PEDIATRICS Vol. 122 No. 5 November 2008, pp. 988-993 (doi:10.1542/peds.2007-3511)
ARTICLE |
Trends in Hospitalizations Associated With Pediatric Traumatic Brain Injuries
Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
 |
ABSTRACT |
|---|
 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
OBJECTIVES. The goals were to describe trends in pediatric traumatic brain injury hospitalizations in the United States and to provide national benchmarks for state and regional comparisons.
METHODS. Analysis of existing data (1991–2005) from the Nationwide Inpatient Sample, the largest longitudinal, all-payer, inpatient care database in the United States, was performed. Children 0 to 19 years of age were included. Annual rates of traumatic brain injury-related hospitalizations, stratified according to age, gender, severity of traumatic brain injury, and outcome, were determined.
RESULTS. From 1991 to 2005, the estimated annual incidence rate of pediatric hospitalizations associated with traumatic brain injury decreased 39%, from 119.4 to 72.7 hospitalizations per 100 000. The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point. Fatal hospitalization rates decreased from 3.5 deaths per 100 000 in 1991–1993 to 2.8 deaths per 100 000 in 2003–2005. The rate of mild traumatic brain injury hospitalizations accounted for most of the overall decrease, whereas nonfatal hospitalization rates for moderate and severe traumatic brain injuries remained relatively unchanged.
CONCLUSIONS. Although pediatric hospitalization rates for mild traumatic brain injuries have decreased over the past 15 years, rates for moderate and severe traumatic brain injuries are relatively unchanged. Our study provides national estimates of pediatric traumatic brain injury hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies.
Key Words: traumatic brain injury • hospitalizations • incidence • trends
Abbreviations: TBI—traumatic brain injury • HCUP—Healthcare Cost and Utilization Project • CI—confidence interval • E-code—external-cause-of-injury code • NIS—Nationwide Inpatient Sample
Each year in the United States, traumatic brain injuries (TBIs) in children (0–19 years of age) are associated with 7000 deaths, 60 000 hospitalizations, and >500 000 visits to an emergency department.1 TBI is the leading cause of death or disability among persons in the United States, with an estimated 2% of people living with a disability as a result of TBI.2 Injuries are the leading cause of death for persons 1 to 19 years of age, accounting for 62% of all deaths in this population, with up to 50% of injury-related deaths being linked to TBIs.3 Pediatric TBIs contribute substantially to the economic burden of health care, with an estimated $1 billion in annual hospital charges.4
Between 1980 and 1995, a changing pattern of TBI hospitalizations was reported by Thurman and Guerrero,5 with a sharp decrease in the rate of mild TBI hospitalizations and a modest increase in the rate of severe TBI hospitalizations among persons of all ages. During that period, the greatest decrease occurred among children 5 to 14 years of age (219 hospitalizations per 100 000 in 1980–1981, compared with 75 hospitalizations per 100 000 in 1994–1995). The study did not report trends in incidence according to age and TBI severity. To our knowledge, there is no published study describing national trends in pediatric TBI-related hospitalizations. The purposes of this study were to describe the trends in pediatric TBI-related hospitalizations in the United States, to examine trends according to age, gender, TBI severity, outcome, mechanism, and intent, to provide national benchmarks for state and regional comparisons, and to discuss the implications of noted trends for injury prevention policy and practice.
|
METHODS |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
Our study used administrative discharge data from the 1991–2005 Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality (Rockville, MD). The NIS was created by the Agency for Healthcare Research and Quality from the state inpatient databases provided by public and private statewide data organizations from participating states, as part of a federal-state-private collaboration. The NIS is the largest, longitudinal, all-payer, inpatient care database in the United States, with an average of 7 million hospitalizations from
1000 hospitals each year. The NIS approximates a 20% stratified random sample of all short-term US community hospitals. The sampling frame for the 2005 NIS included state inpatient data for 90% of all hospital discharges in the United States. Data were obtained from the HCUP Central Distributor, with approval from the institutional review board at the University of Arkansas for Medical Sciences. The NIS includes both patient-level data, such as demographic characteristics (eg, age and gender), admission type and source, up to 15 International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes, insurance status, total hospital charges, length of stay, and discharge disposition, and hospital-level information, such as hospital ownership, number of beds, urban/rural location, geographic region, and teaching status. For this study, eligibility was limited to children who were 0 to 19 years of age at admission and were hospitalized with primary or secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for TBI (codes 800.0–801.9, 803.0–804.9, and 850.0–854.1). The TBI case definition is consistent with the recommendations of the Centers for Disease Control and Prevention,1 as reported previously by Thurman and Guerrero.5 Patients who died while hospitalized were included. The NIS contains no unique identifiers; therefore, to reduce the effects of double-counting multiple hospitalizations attributable to the same injury, hospitalizations of patients who were discharged to another short-term care facility were not included in the analysis.6 The assumption was that we would likely capture the definitive care of such patients in the receiving hospital records.
An Abbreviated Injury Scale score for the head was calculated for each record by using ICDMAP-90 software (Johns Hopkins University and Tri-Analytics, Baltimore, MD). The Abbreviated Injury Scale is widely accepted as a valid measure of injury severity and is used to stratify incidence rates.7–9 As described by Thurman et al,2 Abbreviated Injury Scale scores of 1 and 2 were considered "mild," a score of 3 was considered "moderate," and scores of 4, 5, and 6 were considered "severe." The mechanism of injury was determined on the basis of external-cause-of-injury codes (E-codes). We categorized mechanisms of injury by using the Centers for Disease Control and Prevention-recommended framework for presenting injury morbidity data.10 Similarly, we determined intent of injury (ie, unintentional, intentional, or undetermined) by using available E-codes.
To generate national estimates of hospitalizations from the NIS, we used the appropriately scaled discharge weights provided by the HCUP. With these weights, national estimates of hospitalization rates are comparable across years, despite the varying numbers of states participating in each year of the HCUP. All analyses were performed with the appropriate weighted, stratified, sample design, by using the survey command options within Stata 10.0/MP (Stata, College Station, TX). For the incidence rate calculations, we used midyear US Census estimates for the national civilian population during this time period.11 We present estimated crude hospitalization incidence rates according to age, gender, outcome, and injury severity. Because E-codes were missing for up to 55% of hospitalizations before 1997, we compared 2-year aggregate data for the years 1998–1999 and 2004–2005, to evaluate changes in injury mechanism and intent over time.
|
RESULTS |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
Pediatric hospitalizations attributable to TBIs decreased from an estimated 86 312 hospitalizations in 1991 to 59 418 hospitalizations in 2005. From 1991 to 2005, the estimated annual incidence rate of pediatric hospitalizations associated with TBIs decreased 39%, from 119.4 to 72.7 hospitalizations per 100 000 (Fig 1). The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point (Table 1). In-hospital mortality rates decreased from an average of 2534 deaths per year between 1991 and 1993 to 2266 deaths per year in the 2003–2005 period; fatal hospitalization rates decreased from 3.5 deaths per 100 000 (95% confidence interval [CI]: 3.1–3.9 deaths per 100 000) in 1991–1993 to 2.8 deaths per 100 000 (95% CI: 2.5–3.1 deaths per 100 000) in 2003–2005. The rate of mild TBI hospitalizations accounted for most of the overall decrease, with a decrease from 64.6 hospitalizations per 100 000 in 1991–1993 to 23.8 hospitalizations per 100 000 in 2003–2005; nonfatal hospitalization rates for moderate and severe TBIs remained unchanged over the 15 years, with the exception of older teen-aged girls (15–19 years of age), who experienced a 16.7% increase in rate, from 25.8 to 30.1 hospitalizations per 100 000 (Table 2 and Fig 2). Fatal hospitalization rates among persons with moderate to severe TBIs decreased from 3.3 deaths per 100 000 in 1991–1993 to 2.7 deaths per 100 000 in 2003–2005. Figure 2 illustrates the substantial decrease in mild TBI hospitalization rates during the 1990s and the relatively stable hospitalization rates for moderate to severe TBIs.
|
|
|
|
Because E-codes frequently were missing for TBI hospitalizations in the early years of the NIS (through 1997), we compared more-recent data years (1998–1999 versus 2004–2005), which included E-codes for
90% of TBI hospitalizations. We observed a significant increase in pediatric TBI hospitalization rates for traffic-related motorcycle crashes, primarily among teen-aged boys 15 to 19 years of age (Table 3). The overall rate of "other transport-related" TBI hospitalizations (eg, involving nontraffic motorcycle crashes, off-road vehicles, or all-terrain vehicles) increased by >65% during this time period, with significant increases for children 5 to 19 years of age. Bicycle, pedestrian, and firearm TBI hospitalizations all seemed to have decreased during this time, whereas minimal changes were observed for motor vehicle crash occupants and fall-related hospitalizations. Table 4 presents the results according to injury intent (ie, unintentional, intentional, or uncertain). No significant differences were observed according to overall intent.
|
|
|
DISCUSSION |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
We observed a major decrease in the rate of pediatric hospitalizations for mild TBI during the 1990s, although rates seemed to have stabilized in more-recent years. Thurman and Guerrero5 reported the declining trend in mild TBI hospitalizations among people of all ages in their review of 1980–1995 data, and they suggested that more-restrictive hospital admission criteria might explain part of this decrease. Our study of pediatric TBI hospitalizations offers some evidence that any major change in hospital practices for this population might have been completed by the end of the 1990s.
Between 1989 and 1998, TBI-associated death rates decreased for children in all age groups between 0 and 19 years.12 We were unable to identify any published, national, TBI death rate data for the subsequent period, possibly because of the change to International Classification of Diseases, 10th Revision, codes for death certificates and the challenges of assessing trends across different coding schemes. Reductions in TBI mortality rates might be attributable in part to the successes of injury prevention efforts, improvements in the delivery of prehospital and/or hospital care, or the development of trauma systems in many states.13–16 Over the 15-year period, we observed a reduction in fatal TBI hospitalization rates, particularly among patients with moderate/severe TBIs, which offers some support for the contribution of health care improvements to the reduction in TBI-related death rates.
Our assessment of incidence trends according to mechanism was limited to 1998–2005 because of extensive missing data on the external cause of injury in the early years of the HCUP. By limiting the analysis to later years, however, we avoided potential confounding that might have occurred because of changing hospital admission practices for patients with mild TBIs. Between 1998–1999 and 2004–2005, we did not observe a difference in TBI hospitalization rates for pediatric motor vehicle occupants. One possible explanation for a lack of improvement might be that interventions such as safer car designs and increased child passenger restraint use might allow some children who otherwise would have died at the scene to survive to reach the hospital. Without more-recent, TBI-related death data, we cannot substantiate this idea. The decrease in bicycle-related TBI hospitalizations offers some evidence in support of bicycle helmet interventions aimed at children. Nationally, the Youth Risk Behavior Surveillance System reported that the proportion of children who never wore a helmet while riding a bicycle decreased from 88.4% in 1997 to 83.4% in 2005.17 In addition, fewer youths reported carrying guns in the past 30 days and fewer reported carrying guns or weapons to school. This may explain some of the observed decrease in firearm-related TBI hospitalizations during this time period. Of concern is the observed increase in motorcycle-related TBI hospitalizations. Motorcycle registrations increased by >50% between 1998 and 2005, from 3.8 million to >6 million registered in the United States.18 At the same time, motorcycle-related crash fatalities doubled from 2294 to 4553 deaths per year.19 With increasing fuel prices, the growth in motorcycle use may continue into the future. Despite evidence supporting the effectiveness of motorcycle helmets in preventing TBIs, only 20 states have comprehensive motorcycle helmet laws.20 Rates of hospitalizations attributable to other transport modes, such as off-road motorcycles and all-terrain vehicles, also have increased. A lack of comprehensive helmet laws for these riders also places young people at excessive risk.
Several limitations are worth noting. First, we relied on the ICDMAP-90 program to determine injury severity. Misclassification of TBI severity because of incomplete or inaccurate injury coding is possible. Shore et al21 studied the validity of administrative data for characterizing TBI-related hospitalizations and reported the potential for underreporting of mild TBIs in hospital discharge data. Therefore, some of the decrease in mild TBI incidence might have resulted from changes in coding over time. However, the consistency observed for moderate and severe TBI rates supports the use of administrative data for trend analysis. Second, the NIS does not include hospitalizations at federal hospitals (eg, military and Veterans Administration facilities). The true TBI hospitalization rates are likely to be greater because of the potential for admission to federal hospitals. This is likely to be less a factor in this analysis of pediatric TBIs than in studies of adult hospitalizations, however. Finally, our study does not include children with TBIs who died before reaching a hospital.
|
CONCLUSIONS |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
Although pediatric hospitalization rates for mild TBIs decreased over the past 15 years, we did not observe a decrease in hospitalization rates for children with moderate to severe TBIs. One possible explanation is that better prehospital care and improved access to trauma centers now allow some children who previously would have died at the scene to reach a hospital for definitive care. We did observe some improvement in hospital outcomes for critically ill children with TBIs.
Given that the estimated lifetime medical costs for persons who experience TBIs exceed $9 billion annually, future efforts should focus on translating effective injury prevention strategies into public health practice.22 Primary seat belt laws, motorcycle helmet requirements for on-road and off-road vehicle users (including all-terrain vehicle users), and comprehensive, graduated, driver's licensing programs for young drivers offer the potential to reduce TBI-related hospitalization rates in the coming years. Our study provides national estimates of pediatric TBI hospitalization rates that can be used as benchmarks to inform injury prevention efforts through targeting of effective intervention strategies. Given the significant burden of TBIs in real and human costs, additional monitoring of pediatric TBIs seems warranted. Currently, resources for comprehensive monitoring of pediatric TBIs seem to be lacking. Multiple, coordinated, surveillance systems are needed to improve knowledge of TBIs and to support injury prevention and treatment efforts. Building better data systems to conduct pediatric TBI research on health care quality in both prehospital and hospital settings could assist in reducing TBI-related mortality and morbidity rates for children.
|
ACKNOWLEDGMENTS |
|---|
Support for Dr Bowman was provided in part by the Arkansas Biosciences Institute, a partnership of scientists from Arkansas Children's Hospital, Arkansas State University, the University of Arkansas Division of Agriculture, the University of Arkansas, Fayetteville, and the University of Arkansas for Medical Sciences. The Arkansas Biosciences Institute is the major research component of the Tobacco Settlement Proceeds Act of 2000.
|
FOOTNOTES |
|---|
Accepted Jan 31, 2008.
Address correspondence to Stephen M. Bowman, PhD, Department of Pediatrics, CARE/Peds Slot 512-26, Arkansas Children's Hospital, 800 Marshall St, Little Rock, AR 72202-3591. E-mail: bowmanstephenm{at}uams.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject TBI is the leading cause of death and disability among persons in the United States. Pediatric TBIs contribute substantially to the economic burden of health care, with an estimated $1 billion in annual hospital charges.
|
| What This Study Adds Our study provides national estimates of pediatric TBI hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies.
|
|
REFERENCES |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
1. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States. Atlanta, GA: Centers for Disease Control and Prevention; 2006
2. Thurman DJ, Alverson C, Dunn KA, Guerrero J, Sniezek JE. Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehabil. 1999;14 (6):602 –615[Web of Science][Medline]
3. National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System. Available at: http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html. Accessed October 29, 2007
4. Schneier AJ, Shields BJ, Hostetler SG, Xiang H, Smith GA. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States.
Pediatrics. 2006;118
(2):483
–492
5. Thurman D, Guerrero J. Trends in hospitalization associated with traumatic brain injury.
JAMA. 1999;282
(10):954
–957
6. Westfall JM, McGloin J. Impact of double counting and transfer bias on estimated rates and outcomes of acute myocardial infarction. Med Care. 2001;39 (5):459 –468[CrossRef][Web of Science][Medline]
7. Baker SP, O'Neill B, Haddon W Jr, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14 (3):187 –196[Web of Science][Medline]
8. American College of Surgeons, Committee on Trauma. Resources for Optimal Care of the Injured Patient, 2006. Chicago, IL: American College of Surgeons; 2006
9. Moore EE, Feliciano DV, Mattox KL. Trauma. 5th ed. New York, NY: McGraw-Hill; 2004
10. National Center for Health Statistics. Framework for presenting nature of injury data: the Barell Injury Diagnosis Matrix: classification by body region and nature of the injury. Available at: www.cdc.gov/ncipc/osp/matrix2.htm. Accessed August 27, 2008
11. Barrett M, Coffey R, Levit K, Nagamine M. Population Denominator Data for Use With the HCUP Databases. Rockville, MD: Agency for Healthcare Research and Quality; 2006. HCUP Methods Series Report 2006–06
12. Adekoya N, Thurman DJ, White DD, Webb KW. Surveillance for traumatic brain injury deaths: United States, 1989–1998. MMWR Surveill Summ. 2002;51 (10):1 –14[Medline]
13. Rivara FP, Thompson DC, Beahler C, MacKenzie EJ. Systematic reviews of strategies to prevent motor vehicle injuries. Am J Prev Med. 1999;16 (1 suppl):1 –5[Web of Science][Medline]
14. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality.
N Engl J Med. 2006;354
(4):366
–378
15. Bulger EM, Nathens AB, Rivara FP, MacKenzie E, Sabath DR, Jurkovich GJ. National variability in out-of-hospital treatment after traumatic injury. Ann Emerg Med. 2007;49 (3):293 –301[CrossRef][Web of Science][Medline]
16. Tiesman H, Young T, Torner JC, McMahon M, Peek-Asa C, Fiedler J. Effects of a rural trauma system on traumatic brain injuries. J Neurotrauma. 2007;24 (7):1189 –1197[CrossRef][Web of Science][Medline]
17. Centers for Disease Control and Prevention. Youth Risk Behavioral Surveillance System: comprehensive results. Available at: http://apps.nccd.cdc.gov/yrbssCompTableoneLoc.asp?x=1&Loc=XX&Year1=1997&Year2=2005. Accessed October 31, 2007
18. National Center for Statistics and Analysis. Traffic Safety Facts: 2006 Traffic Safety Annual Assessment: A Preview. Washington, DC: National Highway Traffic Safety Administration; 2007. Publication DOT HS 810–791
19. National Center for Statistics and Analysis. 2005 Traffic Safety Facts: Motorcycles. Washington, DC: National Highway Traffic Safety Administration; 2006. Publication DOT HS 810–620
20. National Highway Traffic Safety Administration. Traffic Safety Facts: Motorcycle Helmet Use Laws. Washington, DC: National Highway Traffic Safety Administration; 2005
21. Shore AD, McCarthy ML, Serpi T, Gertner M. Validity of administrative data for characterizing traumatic brain injury-related hospitalizations. Brain Inj. 2005;19 (8):613 –621[Web of Science][Medline]
22. Finkelstein EA, Corso PS, Miller TR. The Incidence and Economic Burden of Injuries in the United States. New York, NY: Oxford University Press; 2006
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
This article has been cited by other articles:
|
|
 |
|
  Z. Yu and B. Morrison III Experimental Mild Traumatic Brain Injury Induces Functional Alteration of the Developing Hippocampus J Neurophysiol, January 1, 2010; 103(1): 499 - 510. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
