1. Disability After Traumatic Brain Injury among Hispanic Children
Nathalia Jimenez M.D.MPH
Department of Anesthesiology University of Washington; Seattle Children’s Hospital

2. Background: TBI in children
Traumatic Brain Injury (TBI)
leading cause of death from trauma in children in the U.S, and one of the most common causes of acquired disability. (CDC 2011)
40% children (moderate/severe TBI) significant long term disability. (Rivara 2011, 2012)

3. Background: TBI is a significant problem for Hispanic children
Hispanic children are at risk for poor outcomes after TBI
↓ insurance rates
36% Hispanic children (6.1 million) live in poverty
Hispanic parents lowest educational attainment of all racial/ethnic groups.
Hispanic adults with TBI have less access to rehabilitation services (Marquez de la Plata 2007), lower functional outcomes (Staudenmayer 2007)
There were no studies on long term outcomes after TBI in Hispanic children
In 2010 there were 50 million Hispanics in the US (43% increase since 2000); in 2011, 24% of children <18 years were Hispanic. (US census 2011)
More importantly, growth of the Hispanic population over last 5 years is mostly due to nativity not immigration. From the proportion of Latino children in the U.S, increased 39%. In 2012 it was estimated that 23% of US children were Hispanic.

4. objective: Primary Aim
to compare disability in areas of functioning after TBI, between Hispanic and non Hispanic White (NHW ) children.
Hypothesis
Disability will be more common among Hispanic children and it will improve at a slower pace compared to NHW children.

5. methods: Bilingual (Spanish/English) cohort children; TBI (2008-2011)
74 Hispanic & 457 NHW children (<18 y)
recruited at 10 hospitals: 2 children’s hospitals (SCH, CHOP), 1 level I trauma center (HMC), 4 level 3&4 trauma centers and 3 non-trauma centers in Washington state.

6. methods: Outcome measures: baseline, 3,12,24 & 36 months after injury.
Health related quality of life: Pediatric quality of life inventory-PedsQL
Adaptive skills: Adaptive Behavior Assessment systems-ABAS II scale,
communication and self-care subscales.
Participation in activities: Child & Adolescent Scale of Participation-CASP scale
Mild TBI I no CT or normal CT scan
Mild TBI II skull FX w/o ICH
Mild TBI III ICH but still meet criteria for mild TBI clinically
Survey administered to children 14+ (if cognitively able)or parents

7. Population Characteristics:
Results
Population Characteristics:
N=528
Non Hispanic White N=457
Hispanic
N=74
Total n % P
Age at injury 0-4
146
25.2
41.9
0.02
5-9
121
23.2
20.3
10-14
147
29.3
17.6
15-17
117
22.3
Male Gender
347
66.3
59.5
0.25
Insurance None 24
3.5
10.8
<0.0001
Other
136
17.1
78.4
Private
371
79.4
Income <30k
109
12.7
68.9
30-60k 97
19.0
13.5
Over 60
303
64.8
9.5
Respondent education
<high school 51
2.0
56.8
English Language
478
100
28.4

8. Injury Characteristics
Results
Injury Characteristics
Non-Hispanic White
n=449
Hispanic
N=68
significance
Total n % P
TBI severity
0.02
Mild uncomplicated (I)
355
68.3
58.1
Mild skull fracture (II) 27
5.5
2.7
Mild ICH (III) 80
15.1
14.9
Moderate TBI 62
10.3
20.3←
Severe TBI 7
0.9
4.1←
Intent
0.002
Intentional 25
3.6
13.4←
Unintentional
490
96.4
86.6
ISS Mean(SD)
517
6.8(9.3)
10.2(10.9)
0.01
Pre-injury comorbidities(%)
0.004
None
206
35.9
56.8← 1
116
22.1
20.3 2 77
15.8
6.7
>=3
132
26.3
16.2

9. Results Functional Outcomes Baseline ∆ 0-3 mo ∆ 0-12 mo ∆ 0-24 mo
mean
Adjusted Δ
(95% CI)
Adjusted Δ (95% CI)
PedsQL** (n)
(450)
(443)
(444)
(461)
(445)
Non-Hispanic White
86.3
-5.4 (-6.7,-4.1)
-5.0 (-6.3,-3.7)
-4.7 (-6.0,-3.5)
-4.7 (-6.2,-3.3)
Hispanic
89.9
-15.2 (-19.9,-10.6)
-13.0 (-17.8,-8.2)
-12.2 (-17.6,-6.8)
-15.5 (-20.8,-10.2)
Difference
(Hispanic- NHW)
-9.8 (-14.7,-5.0)
-8.0 (-13.0,-3.0)
-7.5 (-13.0,-1.9)
-10.8 (-16.3,-5.3)
Adjusted for age, gender, injury intention & severity ,parental income & education, family function at baseline

10. Results Functional Outcomes baseline ∆ 0-3 mo ∆ 0-12 mo ∆ 0-24 mo
ABAS Communication (n)
(530)
(521)
(491)
(466)
(443)
Non-Hispanic White
10.6
0.03 (-0.2,0.3)
0.2 (-0.01,0.5)
0.2 (-0.1,0.5)
0.3 (0.04,0.6)
Hispanic
10.2
-1.2 (-2.0,-0.4)
-1.7 (-2.7,-0.8)
-1.9 (-2.8,-0.9)
Difference
(Hispanic- non-Hispanic White)
-1.2 (-2.1,-0.4)
-1.4 (-2.3,-0.6)
-2.0 (-3.0,-1.0)
-2.2 (-3.2,-1.2)
ABAS Self-Care (n)
9.2
0.3 (0.01,0.6)
0.4 (0.1,0.7)
0.6 (0.3,0.9)
0.7 (0.4,1.1)
9.9
0.8 (-1.7,0.004)
-1.2 (-2.2,-0.3)
-0.9 (-1.8,0.1)
-1.2 (-2.3,-0.1)
-1.1 (-2.0,-0.2)
-1.6 (-2.6,-0.7)
-1.5 (-2.5,-0.5)
-1.9 (-3.0,-0.8)
Adjusted for age, gender, injury intention & severity ,parental income & education, family function at baseline

11. Results Functional Outcomes baseline ∆ 0-3 mo ∆ 0-12 mo ∆ 0-24 mo
CASP* (n)
(385)
(377)
(370)
(374)
(378)
Non-Hispanic White
94.9
-0.7 (-1.7,0.3)
0.1 (-0.8,1.1)
0.1 (-1.0,1.1)
1.1 (0.1,2.0)
Hispanic
93.0
-6.3 (-10.1,-2.6)
-1.0 (-3.7,1.8)
-1.1 (-5.0,2.8)
-2.1 (-6.6,2.4)
Difference
(Hispanic- non-Hispanic White)
-5.6 (-9.5,-1.7)
-1.1 (-4.0,1.8)
-1.2 (-5.2,2.8)
-3.2 (-7.8,1.5)
Adjusted for age, gender, injury intention & severity , parental income & education, and family function at baseline

12. Conclusion:
Disparities in long term-disability after TBI for Hispanic children.
Important differences in demographic and injury characteristics of Hispanic children
future studies are needed to
understand patterns, barriers and facilitators for use of rehabilitation services by Hispanic children
design prevention measures and rehabilitation care tailored to the needs of Hispanic children and families

13. Nathalia Jimenez M.D.MPH
Parental English Proficiency & Interpreted Care on Postoperative Pain Management
Nathalia Jimenez M.D.MPH
Department of Anesthesiology University of Washington; Seattle Children’s Hospital

14. Background: Pain and children
44% of surgical pediatric patients report moderate-severe pain (Groenewald 2012)
Pain is a subjective symptom  self report is the gold standard
Adequate pain assessment requires good communication between care providers, patients and caregivers
60% of analgesic medications ( specially opioids) are given “as needed”

15. objective:
To determine the association between parental-English proficiency and frequency of pain assessments in surgical pediatric patients
To determine the association between parental-English proficiency and analgesic treatment in surgical pediatric patients
To determine if use of professional interpretation was associated with fewer disparities in pain management in surgical patients with LEP.

16. methods: Study population:
Children <18 years, had inpatient surgery at SCH (12/08-06/09) AND whose parents self- identified as LEP at admission (use of an interpreter)
Children whose parents self-identified as English proficient (EP)
Matched by age (<1, 1-3,4-7,8-12,13+), surgical procedure and admission date (± 1 month).
Excluded: ICU patients

17. methods: Outcome variables:
Frequency of pain assessments. [5 days or discharge]
Type of analgesic medications: opioid/non-opioid
Predictor variables:
Number of professional interpretations: Phone or in person.
English proficiency “would you prefer communication about your child’s health in English or another Language?”
Covariates: sex, hospital length of stay, severity of illness (American Society of Anesthesia classification)
Mild TBI I no CT or normal CT scan
Mild TBI II skull FX w/o ICH
Mild TBI III ICH but still meet criteria for mild TBI clinically
Survey administered to children 14+ (if cognitively able)or parents

18. Limited English Proficient
Results
Population Characteristics:
English Proficient
n= 237
Limited English Proficient
Limited English Proficient
<2 daily interpretations
n= 151
≥2 daily interpretations
n= 86
Age in years mean (SD)*
7.7 (5.7)
7.4 (5.5)
‡8.4 (5.7)
5.8 (4.7)
Sex: Female n (%)
106 (45%)
115 (49%)
76 (50%)
39 (45%)
ASA status:
I-II n (%)
III
181 (75%)
56 (24%)
189 (79%)
48 (21%)
119 (79%)
32 (31%)
67 (81%)
19 (19%)
Length of Stay in days mean (SD)
4 (8.4)
4 (5.8)
4.5 (6.6)
3.1 (3.6)
† Significantly different between EP and LEP patients (p<0.05)
‡ Significantly different between LEP patients with
less than two vs. two or more interpretations per hospital day (p<0.05).

19. Limited English Proficient
Results
Pain Assessment and Mean Pain Scores
English Proficient
n= 237
Limited English Proficient
Limited English Proficient
<2 daily interpretations
n= 151
≥2 daily interpretations
n= 86
Number of daily pain assessments
Median (IQR 25-75)
†9.3
( )
7.3
( )
8.1
( )
7.1
( )
Regression analyses adjusted for clustering by individual patient, age and sex.
† Significantly different between EP and LEP patients (p<0.05)
‡ Significantly different between LEP patients with
less than two vs. two or more interpretations per hospital day (p<0.05).

20. Type of analgesic administered, by level of reported pain severity
Results
Opioid analgesic Doses Administered
Type of analgesic administered, by level of reported pain severity
English proficient
n= 237
Limited English Proficient
n=237
≤ 2 daily interpretations
n=151
≥2 daily interpretations
n=86
opioid
n doses (%)*
975
(100%)
968
726
242
mild pain
(pain scores 0-3)
†296
(30%)
214
(22%)
153
(21%) 61
(25%)
moderate pain
(pain scores 4-7)
†481
(49%)
473
343
(47%)
130
(54%)
severe pain
(pain scores 8-10)
†198
(20%)
281
(29%)
230
(32%) 51
Regression analyses adjusted for clustering by individual patient, age and sex.
† Significantly different between EP and LEP patients (p<0.05)
‡ Significantly different between LEP patients with
less than two vs. two or more interpretations per hospital day (p<0.05).

21. Conclusion: Children of LEP parents received fewer pain assessments
and were less likely to receive opioid analgesics for similar levels of pain when compared to children of EP parents.
More frequent use of professional interpreters when assessing pain may be associated with fewer disparities in pain management.

22. Questions?
Nathalia Jimenez MD, MPH.

23. Adult PAIN study