Traumatic Brain Injury Related Hospitalization and Mortality in California

Objective. The aim of this study is to describe the traumatic brain injury (TBI) population and causes and identify factors associated with TBI hospitalizations and mortality in California. Methods. This is a cross-sectional study of 61,188 patients with TBI from the California Hospital Discharge Data 2001 to 2009. We used descriptive, bivariate, and multivariate analyses in SAS version 9.3. Results. TBI-related hospitalizations decreased by 14% and mortality increased by 19% from 2001 to 2009. The highest percentages of TBI hospitalizations were due to other causes (38.4%), falls (31.2%), being of age ≥75 years old (37.2%), being a males (58.9%), and being of Medicare patients (44%). TBIs due to falls were found in those age ≤4 years old (53.5%), ≥75 years old (44.0%), and females (37.2%). TBIs due to assaults were more frequent in Blacks (29.0%). TBIs due to motor vehicle accidents were more frequent in 15–19 and 20–24 age groups (48.7% and 48.6%, resp.) and among Hispanics (27.8%). Higher odds of mortality were found among motor vehicle accident category (adjusted odds ratio (AOR): 1.27, 95% CI: 1.14–1.41); males (AOR: 1.36, 95% CI: 1.27–1.46); and the ≥75-year-old group (AOR: 6.4, 95% CI: 4.9–8.4). Conclusions. Our findings suggest a decrease in TBI-related hospitalizations but an increase in TBI-related mortality during the study period. The majority of TBI-related hospitalizations was due to other causes and falls and was more frequent in the older, male, and Medicare populations. The higher likelihood of TBI-related mortalities was found among elderly male ≥75 years old who had motor vehicle accidents. Our data can inform practitioners, prevention planners, educators, service sectors, and policy makers who aim to reduce the burden of TBI in the community. Implications for interventions are discussed.


Introduction
Traumatic brain injury (TBI) is defined by the Centers for Disease Control and Prevention (CDC) as an injury to the head resulting from blunt or penetrating trauma or from acceleration-deceleration of force causing neurological or neuropsychological abnormalities, such as altered level of consciousness, intracranial lesion, memory loss, skull fracture, or death [1]. In the United States, during 2002-2007, approximately 1.7 million Americans sustained some kind of traumatic brain injury, annually. This led to 275,000 hospitalizations (16%), over 1.3,000,000 million visits to the Emergency Department (81%), 52,000 deaths (3.0%), and 124,000 disabilities [2,3].
TBI-related direct and indirect costs, including medical costs and loss of productivity, totaled an estimated $60 billion in the United States, annually [4]. Findings from the Centers for Disease Control and Prevention data suggest that TBIrelated hospitalization (TBI-H) and TBI-related mortality (TBI-M) increased by 3 [5].
Our study aim is to examine sociodemographic variables related to TBI-H, TBI-related causes (TBI-C), and TBI-M in California. Based on the existing literature, we hypothesize that there will be a statistically significant age, gender, and racial differences with respect to TBI-H, TBI-C, and TBI-M. Findings from this study can inform health policy makers and health promotion programmers to identify populations at greater risk of TBI-H and TBI-M in California. In addition, identifying sociodemographic disparities in the experience of TBI can inform practitioners, prevention planners, educators, and service sectors who aim to reduce the burden of TBI in their community.

Design and Study
Data. This was a cross-sectional study of data obtained from the Office of Statewide Health Planning and Development (OSHPD), a database that contains a summary of all the inpatient hospital discharges in California and is used for billing and payment services. For this study we used California hospital discharge data for 2001-2009 (See Figure 1). The data provided by the OSPHD includes patient demographics (age, sex, and race/ethnicity), diagnostic codes, source of payment (i.e., insurance), admission year, length of hospital stay, and disposition. All patients were eligible to be included in the study. Only patients with complete data in all the variables were included in the analysis ( = 61, 188).
We used the International Classification of Diseases, 9th Revision, and Clinical Modification (ICD-9-CM) to identify TBI-H (Table 1). To identify TBI-M, we used ICD-10-CM. To classify TBI-C, we used CDC framework for injury categorization using E codes that are grouped into five categories: motor vehicle accidents; falls (unintentional and undetermined); assaults (including firearms and other methods); struck by and struck against (including homicide and injury purposely inflicted by another person).

Date Analysis.
All analyses were obtained using Statistical Analysis Software, SAS version 9.3. We used frequency (count and percentage) to depict the overall characteristics of the sample for the categorical variables (age, sex, race/ethnicity, insurance status, length of hospital stay, and years of admission). We conducted bivariate analysis using the chi square test to determine the statistical difference in the outcome variables (TBI-H and TBI-M) by the main independent variable (TBI-C) and the other independent variables (age, gender, race/ethnicity, length of stay, severity, insurance status, and admission year). We used unadjusted logistic regressions to determine the association between each independent variable and the TBI-M. In addition, we performed multiple logistic regression to test the independent association between study predictor variables and TBI-M while controlling for the other variables in the model (i.e., age, gender, race/ethnicity, admission year, length of stay, insurance status, and severity). Unadjusted and adjusted odds ratios and 95% confidence intervals (CIs) are presented, and statistical significance is considered at value ≤ 0.05.

Sample Characteristics.
The study included 61,188 hospital admissions. The average age of the population was 54.9 years, and standard deviation was 27.5 years.    The average length of hospital stay was 5.9 days, the standard deviation was 9.2 days, and the median was 3 days. More than half of all admissions (57.7%) were for six days or longer. About two thirds of admissions were evaluated as serious to critical (65.1%).

Discussion
In this study, we identified trends as well as sociodemographic factors and causes of injuries related to TBI hospitalization and mortality. Our findings show that, from 2001 to 2009, the percentage of TBI-H in California decreased while mortality from such injuries increased. The lower percentage of TBI-H suggests that those with critical injuries may succumb before reaching a hospital, due to the lack of transportation or accessibility to adequate care, for example, living at a great distance away. In Trunkey and Blaisdel's "trimodel distribution of trauma deaths, " they refer to this as prehospital deaths [7]. Alternatively, the difference may simply reflect improved, pre-hospital care in California. Future studies can elucidate underlying mechanisms and remediable causes and treat them by the most effective interventions.
We found an increasing trend in TBI-M in our study. This may reflect the loss of the proverbial "golden hour" of trauma care in California that could increase early hospital deaths. It may also suggest "late deaths" due to trauma-related complications such as sepsis [7]. Faul et al. showed that the percentage of TBI-M in United States increased by 3.5%, during 2002-2006 [3]. However, the observed differences could be due to variations in the age distribution of our study population and causes of TBI. For example, our study consisted of 37.2% age ≥ 75 years, compared to 22% in Faul et al., and included higher percentages of falls and assaults.
Our findings suggest a high burden of TBI in California, which can lead to substantial long-term cognitive, emotional, and functional disability [8]. It is estimated that 124,000 persons discharged from TBI-related hospitalization developed TBI-related disability one year after the injury [6]. In a 2005 study by Zaloshnja et al., it was estimated that 3.2 million Americans were living with TBI-related long-term disability. Approximately half of these individuals were of ages of 40-49 years old, and 25% were those ≥ 70 years of age [9]. Our findings suggest the need for quality assessment of TBIrelated care in California that will identify areas for tertiary prevention of trauma deaths.
Our findings also show that, in California, the highest percentages of TBI-H were in those of ≥ 75 years of age, males, Whites, and those who had Medicare coverage. In regard to TBI-M, it was more likely to occur in those of ≥ 75 years age, male, and those with Medicaid. These findings are similar to previous national studies of TBI [10][11][12][13][14]. For example in 2003, Rutland-Brown et al. showed that those of 65 years of age and older had the highest rates of TBIrelated hospitalizations and mortality (234.1 per 100,000 and 38.4 per 100,000, resp.) [2]. With the steady increase in the population of those 65 and older, it seems there is a need to  reduce the burden of unintentional falls and motor vehiclerelated accidents in this subpopulation [15,16]. Specifically, primary care providers and emergency physicians are in the unique position of being able to inform elderly individuals and their caregivers of risks associated with fall injuries and motor vehicle crashes. Moreover, evidence-based preventions, which are cost effective and focus on environmental modifications to reduce the risk of unintentional fall in this population, as well as their susceptibility to injury in motor vehicle crashes, are needed [15,17]. The higher TBI hospitalizations and mortality among male relative to female had been reported in previous studies [3,5,14,[18][19][20]. For example, from 1980 to 1995, the average rate of TBI-related hospitalizations was 1.8 times higher in male than female. In 1994, male death rates were 3.3 times higher than females [21], Fall-related TBI deaths were about 3 times higher in males than females (3.2 versus 1.3 per 100,000), and motor vehicle-traffic related TBI deaths were about 2 times higher in males than females (9.9 versus 4.3 per 100,000) during 1989-1998 [22]. Although reasons for differences in males and females remain unclear, previous research suggested differences in physiological responses and lifestyle-related behaviors [8,19,20].
Our data showed that Blacks had higher adjusted odds of mortality relative to Whites, but it was not statistically significant. Different from our findings, others have reported racial differences in the incidence of TBI-related hospitalizations and mortality. For example, TBI data from the United States for 1995-2001 identifies that both Blacks and American Indians/Alaska natives as the groups with the highest TBI-related hospitalizations [23,24]. Also, TBIrelated death rates for 1994 were high among Blacks (25.5 per 100,000) than Whites (19 per 100,000) [1]. Data from 1995 to 2001 also point out Blacks as the highest risk group for TBI-associated death [24,25]. These findings are similar to findings also reported from the IMPACT study [26]. Others have shown that Asian had higher mortality compared to Whites [20,27,28]. Differences could be due to the effect of injury on mortality. In one study, excluding cases of assaults resulted in a significant increase of mortality in Asians compared to Whites, suggesting that assaults may have an effect on mortality [28]. In our study, we found that assaults were the leading cause of TBI in Blacks, a finding   that was noted in the IMPACT study [26]. A high percentage of assault-related injuries in Blacks emphasize the need to strengthen community-based primary prevention programs as well as clinical prevention services in the community for this group. According to this California discharge data, falls were the leading cause of TBI-H in those of ages of 0-4 years old and ≥ 75 years age group, for males and females, as well as Whites and Asians. Findings of studies that examined TBI-H in children are consistent with ours; that is, falls were the leading causes of hospitalizations in children of 0-4 years old [23,29,30]. We did not examine the causes of falls among this age group in our study since it was not in the scope of our aims, but previous findings show that the leading causes of falls in infants are falling from bed, stairs, furniture, and chair [30]. Also, for the older age group, others have found that those in the ≥ 75 years of age group are more subject to falls [2,16,30], which is consistent with our data showing a higher percentage of TBI-H caused by falls in those of age ≥ 75 years old.
Although this study provides a population based analysis of TBI for California, it presents some limitations. More specifically, missing data limited our ability to generalize the findings to the general population. For example, OSPHD does not include data from the Veterans Affairs Medical Center. Also, to protect the identity of individual patients, OSHPD masks some data elements for some encounters. Masking affects age, sex, race, ethnicity, and zip code to varying degrees. Additionally, our numbers do not include patients who were seen in the emergency department or who did not receive injury related care, therefore leading to possible underestimation of the overall percentage of TBI. Also this study focused on aggregated falls and did not count for possible differences in the presentation of individual types of falls. Finally, as helpful as ICD-9 code data are for identifying burden of injury and its causal factors, its use as a research tool is limited due to its potential for missing data. This could significantly impact research outcomes [31]. In our study, however, we did not have any missing ICD codes for the primary diagnosis in the total sample because we selected the sample based on the identifying of ICD-9 codes.

Conclusions
Our findings demonstrate the recent trends of risk factors in TBI in California, showing a decrease in TBI-H over the years. They also depict an increase in the percentage of TBI-M during the same period, suggesting that TBI mortality remains a public health challenge in California. In terms of preventing acute, early, and late TBI-related deaths, our findings suggest the need for early identification of potentially fatal TBI injuries. From a primary prevention perspective, our findings also highlight the need for programs geared specifically toward falls, assaults, and motor vehicle accident-related injuries.
In addition, our results suggest differences in demographic factors associated with TBI hospitalizations and mortality in California. These include younger children, older adults, and females, who were at higher risk for fall-related TBIs; younger adults, elderly, and Hispanics, who were at higher risks for motor vehicle accidents-related TBIs; and males and Blacks who had higher risks for assault-related TBIs. Targeted injury preventative strategies for different subgroups are needed to focus on their specific risk for TBI and their common risky behavioral practices [16,[32][33][34]. Further research is required to determine factors associated with TBIrelated emergency department visits and post-TBI hospitalization outcome in California.

TBI:
Traumatic brain injury TBI-H: Traumatic brain injury related hospitalization TBI-C: Traumatic brain injury related causes TBI-M: Traumatic brain injury related mortality AOR: Adjusted