Advertisement

A Prospective Study on Employment Outcome 3 Years After Moderate to Severe Traumatic Brain Injury

Published:April 16, 2012DOI:https://doi.org/10.1016/j.apmr.2012.01.018

      Abstract

      Grauwmeijer E, Heijenbrok-Kal MH, Haitsma IK, Ribbers GM. A prospective study on employment outcome 3 years after moderate to severe traumatic brain injury.

      Objectives

      To evaluate the employment outcome in patients with moderate to severe traumatic brain injury (TBI) and to identify which patients are at risk of unemployment 3 years after injury.

      Design

      Prospective cohort study.

      Setting

      Patients with moderate and severe TBI discharged from the neurosurgery departments of 3 level 1 trauma centers in The Netherlands.

      Participants

      Patients aged 18 to 65 years (N=113; mean age ± SD, 33.2±13.1y; 73% men) who were hospitalized with moderate (26% of patients) to severe (74% of patients) TBI.

      Interventions

      Not applicable.

      Main Outcome Measures

      The main outcome measure was employment status. Potential predictors included patient characteristics, injury severity factors, functional outcome measured at discharge from the acute hospital with the Glasgow Outcome Scale (GOS), Barthel Index (BI), and FIM, and cognitive functioning measured with the Functional Assessment Measure (FAM).

      Results

      Ninety-four patients (83%) completed the 3-year follow-up. The employment rate dropped from 80% preinjury to 15% at 3 months postinjury and gradually increased to 55% after 3 years. The employment rate significantly increased from 3 months up to 1 year, but it did not change significantly from 1 to 3 years postinjury. Age, length of hospital stay, discharge to a nursing home (vs home), psychiatric symptoms, and BI, GOS, FIM, and FAM scores were found to be significant univariate determinants for employment status. By using multiple logistic regression analysis, the FAM score (adjusted odds ratio 1.1; P<.000) and psychiatric symptoms (adjusted odds ratio .08; P<.019) were selected as independent predictors for employment status. A FAM cutoff score of less than 65 to identify patients at risk of long-term unemployment had a good diagnostic value.

      Conclusions

      Patients with TBI with psychiatric symptoms and impaired cognitive functioning at hospital discharge are at the highest risk of long-term unemployment. These factors should be the focus of vocational rehabilitation.

      Key Words

      List of Abbreviations:

      BI (Barthel Index), FAM (Functional Assessment Measure), GCS (Glasgow Coma Scale), GOS (Glasgow Outcome Scale), ROC (receiver operating characteristics), RTW (return to work), TBI (traumatic brain injury)
      TRAUMATIC BRAIN INJURY (TBI) is a leading cause of death and disability worldwide. It is 3 times more common in men than in women; young people and the elderly are at the highest risk. The most common mechanisms of injury are traffic accidents, falls, and violence.
      • Shames J.
      • Treger I.
      • Ring H.
      • Giaquinto S.
      Return to work following traumatic brain injury: trends and challenges.
      • Greenwald B.
      • Burnett D.
      • Miller M.
      Congenital and acquired brain injury: epidemiology and pathophysiology.
      Approximately 1.6 million patients with TBI are admitted to hospitals each year in Europe.
      • Andlin-Sobocki P.
      • Jonsson B.
      • Wittchen H.U.
      • Olesen J.
      Cost of disorders of the brain in Europe.
      • Tagliaferri F.
      • Compagnone C.
      • Korsic M.
      • Servadei F.
      • Kraus J.
      A systematic review of brain injury epidemiology in Europe.
      In the United States, the incidence of TBI is estimated to be 200 per 100,000 people per year.
      • Shames J.
      • Treger I.
      • Ring H.
      • Giaquinto S.
      Return to work following traumatic brain injury: trends and challenges.
      The outcome after TBI can vary from complete recovery to death, with many patients having long-term physical, cognitive, and psychosocial disabilities. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work (RTW), with severe consequences to the patient and the patient's family, both economic and psychosocial.
      • Shames J.
      • Treger I.
      • Ring H.
      • Giaquinto S.
      Return to work following traumatic brain injury: trends and challenges.
      Several medical, physical, and psychosocial therapies that improve the chances of returning to work are currently being implemented in rehabilitation settings. In order to treat patients in an optimal way, it is important to identify which patients are at high risk of long-term unemployment and which patients are not.
      Many studies have been performed on the prediction of TBI outcomes with many candidate predictors available, varying from preinjury sociodemographic factors and clinical variables related to injury severity to postinjury behavioral and psychosocial variables.
      • van Velzen J.M.
      • van Bennekom C.A.M.
      • Edelaar M.J.A.
      • Sluiter J.K.
      • Frings-Dresen M.H.
      Prognostic factors of return to work after acquired brain injury: a systematic review.
      However, the outcomes of these studies may vary considerably, because of patient mix, differences in definitions of outcome variables, assessment methods, and study design. The majority of studies on employment outcomes are performed at 1 or more points in time, in a retrospective, cross-sectional study design.
      • Hoofien D.
      • Gilboa A.
      • Vakil E.
      • Donovick P.J.
      Traumatic brain injury (TBI) 10–20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning.
      • Franulic A.
      • Carbonell C.G.
      • Pinto P.
      • Sepulveda I.
      Psychosocial adjustment and employment outcome 2, 5 and 10 years after TBI.
      • Devitt R.
      • Colantonio A.
      • Dawson D.
      • Teare G.
      • Ratcliff G.
      • Chase S.
      Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury.
      Changes over time cannot be studied in these study designs. Only a few studies have been published in which a cohort of patients with TBI has been followed prospectively. Unfortunately, follow-up time often ends 1 year after TBI.
      • Johnstone B.
      • Mount D.
      • Schopp L.H.
      Financial and vocational outcomes 1 year after traumatic brain injury.
      • Benedictus M.R.
      • Spikman J.M.
      • van der Naalt J.
      Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work.
      Prospective follow-up studies with a more than 1-year follow-up time after injury are scarce.
      • Nolin P.
      • Heroux L.
      Relations among sociodemographic, neurologic, clinical, and neuropsychologic variables, and vocational status following mild traumatic brain injury: a follow-up study.
      Exceptions are the large prospective database studies, such as the Traumatic Brain Injury Model Systems. These database studies have their own methodologic difficulties, such as missing values and high losses to follow-up (42% after 1 year and 68% after 5 years), which could be a threat to the validity of the results.
      • Hammond F.M.
      • Grattan K.D.
      • Sasser H.
      • et al.
      Five years after traumatic brain injury: a study of individual outcomes and predictors of change in function.
      Many measures of early functional status and global outcomes have been found to be predictive of unemployment after TBI. What is often missing in these studies is the calculation of the optimal cutoff value of the measurement instrument to decide which patient is at risk and which patient is not. The diagnostic value of a measurement instrument and the optimal cutoff score can be evaluated by using receiver operating characteristics (ROC) analysis.
      • Homaifar B.Y.
      • Brenner L.A.
      • Gutierrez P.M.
      • et al.
      Sensitivity and specificity of the Beck Depression Inventory-II in persons with traumatic brain injury.
      The cutoff value helps clinicians and rehabilitation professionals in deciding which patients should be selected for a specific treatment. The current study is a prospective study in which a cohort of patients with moderate to severe TBI was followed from hospital admission until 3 years postinjury at regular time intervals. The aim of the study was to evaluate the employment rate up to 3 years after moderate and severe TBI and to identify which patients are at risk of unemployment in the long term.

      Methods

      Procedure

      Patients with TBI were consecutively enrolled between January 1999 and April 2004 at 3 Dutch acute care hospitals, which were all level 1 trauma centers—Erasmus Medical Centre, Rotterdam (January 1999 to April 2004); Medical Centre Haaglanden, The Hague (January 2003 to February 2004); and University Medical Centre Utrecht, Utrecht (April 2003 to February 2004)—and prospectively followed for 3 years. All study centers served as treatment centers for acute hospital care for all patients with moderate to severe TBI within their regions. Patients were treated in accordance with the European Brain Injury Consortium guidelines.
      • Maas A.I.
      • Dearden M.
      • Teasdale G.M.
      • et al.
      European Brain Injury Consortium
      EBIC-guidelines for management of severe head injury in adults.
      In The Netherlands patients are discharged from the acute care hospitals to the initially referring neurology department of local hospitals, to their homes (with or without outpatient rehabilitation), to inpatient rehabilitation centers, or to a nursing home.
      • Ribbers G.M.
      Traumatic brain injury rehabilitation in the Netherlands: dilemmas and challenges.
      Upon admission, patients with acute TBI or family members were asked whether they were willing to participate in the study. When possible, informed consent was obtained from the patient. Otherwise, informed consent was obtained from a family member and patients were asked to give consent at a later time. The medical ethics committee of Erasmus Medical Centre approved this study. Baseline measurements were performed at hospital admission, and patients were followed prospectively at 3, 6, 12, 18, 24, and 36 months postinjury.

      Participants

      Inclusion criteria were admission to a hospital for moderate (Glasgow Coma Scale [GCS] score of 9–12) or severe (GCS score of 3–8) TBI due to a nonpenetrating trauma.
      Exclusion criteria were insufficient knowledge of the Dutch language to participate in the study or serious pretraumatic neurologic, oncologic, or systemic impairments (eg, spinal cord injury, psychiatric disorder, and cancer) that may interfere with TBI-related disability assessment.

      Data Collection

      Data were collected from the patient and/or a significant other or primary caregiver. Baseline sociodemographic and clinical data were obtained by the treating physicians in collaboration with the neurosurgery department of each participating hospital. The lowest GCS score within 24 hours of admission was recorded. Other baseline and follow-up data were gathered at different locations, including the department of neurosurgery, rehabilitation centers and various nursing homes in the area, and at the patients' homes. All follow-up data were collected by 2 trained research psychologists, who visited the patients at the medical institution or at their homes for each measurement. In The Netherlands, patients with severe deficits who suffer from posttraumatic amnesia, recover slowly, and have a poor physical condition are transferred to nursing homes. Patients with some anterograde memory function, sufficient attention span, and a physical condition that allows for a minimum of 2 to 3 therapy sessions of 15 minutes per day are transferred to specialized inpatient rehabilitation clinics.
      • Ribbers G.M.
      Traumatic brain injury rehabilitation in the Netherlands: dilemmas and challenges.

      Measurement Instruments

      Employment outcome was recorded during each visit by means of structured interviews. Employment outcome included questions on employment status (yes/no), type of work, and workload (full-time, part-time, unemployed). The type of work was classified into 4 categories: professional/managerial, skilled, manual labor, and unemployed or student. The first category included executive, administrative, and managerial functions and professional specialties. The second category included technicians and administrative support, precision production, craft, and repair personnel. The third group incorporated people working as machine operators, assemblers, transporters, and cleaners. This classification is largely based on the article of Walker et al.
      • Walker W.C.
      • Marwitz J.
      • Kreutzer J.S.
      • Hart T.
      • Novack T.A.
      Occupational categories and return to work after traumatic brain injury: a multicenter study.
      We did not exclude previously unemployed persons or students, but we analyzed these patients separately in a fourth category.
      The presence (yes/no) and type of psychiatric symptoms were observed during hospitalization by the medical staff and also recorded at each visit by the research psychologist in a structured interview, which included self-reported depression, anxiety, and other serious psychiatric symptoms.
      Functional outcome was assessed with the FIM and the Barthel Index (BI) at hospital discharge.
      • Turner-Stokes L.
      • Nyein K.
      • Turner-Stokes T.
      • Gatehouse C.
      The UK FIM+FAM: development and evaluation.
      • Mahoney F.I.
      • Barthel D.W.
      Functional evaluation: the Barthel Index.
      Cognitive outcome was measured with the Functional Assessment Measure (FAM). The FIM and FAM have a good reliability and validity.
      • Stineman M.G.
      • Shea J.A.
      • Jette A.
      • et al.
      The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories.
      • McPherson K.M.
      • Pentland B.
      • Cudmore S.F.
      • Prescott R.J.
      An interrater reliability study of the Functional Assessment Measure (FIM+FAM).
      • Hawley C.A.
      • Taylor R.
      • Hellawell D.J.
      • Pentland B.
      Use of the Functional Assessment Measure (FIM+FAM) in head injury rehabilitation: a psychometric analysis.
      • Donaghy S.
      • Wass P.J.
      Interrater reliability of the Functional Assessment Measure in a brain injury rehabilitation program.
      They consist of 30 items that are evaluated on a 7-point scale (completely independent to totally dependent). The FIM evaluates motor functioning with respect to self-care, sphincter control, transfers, and locomotion, whereas FAM evaluates cognitive and communication functioning and psychosocial adjustment. The FIM motor scale score ranges from 18 (totally dependent) to 126 (totally independent), and the FAM cognitive scale score ranges from 12 (totally dependent) to 84 (totally independent). The research psychologists were qualified FIM/FAM assessors. The BI also has a good reliability and validity.
      • Collin C.
      • Wade D.T.
      • Davies S.
      • Horne V.
      The Barthel ADL Index: a reliability study.
      This instrument consists of 10 items on activities of daily living (grooming, dressing, bathing, and bowel and bladder status), each with 2 or 4 response categories (0–3 points). Total scores range from 0 (severely restricted) to 20 (no restrictions).
      The Glasgow Outcome Scale (GOS) is a widely accepted measure for general outcome after TBI. The full GOS encompasses 5 outcome categories: death, vegetative state, severe disability, moderate disability, and good recovery.
      • van Baalen B.
      • Odding E.
      • Maas A.I.
      • Ribbers G.M.
      • Bergen M.P.
      • Stam H.J.
      Traumatic brain injury: classification of initial severity and determination of functional outcome.
      • Jennett B.
      • Bond M.
      Assessment of outcome after severe brain damage: a practical scale.

      Statistical Analysis

      Descriptive analyses were performed for the total group and for 2 subgroups that were defined as the persons who were employed preinjury and the persons who were unemployed preinjury. The course of employment status over time was calculated by using generalized estimating equations to fit a logistic regression analysis with repeated measurements. This analysis takes into account that multiple measurements within subjects are correlated.
      By using univariable and multiple logistic regression methods, we evaluated the effect of potential predictors, which were measured at baseline, on employment status (unemployed vs employed) at 36-month follow-up. Potential predictors included patient characteristics (age, sex, partner, educational level), injury severity variables (length of hospital stay, TBI severity [moderate (GCS score 9–12) or severe (GCS score 3–8)]), presence of psychiatric symptoms (yes/no), employment variables (preinjury employment, occupational category, preinjury workload [full-time, part-time, unemployed]), and functional outcomes at hospital discharge (GOS, BI, FIM, FAM).
      ROC analysis was performed to evaluate the diagnostic value of the measurement instrument selected. The area under the ROC curve was calculated, which indicates how well the test discriminates between diseased and nondiseased patients. An area of 100% indicates perfect diagnostic value, whereas an area of 50% is equal to flipping a coin, which means no diagnostic value. The optimal cutoff score was defined as the point on the ROC curve that maximizes sensitivity and specificity.
      For all statistical analyses, we used the Statistical Package for the Social Sciences, version 16.a

      Results

      In total, 549 patients were screened. Of these patients, 153 patients died and 229 patients were excluded on the basis of exclusion criteria (90 patients were out of the age range, 46 patients showed mild TBI, 45 patients had severe comorbidity, 42 patients were transferred to another area, and 6 patients did not master the Dutch language). This left 167 eligible patients, from which 113 were willing to take part in this study. No patient refused to participate after informed consent from a family member was obtained. After 3 years, 19 patients were lost to follow-up (17%). Patients who were lost to follow-up did not differ significantly from patients with complete follow-up in baseline characteristics, except for GCS score, educational level, and preinjury employment status. Patients who were lost to follow-up compared with patients with complete follow-up had a higher mean GCS score (7.95 vs 6.52; P<.035), had more often a low educational level (88% vs 44%; P<.001), and were more often unemployed preinjury (53% vs 14%; P<.001).
      The mean age ± SD of the study population was 33.2±13.1 years, the majority (73%) were men, and 74% had severe TBI. The employment rate preinjury was 80%. For comparison, in The Netherlands, the employment rate of the total working population varied from 74% to 77% for men and from 51% to 57% for women, respectively, during the study period.
      [Central Bureau for Statistics: figures on unemployment from 1998-2007] [Dutch].
      Patient characteristics are listed in table 1.
      Table 1Characteristics of Patients With Moderate to Severe TBI for the Total Group and Subgroups of Employed and Unemployed Patients Preinjury
      Patient CharacteristicsEmployment Status PreinjuryTotal Group (N=113)
      EmployedUnemployed
      (n=88)(n=22)
      Mean age ± SD (y)34.0±11.929.4±15.533.2±13.1
      Sex: male, n (%)68 (77)12 (54)82 (73)
      Living with partner, n (%)47 (53)4 (18)52 (46)
      Educational level, higher, n (%)49 (56)4 (18)54 (50)
      Psychiatric symptoms, n (%)9 (11)0 (0)9 (8)
      Mean length ± SD of hospital stay (d)41.2±30.531.7±18.139.7±28.4
      TBI severity, n (%)
       Moderate (GCS score 9–12)23 (26)6 (27)29 (26)
       Severe (GCS score 3–8)65 (74)16 (73)84 (74)
      Hospital discharge destination, n (%)
       Rehabilitation center35 (40)7 (32)42 (38)
       Nursing home14 (16)2 (9)16 (15)
       Home39 (44)13 (59)52 (47)
      Occupational category preinjury, n (%)
       Professional/managerial14 (16)NA14 (12)
       Skilled25 (28)NA25 (22)
       Manual labor47 (53)NA47 (42)
       Unemployed/studentNA22 (100)22 (19)
      Workload preinjury, n (%)
       Full-time66 (75)NA66 (60)
       Part-time22 (25)NA22 (20)
       UnemployedNA22 (100)22 (20)
      Abbreviation: NA, not applicable.

      Course of Employment Rate

      The mean employment rate at different time points during follow-up is presented in figure 1. This figure shows that the employment rate dropped from 80% preinjury to a level of 12% at 3-month follow-up and then gradually increased to 55% at 3-year follow-up. The employment rate significantly increased from 3 months up to 1 year (P<.000), but it did not change significantly from 1 to 3 years postinjury (P<.097).
      Figure thumbnail gr1
      Fig 1Mean employment rate over time. The error bars indicate the upper and lower bounds of the 95% confidence intervals. The employment rate significantly improved until 12 months postinjury and then remained stable over time.

      Employment Status Preinjury

      The descriptive statistics of the total population and the 2 subgroups of previously employed versus unemployed are listed in table 1. The patients who were employed preinjury had a mean age of 34 years, were mostly men (77%), and were mostly married or living with partner or family (53%); the majority of these had a high educational level (at least high school; 56%). There were 9 patients (11%) with new or recurrent psychiatric symptoms during acute hospitalization, such as symptoms of depression or anxiety, which did not interfere with study inclusion criteria. The severity of TBI was equally distributed over the previously employed and unemployed patients. The smallest percentage (16%) of employed patients in this study was working on a managerial level, and the largest percentage (53%) included manual laborers. A quarter of the employed persons were part-time workers.

      Employment Outcome 3 Years After TBI

      Table 2 shows the characteristics and outcomes of patients who were employed versus unemployed 3 years after TBI. At this time, 53 patients (56%) were employed and 41 patients (44%) were unemployed. The mean age of the employed patients was 29.5 years, which is almost 5 years younger than the mean age of patients employed before the TBI (see table 1). Only 1 of the 9 patients with psychiatric symptoms during hospitalization was employed 3 years after TBI. Of the 22 previously unemployed, 4 patients found employment during follow-up (18%), 9 remained unemployed (41%), and 9 were lost to follow-up (41%). From the 88 previously employed, 33 patients lost their job (38%), 34 kept the same job (39%), 19 patients changed their employment (22%), and 2 patients were lost to follow-up (2%). From the 19 patients who changed their employment, 7 had a positive career change (37%) and 12 were demoted to a lower job status (63%). Thirteen patients changed from full-time to part-time jobs, and 5 part-timers became full-time workers over time (data not shown). The occupational categories were almost equally distributed over the employed and unemployed patients 3 years after TBI.
      Table 2Differences in Characteristics and Outcomes Between Patients Who Were Employed Versus Unemployed 3 Years After TBI
      Characteristics/OutcomesEmployment Status 3y After TBIP
      EmployedUnemployed
      (n=53)(n=41)
      Age ± SD (y)29.5±10.737.9±14.2.000
      Sex: male, n (%)38 (72)28 (68).720
      Living with partner, n (%)25 (47)21 (49).697
      Educational level, high, n (%)30 (57)22 (55).877
      Psychiatric symptoms, n (%)1 (2)8 (21).003
      Mean length ± SD of hospital stay (d)30.5±17.656.2±35.2.002
      TBI severity, n (%)
       Moderate (GCS score 9–12)13 (24)7 (17).381
       Severe (GCS score 3–8)40 (76)34 (83)
      Hospital discharge destination, n (%)
       Rehabilitation center21 (40)18 (44).001
       Nursing home2 (4)12 (29)
       Home30 (57)11 (27)
      Occupational category preinjury, n (%)
       Professional/managerial7 (13)6 (15).340
       Skilled14 (26)9 (23)
       Manual labor27 (51)16 (39)
       Unemployed/student5 (9)9 (23)
      Workload preinjury, n (%)
       Full-time33 (62)24 (59).119
       Part-time15 (28)8 (20)
       Unemployed/student4 (8)9 (22)
      GOS score <4, n (%)
       Hospital discharge22 (50)26 (87).001
       3y after TBI1 (2)6 (15).041
      BI, mean ± SD
       Hospital discharge17.2±4.512.3±7.6.001
       3y after TBI19.6±2.318.4±4.5.116
      FIM, mean ± SD
       Hospital discharge109±16.886±32.7.000
       3y after TBI122±3.6110±23.5.002
      FAM, mean ± SD
       Hospital discharge68±9.152±18.8.000
       3y after TBI79±4.770±14.3.001

      Determinants of Employment Status

      The patients employed at 3 years after TBI differed significantly from those who were unemployed regarding indices of severity of initial trauma and residual deficits (see table 2). Employed persons were significantly younger, less often demonstrated psychiatric symptoms, and were less impaired, with a shorter length of hospital stay and higher scores on the GOS, BI, FIM, and FAM at hospital discharge than unemployed patients.
      There were no significant differences at 36 months when the 2 groups were compared based on sex, educational level (high school or not), living with partner or family or not, and the 4 professional categories listed in table 2.
      Using multiple logistic regression analysis (table 3), the FAM (adjusted odds ratio 0.92; P<.002) and psychiatric symptoms (adjusted odds ratio 10.6; P<.019) were selected as independent predictors of unemployment 3 years after TBI, indicating that patients with better cognitive function score and no psychiatric symptoms during hospitalization had a significantly higher chance of being employed during follow-up.
      Table 3Significant Risk Factors, Measured at Hospital Discharge, for Long-Term Unemployment
      Risk FactorUnivariablePMultivariableP
      OROR
      Age (per year)1.06.003
      Length of hospital stay (per day)1.04.000
      Hospital discharge destination
       Rehabilitation center (vs home)0.43.075
       Nursing home (vs home)0.06.001
      Psychiatric symptoms (yes)13.90.01510.60.049
      GOS score (<4)6.50.002
      BI score0.86.001
      FIM score0.96.001
      FAM score0.92.0000.92.002
      Abbreviation: OR, odds ratio.

      Selecting Patients at Risk of Long-Term Unemployment Using the FAM

      Figure 2 shows the ROC curve of the FAM instrument. The area under the curve was 79.3% (95% confidence interval, 68.1–90.5), indicating a reasonable diagnostic value. A FAM score of less than 65 at hospital discharge was selected as the optimal cutoff score to identify patients at risk of long-term unemployment. Patients with a FAM score of less than 65 had a 6.9 times greater chance of long-term unemployment than did patients with a score of ≥65 (odds ratio 6.9; 95% confidence interval, 2.5–19.4). The FAM cutoff score of less than 65 had a sensitivity of 75%, specificity of 70%, positive predictive value of 65%, and negative predictive value of 79%.
      Figure thumbnail gr2
      Fig 2ROC curve: sensitivity and specificity of the FAM for identification of long-term unemployment.

      Discussion

      In this prospective study on patients with moderate and severe TBI we found that age, length of hospital stay, discharge to a nursing home (vs home), psychiatric symptoms, a relatively low BI score, GOS score of less than 4, and relatively low FIM and FAM scores at hospital discharge are risk factors of unemployment at 3-year follow-up. Earlier studies showed that the Disability Rating Scale,
      • Wright J.
      The Center for Outcome Measurement in Brain Injury
      Introduction to the Disability Rating Scale.
      • Gollaher K.
      • High W.
      • Sherer M.
      • et al.
      Prediction of employment outcome one to three years following TBI.
      the FIM, and the length of hospital stay show a consistent correlation with the ability to RTW.
      • Keyser-Marcus L.A.
      • Bricout J.C.
      • Wehman P.
      • et al.
      Acute predictors of return to employment after traumatic brain injury: a longitudinal follow-up.
      Age older than 40 years has been shown to be a significant negative predictor of RTW.
      • Keyser-Marcus L.A.
      • Bricout J.C.
      • Wehman P.
      • et al.
      Acute predictors of return to employment after traumatic brain injury: a longitudinal follow-up.
      • Ponsford J.L.
      • Olver J.H.
      • Curran C.
      • Ng K.
      Prediction of employment status 2 years after traumatic brain injury.
      The most important predictors for long-term unemployment in our study were cognitive functioning as measured with FAM and the presence of psychiatric symptoms, such as depression and anxiety. We found that the FAM score was more predictive of employment outcome than the FIM score, which is in agreement with the study of Gurka et al.
      • Gurka J.A.
      • Felmingham K.L.
      • Baguley I.J.
      • Schotte D.E.
      • Crooks J.
      • Marosszeky J.E.
      Utility of the Functional Assessment Measure after discharge from inpatient rehabilitation.
      In previously published studies, cognitive impairments were also predictive of RTW in patients with moderate to severe TBI at 1 year postinjury.
      • Benedictus M.R.
      • Spikman J.M.
      • van der Naalt J.
      Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work.
      • Sherer M.
      • Sander A.M.
      • Nick T.G.
      • High W.M.
      • Malec J.F.
      • Rosenthal M.
      Early cognitive status and productivity outcome after traumatic brain injury: findings from the TBI Model Systems.
      Furthermore, we found that patients with psychiatric symptoms at hospital discharge were at risk of long-term unemployment, adjusting for the FAM score. Depression and anxiety are the most common psychiatric problems in patients with TBI. Our findings suggest that cognitive rehabilitation and adequate treatment of psychiatric symptoms are important targets for vocational rehabilitation programs in rehabilitation centers. In The Netherlands, vocational rehabilitation programs are offered to patients who are not able to work for more than 6 to 12 months. Patients are eligible for this program if they have physical complaints in combination with psychosocial problems. The patient will be examined by a rehabilitation doctor and will receive a work-related training of 12 to 15 weeks. The costs are paid by the employer. If suited for the program, generally every employee has access to this program.
      This study focuses on preinjury and early recovery factors to identify patients at risk of unemployment in the long term. This is of value because it can help to target persons at risk for poor outcomes early in the recovery process so that a tailored rehabilitation program can be offered to each individual. Concurrent factors, such as emotional functioning and family support, could also influence the employment outcome, but these were not assessed in this study.
      FAM cutoff scores to identify patients at risk of long-term unemployment have not been published before to our knowledge. We showed that a FAM score of less than 65 is a cutoff score with reasonable diagnostic value for the prediction of unemployment 3 years after TBI. Our results may help rehabilitation professionals in the early selection of patients who may benefit most from vocational rehabilitation programs.
      TBI severity based on the GCS score did not predict employment outcome in our study. Patients with mild TBI were not included in our sample, and the group with moderate TBI was relatively small. Shames et al
      • Shames J.
      • Treger I.
      • Ring H.
      • Giaquinto S.
      Return to work following traumatic brain injury: trends and challenges.
      state that TBI classification in mild, moderate, or severe may not be sufficiently sensitive to appropriately describe and therefore predict outcomes. Some authors have suggested that the “motor component” of the GCS may yield a higher predictive value.
      • Balestreri M.
      • Czosnyka M.
      • Chatfield D.A.
      • et al.
      Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years.
      Marion and Carlier
      • Marion D.W.
      • Carlier P.M.
      Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injuries: results of a national survey.
      point out the difficulty of determining the initial GCS score in a reproducible manner. More aggressive prehospital treatment (involving early sedation and intubation) leads to more difficulty in obtaining a valid neurologic examination in the first 24 hours after trauma as well as progress in clinical management.
      In our sample, 3 months after TBI the employment rate dropped from 80% preinjury to 12%. Thereafter, it increased, especially in the first year, reaching a level of 55% at 3-year follow-up. In a recent review, the overall estimate of RTW 1 year after TBI was found to be 40.7%, ranging from 0% to 84%.
      • van Velzen J.M.
      • van Bennekom C.A.
      • Edelaar M.J.
      • Sluiter J.K.
      • Frings-Dresen M.H.
      How many people return to work after acquired brain injury? A systematic review.
      In the review of Shames,
      • Shames J.
      • Treger I.
      • Ring H.
      • Giaquinto S.
      Return to work following traumatic brain injury: trends and challenges.
      RTW rates were in the 12% to 70% range. These wide ranges are caused by the heterogeneity between studies included in the reviews. The studies reviewed showed a wide variety of patient populations (ranging from including patients with severe TBI only to excluding patients with severe TBI), different follow-up times, different study designs (both retrospective and prospective), and different thresholds of determining the success of RTW outcomes.
      Some studies include sheltered work and unpaid work while other studies focus on competitively employed individuals and amount of income.
      • Shames J.
      • Treger I.
      • Ring H.
      • Giaquinto S.
      Return to work following traumatic brain injury: trends and challenges.
      The employment rate in our study was on the high side compared with that in other studies. Although the loss to follow-up rate was low, we found that unemployed persons were more likely than employed persons to be lost to follow-up. Moreover, not only heterogeneity between studies but also country-specific economic factors will influence employment outcomes. In The Netherlands, the general unemployment rate is one of the lowest in Europe. Furthermore, in the Dutch social security system employers are encouraged to employ disabled persons by financial compensation regulations. Employers are fully compensated in the case of illness of a disabled person, receive financial compensation for adjusting the work space, and are allowed to pay less than the minimum salary (the government supplements the employee's salary).
      Furthermore, we found that the mean employment rates remained quite stable after the first year postinjury. Kreutzer et al
      • Kreutzer J.S.
      • Marwitz J.H.
      • Walker W.
      • et al.
      Moderating factors in return to work and job stability after traumatic brain injury.
      followed patients over a period of 4 years and found that 34% of the patients in the study were stably employed.
      Possl et al
      • Possl J.
      • Jurgensmeyer S.
      • Karlbauer F.
      • Wenz C.
      • Goldenberg G.
      Stability of employment after brain injury: a 7-year follow-up study.
      found an overall 53% RTW rate, but 28% of patients retired within a 2-year period after an unsuccessful work trial (the study contained both patients with TBI and those with no trauma).
      The occupational categories and workload preinjury (full-time, part-time, unemployed) turned out not to be predictors for being employed 3 years after TBI. Prior research has shown that preinjury employment status (employed vs unemployed) greatly influences the odds of successful RTW. Walker et al
      • Walker W.C.
      • Marwitz J.
      • Kreutzer J.S.
      • Hart T.
      • Novack T.A.
      Occupational categories and return to work after traumatic brain injury: a multicenter study.
      found that the type of occupation also influences RTW outcome, with the best prospect for RTW among patients with professional/managerial jobs. We could not reproduce these results, which might be due to the difference in study size (113 vs 1341 patients) and different distribution of patients over the different categories. Walker
      • Walker W.C.
      • Marwitz J.
      • Kreutzer J.S.
      • Hart T.
      • Novack T.A.
      Occupational categories and return to work after traumatic brain injury: a multicenter study.
      used a different definition of returning to work and excluded unemployed patients and students from their study sample, whereas we analyzed those in an extra category. The percentage of patients with managerial jobs in both studies was comparable (14% each), but the skilled and manual labor categories differed (21% vs 56% for the skilled category and 45% vs 29% for the manual labor category).
      Patients in our study were not selected on employment status preinjury. In many studies on RTW or employment outcomes, only employed patients are included. In our study, unemployed patients were followed over time. In this way, we found that some of the previously unemployed patients or students were able to find employment after TBI.

      Study Limitations

      Some limitations of this study should be noted. The study population of 113 patients might not be large enough to detect small but important differences. Of the 113 patients, 95 completed the 3-year follow-up. A percentage of patients lost to follow-up of 17% could have had an effect on the outcomes. However, a successful follow-up rate of 83% of the population over 3 years' time is much higher than the follow-up rates in other prospective cohort studies. In the Traumatic Brain Injury Model Systems, for example, the 1-year follow-up rate was 58% and the 5-year follow-up rate was 32%.
      • Hammond F.M.
      • Grattan K.D.
      • Sasser H.
      • et al.
      Five years after traumatic brain injury: a study of individual outcomes and predictors of change in function.
      Another limitation is that the collected data did not allow detailed conclusions such as whether a patient returned to his previous work, whether the level and extent of employment preinjury differed from follow-up, and whether there was a change in income over the years.
      Reviewing statistical data on employment rates of the general Dutch working population, we found that the employment rates varied during the years of inclusion and follow-up, and employment rates among men were higher than among women (patients with TBI are mainly men).
      [Central Bureau for Statistics: figures on unemployment from 1998-2007] [Dutch].
      We did not adjust our data for these effects.
      In summary, local economic factors, such as general unemployment effects and financial arrangements for companies to employ disabled persons, might have had their effect on our study results, limiting the generalizability of the results.

      Conclusions

      The complex consequences of moderate and severe TBI may cause hindrances for finding employment or RTW. However, as in earlier work, our results show that is no reason for therapeutic nihilisms. Further studies are needed to identify the pivotal determinants and timing of a successful vocational rehabilitation program. Cognitive ability and psychiatric symptoms, such as depression, seem to be important targets.
      • a
        SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

      References

        • Shames J.
        • Treger I.
        • Ring H.
        • Giaquinto S.
        Return to work following traumatic brain injury: trends and challenges.
        DisabilRehabil. 2007; 29: 1387-1395
        • Greenwald B.
        • Burnett D.
        • Miller M.
        Congenital and acquired brain injury: epidemiology and pathophysiology.
        Arch Phys Med Rehabil. 2003; 84: S3-S7
        • Andlin-Sobocki P.
        • Jonsson B.
        • Wittchen H.U.
        • Olesen J.
        Cost of disorders of the brain in Europe.
        Eur J Neurol. 2005; 12: 1-27
        • Tagliaferri F.
        • Compagnone C.
        • Korsic M.
        • Servadei F.
        • Kraus J.
        A systematic review of brain injury epidemiology in Europe.
        Acta Neurochir. 2006; 148: 255-268
        • van Velzen J.M.
        • van Bennekom C.A.M.
        • Edelaar M.J.A.
        • Sluiter J.K.
        • Frings-Dresen M.H.
        Prognostic factors of return to work after acquired brain injury: a systematic review.
        Brain Inj. 2009; 23: 385-395
        • Hoofien D.
        • Gilboa A.
        • Vakil E.
        • Donovick P.J.
        Traumatic brain injury (TBI) 10–20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning.
        Brain Inj. 2001; 15: 189-209
        • Franulic A.
        • Carbonell C.G.
        • Pinto P.
        • Sepulveda I.
        Psychosocial adjustment and employment outcome 2, 5 and 10 years after TBI.
        Brain Inj. 2004; 18: 119-129
        • Devitt R.
        • Colantonio A.
        • Dawson D.
        • Teare G.
        • Ratcliff G.
        • Chase S.
        Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury.
        Disabil Rehabil. 2006; 28: 547-559
        • Johnstone B.
        • Mount D.
        • Schopp L.H.
        Financial and vocational outcomes 1 year after traumatic brain injury.
        Arch Phys Med Rehabil. 2003; 84: 238-241
        • Benedictus M.R.
        • Spikman J.M.
        • van der Naalt J.
        Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work.
        Arch Phys Med Rehabil. 2010; 91: 1436-1441
        • Nolin P.
        • Heroux L.
        Relations among sociodemographic, neurologic, clinical, and neuropsychologic variables, and vocational status following mild traumatic brain injury: a follow-up study.
        J Head Trauma Rehabil. 2006; 21: 514-526
        • Hammond F.M.
        • Grattan K.D.
        • Sasser H.
        • et al.
        Five years after traumatic brain injury: a study of individual outcomes and predictors of change in function.
        NeuroRehabilitation. 2004; 19: 25-35
        • Homaifar B.Y.
        • Brenner L.A.
        • Gutierrez P.M.
        • et al.
        Sensitivity and specificity of the Beck Depression Inventory-II in persons with traumatic brain injury.
        Arch Phys Med Rehabil. 2009; 90: 652-656
        • Maas A.I.
        • Dearden M.
        • Teasdale G.M.
        • et al.
        • European Brain Injury Consortium
        EBIC-guidelines for management of severe head injury in adults.
        Acta Neurochir (Wien). 1997; 139: 286-294
        • Ribbers G.M.
        Traumatic brain injury rehabilitation in the Netherlands: dilemmas and challenges.
        J Head Trauma Rehabil. 2007; 22: 231-235
        • Walker W.C.
        • Marwitz J.
        • Kreutzer J.S.
        • Hart T.
        • Novack T.A.
        Occupational categories and return to work after traumatic brain injury: a multicenter study.
        Arch Phys Med Rehabil. 2006; 87: 1576-1582
        • Turner-Stokes L.
        • Nyein K.
        • Turner-Stokes T.
        • Gatehouse C.
        The UK FIM+FAM: development and evaluation.
        Clin Rehabil. 1999; 13: 277-287
        • Mahoney F.I.
        • Barthel D.W.
        Functional evaluation: the Barthel Index.
        Md State Med J. 1965; 14: 61-65
        • Stineman M.G.
        • Shea J.A.
        • Jette A.
        • et al.
        The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories.
        Arch Phys Med Rehabil. 1996; 77: 1101-1108
        • McPherson K.M.
        • Pentland B.
        • Cudmore S.F.
        • Prescott R.J.
        An interrater reliability study of the Functional Assessment Measure (FIM+FAM).
        Disabil Rehabil. 1996; 18: 341-347
        • Hawley C.A.
        • Taylor R.
        • Hellawell D.J.
        • Pentland B.
        Use of the Functional Assessment Measure (FIM+FAM) in head injury rehabilitation: a psychometric analysis.
        J Neurol Neurosurg Psychiatry. 1999; 67: 749-754
        • Donaghy S.
        • Wass P.J.
        Interrater reliability of the Functional Assessment Measure in a brain injury rehabilitation program.
        Arch Phys Med Rehabil. 1998; 79: 1231-1236
        • Collin C.
        • Wade D.T.
        • Davies S.
        • Horne V.
        The Barthel ADL Index: a reliability study.
        Int Disabil Stud. 1988; 10: 61-63
        • van Baalen B.
        • Odding E.
        • Maas A.I.
        • Ribbers G.M.
        • Bergen M.P.
        • Stam H.J.
        Traumatic brain injury: classification of initial severity and determination of functional outcome.
        Disabil Rehabil. 2003; 25: 9-18
        • Jennett B.
        • Bond M.
        Assessment of outcome after severe brain damage: a practical scale.
        Lancet. 1975; 1: 480-484
      1. [Central Bureau for Statistics: figures on unemployment from 1998-2007] [Dutch].
        (Accessed February 28, 2012)
        • Wright J.
        • The Center for Outcome Measurement in Brain Injury
        Introduction to the Disability Rating Scale.
        (Accessed October 6, 2011)
        • Gollaher K.
        • High W.
        • Sherer M.
        • et al.
        Prediction of employment outcome one to three years following TBI.
        Brain Inj. 1998; 12: 255-263
        • Keyser-Marcus L.A.
        • Bricout J.C.
        • Wehman P.
        • et al.
        Acute predictors of return to employment after traumatic brain injury: a longitudinal follow-up.
        Arch Phys Med Rehabil. 2002; 83: 635-641
        • Ponsford J.L.
        • Olver J.H.
        • Curran C.
        • Ng K.
        Prediction of employment status 2 years after traumatic brain injury.
        Brain Inj. 1995; 9: 11-20
        • Gurka J.A.
        • Felmingham K.L.
        • Baguley I.J.
        • Schotte D.E.
        • Crooks J.
        • Marosszeky J.E.
        Utility of the Functional Assessment Measure after discharge from inpatient rehabilitation.
        J Head Trauma Rehabil. 1999; 14: 247-256
        • Sherer M.
        • Sander A.M.
        • Nick T.G.
        • High W.M.
        • Malec J.F.
        • Rosenthal M.
        Early cognitive status and productivity outcome after traumatic brain injury: findings from the TBI Model Systems.
        Arch Phys Med Rehabil. 2002; 83: 183-192
        • Balestreri M.
        • Czosnyka M.
        • Chatfield D.A.
        • et al.
        Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years.
        J Neurol Neurosurg Psychiatry. 2004; 75: 161-162
        • Marion D.W.
        • Carlier P.M.
        Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injuries: results of a national survey.
        J Trauma. 1994; 36: 89-95
        • van Velzen J.M.
        • van Bennekom C.A.
        • Edelaar M.J.
        • Sluiter J.K.
        • Frings-Dresen M.H.
        How many people return to work after acquired brain injury?.
        Brain Inj. 2009; 23: 473-488
        • Kreutzer J.S.
        • Marwitz J.H.
        • Walker W.
        • et al.
        Moderating factors in return to work and job stability after traumatic brain injury.
        J Head Trauma Rehabil. 2003; 18: 128-138
        • Possl J.
        • Jurgensmeyer S.
        • Karlbauer F.
        • Wenz C.
        • Goldenberg G.
        Stability of employment after brain injury: a 7-year follow-up study.
        Brain Inj. 2001; 15: 15-27