Rural-Urban Parity and Socioeconomic Gaps in Traumatic Brain Injury Outcomes

Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Rural residence and low community income are independently associated with poorer health outcomes, mediated by variations in injury mechanism and healthcare access. We evaluated the impact of geographic location on injury patterns and acute-care metrics in adults with TBI treated at Maryland's statewide Level I trauma center.

Adults (≥18 years of age) with radiographically confirmed TBI admitted between 2017 and 2021 were identified retrospectively from the institutional trauma registry. Rural residence was defined using Rural-Urban Commuting Area codes. This single-center study included only patients surviving to hospital admission. Primary outcomes included hospital length of stay (LOS) and discharge to hospice or death. Secondary outcomes included intensive care unit (ICU) and ventilator days and discharge disposition.

Of 2,812 patients diagnosed with TBI during the study period, 267 (9.5%) resided in rural areas. Compared with nonrural patients, rural patients were older (median age 67 vs 60 years, P < .001) and lived in lower income communities. However, after adjustment for demographic and clinical covariates, rural residence was not associated with higher hospital LOS quartile category (adjusted odds ratio [aOR] 1.18; 95% CI, 0.91-1.53; P = .20), discharge to hospice or death (aOR 1.67; 95% CI, 0.95-2.94), or discharge to a nonhome setting (aOR 0.93; 95% CI, 0.66-1.31). Groups showed no significant differences in critical care use, including ICU and ventilator durations. Worse outcomes were associated primarily with injury severity, including lower Glasgow Coma Scale scores and higher Injury Severity Scores.

In a well-established regional trauma network, we found that among patients admitted with traumatic brain injury, residing in a rural area was not independently associated with worse in-hospital outcomes compared to patients who resided in nonrural (urban and suburban) communities. These findings suggest that a coordinated statewide trauma triage and access to tertiary neurotrauma care may help other systems similarly reduce rural disparities after severe head injury.