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The Epidemiology of Pediatric Traumatic Brain Injury in Minnesota
Samuel R. Reid, MD;
Jon S. Roesler, MS;
Anna M. Gaichas, MS;
Albert K. Tsai, MD
Arch Pediatr Adolesc Med. 2001;155:784-789.
ABSTRACT
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Objectives To determine the epidemiology of pediatric traumatic brain injury (TBI)
in a midwestern state and to examine differences between metropolitan and
nonmetropolitan residents.
Design Population-based case series.
Participants Patients aged 0-19 years sustaining TBI in 1993 that resulted in hospitalization
or death.
Interventions None.
Main Outcome Measures Incidence, mortality and case-fatality rates, length of hospital stay,
discharge status, and Glasgow Outcome Scale score.
Results Nine hundred seventy-seven patients met inclusion criteria. Incidence,
mortality, and case-fatality rates were 73.5 per 100 000, 9.3 per 100 000,
and 12.8 per 100, respectively. Higher median household incomes and percentages
of adult high-school graduates in a patient's census block group correlated
with lower incidence. Median length of stay was 2 days. Of those included
in the study, 720 patients (74%) were discharged home with self-care. Three
hundred fifty-seven patients met criteria for severe TBI; 346 (97%) were assigned
Glasgow Outcome Scale scores, of which 161 (47%) had disabilities or died.
Severe TBI was associated with nonmetropolitan residence, higher median household
income, and certain injury mechanisms. Incidence was similar for metropolitan
and nonmetropolitan residents. Median head-region Abbreviated Injury Score,
Injury Severity Score, and mortality and case-fatality rates were higher for
nonmetropolitan residents.
Conclusions This study reports the lowest incidence of pediatric TBI that results
in death or hospitalization to date. One half of severely injured patients
suffered poor outcomes. A greater proportion of nonmetropolitan than metropolitan
residents suffered severe TBI and had higher mortality and case-fatality rates.
INTRODUCTION
TRAUMATIC BRAIN injury (TBI) is an important cause of morbidity and
mortality in children and adolescents. It results in considerable health care
cost and, for many survivors, permanent disability.1
To demonstrate the burden and distribution of pediatric TBI, and to
compare differences between metropolitan and nonmetropolitan populations,
this report analyzes the magnitude of the problem, identifies those groups
at greater risk for TBI, explores factors associated with greater injury severity,
and describes outcomes.
PATIENTS AND METHODS
CASE ASCERTAINMENT
Minnesota Statute 144.661-665 requires Minnesota hospitals to report
all admissions of patients with TBI identified from International
Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Some hospitals from bordering states voluntarily
report cases of Minnesota residents admitted with TBI. These reports constitute
the Minnesota Department of Health TBI Registry. The registry records age;
sex; county of residence; county of injury; dates of injury, admission, and
discharge; ICD-9-CM nature-of-injury codes; and external-cause-of-injury
codes. From registry data, we identified a population of children and adolescents
with TBI who met the following criteria: (1) injury assigned ICD-9-CM codes 800.00 to 801.99, 803.00 to 804.99, or 850.00 to 854.19;
(2) injury resulted in hospitalization or death; (3) resident of Minnesota;
(4) injury sustained during 1993; and (5) aged 0 to 19 years at time of injury.
For morbidity statistics, patients injured in 1993 but hospitalized after
1993 were included. Also included were Minnesota residents who sustained a
TBI outside Minnesota but were subsequently admitted to a Minnesota hospital
for that injury.
Additional cases of fatal TBI involving patients meeting inclusion criteria
were identified from death certificates. Death certificates from 1993 listing
a qualifying ICD-9-CM code were reviewed. Those cases
involving Minnesota residents aged 0 to 19 years at time of death were included
in the study. All death certificate cases with an ICD-9-CM code of 873.0 to 873.9 (open wound of head) without a qualifying TBI
code were reviewed and found to involve TBI.
DATA COLLECTION
Prehospital, emergency department (ED) and inpatient records for each
case were abstracted by trauma registrars retrospectively to determine principal
and injury-related ICD-9-CM codes and final dispositions.
Final dispositions were categorized as (1) home with age-appropriate self-care;
(2) home with nonskilled assistance; (3) home with skilled assistance; (4)
home with outpatient rehabilitation services; (5) residential facility without
skilled care; (6) residential facility with skilled care; (7) inpatient rehabilitation
facility; (8) died in the field, were dead on arrival, or died in the ED;
and (9) inpatient death. When patients had multiple admissions for consequences
of the same injury, data from admissions subsequent to the initial hospitalization
were analyzed for length of stay only.
A second abstraction of hospital charts was performed for patients with
hospital stays longer than 1 day and a head-region Abbreviated Injury Score
(HR-AIS) of less than 2, or who died at the hospital. Injury Severity Score
(ISS) and Glasgow Outcome Scale (GOS) score were recorded. The GOS score was
assigned on the basis of review of discharge summaries, discharge orders,
and medical chart entries from relevant hospital staff and consultants.
DEFINITIONS AND OTHER METHODS
A severe-injury cohort of patients was defined as those who had an HR-AIS
of greater than 2 or who died. In accordance with Centers for Disease Control
and Prevention guidelines, all deaths occurring before inpatient admission
to the hospital, including ED deaths, were defined as preadmission
deaths.
A child's residence was determined to be metropolitan or nonmetropolitan
using the method previously described by Goldsmith et al.2
Median household income and the percentage of high school graduates living
in a child's area of residence were determined by geocoding the child's home
address within the census block group of which it was a part,3
and then using 1990 US census data.4
Data obtained from the Minnesota Center for Health Statistics and the
US Census Bureau were combined with registry data to calculate incidence and
frequency distributions with respect to age, socioeconomic status, and metropolitan
vs nonmetropolitan residency. Incidence and mortality rates were derived after
applying capture-recapture analysis to data from the registry and death certificates.
Capture-recapture analysis makes it possible to estimate the total number
of subjects from the overlap of those subjects captured by one data set (eg,
the TBI registry) and those captured by another (eg, the death certificates).
Its use has recently been applied to epidemiology and public health research.5, 6, 7
For determination of mortality rates, 1 child who was injured in 1993
but died in 1994 was excluded. Information entered into the registry or death
certificates was collected through December 31, 1996. This study was reviewed
by the Minnesota Department of Health Institutional Review Board and determined
to be exempt from the need for formal approval.
STATISTICAL ANALYSIS
Statistical methods for metropolitan and nonmetropolitan comparisons
included the following: z tests for rates, assuming
events follow a Poisson distribution8; Wilcoxon
nonparametric tests for length of stay, HR-AIS, ISS, and GOS score; and continuity-corrected  2 analysis for mechanism differences for selected age groups. We performed
multivariate analyses of variables associated with severity and outcome using
backward stepwise logistic regression and statistical analyses with commercially
available software (SAS:PROC LOGISTIC and SAS 6.12, respectively; SAS Institute
Inc, Cary, NC).
RESULTS
Nine hundred seventy-seven patients met the inclusion criteria; of these,
902 were identified from the registry, and 75 were identified from death certificates. Figure 1 diagrams selected subsets of our
population.
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Guide to important subsets of the study population. Asterisk indicates
that the capture-recapture method does not allow assignment of estimated deaths
into categories such as metropolitan/nonmetropolitan residence or hospital/preadmission
deaths; dagger, includes 1 patient who died in 1994.
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MORTALITY AND CASE-FATALITY RATES
There were 120 deaths in our study population; 79 of these were preadmission
deaths. One child who died in 1994 was excluded from the calculation of mortality
rates. Through capture-recapture analysis, we estimated an additional 6 deaths
(95% confidence interval [CI], 0-13) not identified from the registry or death
certificates. Given that the population of persons aged 0 to 19 years in Minnesota
during 1993 was 1 337 669,9 we determined
a mortality rate of 9.3 per 100 000. The case-fatality rate was 12.8%.
For those patients who survived to hospital admission, the case-fatality rate
was 4.6%. Capture-recapture analysis does not allow assignment of estimated
deaths to the preadmission or hospital setting. The 6 additional deaths estimated
by capture-recapture were excluded from the postadmission case-fatality rate
calculation.
INCIDENCE
By including the additional 6 deaths estimated by capture-recapture
analysis, we determined an overall incidence of 73.5 per 100 000 (983/1 337 669).
Incidence peaks in infancy (<1 year of age), early childhood (ages 6 and
7 years), and adolescence (ages 13-19 years) were observed. At each of these
years of age, incidence of TBI exceeded 39. We noted a higher incidence for
male than for female patients. The rate of TBI decreased as median household
income and percentage of high school graduates in the census block increased.
MECHANISM OF INJURY
Table 1 summarizes the leading
causes of TBI for each age group.
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Table 1. Leading Causes of TBI by Age Group*
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SEVERE-INJURY COHORT
Three hundred fifty-seven patients met our criteria for severe injury.
Children who did not meet our criteria for the severe-injury cohort (n = 620)
had a hospital length of stay of less than 2 days and were discharged home
with age-appropriate self-care, or had an HR-AIS of less than 3. Seventy-five
patients in the severe-injury cohort were identified from death certificates
only; these cases lacked all in-hospital data elements, including HR-AIS and
ISS. Of the patients in the severe-injury cohort with a known HR-AIS, 126
(45%) had a score of 3; 67 (24%), a score of 4; 81 (29%), a score of 5; 3
(1%), a score of 6; and 3 (1%), a score of 9 (eg, unknown).
RISK FACTORS FOR SEVERE INJURY
Table 2 summarizes the results
of multivariate analyses identifying factors associated with severe TBI.
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Table 2. Factors Associated With Severe TBI*
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OUTCOMES
Of the 974 patients for whom the final discharge status was known, 120
(12%) died, 720 (74%) were discharged home for age-appropriate self-care,
and 134 (14%) were discharged to a residential or inpatient facility or home
to receive assistance or care from others. The median length of hospital stay
was 2 days.
For the 346 patients in the severe-injury cohort for whom the GOS score
was known, outcomes in terms of GOS were as follows: good recovery, 185 (53%);
moderate disability, 29 (8%); severe disability, 10 (3%); vegetative state,
2 (1%); and death, 120 (35%).
METROPOLITAN RESIDENCE VS NONMETROPOLITAN RESIDENCE
Table 3 summarizes differences
in pediatric TBI between metropolitan and nonmetropolitan residents. In 1993,
census and Minnesota Center for Health Statistics data indicate that 876 728
and 460 941 persons aged 0 to 19 years were living in metropolitan and
nonmetropolitan Minnesota, respectively.9 Reapplication
of capture-recapture analysis to both populations estimated no additional
deaths (95% CI, 0-1) among metropolitan residents and 9 additional deaths
(95% CI, 0-19) among nonmetropolitan residents.
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Table 3. Metropolitan and Nonmetropolitan Comparisons*
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Fifty-seven deaths occurred in residents of metropolitan areas compared
with 62 in residents of nonmetropolitan areas. For 854 patients for whom county
of injury was known, 691 (81%) were injured in their county of residence.
No differences were observed between the 2 groups with respect to age or sex.
MECHANISM OF INJURY
Residents of nonmetropolitan areas had a significantly higher incidence
of TBI related to motor-vehicle occupancy during a crash (P = .002) and significantly higher mortality rates for this category
of TBI (P<.001).
SEVERE-INJURY COHORT
The HR-AIS, ISS, and GOS score were assigned only to patients in the
severe-injury cohort (Table 3).
Patients missing HR-AIS and ISS (n = 80) and those not missing the scores
(n = 277) did not differ significantly with regard to metropolitan vs nonmetropolitan
residency (P = .11).
OUTCOMES
Residents of metropolitan and nonmetropolitan areas did not significantly
differ with regard to median length of stay. Of 193 severely injured metropolitan
residents, 110 (57%) had a good recovery as defined by GOS; of 153 severely
injured nonmetropolitan residents, 75 (49%) had a good recovery (P = .07).
COMMENT
Although many previous studies of TBI have examined general populations,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26
this is one of the few population-based studies to gather data on the characteristics
of TBI in a defined pediatric population. By using a uniform data system case
definition rather than a clinical case definition, our study conforms to Centers
for Disease Control and Prevention guidelines.27
By including data on patients with fatal TBI who never presented to a hospital,
our data may more accurately depict the full societal burden of pediatric
TBI than do studies that examined only hospitalized patients.
MORTALITY AND CASE-FATALITY RATES
The mortality rate in this population (9.3/100 000) compares favorably
with those of previous studies of pediatric populations.28, 29, 30, 31
Dunn et al29 used a method similar to ours
in a 1994 study of 7 states and reported a higher mortality rate (11.6/100 000).
Capture-recapture analysis was not used to estimate missing cases. Comparison
with other studies is problematic because of methodological differences and
unreported mortality rates. Lower rates of motor-vehicle crashes and of driving
under the influence of alcohol and improvements in roadways and motor vehicles
by 1993 may account for some reduction in mortality.32
Injury severity, and therefore mortality, may have been reduced by the increased
use of seat belts and infant and child car seats, improved crash characteristics
of motor vehicles, and improved prehospital medical care.33
Few previous population-based studies report case-fatality rates for
children. However, our postadmission case fatality rate (4.6%) is higher than
that reported by Kraus et al30 (2.5%) for a
population younger than 15 years. This difference may reflect a trend toward
outpatient management of mild TBI.33
INCIDENCE
The rate of pediatric TBI reported in this study (73.5/100 000)
is notably lower than previously reported rates.28, 29, 30, 31, 34
Previous studies have documented rates ranging from 90 per 100 000 to
300 per 100 000, with an average of 180 per 100 000.34
Dunn et al29 reported an incidence of 90 per
100 000 for the group aged 0 to 19 years. Kraus et al,28
in a study of patients younger than 15 years, reported an incidence of 185
per 100 000. This difference cannot entirely be attributed to differences
in methods. The reasons for our lower incidence may parallel those that may
explain our lower mortality rate. If injury frequency and severity were reduced
by these means, fewer victims injured as a result of motor-vehicle occupancy
during a crash may have required hospitalization. In addition, the growth
of managed care and the wide availability of computed tomography to rule out
significant injury may have increased the propensity for acute care physicians
to treat children with TBI as outpatients.33
A small portion of the difference may be attributable to incomplete
reporting by certain hospitals. Previously reported rates of TBI for all age
groups are lower in western counties of Minnesota.35
Children injured in these areas may be treated in facilities located in a
neighboring state. Reporting compliance by these facilities is variable. However,
the population of western Minnesota is not large enough to account for the
entire difference between our rate and that of Dunn et al.29
Unfortunately, in 1993, no standard procedure for assessing the sensitivity
of injury registries existed. Because we had no second, independent data set
(eg, hospital discharge data) with which to compare nonfatal cases from the
registry, capture-recapture methods could not be applied to give an estimate
of missing cases. To the extent that underreporting occurred, our study is
limited. If underreporting occurred in a nonrandom manner, bias may have been
introduced. We were unable to evaluate the positive predictive value of case
reports.
MECHANISMS
As in previous reports, falls and mechanisms involving motor vehicles
account for most injuries.10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 29, 30, 31, 32
Injuries involving motor vehicles were statistically associated with severe
injury, whereas falls were not. Because injuries involving motor vehicles
are among the most frequent and most severe, efforts to prevent pediatric
TBI must continue to make motor vehicle safety a priority.
RISK FACTORS FOR SEVERE INJURY
Not surprisingly, injury mechanisms involving firearms, child abuse,
all-terrain vehicles, and motor vehicles were correlated with severe injury.
These mechanisms have been the subject of considerable prevention and intervention
activities, such as those promoting trigger locks, crisis nurseries, regulation
of all-terrain vehicles, and graduated driver's licensing for minors. Clearly,
continued activities are needed in these areas.
The associations of nonmetropolitan residence and higher median household
income with severe TBI are not easily explained. Nonmetropolitan residency
has been associated with greater motor vehicle travel at higher speeds and
on roads with multiple access points.36 Greater
exposure may result in more crashes and severe TBI. Although higher median
household incomes are associated with decreasing incidences of TBI,17 we have noted a greater proportion of severe injury.
Perhaps children in these groups have greater access to higher-risk mechanisms,
such as motor vehicles at younger ages, all-terrain vehicles, and recreational
sports. Unfortunately, our data set does not describe exposures (eg, vehicle
miles traveled) relative to various injury mechanisms.
OUTCOME
As in previous reports, most hospitalized patients were discharged home
with age-appropriate self-care after a brief hospital stay.14, 17, 18
For the analysis of functional outcome, we excluded nonsevere cases of TBI.
The outcome of these injuries, at least as determined using the GOS, is typically
good. Nearly half of our severe-injury cohort, however, had less than good
outcomes as defined when using the GOS. In addition, subtle but important
functional problems may not be detected using the GOS. Although we cannot
quantify it, the personal and societal cost of pediatric TBI is clearly high.
Our study design necessitated assigning GOS scores retrospectively based
on the functional status of each child at hospital discharge. To the extent
that this diverges from the standard application of the GOS, this is a potential
limitation of our study.
METROPOLITAN VS NONMETROPOLITAN RESIDENCE
Little is known about the differences in epidemiology of TBI for residents
of metropolitan vs nonmetropolitan areas, particularly for pediatric populations.
For a general population, Fife et al17
has previously reported an increased incidence of TBI in areas with greater
population density. In contrast, Gabella et al37
has reported lower incidence of TBI requiring hospitalization and fatal TBI
in urban areas, compared with rural areas. We found little difference in the
incidence of TBI requiring hospitalization and fatal TBI in a pediatric population
in metropolitan and nonmetropolitan areas. Metropolitan vs nonmetropolitan
residence may have little impact on the incidence of TBI in childhood.
We found, however, a striking disparity between mortality rates for
residents of metropolitan and nonmetropolitan areas. This is consistent with
the analysis by Gabella et al37 of TBI requiring
hospitalization and fatal TBI in urban and rural areas for a general population.
Previous studies have noted higher rural mortality rates for all childhood
injuries and have implicated motor-vehicle crashes as an important factor.38, 39 Our findings support this by noting
a higher mortality rate related to motor-vehicle occupancy during a crash
for residents of nonmetropolitan areas. Because of insufficient data regarding
severity of brain injury for preadmission deaths, we were unable to determine
whether the discrepancy between metropolitan and nonmetropolitan mortality
rates would remain after controlling for severity.
Higher mortality rates for residents of nonmetropolitan areas may result
from greater injury severity. Residents of nonmetropolitan areas in our severe-injury
cohort had significantly higher HR-AIS, perhaps as a result of more forceful
injury mechanisms (ie, motor vehicle occupancy during a crash).
Although injury severity was greater for residents of nonmetropolitan
areas, we did not detect a statistically significant difference in outcomes
between residents of metropolitan and those of nonmetropolitan areas. This
may reflect insensitivity on the part of the GOS in describing outcomes.
A possible limitation of this study is its classification of patients
into metropolitan and nonmetropolitan populations based on residence. Our
findings are relevant regardless of whether TBI is influenced by the injury
environment or by the characteristics of individuals living in a particular
environment. Eighty-one percent of our patients were injured in their county
of residence. This is comparable to data reported by Gabella et al,37 who found that 89% of patients who died and 92% of
patients who survived were injured in their county of residence. We agree,
then, that county of residence serves as a reasonable proxy for county of
injury.
CONCLUSIONS
To our knowledge, this study reports the lowest incidence of pediatric
TBI that results in death or hospitalization to date. A greater proportion
of pediatric residents of nonmetropolitan areas sustained severe injuries,
and pediatric residents of nonmetropolitan areas had higher mortality rates
than their metropolitan counterparts, presumably due in large part to motor-vehicle
crashes. No differences in outcomes were observed between nonmetropolitan
and metropolitan residents.
AUTHOR INFORMATION
Accepted for publication February 10, 2001.
This study was supported in part by grants MCH-274001-01-0 and MCH-274002
from the Emergency Medical Services for Children Program of Minnesota, Minneapolis.
Preliminary findings from this study were presented at the American
Academy of Pediatrics Annual Meeting, San Francisco, Calif, October 19, 1998.
We thank James M. Kaufmann, PhD, for editing earlier versions of this
article.
From the Department of Emergency Medicine, Children's Hospitals and
Clinics (Dr Reid), and the Minnesota Department of Health (Mr Roesler and
Ms Gaichas), St Paul; and the Department of Emergency Medicine, Hennepin County,
Medical Center, Minneapolis, Minn (Dr Tsai).
Corresponding author and reprints: Samuel R. Reid, MD, Pediatric
Emergency Medicine, Children's Hospitals and Clinics, 345 N Smith Ave, St
Paul, MN 55102 (e-mail: krinandsam{at}aol.com).
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