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Figure.
Relative Changes in Traumatic Brain Injury (TBI) and Total Emergency Department (ED) Visit Rates Over Time
Relative Changes in Traumatic Brain Injury (TBI) and Total Emergency Department (ED) Visit Rates Over Time

Error bars indicate 95% CIs.

Table.  
Characteristics of Emergency Department Visits for Traumatic Brain Injury, 2006-2010a
Characteristics of Emergency Department Visits for Traumatic Brain Injury, 2006-2010a
1.
Traumatic brain injury legislation. National Conference of State Legislatures. http://www.ncsl.org/research/health/traumatic-brain-injury-legislation.aspx. Accessed March 25, 2014.
2.
Faul  M, Xu  L, Wald  MM, Coronado  VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Centers for Disease Control and Prevention. http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf. Accessed April 17, 2014.
3.
Nationwide emergency department sample. Healthcare Cost and Utilization Project. http://www.hcup-us.ahrq.gov/nedsoverview.jsp. Accessed May 30, 2013.
4.
Langlois  JA, Rutland-Brown  W, Thomas  KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.
5.
Thurman  D, Guerrero  J.  Trends in hospitalization associated with traumatic brain injury. JAMA. 1999;282(10):954-957.
PubMedArticle
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Injury prevention and control: data and statistics: matrix of E-code groupings. Centers for Disease Control and Prevention. http://www.cdc.gov/injury/wisqars/ecode_matrix.html. Accessed July 11, 2013.
Research Letter
May 14, 2014

Trends in Visits for Traumatic Brain Injury to Emergency Departments in the United States

Author Affiliations
  • 1Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
JAMA. 2014;311(18):1917-1919. doi:10.1001/jama.2014.3979

In the last decade, traumatic brain injury (TBI) garnered increased attention, including public campaigns and legislation to increase awareness and prevent head injuries.1 The Centers for Disease Control and Prevention (CDC) describes TBI as a serious public health concern.2 We sought to describe national trends in emergency department (ED) visits for TBI.

Methods

We conducted a population-based descriptive epidemiological study of TBI visits to EDs in the United States from 2006 through 2010, using the Nationwide Emergency Department Sample (NEDS) database, a nationally representative data source including 25 million to 50 million visits from more than 950 hospitals each year, representing a 20% stratified sample of EDs.3 We included visits with any International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of TBI as defined by the CDC.4 We evaluated patient demographics, injury severity,5 associated injuries, disposition, mechanism of injury,6 and hospital characteristics.

We report descriptive statistics with 95% confidence intervals. We evaluated trends using weighted linear regression. We used Stata version 12.1 (StataCorp) and Prism version 6.0 (GraphPad) for analyses. The NEDS uses a multistaged probabilistic survey scheme; we applied prescribed weighting procedures to account for the unequal sampling probabilities, stratification, and clustering and to produce national estimates using the Stata svy set of commands. We considered 2-sided P values less than .05 significant. The NEDS contains deidentified data, and the University of Pittsburgh institutional review board waived the requirement for informed consent.

Results

Between 2006 and 2010, there were 138 223 016 (unweighted) ED visits in the NEDS, of which 1.7% received a diagnosis of TBI. By 2010, there were an estimated 2 544 087 (weighted) ED visits for TBI. Visits for TBI increased by 29.1% (95% CI, 18.9% to 39.2%) during the study period from 637 (95% CI, 582 to 692) TBI visits per 100 000 person-years in 2006 to 822 (95% CI, 758 to 887) TBI visits per 100 000 person-years in 2010. By comparison, total ED visits increased by 3.6% (95% CI, −0.7% to 8.0%) from 40 228 (95% CI, 38 705 to 41 752) visits per 100 000 person-years in 2006 to 41 691 (95% CI, 39 948 to 43 433) visits per 100 000 person-years in 2010 (P = .002 comparing TBI and total ED visit trends) (Figure).

The majority of the increase in the incidence of TBI occurred in visits coded as concussion or unspecified head injury (Table). Children younger than 3 years and adults older than 60 years had the largest increase in TBI rates. The majority of visits were for minor injuries and most patients were discharged from the ED. Forty percent (95% CI, 39.6%-41.1%) of TBI visits had at least 1 other injury, including open wounds of the head, neck, or trunk (20.7%; 95% CI, 20.3%-21.1%); sprains and strains (11.3%; 95% CI, 11.0%-11.7%); and fractures not of the face (7.8%; 95% CI, 7.4%-8.3%). Most TBI cases were secondary to falls. Most visits were at general EDs and those without a trauma center designation.

Discussion

Between 2006 and 2010, the rate of increase in TBI visits was 8-fold more than the rate of increase of total ED visits. This increase in TBI visits, largely due to increased visits for concussion and unspecified head injury, may reflect a variety of factors, including increased TBI exposure, awareness, diagnoses, or a combination. The increase in TBI among the very young and very old may indicate these age groups do not benefit as much from public health interventions, such as concussion1 and helmet laws and safer sports’ practices. We observed that most visits for TBI were not at trauma centers; similarly, although nearly one-third of visits were by children, less than 2% of visits were to pediatric-specific EDs. This underscores the high and increasing burden for TBI care at nonspecialized centers.

Our study is limited by not having data on visits to federal hospitals or on patients who died prior to ED arrival and potential miscoding, particularly given the large proportion of visits coded as unspecified head injury, which may have included visits for a more specific TBI diagnosis or for non-TBI diagnoses such as lacerations. Nonetheless, our study suggests increasing trends in ED-diagnosed rates of TBI.

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Article Information
Section Editor: Jody W. Zylke, MD, Senior Editor.

Corresponding Author: Jennifer R. Marin, MD, MSc, Department of Pediatrics, University of Pittsburgh School of Medicine, 4401 Penn Ave, AOB Ste 2400, Pittsburgh, PA 15224 (jennifer.marin@chp.edu).

Author Contributions: Dr Marin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Marin, Yealy, Mannix.

Acquisition, analysis, or interpretation of data: Marin, Weaver, Mannix.

Drafting of the manuscript: Marin, Yealy, Mannix.

Critical revision of the manuscript for important intellectual content: Marin, Weaver, Yealy, Mannix.

Statistical analysis: Marin, Weaver, Mannix.

Obtained funding: Marin.

Administrative, technical, or material support: Marin, Yealy.

Study supervision: Marin, Yealy, Mannix.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Support for this study was provided by the National Heart, Lung, and Blood Institute (K12HL109068) (J.R.M.).

Role of the Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Traumatic brain injury legislation. National Conference of State Legislatures. http://www.ncsl.org/research/health/traumatic-brain-injury-legislation.aspx. Accessed March 25, 2014.
2.
Faul  M, Xu  L, Wald  MM, Coronado  VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Centers for Disease Control and Prevention. http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf. Accessed April 17, 2014.
3.
Nationwide emergency department sample. Healthcare Cost and Utilization Project. http://www.hcup-us.ahrq.gov/nedsoverview.jsp. Accessed May 30, 2013.
4.
Langlois  JA, Rutland-Brown  W, Thomas  KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.
5.
Thurman  D, Guerrero  J.  Trends in hospitalization associated with traumatic brain injury. JAMA. 1999;282(10):954-957.
PubMedArticle
6.
Injury prevention and control: data and statistics: matrix of E-code groupings. Centers for Disease Control and Prevention. http://www.cdc.gov/injury/wisqars/ecode_matrix.html. Accessed July 11, 2013.
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