Traumatic brain injury in the united states



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TRAUMATIC BRAIN INJURY IN THE UNITED STATES

Emergency Department Visits, Hospitalizations and Deaths 2002 – 2006


Prepared by: the Division of Injury Response, National Center for Injury Prevention and Control

Centers for Disease Control and Prevention, U.S. Department of Health and Human Services



Traumatic Brain Injury In The United States: Emergency Department Visits, Hospitalizations and Deaths 2002 – 2006

is a publication of the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.


Centers for Disease Control and Prevention: Thomas R. Frieden, MD, MPH, Director
National Center for Injury Control and Prevention: Robin Ikeda, MD, MPA, Acting Director
Division of Injury Response: Richard C. Hunt, MD, FACEP, Director
Authors from the Division of Injury Response:

Mark Faul, PhD, MS, Behavioral Scientist

Likang Xu, MD, MS, Mathematical Statistician

Marlena M. Wald, MPH, MLS, Epidemiologist

Victor Coronado, MD, MPH, Medical Officer
The authors would like to thank Dr. Vikas Kapil and Dr. Lisa McGuire for their editorial comments as well as, Karen Thomas, MPH, for her programming assistance. The authors also offer sincere appreciation to the many advisors for this report including Dionne J. Williams, MPS and Kevin Webb for their guidance.
Suggested citation: Faul M, Xu L, Wald MM, Coronado V. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths, 2002-2006. Atlanta, Georgia: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

The Power of Data…

Society is more likely to wage a battle against the ravages of traumatic brain injury if it understands how pernicious, pervasive, and huge the problem is.

This body of work is a vital tool for those who devise the strategies for prevention and treatment. However, a critical dimension will be lost if one sees it only as data, if one does not try to put even a fleeting face behind the numbers. They represent people who – if they survived – have had their lives significantly worsened, their dreams most likely lost, their care a burden to countless others, their injury a rent in the fabric of their (and our) community.

We are finding better ways to prevent injury and improve acute care. We who are injured may experience improvement both in function and in the quality of our lives when we have access to rehabilitation and support to develop and utilize our remaining strengths and abilities.

As a survivor, as a disabled physician, I applaud this publication as a step toward making that possible.

Claudia L. Osborn, DO, FACOI



College of Osteopathic Medicine, Michigan State University

Table of Contents


Sections

Executive Summary, Page 6

Introduction, Page 9

Overview of TBI in the United States, Page 11

Average Annual Numbers of All Visits, All Injuries, and Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths, United States, 2002-2006, Page 11

--TBI by Age: Comparing the Numbers, Page 13

--TBI by Age: Comparing the Rates, Page 14

--TBI by Sex: Comparing the Numbers, Page 15

--TBI by Sex: Comparing the Rates, Page 16

Estimated Average Annual Numbers of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths, by External Cause, United States, 2002-2006, Page 17

--TBI by External Cause: Comparing the Percentages, Page 19

--TBI by External Cause: Comparing the Percentages by Age Groups, Page 20

Summary of Findings, Page 23

Conclusion, Page 23





Table of Contents Continued

Appendix A: Tables and Figures, Page 24

Estimated Average Annual Numbers, Rates, and Percentages of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths by Age Group, United States, 2002-2006, Page 25

--By Age Group and Disposition, Page 26

--By Age Group and Sex, Page 27

--By Age Group and Race, Page 28

--By Age Group and External Cause, Page 30

--By Age Group and Specific Motor Vehicle Traffic (MVT) External Causes, Page 32

Estimated Average Annual Numbers and Percentages of Traumatic Brain Injury-related Emergency Department Visits, by Age Group and Expected Source of Payment, United States, 2002-2006, Page 34

Estimated Average Annual Numbers and Percentages of Traumatic Brain Injury-related Hospitalization, by Age Group and Disposition, United States, 2002-2006, Page 36

Estimated Average Annual Numbers and Percentages of Traumatic Brain Injury-related Hospitalization, by Age Group and Sex, United States, 2002-2006, Page 38

--By Age Group and Race, Page 39

--By Age Group and External Cause, Page 40

--By Age Group and Specific Motor Vehicle Traffic (MVT) External Causes, Page 42

--By Age Group and Expected Source of Payment, Page 44

Average Annual Numbers, Rates, and Percentages of Traumatic Brain Injury-related Deaths, by Age Group and Sex, United States, 2002-2006, Page 46

--By Age Group and Race, Page 47

--By Age Group and External Cause, Page 48

--By Age Group and Specific Motor Vehicle Traffic (MVT) External Causes, Page 49

Annual Number of all Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths, United States, 2002-2006, Page 50

--Within Children Ages 0-14, Page 52

--Within Adults Ages 65 and Older, Page 54

Appendix B, Methods and Data Sources, Page 56

Data Sources, Page 57

Identification of TBI Cases, Page 59

External Cause of Injury, Page 62

Population Data, Page 62

Statistical Analysis and Age-Adjusted Rates, Page 64

Estimated Average Annual 2002-2006 Population by Age Group, Sex, and Race: Weights for 2000 Standard Population by Age Group, Page 66

Limitations, Page 67

References, Page 71


Executive Summary
Background and Purpose of the Report

Traumatic brain injury (TBI) is an important public health problem in the United States (U.S.). Because the complications that result from TBI, such as impaired cognition and memory, are often not readily apparent, and because awareness about TBI among the general public is limited, it is frequently referred to as the “silent epidemic.”



Population-based data on TBI in the U.S. are critical to understanding the impact of TBI on the American people. This report presents basic data about emergency department (ED) visits, hospitalizations, and deaths for the years 2002 through 2006. ED visits represent approximately 80% of all TBIs. These data answer a wide range of important questions about how many TBIs occur each year in the U.S., who is affected, and how these TBIs occur. The report is intended as a reference for policy makers, service providers, educators, researchers, advocates, and others interested in knowing more about the impact of TBI.
This document is designed to be an update to a previously published report in 2006, entitled Traumatic Brain Injury in the United States: Emergency department visits, hospitalizations, and deaths which covered the years 1995-2001.

Highlights of the Results
Each year in the United States:


  • Approximately 1.7 million people sustain a TBI. Of them, about 52,000 die, 275,000 are hospitalized, and 1,365 million are treated and released from an ED.




  • Approximately 511,000 TBIs occur among children ages 0 to 14 years; ED visits account for more than 90% of the TBIs in this age group.




  • Falls are the leading cause of TBI. Rates are highest for children ages 0 to 4 years and for adults 65 years or older.

  • In every age group, TBI rates are higher for males than for females.




  • Falls result in the greatest number of TBI-related hospitalizations.




  • Adults ages 75 years or older have the highest rates of TBI-related hospitalization and death.




  • Motor vehicle-traffic (MVT) is the leading cause of TBI-related death. Rates are highest for ages 20 to 24 years.



Conclusion
An estimated 1.7 million TBI-related deaths, hospitalizations, and ED visits occur in the U.S. each year. An estimated 124,626 people with TBI experience long-term impairment or disability from their injury. [Citation Number 4] Thus, TBI prevention to reduce the incidence of TBIs and improved acute care, and rehabilitation services to reduce the likelihood of TBI-related disability are critical.

Introduction
Background
Traumatic brain injury (TBI) is an important public health issue in the U.S. It is frequently referred to as the “silent epidemic”, because the complications that result from TBI, such as those of impaired cognition and memory, are often not visible, and because awareness about TBI among the general public is limited. Population-based data on TBI in the U.S. are critical to understanding the impact of the TBI on the American people. A previous CDC report, Traumatic Brain Injury in the United States: A Report to Congress,[Citation Number One] provided useful information about TBI. It included information about TBI-related deaths and hospitalizations; however, it did not describe TBIs of patients who were treated and released from the ED. ED visits account for about 80% of TBIs and include a large number of mild TBIs and are included in this report.

TBI is generally categorized as mild, moderate or severe. Most TBIs are mild TBI (MTBI). MTBI refers to those in which the injury to the brain itself is diagnosed as mild at the time the person is initially evaluated. Most people recover fully from a MTBI, but occasionally have serious long-term consequences may occur. For this reason, more data are needed about MTBIs, including those seen in the ED. Additional information on MTBI can be found in TBI in the United States: A Report to Congress, published by CDC in 2003.[Citation Number Two]

Major sections of this report include:


  • TBI as a portion of all injuries

  • TBI by age

  • TBI by race

  • TBI by external cause

  • TBI trends

  • Overall, trends show the frequency of TBI cases increasing from 2002 to 2006 with a peak noted in 2005.

State level data fro ED visits and hospitalizations are not available. Therefore, TBI state estimates could not be created. Also, this report does not include TBIs from federal, military, or Veterans’ Administration hospitals.


Purpose of the Report
This report, Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths, 2002-2006, presents data on the incidence of TBI. This report answers a wide range of important questions about how many TBIs occur each year in the U.S., who is affected, and how these TBIs occur. These data can answer questions such as “Do men sustain TBIs more often than women? Are children more likely to have a TBI than adults? Are motor vehicle-traffic injuries a substantial cause of TBI among older adults?” This report is intended as a reference for policy makers, service providers, educators, researchers, advocates, and others interested in knowing more about the impact of TBI in the U.S. This information can be used to document the need for TBI prevention, to identify priorities for research, and to support the need for services among those living with TBI-related impairment and disability.
Contents and Organization
This report describes TBI-related ED visits, hospitalizations, and deaths in the U.S. for the years 2002 through 2006. Average annual numbers of TBIs per year and annual rates are reported. The numbers show the magnitude of the problem, but the rates are also important. Rates show how a certain group is affected by TBI by relating the number of TBIs to the size of the population. For example, a relatively small number of TBIs occurring in a small population (e.g., persons ages 75 years or older) would result in a higher TBI rate than if the same number of TBIs occurred in a larger population (e.g., persons ages 25 to 34 years). The report findings are organized into two main sections. The Overview summarizes and interprets some key findings. The Appendices present more detailed data tables, along with a description of the methods and limitations.

Overview of TBI in the United States
In the U.S., approximately 1.7 million traumatic brain injures occur each year. Of the approximately 1.7 million TBI injuries occurring each year, 1,365,000 (80.7%) were ED visits, 275,000 (16.3%) were hospitalizations, and 52,000 (3.0%) were deaths. The following figure is a pyramid depicting the estimated average annual number of TBI-related ED visits, hospitalizations, and deaths in the U.S. for the years 2002 to 2006. The base of the pyramid is represented by dashes because this number is unknown. Anecdotal evidence indicates that individuals with a TBI may decide to treat themselves at home or seek other forms of medical treatment that are not tracked by existing national data sets. Data for the number of individuals receiving other medical are or no care are not included in this report. (See Limitations section in Appendix B) The next level above the pyramid’s base is ED visits. The estimate for these visits is 1,365,000. Above ED visits is that of hospitalizations with an estimate of 275,000. Finally, at the top of the pyramid is the estimate for TBI deaths which equals 52,000.
Figure 1: Estimated Average Annual Number of Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths, United States, 2002-2006

The following table, Table A, depicts the estimated annual average number of ED visits, hospitalizations, and deaths for all injuries in the U.S. for the years 2002-2006. Included in this table are the estimates of TBI as a sub-set of all injuries. For these years, TBI comprised 4.8% of all injuries seen in EDs and 15.1% of all hospitalizations. Of all injury-related deaths in the U.S., TBI was a contributing factor 30.5% of the time.



Table A: Estimated Percentage of All Injuries, and Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths, United States, 2002-2006





All Injuries

Traumatic Brain Injuries

Category

All Visits

Number

% of All Visits

Number

% of All Injuries

% of All Visits

ED Visits

96,839,411

28,697,028

29.6

1,364,797

4.8

1.4

Hospitalizations

36,693,646

1,826,548

5.0

275,146

15.1

0.7

Deaths

2,432,714

169,055

6.9

51,538

30.5

2.1






















Total

135,965,771

30,692,631

22.6

1,691,481

5.5

1.2

Notes regarding the data in Table A: For the category ED Visits, persons who died in the ED, were admitted to the hospital from the ED, or were transferred from the ED to another facility were excluded. For the category Hospitalizations, in-hospital deaths and patients who transferred from another hospital were excluded. For the category of TBI-related Deaths, 128 mortality records for the years 2002-2006 were omitted because of missing age information.


TBI by Age: Comparing the Numbers

Table B: Estimated Average Annual Numbers of Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths by Age Group, United States, 2002-2006


Age Group


ED Visits

Hospitalizations

Deaths

Total

Children (0-14 years)


473,947

35,136

2,174

511,257

Older Adults (> 65 years)


141,998

81,499

14,347

237,844

Notes regarding the data in Table B: The estimated annual average number of TBI that occurs each year among children ages 0 to 14 years is 511,257. In contrast, the number of traumatic brain injuries that occur each year among older adults ages 65 and older is 237,844. TBI-related ED visits accounted for a larger proportion of children (92.7%) than in older adults (59.7%).



TBI by Age: Comparing the Rates
The following figure, Figure 2, is a graph depicting the estimated average annual rates of TBI-related ED visits, hospitalizations, and deaths by age groups in the U.S. for the years 2002 to 2006. This graph is a comparison of TBI rates and outcome by age. The x axis represents age in years. Reading left to right the units of measure are: 0-4, 5-9, 10-14, 15-19, 20-24, 25-34, 35-44,45-54, 55-64,65-74, and greater than or equal to 75 years. The y axis represents the rate per 100,000 population. The units of measure, beginning with zero and in ascending order are 200, 400, 600, 800, 1,000, 1,200, and 1,400. Three lines are plotted on the graph: ED visits, Hospitalizations, and Deaths. During 2002 to 2006, very young children ages 0 to 4 years had the highest rate of TBI-related ED visits, 1,256 per 100,000 population, followed by older adolescents ages 15 to 19 years, 757 per 100,000. From age 20 to age 64 the rates for ED visits steadily decline, then begin to rise again for those ages 65-74. The highest rates of TBI-related hospitalization and death occurred among adults age 75 years or older (339 per 100,000 and 57 per 100,000, respectively).
Figure 2: Estimated Average Annual Rates of Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths, by Age Group, United States, 2002-2006
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