington University in St. Louis School of Medicine

Division

West Florida

Hospital

Brandon Regional Hospital

Document Type

Manuscript

Publication Date

12-16-2025

Keywords

Continuity of care, Health disparities, Outpatient follow-up, Post acute care, Traumatic brain injury

Disciplines

Medicine and Health Sciences | Nervous System Diseases | Public Health | Surgery | Wounds and Injuries

Abstract

INTRODUCTION: Traumatic brain injury (TBI) is a significant public health problem with patients frequently suffering long-term neurologic, psychiatric, and cognitive symptoms. Systematic outpatient follow-up after hospital discharge is critical for identifying residual deficits and improving functional outcomes. We hypothesize that the majority of TBI patients do not engage in routine outpatient follow-up after their index admission and may not receive ancillary services necessary for long-term recovery.

METHODS: We conducted a retrospective, single-center analysis of all admitted TBI patients between January 2022 and January 2024. Patients with radiographically confirmed TBI who were expected to survive to follow-up were included. Chart reviews determined post discharge appointments and referrals to ancillary services, including physical therapy, occupational therapy, speech-language pathology, and neurocognitive testing.

RESULTS: Among 1142 TBI patients, 605 (53%) returned for outpatient follow-up. Of those, 543 (89.8%) patients were seen in neurosurgery clinic, primarily for repeat imaging and/or post surgical care. Clinic documentation rarely discussed quality of life, cognitive deficits, or behavioral changes, and ancillary referrals were infrequent (< 2%). In multivariate analysis, discharge to a nonrehabilitative facility (odds ratio (OR): 0.541, P < 0.001) and uninsured status (OR 0.591, P = 0.016) were independently associated with decreased likelihood of follow-up. Higher Abbreviated Injury Scale Head scores (OR 1.446, P < 0.001) and decompressive craniectomy (OR 2.867, P = 0.003) were associated with increased likelihood of follow-up.

CONCLUSIONS: Nearly half of TBI patients did not receive outpatient follow-up after discharge, and utilization of ancillary services was low, revealing significant gaps in post acute care. Targeted strategies to improve post discharge follow-up are essential to support long-term recovery in this vulnerable population.

Publisher or Conference

Journal of Surgical Research

Recommended Citation

Henriquez MJ, Wang D, Sanchez FC, et al. Lost in Transition: Long-term Follow-up in Traumatic Brain Injury Patients. J Surg Res. Published online December 16, 2025. doi:10.1016/j.jss.2025.11.042