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Traumatic Brain Injury -- Colorado, Missouri, Oklahoma, and Utah, 1990-1993

In 1992, traumatic brain injuries (TBIs) accounted for 34% of all injury deaths in the United States (1). To provide current estimates of TBI-associated morbidity and deaths, CDC has developed guidelines for public health agencies to use for TBI surveillance (2). This report describes recent findings from Colorado, Missouri, Oklahoma, and Utah based on these guidelines. These findings indicate a decrease in the annual rate of TBI and that rates of TBI are highest in association with falls and motor-vehicle crashes.

State health departments in Colorado, Missouri, Oklahoma, and Utah reviewed hospital discharge data using CDC guidelines to identify cases of TBI (International Classification of Diseases, Ninth Revision, Clinical Modification, codes 800.0-801.9, 803.0-804.9, and 850.0-854.1). The review identified all cases of TBI among patients in acute-care hospitals who had been discharged with primary or secondary diagnoses in these code ranges. In addition, the review identified TBI-related deaths and collected information from all death certificates or medical examiner reports that listed TBI or head injury in the sequence of conditions resulting in death. Records were linked to eliminate duplicate cases reported from more than one source. Supplementary information on external cause of injury was obtained from abstracts of medical records or health-care provider report forms for all cases (Missouri and Oklahoma) or from random samples of cases (Colorado {13% sample} and Utah {10% sample}). The periods of analysis were 1991-1993 for Colorado, 1992-1993 for Missouri and Oklahoma, and 1990-1993 for Utah. The combined TBI incidence rate for all four states was calculated using the sum of the mean annual number of cases for each state and the sum of the population of each state estimated at the midpoint of the surveillance period (13.7 million total).

During the periods of surveillance, the mean annual number of TBIs reported from the four states was 13,978; of these, 3172 (23%) were fatal, and 11,611 (83%) persons were hospitalized. Most cases (9363 {67%}) occurred among males.

The annual combined rate of TBI for these states was 102.1 per 100,000 population (102.8 age-adjusted to 1990 U.S. population) (Table_1). State-specific rates were 101.9, 103.0, 97.7, and 108.0 for Colorado, Missouri, Oklahoma, and Utah, respectively. The incidence of TBI was highest among persons aged 15-24 years (176.7) and persons aged greater than or equal to 75 years (186.2) (Table_2). Rates for males were approximately twice those for females (140.0 and 66.0, respectively).

The combined rate of hospitalizations for TBI was 84.8 per 100,000. The overall TBI-related death rate was 23.2. Among all fatal cases, 2367 (17%) persons died without being admitted to a hospital, and 805 (6%) died while receiving acute care in a hospital.

Transportation-related occurrences (including involvement of motor vehicles, bicycles, pedestrians, or recreational vehicles) accounted for 47% of all injuries; falls accounted for 23% of injuries. Firearm-associated injuries and assaults not involving firearms accounted for 10% and 9% of reported injuries, respectively. The highest rates of TBI were associated with falls among persons aged greater than or equal to 75 years (119.5) and with transportation among persons aged 15-24 years (114.6) (Table_3).

Reported by: B Gabella, MSPH, R Hoffman, MD, State Epidemiologist, Colorado Dept of Public Health and Environment. G Land, MPH, M van Tuinen, PhD, Missouri Dept of Health. S Mallonee, MPH, P Archer, MPH, M Crutcher, MD, State Epidemiologist, Oklahoma State Dept of Health. C Burnett, FI White, EdD, CR Nichols, MPA, State Epidemiologist, Utah Dept of Health. Div of Acute Care, Rehabilitation Research, and Disability Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: The epidemiologic patterns of TBI described in this report are similar to those based on an analysis of 1993 National Hospital Discharge Survey (NHDS) data, which indicated that an estimated 102.3 (95% confidence interval=90.9-113.7) TBI-related hospitalizations occurred per 100,000 population. However, the rates in this report and the NHDS estimate are substantially lower than rates during 1974-1986 (approximately 200 cases of TBI per 100,000 population annually during most of that period) (3). From 1979 through 1992, the TBI-associated death rate declined by 22%, largely because of a decrease in TBI-related deaths associated with motor-vehicle crashes (1). The findings in this report and from NHDS suggest a decline of approximately 50% in combined morbidity and death during a corresponding interval, indicating a disproportionately larger decrease in rates of nonfatal TBI that resulted in hospitalization. This decrease may reflect in part successes in injury-prevention efforts and changes in criteria for admitting patients to hospitals (e.g., patients with mild injuries are more frequently excluded).

The findings in this report suggest options for strengthening prevention efforts. For example, the high rates of transportation-related TBI indicate a need for improved prevention of motor-vehicle-related injuries through promotion of the use of occupant restraints and helmets. The rate of TBI attributable to falls among persons aged greater than or equal to 75 years was the highest among all categories of age and cause; additional data about the circumstances of these falls can assist in planning effective prevention strategies.

CDC is promoting the development of a multistate TBI surveillance system to further characterize risk factors for and the incidence, external causes, severity, and outcomes of TBI. This information will enable the development and targeting of prevention programs focused on specific causes and populations and will assist in facilitating access to health care and other services for injured persons.

References

  1. Sosin DM, Sniezek JE, Waxweiler RJ. Trends in death associated with traumatic brain injury, 1979 through 1992: success and failure. JAMA 1995;273:1778-80.

  2. Thurman DJ, Sniezek JE, Johnson D, Greenspan A, Smith SM. Guidelines for surveillance of central nervous system injury. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1995.

  3. Kraus JF. Epidemiology of head injury. In: Cooper PR, ed. Head injury. 3rd ed. Baltimore, Maryland: Williams and Wilkins, 1993:1-25.



Table_1
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TABLE 1. Mean annual number and rate * of traumatic brain injury +, by state -- Colorado, Missouri, Oklahoma, and Utah, 1990-1993 &
===============================================================================================================================================================
                                                     No. fatal cases
                                       ------------------------------------
State                 Population        Not hospitalized       Hospitalized      No. nonfatal cases          Total       Crude rate       Age-adjusted rate
---------------------------------------------------------------------------------------------------------------------------------------------------------------
Colorado               3,465,025                     429                243                    2859           3530            101.9                   104.8
Missouri               5,213,792                     924                330                    4118           5371            103.0                   104.1
Oklahoma               3,219,503                     738                144                    2264           3145             97.7                    98.1
Utah                   1,789,157                     277                 89                    1566           1932            108.0                   105.7

Total @               13,687,477                    2367                805                  10,806         13,978            102.1                   102.8
---------------------------------------------------------------------------------------------------------------------------------------------------------------
* Per 100,000 persons.
+ International Classification of Diseases, Ninth Revision, Clinical Modification, codes 800.0-801.9, 803.0-804.9, and 850.0-854.1
& Information was collected for 1991-1993 in Colorado, 1992-1993 in Missouri and Oklahoma, and 1990-1993 in Utah.
@ Numbers may not add to total because of rounding.
===============================================================================================================================================================

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Table_2
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TABLE 2. Rate * of traumatic brain injury +, by age group
and sex -- Colorado, Missouri, Oklahoma, and Utah, 1990-1993 &
===============================================================
Age group (yrs)        Male      Female         Total
---------------------------------------------------------------
  <=5                 116.5        84.6         101.0
 5-14                  91.1        47.1          69.7
15-24                 249.3       101.6         176.7
25-34                 154.7        56.9         105.7
35-44                 121.2        47.7          84.1
45-54                  98.3        39.7          68.4
55-64                  95.1        41.3          67.0
65-74                 113.4        57.1          82.2
 >=75                 243.4       154.9         186.2

Total                 140.0        66.0         102.1
---------------------------------------------------------------
* Per 100,000 persons.
+ International Classification of Diseases, Ninth Revision,
  Clinical Modification, codes 800.0-801.9, 803.0-804.9, and
  850.0-854.1.
& Information was collected for 1991-1993 in Colorado,
  1992-1993 in Missouri and Oklahoma, and 1990-1993 in Utah.
===============================================================

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Table_3
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TABLE 3. Rate * of traumatic brain injury +, by external cause of injury & and age group -- Colorado, Missouri, Oklahoma, and Utah, 1990-1993 @
==========================================================================================================================================================
                                                                        External cause of injury
                                     ---------------------------------------------------------------------------------------------------------------------
Age group (yrs)                       Transport        Falls       Firearms          Nonfirearm assaults       Sports/ Recreation       Other/ Unknown
----------------------------------------------------------------------------------------------------------------------------------------------------------
   <5                                      25.9         50.6            0.7                 12.8                      0.8                   10.5
 5-14                                      36.2         11.8            1.9                  1.4                      5.1                    8.0
15-24                                     114.6         12.9           20.6                 14.0                      6.6                   15.2
25-34                                      55.6          9.4           11.2                 14.9                      2.7                    9.4
35-44                                      42.1         11.5           11.2                 12.5                      1.5                    9.0
45-54                                      28.5         17.0            8.4                  5.7                      0.7                    9.1
55-64                                      27.1         19.5            8.8                  2.7                      0.6                    5.3
65-74                                      25.3         35.2           10.7                  3.0                      0.1                    7.7
 >=75                                      38.4        119.5           13.4                  2.9                      0.2                    9.5

Total                                      48.2         23.3            9.8                  8.7                      2.6                    9.5
----------------------------------------------------------------------------------------------------------------------------------------------------------
* Per 100,000 persona.
+ International Classic of Diseases, Ninth Revision, Clinical Modification, codes 800.0-801.9, 803.0-804.9, and 850.0-854.1.
& Information obtained from all cases reported in Missouri and Oklahoma and random samples of cases reviewed in Colorado (13% sample) and Utah
  (10% sample). Estimated mean annual number of cases by cause were 6597 transportation-related, 3186 fall-related, 1346 firearm-related, 1191
  nonfirearm assault-related, and 353 sports- and recreation-related. An estimated mean of 727 and 579 cases each year were related to other and
  unknown causes, respectively.
@ Information was collected for 1991-1993 in Colorado, 1992-1993 in Missouri and Oklahoma, and 1990-1993 in Utah.
==========================================================================================================================================================

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