A Multidimensional Approach to Assessing Factors Impacting Health-Related Quality of Life after Pediatric Traumatic Brain Injury
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study and Study Participants
2.2. Ethical Approval
2.3. Procedure
2.4. Methods
2.4.1. Pre-Injury Characteristics
2.4.2. Injury-Related Characteristics
2.4.3. Post-Injury Outcomes
2.5. Statistical Considerations
2.6. Missing Data
2.7. Path Analysis
- The ratio of chi-square statistics/degrees of freedom (χ2/df < 3) [57];
- The root mean square error of approximation (RMSEA; mediocre within 0.08–0.10, fair within 0.05–0.08, ideal fit < 0.05), as well as 90% confidence limits (adequate within 0.0001–0.090, ideal within 0.0001–0.054) [58];
- Standardized root mean square residual (SRMR; ideal < 0.055) [58];
- Goodness-of-fit index (GFI) and comparative fit index (CFI) (> 0.90 acceptable, > 0.94 very good fit) [58].
3. Results
3.1. Participants
3.2. Missing Data
3.3. Overview of the Analysis
3.3.1. The Initial and the Revised Measurement Model
3.3.2. The First and Revised Empirical SEM
4. Discussion
4.1. Limitations
4.2. Implications
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A. Instruments and Measures
Appendix A.1. Post-Injury Outcomes
Appendix A.1.1. Kings Outcome Scale for Childhood Head Injury (KOSCHI)—Investigator Rated
Appendix A.1.2. Post-Concussion Symptom Inventory (PCSI-SR8/SR13)—Self-Reported by Children and Adolescents
Appendix A.1.3. Patient Health Questionnaire 9 (PHQ-9)—Parent Rated
Appendix A.1.4. Generalized Anxiety Disorder-7 (GAD-7)—Parent Rated
Appendix A.2. TBI-Specific HRQoL Measure
Quality of Life after Traumatic Brain Injury in Kids/Adolescents (QOLIBRI-KID/ADO)—Self-Reported by Children and Adolescents
References
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Children’s Characteristics | KID (n = 152) | ADO (n = 148) | Total (n = 300) | (Chi-Square, df) p-Value |
---|---|---|---|---|
Pre-Injury Characteristics | ||||
Age (years) | N/A | |||
Mean (SD) | 10.6 (1.40) | 15.2 (1.47) | 12.9 (2.72) | |
Median (Range) | 10.5 (8.0–12.9) | 14.9 (13.0–17.9) | 12.9 (8.0–17.9) | |
Sex N (%) | (0.44, 1) 0.508 | |||
Female | 58 (38.2) | 62 (41.9) | 120 (40.0) | |
Male | 93 (61.2) | 85 (57.4) | 178 (59.3) | |
Missing | 1 (0.7) * | 1 (0.7) | 2 (0.7) | |
Education (of both parents) N (%) | (0.91, 1) 0.340 | |||
University | 97 (63.8) | 92 (62.2) | 189 (63.0) | |
Other than university | 44 (28.9) | 53 (35.8) | 97 (32.3) | |
Missing | 11 (7.9) | 3 (2.0) | 14 (4.7) | |
Employment (of both parents) N (%) | (0.86, 1) 0.353 | |||
Employed (>35 h/week) | 129 (84.9) | 133 (89.9) | 262 (87.3) | |
Other than >35 h/week | 18 (11.8) | 13 (8.8) | 31 (10.3) | |
Missing | 5 (3.3) | 2 (1.4) | 7 (2.3) | |
Previous TBI N (%) | (0.01, 1) 0.941 | |||
No | 126 (82.9) | 119 (80.4) | 245 (81.7) | |
One or more TBIs | 26 (17.1) | 24 (16.2) | 50 (16.7) | |
Missing | 0 (0.0) | 5 (3.4) | 5 (1.7) | |
Prior cognitive, sensory, or physical impairment N (%) | (0.83, 1) 0.362 | |||
No | 112 (76.7) | 102 (68.9) | 214 (71.3) | |
Yes | 40 (26.3) | 46 (31.1) | 86 (28.7) | |
Neurological disease N (%) | (0.39, 1) 0.535 | |||
No | 143 (94.1) | 131 (88.5) | 274 (91.3) | |
Yes | 9 (5.9) | 11 (7.4) | 20 (6.7) | |
Missing | 0 (0.0) | 6 (4.1) | 6 (2.0) | |
Chronic disease N (%) | (0.55, 1) 0.457 | |||
No | 116 (76.3) | 103 (69.6) | 219 (73.0) | |
Yes | 36 (23.7) | 39 (26.4) | 75 (25.0) | |
Missing | 0 (0.0) | 6 (4.1) | 6 (2.0) | |
Treatment for mental health disorder N (%) | (2.64, 1) 0.104 | |||
No | 137 (90.1) | 130 (87.8) | 267 (89.0) | |
Yes *** | 9 (5.9) | 17 (11.5) | 26 (8.7) | |
Missing | 6 (3.9) | 1 (0.7) | 7 (2.3) | |
Injury-Related Characteristics | ||||
TBI severity N (%) | (0.57, 1) 0.452 | |||
Mild | 106 (69.7) | 109 (73.6) | 215 (71.7) | |
Moderate or severe | 46 (30.3) | 39 (26.4) | 85 (28.3) | |
Imaging finding (lesion) N (%) | (0.05, 1) 0.819 | |||
No | 105 (69.1) | 99 (66.9) | 204 (68.0) ** | |
Yes | 43 (28.3) | 43 (29.1) | 86 (28.7%) | |
Missing | 4 (2.6) | 6 (4.1) | 10 (3.3) | |
Retrograde amnesia N (%) | (12.64, 1) <0.001 | |||
No | 124 (81.6) | 93 (62.8) | 217 (72.3) | |
Yes | 25 (16.4) | 50 (33.8) | 75 (25.0) | |
Missing | 3 (2.0) | 5 (3.4) | 8 (2.7) | |
Loss of consciousness N (%) | (4.09, 1) 0.043 | |||
No | 111 (73.0) | 92 (62.2) | 203 (67.7) | |
Yes | 40 (26.3) | 55 (37.2) | 95 (31.7) | |
Missing | 1 (0.7) | 1 (0.7) | 2 (0.7) | |
Neurosurgical intervention following injury N (%) | (0.32, 1) 0.571 | |||
No | 127 (83.6) | 120 (81.1) | 247 (82.3) | |
Yes | 24 (15.8) | 27 (18.2) | 51 (17.0) | |
Missing | 1 (0.7) | 1 (0.7) | 2 (0.7) | |
Time since injury (years) | ||||
Mean (SD) | 4.2 (2.55) | 4.9 (2.95) | 4.5 (2.78) | N/A |
Median (Range) | 3.7 (0.2, 9.4) | 4.5 (0.2, 10.2) | 4.1 (0.2, 10.2) | |
Missing | 0 | 1 | 1 |
Post-Injury Outcome Measures | KID (n = 152) | ADO (n = 148) | Total (n = 300) | (Test Statistic, df) p-Value |
---|---|---|---|---|
KOSCHI N (%) | (8.55, 1) 0.004 | |||
3a, 3b, 4a, 4b | 8 (5.3) | 23 (15.5) | 31 (10.3) | |
5a, 5b | 144 (94.7) | 125 (84.5) | 269 (89.7) | |
PCSI ª | ||||
Mean (SD) | 5.0 (5.48) | 19.8 (18.02) | N/A | N/A |
Median (Range) | 3.0 (0–27) | 13.5 (0–75) | ||
Missing | 19 | 22 | ||
GAD-7 | (0.85, 1) 0.358 | |||
Mean (SD) | 3.6 (3.07) | 3.4 (3.56) | 3.5 (3.32) | |
Median (Range) | 3.0 (0–13) | 2.0 (0–17) | 2.0 (0–17) | |
Missing | 5 | 2 | 7 | |
PHQ-9 | (1.73, 1) 0.188 | |||
Mean (SD) | 3.9 (3.36) | 4.7 (4.19) | 4.3 (3.81) | |
Median (Range) | 3.0 (0–17) | 4.0 (0–21) | 3.0 (0–21) | |
Missing | 5 | 2 | 7 | |
GAD-7 (as categorical) N (%) | N/A | |||
None or minimal anxiety (0–4) | 98 (64.5) | 110 (74.3) | 208 (69.3) | |
Mild anxiety (5–9) | 43 (28.3) | 24 (16.2) | 67 (22.3) | |
Moderate to severe anxiety (≥10) | 6 (3.9) | 12 (8.1) | 18 (6.0) | |
Missing | 5 (3.3) | 2 (1.4) | 7 (2.3) | |
PHQ-9 (as categorical) N (%) | N/A | |||
None or minimal depression (0–4) | 98 (64.5) | 89 (60.1) | 187 (62.3) | |
Mild depression (5–9) | 38 (25.0) | 37 (25.0) | 75 (25.0) | |
Moderate to severe depression (≥10) | 11 (7.0) | 20 (13.5) | 31 (10.3) | |
Missing | 5 (3.3) | 2 (1.4) | 7 (2.30) |
QOLIBRI-KID/ADO | KID (n = 152) | ADO (n = 148) | Total (n = 300) | (Chi-Square, df) p-Value |
---|---|---|---|---|
Total score | (10.39, 1) 0.001 | |||
Mean (SD) | 76.9 (10.71) | 72.6 (11.46) | 74.8 (11.27) | |
Median (Range) | 76.4 (43.6–96.4) | 73.6 (27.1–93.6) | 75.7 (27.1–96.4) | |
Missing | 0 | 3 | 3 | |
Cognition | (18.78, 1) <0.001 | |||
Mean (SD) | 78.6 (11.64) | 71.7 (14.29) | 75.2 (13.45) | |
Median (Range) | 78.6 (42.9–100) | 75.0 (25–100) | 75.0 (25–100) | |
Self | (52.54, 1) <0.001 | |||
Mean (SD) Missing | 86.3 (11.83) | 73.6 (16.41) | 80.1 (15.61) | |
Median (Range) | 90.0 (40–100) | 75.0 (15–100) | 85.0 (15–100) | |
Missing | 0 | 1 | 1 | |
Daily life and autonomy | (11.37, 1) <0.001 | |||
Mean (SD) Missing | 88.7 (10.20) 0 | 84.5 (12.24) 2 | 86.6 (11.42) 2 | |
Median (Range) | 92.9 (42.9–100) | 89.3 (28.6–100) | 89.3 (28.6–100) | |
Missing | 0 | 2 | 2 | |
Social relationships | (13.04, 1) <0.001 | |||
Mean (SD) | 84.0 (12.24) | 79.3 (12.85) | 81.7 (12.75) | |
Median (Range) | 87.5 (37.5–100) | 79.2 (29.2–100) | 83.3 (29.2–100) | |
Emotions | (0, 1) 0.997 | |||
Mean (SD) | 52.6 (25.02) | 53.4 (23.08) | 53.0 (24.05) | |
Median (Range) | 56.3 (0–100) | 50.0 (6.3–100) | 53.1 (0–100) | |
Physical problems | (1.06, 1) 0.303 | |||
Mean (SD) | 61.9 (23.47) | 65.2 (19.58) | 63.5 (21.66) | |
Median (Range) | 62.5 (0–100) | 66.7 (8.3–100) | 66.7 (0–100) |
University (n = 189) | Other than University (n = 97) | Missing (n = 14) | (χ2, df) p-Value | |
---|---|---|---|---|
QOLIBRI-KID/ADO Total | (3.07, 1) 0.080 | |||
Mean (SD) | 75.6 (10.73) | 72.5 (12.36) | 78.4 (8.32) | |
Median (Range) | 75.7 (47.9–96.4) | 73.6 (27.1–95) | 80.4 (62.1–90) | |
Missing | 1 | 2 | 0 | |
PHQ-9 | (7.95, 1) 0.005 | |||
Mean (SD) | 3.9 (3.67) | 5.2 (4.01) | 2.8 (2.64) | |
Median (Range) | 3.0 (0–21) | 4.0 (0–17) | 2.0 (0–9) | |
Missing | 1 | 1 | 5 | |
GAD-7 | (5.74, 1) 0.017 | |||
Mean (SD) | 3.1 (3.03) | 4.3 (3.74) | 2.9 (3.06) | |
Median (Range) | 2.0 (0–17) | 3.0 (0–16) | 2.0 (0–10) | |
Missing | 1 | 1 | 5 | |
PCSI Total (log z-transformed) | (3.15, 1) 0.076 | |||
Mean (SD) | −0.1 (0.95) | 0.2 (1.08) | −0.2 (1.07) | |
Median (Range) | 0.0 (−2.6–2.1) | 0.4 (−2.6–2.1) | 0.1 (−1.6–1.7) | |
Missing | 18 | 21 | 2 |
Measurement and SEMs for QOLIBRI-KID/ADO–FIML Method | |||||||||
---|---|---|---|---|---|---|---|---|---|
Model Description | Fit Statistics | ||||||||
χ2 | df (Ratio χ2/df) | p-Value | SRMR | RMSEA | RMSEA 90% CI | GFI | CFI | Difference between Models χ2 diff, df, p-Value | |
1. Initial measurement model (all variables in) | 571.2 | 246 (2.3) | <0.0001 | 0.0849 | 0.0664 | [0.0593, 0.0735] | 0.8598 | 0.8290 | |
2. Revised measurement model without non-significant paths | 452.2 | 164 (2.8) | <0.0001 | 0.0887 | 0.0765 | [0.0682, 0.0850] | 0.8664 | 0.8351 | |
3. First SEM | 456.0 | 165 (2.8) | <0.0001 | 0.0900 | 0.0767 | [0.0683, 0.0851] | 0.8659 | 0.8334 | 3.8, 1 df, 0.051 (Model 3–Model 2) |
4. Revised final SEM * | 456.2 | 166 (2.7) | <0.0001 | 0.0901 | 0.0763 | [0.0680, 0.0847] | 0.8660 | 0.8339 | 0.2, 1 df, 0.655 (Model 4–Model 3) 4.0, 2 df, 0.135 (Model 4–Model 2) |
Construct and Indicators | Standardized Loading | t a | Reliability | Variance Extracted Estimate |
---|---|---|---|---|
Pre-injury characteristics | 0.49 b | 0.16 | ||
Age | 0.24 | 3.31 | 0.06 | |
Education | 0.30 | 4.04 | 0.09 | |
Sensory, cognitive or physical impairment | 0.36 | 5.21 | 0.13 | |
Neurological disease | 0.22 | 2.87 | 0.05 | |
Chronic disease | 0.49 | 6.77 | 0.24 | |
Treatment for mental health disorder | 0.61 | 8.87 | 0.37 | |
Injury-related characteristics | 0.83 b | 0.57 | ||
Imaging finding (lesion) | 0.86 | 36.97 | 0.75 | |
Neurosurgical intervention | 0.70 | 20.65 | 0.49 | |
LOC | 0.43 | 8.60 | 0.19 | |
Severity of injury | 0.92 | 42.48 | 0.84 | |
Post-injury outcome | 0.56 b | 0.38 | ||
PCSI | 0.36 | 5.98 | 0.13 | |
KOSCHI | −0.24 | −4.00 | 0.06 | |
PHQ-9 | 0.88 | 26.26 | 0.78 | |
GAD-7 | 0.75 | 21.39 | 0.57 | |
TBI-specific HRQoL (QOLIBRI-KID/ADO) | 0.82 b | 0.45 | ||
Cognition | 0.82 | 30.63 | 0.67 | |
Self | 0.72 | 21.53 | 0.52 | |
Daily life and autonomy | 0.79 | 27.56 | 0.62 | |
Social relationships | 0.76 | 24.64 | 0.57 | |
Emotions | 0.36 | 6.46 | 0.13 | |
Physical problems | 0.41 | 7.74 | 0.17 |
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von Steinbuechel, N.; Krenz, U.; Bockhop, F.; Koerte, I.K.; Timmermann, D.; Cunitz, K.; Zeldovich, M.; Andelic, N.; Rojczyk, P.; Bonfert, M.V.; et al. A Multidimensional Approach to Assessing Factors Impacting Health-Related Quality of Life after Pediatric Traumatic Brain Injury. J. Clin. Med. 2023, 12, 3895. https://doi.org/10.3390/jcm12123895
von Steinbuechel N, Krenz U, Bockhop F, Koerte IK, Timmermann D, Cunitz K, Zeldovich M, Andelic N, Rojczyk P, Bonfert MV, et al. A Multidimensional Approach to Assessing Factors Impacting Health-Related Quality of Life after Pediatric Traumatic Brain Injury. Journal of Clinical Medicine. 2023; 12(12):3895. https://doi.org/10.3390/jcm12123895
Chicago/Turabian Stylevon Steinbuechel, Nicole, Ugne Krenz, Fabian Bockhop, Inga K. Koerte, Dagmar Timmermann, Katrin Cunitz, Marina Zeldovich, Nada Andelic, Philine Rojczyk, Michaela Veronika Bonfert, and et al. 2023. "A Multidimensional Approach to Assessing Factors Impacting Health-Related Quality of Life after Pediatric Traumatic Brain Injury" Journal of Clinical Medicine 12, no. 12: 3895. https://doi.org/10.3390/jcm12123895
APA Stylevon Steinbuechel, N., Krenz, U., Bockhop, F., Koerte, I. K., Timmermann, D., Cunitz, K., Zeldovich, M., Andelic, N., Rojczyk, P., Bonfert, M. V., Berweck, S., Kieslich, M., Brockmann, K., Roediger, M., Lendt, M., Buchheim, A., Muehlan, H., Holloway, I., & Olabarrieta-Landa, L. (2023). A Multidimensional Approach to Assessing Factors Impacting Health-Related Quality of Life after Pediatric Traumatic Brain Injury. Journal of Clinical Medicine, 12(12), 3895. https://doi.org/10.3390/jcm12123895