Traumatic Brain Injury Leads to Labor Market Consequences

Across Canada, patients who sustain traumatic brain injury (TBI) face potential unemployment and thousands of dollars of personal income loss in the years following their injury, according to a new study.

By the third year, significant income loss was seen regardless of injury severity. It ranged from about $3350 CAD (or nearly $2500 USD) for mild TBI to more than $17,000 CAD (or about $13,000 USD) for severe TBI.

Totaling $588 million CAD ($435 million USD) over 3 years for 25,000 affected patients, the labor market impact could have important implications for health policy, social service resources allocation, and postinjury care pathways, the researchers wrote.

“Establishing these benchmark data is a critical step in understanding the downstream societal implications of TBI and appropriately estimating the value of national preventive efforts,” wrote Armaan Malhotra, MD, and colleagues.

Malhotra is a neurosurgeon with Unity Health Toronto; the Li Ka Shing Knowledge Institute at St. Michael’s Hospital; and the Institute of Health Policy, Management and Evaluation at the University of Toronto, all in Toronto, Ontario, Canada.

The study was published online on October 9 in JAMA Surgery.

Yearly Income Losses 

Malhotra and colleagues conducted a pan-Canadian observational study using the Canadian Hospitalization and Taxation Database to identify patients aged between 19 and 61 years who were hospitalized with TBI and survived hospitalization between 2007 and 2017. Looking at the 3 years after injury, the research team estimated annual personal income and employment loss.

Among 18,050 patients, 74% were men, and the average age was 38 years. The average income was $42,600 CAD (about $31,500 USD) in the fiscal year before injury, and 82% of participants were employed at the time of injury.

Most patients experienced TBI due to a fall (38%), motor vehicle collision (27%), or being struck by an object (19%). About 62% had mild TBI, and 74% were discharged from the hospital without support.

Following TBI, the adjusted average personal income loss was $7635 CAD ($5652 USD) in the first year after injury, $5095 CAD ($3772 USD) in the second year after injury, and $5000 CAD ($3701 USD) in the third year after injury. These amounts reflected relative reductions from preinjury levels of 17.9%, 12%, and 11.7%, respectively.

By severity, the adjusted average personal income loss by the third year after injury was $3354 CAD ($2483 USD) for mild TBI, $6750 CAD ($4997 USD) for moderate TBI, and $17,375 CAD ($12,862 USD) for severe TBI.

During each of the three postinjury years, 7.8% of patients were newly unemployed compared with the preinjury baseline. By severity, the proportion of unemployed people increased by 5.8% for mild TBI, 9.2% for moderate TBI, and 20.2% for severe TBI by the third year, relative to preinjury baseline.

Nationally, the estimated total incurred cost of TBI for 2007-2017 was $588 million CAD ($435 million USD), which accounted for lost income and unemployment displacement among 25,500 TBI survivors and lost income for 1840 patients who died.

“Unfortunately, there is a misconception that concussions — including mild traumatic brain injuries — have mild symptoms that wear off within a few weeks and thus do not need much attention,” said Étienne Gaudette, a health economist at the Institute of Health Policy, Management and Evaluation at the University of Toronto. Gaudette, who wasn’t involved with this study, has researched employment and economic outcomes of patients with mild TBI.

“While some patients recover well, others will have persistent symptoms with long-lasting impact on their quality of life and ability to work,” he said. “In a previous study, we found a dire lack of follow-up care after injury. There is a need to do better for people who suffer concussion.”

Comprehensive Interdisciplinary Care

Although studies of tax data tend to be rare in health research, they can offer insights into the long-term socioeconomic consequences of injury and disease, Nathan O’Hara, associate professor of medicine and co-director of the Center for Orthopaedics, Injury, and Research Innovation at the University of Maryland School of Medicine, Baltimore, wrote in an accompanying commentary in JAMA Surgery.

“The implications of tax data-based health research extend beyond healthcare,” he wrote. “Revealing the economic consequences of health conditions can stimulate policy discussions with various stakeholders.”

Of course, tax-related studies also have limitations, O’Hara wrote, such as data gaps for low-income individuals who don’t file tax returns. In addition, informal employment earnings often go unreported, and major financial events such as bankruptcies may not be captured. Other socioeconomic factors, including changes in employment insurance benefits or social assistance, could offer additional perspectives.

“Collaboration between researchers, policymakers, and data custodians will be key to unlocking the full potential of tax data in health research,” O’Hara wrote. “Such studies have the power to transform our understanding of the long-term socioeconomic impact of health conditions and inform more effective, evidence-based policies.”

Future studies can also investigate the long-term, complex nature of TBI and offer support to patients.

“We know that TBI can negatively impact daily functioning in other aspects of quality of life beyond work. This study highlights the importance of comprehensive interdisciplinary care after brain injury to prevent these long-term sequelae,” said Roger Zemek, MD, clinical research chair in pediatric concussion at the University of Ottawa and scientific director of 360 Concussion Care, both in Ottawa, Ontario, Canada.

Zemek, who wasn’t involved with this study, is also director of the TRANSCENDENT trial, which is a prospective study funded by the Ontario Brain Institute to investigate concussion-related symptoms, biomarkers, diagnosis, recovery, and long-term complications.

“The brain is the most complex organ in the body, and no two brain injuries are ever the same,” Zemek said. “While this complexity poses significant challenges, I remain hopeful for the future of our understanding of how to optimize brain recovery following TBI.”

The study was funded by a Canadian Institutes of Health Research project grant. Malhotra was supported by the American College of Surgeons Resident Research Scholarship. Gaudette, O’Hara, and Zemek reported no relevant financial relationships.

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape Medical News, MDedge, and WebMD.