Emergency Department and Hospital Admission

Transcription

A ―Smart People‖ Project
Emergency Department and Hospital Admission Rates
for Youth Sports-Related Concussions:
A Northeast Florida Utilization Study
Contents
Tables and Figures
p. 2
About the Health Planning Council
p. 4
Background
p. 4
Literature Review
p. 5
Research Questions
p. 7
Data Collection
p. 7
Findings
p. 8
National
p. 9
State
p. 11
Regional
p. 13
Recommendations
p. 36
ED and Hospital Admission Rates for Youth Sport
Related Concussions
References
p. 37
(c) Copyright (October 20, 2011) All Rights Reserved
1
Tables and Figures
Table 1
Table 2
Table 3
Figure 1
Figure 2
Figure 3
Table 4
Figure 4
Figure 5
Figure 6
Figure 7
Table 5
Figure 8
Figure 9
Figure 10
Table 6
Figure 11
Table 7
Figure 12
Table 8
Figure 13
Table 9
Figure 14
Figure 15
Figure 16
Figure 17
Table 10
Figure 18
Table 11
Top 20 Sports/Recreational Activities that Lead to Head Injuries----------------------------------------------------------6
Top 10 Sports-Related Head Injury Categories Among Children Ages 14 and Younger------------------------6
Numbers and age-adjusted rates per 100,000 population for traumatic brain
injury deaths, by year, sex, and race/ethnicity 1997—2007-------------------------------------------------------------------9
Age-Adjusted Rate of Traumatic Brain Injury Deaths (All Ages) By Race 1997-2007--------------------------10
Age-Adjusted Rate of Traumatic Brain Injury Deaths (All Ages) By Gender 1997-2007----------------------10
Age-Adjusted Rate of Traumatic Brain Injury Deaths By Age 1997-2007---------------------------------------------11
The number and rate of Traumatic Brain Injury-Related Deaths by Age Group, Florida
1997-2007________________________________________________________________________11
Non-Fatal Head Injury Hospitalization for Ages 12-18, Florida Department of Health,
1999-2009------------------------------------------------------------------------------------------------------------------------------------------------12
Emergency Department Visits, Patients with TBI versus Non-TBI, 2006-2009------------------------------------13
Emergency Department Visits for Patients with TBI, Sports versus Non-Sports
Related, 2006-2009---------------------------------------------------------------------------------------------------------------------------------14
Emergency Department Visits for Patients with TBI, Sports versus Non-Sports
Related, By Age, 2006-2009--------------------------------------------------------------------------------------------------------------------15
Emergency Department Visits for Patients with TBI, Sports Versus Non-Sports
Related, By Age, 2006-2009 Percentage of TBI Visits that are Sports-Related-----------------------------------15
Emergency Department Visits for Patients with TBI, Sports and Non-Sports
Related, By Gender, 2006-2009--------------------------------------------------------------------------------------------------------------16
Related, By Race, 2006-2009------------------------------------------------------------------------------------------------------------------17
Related, By Payor, 2006-2009-----------------------------------------------------------------------------------------------------------------18
Related, By Payor, 2006-2009 Percentage of TBI Visits that are Sports-Related--------------------------------18
Related, By County, 2006-2009--------------------------------------------------------------------------------------------------------------19
Related, By County, 2006-2009 Percentage of TBI Visits that are Sports-Related-----------------------------19
Related, By Day of the Week, 2006-2009----------------------------------------------------------------------------------------------20
Emergency Department Visits for Patients with TBI, Sports and Non-Sports Related,
By Day of the Week, 2006-2009 Percentage of TBI Visits that are Sports-Related----------------------------20
Related, By Hospital, 2006-2009------------------------------------------------------------------------------------------------------------21
Emergency Department Visits for Patients with TBI, Sports and Non-Sports Related,
By Hospital, 2006-2009 Percentage of TBI Visits that are Sports-Related------------------------------------------21
Emergency Department Percentage of Visits Receiving a CT Scan for TBI
Sports and Non-Sports Related, 2006-2009----------------------------------------------------------------------------------------- 22
Hospital Admissions for Patients with TBI and Non-TBI, 2006-2009--------------------------------------------------- 23
Hospital Admissions for Patients with TBI Sports and Non-Sports Related,
2006-2009----------------------------------------------------------------------------------------------------------------------------------------------- 24
By Age, 2006-2009----------------------------------------------------------------------------------------------------------------------------------25
By Age, 2006-2009 Percentage of TBI Visits that are Sports-Related-------------------------------------------------25
By Gender, 2006-2009----------------------------------------------------------------------------------------------------------------------------26
ED and Hospital Admission Rates for Youth Sport Related Concussions
2
Figure 19
Figure 20
Table 12
Figure 21
Table 13
Figure 22
Table 14
Figure 23
Table 15
Figure 24
Figure 25
Figure 26
Figure 27
By Gender, 2006-2009, Percentage of TBI, ED and Hospitalizations, by Gender_______________ 26
By Race, 2006-2009--------------------------------------------------------------------------------------------------------------------------------27
By Payor, 2006-2009------------------------------------------------------------------------------------------------------------------------------- 28
By Payor, 2006-2009 Percentage of TBI Visits that are Sports-Related-----------------------------------------------28
By County, 2006-2009------------------------------------------------------------------------------------------------------------------------------29
By County, 2006-2009 Percentage of TBI Visits that are Sports-Related---------------------------------------------29
By Day of the Week, 2006-2009--------------------------------------------------------------------------------------------------------------30
By Day of the Week, 2006-2009 Percentage of TBI Visits that are Sports-Related-----------------------------30
By Hospital, 2006-2009----------------------------------------------------------------------------------------------------------------------------31
By Hospital, 2006-2009 Percentage of TBI Visits that are Sports-Related-------------------------------------------31
Mean LOS, 2006-2009-----------------------------------------------------------------------------------------------------------------------------32
Mean Gross Charges, 2006-2009-----------------------------------------------------------------------------------------------------------33
Discharge Status, 2006-2009-----------------------------------------------------------------------------------------------------------------34
Admission Type, 2006-2009--------------------------------------------------------------------------------------------------------------------35
3
About the Health
Planning Council
The Health Planning Council is a nonprofit agency and one of 11 Local
Planning Councils mandated by Florida
State Statute 408.033 to dedicate
resources and expertise to regional
community-based health needs
assessments, healthcare utilization
studies, management of health-related
quality of life indicators and the
development of effective collaborative
partnerships. For over 40 years, we’ve
been making the region healthier by
providing assessment services to our
service delivery area: Baker, Clay,
Duval, Flagler, Nassau, St. Johns and
Volusia Counties. As a neutral regional
planning entity with offices in both
Duval and Volusia Counties, we
provide a range of health planning
expertise without bias or conflicts of
interest. We serve the region by
actively participating and influencing
outcomes to protect and create
healthy, sustainable communities.
Our core focus areas address:
Healthy Communities- Assess
prevalence of disease and issues
impacted by biological, behavioral,
social and environmental
determinants of health
Happy and Healthy PlacesInfluence policy that improves
quality of life and the built
environment
Smart People-Equip decisionmakers and the public with the
information they need to make
informed decisions
Vibrant Partnerships-Develop and
leverage effective collaborations,
networks, systems & healthrelated organizations
Background
In October 2010, the Health Planning
Council announced the topic for the
2011 Utilization Study: The Youth
Sport-Related Concussion Study.
After selecting the topic, the Health
Planning Council worked on
assembling and convening a group
of regional representatives from
area hospitals and sport-related
organizations to form the study
council. The study council would be
charged with determining the
research questions, collecting and
analyzing the local data, and making
formal recommendations. The
group consists of representatives
from Agency for Health Care
Administration (AHCA), Baker County
Hospital Authority, Baptist
Health,Brooks Rehabilitation, Duval
County Medical Society, the Florida
Association of High School Athletics,
Florida Hospital, Halifax Medical
Center, Jacksonville Jaguars,
Jacksonville Sports Medicine
Program, Mayo Clinic, Memorial
Health, Nemours Children’s Clinic,
Office of Research Affairs Center for
Healthy Equity and Quality Research
UF-Shands, Orange Park Medical
Center, Shands Jacksonville, St.
Vincent’s Health, Wolfson Children’s
Hospital, the University of North
Florida, the University of Florida
Emergency Department in
Jacksonville, and a local neuropsychologist.
The study council developed the
following areas of concern regarding
sport-related concussions in children
between the ages of 10-18:
The need to ensure children
safety during sport activities. The
disconnect among community
stakeholders regarding local
expertise and stewardship,
outreach efforts, education,
clinical research, reporting,
treatment, neuro-imaging,
etc…regarding sport related
concussion in children
Communities have a difficult
time identifying and
understanding valid,
quantifiable, baseline data for
incidence and prevalence of
youth sport related concussions
The absence of a formalized
process for reporting youth-related
concussions, which occurs in
community sports associations
and schools
The vital need to educate the
community on how to tell when a
head injury has occurred (termed
―signs and symptoms‖), treatment
and follow up procedures for youth
sport concussions- i.e. coaches,
hospital staff, parents,
pediatricians, students and
athletic trainers
Concussions are difficult to
diagnose; There are hidden signs
and symptoms are often
misdiagnosed or completely
overlooked and missed
Concussion treatment, hospital
discharge procedures, and
ensuring appropriate follow up are
challenges for ED physicians,
primary care physicians,
pediatricians, parents, and
coaches
The need to better understand the
long-term outcomes of the 1st and
subsequent concussive episodes
1, 2, 3 years post concussion
including school performance
The community needs to develop
and agree to the ethical
considerations for allowing
children to return to play after a
concussion to avoid significant
health consequences and deaths
There is a need to better
understand the indications for
utilizing CT scans or other imaging
procedures in the management of
children with minor injury with or
without symptoms of concussions
4
Literature Review
The Health Planning Council assembled 23 peer reviewed articles to assist with selecting initial research questions. The
articles were plotted on a matrix to classify the information for further analysis. Many of the articles were dated within in
the last 10 years and related to head injuries, concussions caused by sports, CT (computed tomographic) scan utilization,
and signs and symptoms. The Health Planning Council looked to the expertise of the Study Council to finalize the research
questions for the study.
Sport-related traumatic brain injuries (TBIs) have received an increase in national and local attention over the last several
years with state and federal governments leading the implementation of laws directing a set of standards and guidelines for
suspected brain injury (Centers for Disease Control and Prevention, 2011) . This is evident by the 60% increase in the
pediatric ED visits of concussion over the last 8 years. The recommendations from the Third International Conference on
Concussion in Sports were to reinforce an individualized evaluation of an athlete’s neurocognitive functioning, symptoms
and balance and a step wise approach in the return to play process. There is also a need for a standardized and objective
tool to aid in the initial evaluation and management of brain injuries (Cohen, Gioia, Atabaki, & Teach, 2009). Despite the
need for a standard ―grading scale‖ to determine the severity of the head injury, it is important to determine return to play
based on a clinical evaluation of the individual athlete (Collie, McCrory, Makdissi, 2006). Substantial knowledge now exists
that will help in evaluating an injured athlete and the most appropriate management scheme in order to prevent permanent
cerebral dysfunction and to establish return to play guidelines (Bailes & Hudson, 2001).
Often times players will suffer from a head injury and never report it. Players and coaches need to be educated on the signs
and symptoms of head injuries as well as proper care procedures. Having a certified athletic trainer at high school sporting
events would greatly aide in the proper diagnosis and treatment of head injuries during these events. It is also vital for the
coaches and athletic trainers to agree upon what concussion grading scale and return to play guidelines will be used
(American Academy of Neurology, Colorado Medical Society, Cantu) (Logan, Bell, & Leonardt, 2001). Often times when a
patient doesn’t fully understand concussions, they will continue to participate in high risk activities despite having
symptoms of a concussion. This can lead to further concussions and Second Impact Syndrome (Delaney, Abuzeyad, Correa,
& Foxford, 2005).
Even though the actual number of head injuries varies between ice hockey, football and soccer, the annual rate for each
sport is comparable (Delaney, 2004). Females sustained a higher rate of concussions than males during sport related
activities (Covassin, Swanik, & Sachs, 2003). Concussion rates tend to be higher among collegiate athletes but they
represent a high proportion of the injuries reported in high school athletes (Gessel, Fields, Collins, Dick, & Cornstock, 2007).
Patients presenting to the emergency department (ED) because of a head injury from a sport-related activity are common
and are typically more severe than other types of sport related injuries treated in the ED (Kelly, Lissel, Rowe, Vincenten, &
Voaklander, 2001). Concussion injury is 6 times more likely to happen during organized sports activity than in other
activities for children ages 6 to 14 (Lovell & Fazio, 2008).
Hospital stays for patients with a traumatic brain injury (TBI) tend to be longer and more costly than hospitalizations for nonTBI injuries. TBI hospitalizations are also more likely to occur among younger patients and males. Patients admitted for TBI
also have a higher in-hospital death rate than other injuries (Russo & Steiner, 2007). The American Association of
Neurological Surgeons reports that the leading cause of death from sports-related injuries is TBI. They define TBI as ―a blow
or jolt to the head or a penetrating head injury that disrupts the normal function of the brain‖. According to an AANS study
that utilized Consumer Product Safety Commission (CPSC) data, 446,788 sports-related head injuries were treated in U.S.
emergency departments in 2009. The actual incidence of these injuries could in fact be larger due to the exclusion of data
for product categories with 1,200 injuries or less. Additionally, not all head injuries are treated in emergency departments.
5
Table 1
The following 20 sports/recreational activities represent the categories contributing to the
highest number of estimated head injuries treated in U.S. hospital emergency rooms in 2009 (All ages).
Cycling
Estimated Number of
Head Injuries
85,389
Football
46,948
Baseball and Softball
Basketball
38,394
34,692
28,716
Sport
Water Sports (Diving, Scuba Diving, Surfing, Swimming, Water Polo, Water Skiing,
Water Tubing)
Powered Recreational Vehicles (ATVs, Dune Buggies, Go-Carts, Mini bikes, Off-road)
Soccer
26,606
24,184
Skateboards/Scooters
23,114
Fitness/Exercise/Health Club
18,012
Winter Sports (Skiing, Sledding, Snowboarding, Snowmobiling)
16,948
Horseback Riding
14,466
Gymnastics/Dance/Cheerleading
10,223
Golf
Hockey
10,035
Other Ball Sports and Balls, unspecified
8,145
6,883
Trampolines
5,919
Rugby/Lacrosse
5,794
Roller and Inline Skating
3,320
Ice Skating
4,608
Table 2
Source: American Association of Neurological Surgeons
The top 10 sports-related head injury categories among children ages 14 and younger:
Sport
Cycling
Football
Baseball and Softball
Basketball
Skateboards/Scooters
Water Sports
Soccer
Powered Recreational Vehicles
Winter Sports
Trampolines
Estimated Number of Head Injuries
40,272
21,878
18,246
14,952
14,783
12,843
8,392
6,818
6,750
5,025
Source: American Association of Neurological Surgeons
6
―Injury is the leading cause of morbidity and mortality for youths aged 10-19 years.‖ (Laraque, Barlow, & Durkin, 1999,
p.551). Establishing preventive measures is going to play a key role in reducing the number of sport related head injuries.
In order to establish these measures there needs to be an increase in knowledge of concussion rates, patterns and risk
factors (Gessel, et al., 2007). Continual analysis of the available data will also help reduce the number of sport related
head injuries (Mueller, 2001). Injury prevention activities should utilize both data and sound theoretical frameworks to
reduce the injury mortality and morbidity in youth (Laraque, et al., 1999).
Research Questions
Additionally, after a robust discussion, testimony from sport-related concussion experts, literature extracted from peerreviewed journals, and the careful narrowing of the study’s scope, The Study Council agreed upon four core research
questions to pursue:




RQ1: How prevalent were Emergency Department visits for sport-related and non-sports related Traumatic Brain
Injuries (TBI) in children between the ages of 10-18 in a seven county region in Northeast Florida between 20062009?
RQ2: How prevalent were Hospital Admissions for sport-related and non-sports related Traumatic Brain Injuries
(TBI) in children between the ages of 10-18 in a seven county region in Northeast Florida between 2006-2009?
RQ3: What were the demographic characteristics of children between the ages of 10-18 with sport-related and
non-sports related Traumatic Brain Injuries (TBI) in a seven county region in Northeast Florida between 20062009?
RQ4: What was the utilization pattern for neuro-imaging (i.e. CT scans) for children between the ages of 10-18
presenting in Emergency Departments in Northeast Florida between the years 2006-2009?
Data Collection
The Health Planning Council requested and received an IRB study exemption from the University of Florida’s Institutional
Review Board. An IRB number was assigned by the University of Florida’s Executive Committee and is available for review
upon request. Based on the four core research questions, members of the Study Council identified and collected several
secondary ―qualified‖ healthcare utilization data from Florida’s Agency for Health Care Administration (AHCA). This is
aggregate utilization data; no personal identifying information or patient level data was retrieved or included in the data.
The Center for Healthy Equity and Quality Research at the University of Florida, College of Medicine – Jacksonville (CHEQR)
developed an analysis plan to ensure a complete and valid data analysis process. Throughout this report, you will see the
terms ―concussion‖, ―head injury‖, and ―traumatic brain injury (TBI)‖ used interchangeably. This is due, in large part, by an
inconsistent definition and use of the word ―concussion‖ between the local, state and national medical communities,
levels of government, sport-related organizations, and researchers. For this report, the study council attempted to use the
term ―traumatic brain injury‖ or ―TBI‖ where ever appropriate, while trying to maintain the validity of the national and state
reported data.
The following information outlines the analysis plan and the secondary data requested from AHCA:
Definitions for 7-County Regional Data
Population: Children 10 – 18
2006-2009 trends
959.01 - Head Injury without LOC
854 through 854.19 - Intracranial Injury of Other and Unspecified Nature
850 through 850.9 - Concussion
Copyright
(October
20,as2011)
Allone
Rights
Reserved
1. (c)
Traumatic
Brain Injury
was coded
including
or more
of the following IDC9 codes:
900.9 (900 through 900.9) - Head Trauma: Injury to Blood Vessels of Head and Neck
7
2. Sports related was defined as including one or more of the following ECodes:
E849.4 - Occurrence Sports/Recreational Related Injury Codes
E886.0 - In sports
o Tackles in sports
E917.0 - In sports without subsequent fall
o Kicked or stepped on during game (football) (rugby)
o Struck by hit or thrown ball
o Struck by hockey stick or puck
E917.5 - Object in sports with subsequent fall
o Knocked down while boxing
3. CPT Scans was defined as including any of the following Procedure Codes for CT scan:
70450 - CT Head/Brain w/o Contrast
70460 - CT Brain with Contrast
70470 - CT Brain w/o Without Contrast
Analysis Plan
Outpatient- Emergency Department (ED) visits:
Data was analyzed for Emergency Department visits for a seven county region including Baker, Clay, Duval, Flagler,
Nassau, St. Johns, & Volusia counties. Patients who visited the ED and received an ICD9 code in any of the first 9
diagnoses for Traumatic Brain Injury (TBI) were first compared against all ED visits, and then classified into sports and nonsports related TBI. Analysis examined demographic characteristics of patients with TBI sports and non-sports related injuries.
Demographic characteristics included the patient’s age, gender, race, method of ED payment, county of residence, and the
day of the week they come to the ED. Information was also analyzed by hospital and by procedure code to examine CT
utilization rates.
Inpatient Hospital Admissions:
Data was analyzed for Hospital Admissions for a seven county region including Baker, Clay, Duval, Flagler, Nassau, St.
Johns, & Volusia counties. Patients who were admitted to the hospital and received an ICD9 code in any of their diagnostic
categories (primary – the 9th diagnosis) for Traumatic Brain Injury (TBI) were first compared against all hospital admissions,
and then by sports and non-sports related TBI. Analysis was then completed to examine demographic characteristics of
patients with TBI sports and non-sports related injuries. Demographic characteristics included the patient’s age, gender,
race, method of hospital payment, county of residence, and the day of the week they came to the hospital. Information was
also analyzed by hospital and by hospitalization characteristics including length of stay (LOS), gross charges, and source of
admission and discharge status.
Additional data for the seven-county region of Northeast Florida was gathered from the Florida Community Health
Assessment Resource Tool Set (CHARTS) and the Florida Department of Health. Data on the state level was collected from
CHARTS and the Well Florida Council. National data was collected from the Centers for Disease Control (CDC), the Journal of
Head Trauma Rehabilitation, and the Well Florida Council.
Findings
The following section reports comprehensive data collected from all sources, progressing from a national scope, to a
statewide scope, and finally data concerning the seven counties of Northeast Florida: Baker, Clay, Duval, Flagler, Nassau, St.
Johns, and Volusia.
8
National Data
Table 3
Year
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Numbers and age-adjusted rates per 100,000 population for traumatic brain injury
deaths, by year, sex, and race/ethnicity 1997--2007
Sex
M
F
Total
M
F
Total
M
F
Total
M
F
Total
M
F
Total
M
F
Total
M
F
Total
M
F
Total
M
F
Total
M
F
Total
M
F
Total
White, nonHispanic
No.
28,165
10,887
39,052
28,293
11,143
39,436
27,884
11,145
39,029
27,357
10,528
37,885
28,634
10,883
39,517
28,519
10,897
39,416
28,394
10,937
39,331
28,502
11,391
39,893
29,497
11,340
40,837
29,119
11,385
40,504
29,593
11,462
41,055
Rate
30
9.9
19.3
30
10
19.3
29.4
9.8
18.9
28.6
9.4
18.3
29.6
9.5
18.9
29.2
9.5
18.7
28.9
9.4
18.5
28.7
9.7
18.6
29.4
9.5
18.9
28.7
9.4
18.6
28.9
9.3
18.6
Black, nonHispanic
No.
5,571
1,707
7,278
5,334
1,598
6,932
5,166
1,638
6,804
4,947
1,502
6,449
5,028
1,457
6,485
4,909
1,467
6,376
5,030
1,539
6,569
4,934
1,510
6,444
5,229
1,514
6,743
5,296
1,446
6,742
5,069
1,441
6,510
Rate
37.2
10
22.4
35.7
9.2
21.2
34.4
9.4
20.7
31.7
8.4
19
32
8.2
19
30.9
8
18.4
31
8.4
18.8
30.6
8.2
18.3
31.5
8.2
18.9
31.2
7.6
18.4
29
7.5
17.5
American
Indian/Alaska
Native
No.
Rate
465
50.7
153
15.4
618
32
423
41.6
179
16.6
602
28.5
441
43.4
165
15.7
606
29
421
40
170
14.7
591
26.6
437
40.3
190
16.7
627
28
485
42.8
174
14.9
659
28.4
503
45.3
166
14.7
669
29.4
439
38.5
166
13.4
605
25.3
478
39.6
160
13.2
638
26
460
38.5
154
12.3
614
24.9
429
36.3
145
11.7
574
23.6
Hispanic
No.
3,468
836
4,304
3,444
887
4,331
3,445
870
4,315
3,656
939
4,595
3,921
989
4,910
3,968
989
4,957
4,023
1,068
5,091
3,996
1,040
5,036
4,324
1,091
5,415
4,322
1,057
5,379
4,197
1,086
5,283
Rate
24.8
6.3
15.3
23.9
6.7
15.1
23.8
6.3
14.7
23.2
6.6
14.8
23.3
6.7
14.9
23
6.2
14.4
22.4
6.7
14.5
21.3
6.3
13.8
22.7
6.2
14.4
21.7
5.9
13.7
20.8
5.8
13.3
Other/
Unknown
No.
854
357
1,211
842
363
1,205
829
358
1,187
808
352
1,160
855
366
1,221
890
386
1,276
825
398
1,223
755
417
1,172
884
389
1,273
832
394
1,226
884
410
1,294
Total
No.
38,523
13,940
52,463
38,336
14,170
52,506
37,765
14,176
51,941
37,189
13,491
50,680
38,875
13,885
52,760
38,771
13,913
52,684
38,775
14,108
52,883
38,626
14,524
53,150
40,412
14,494
54,906
40,029
14,436
54,465
40,172
14,544
54,716
Rate
30.5
9.6
19.3
30.1
9.6
19.1
29.3
9.4
18.7
28.3
8.9
18
29.2
9
18.5
28.7
9
18.2
28.4
8.9
18.1
27.9
9.1
18
28.8
8.9
18.3
28.1
8.8
17.9
27.9
8.7
17.8
Source: Centers for Disease Control and Prevention, Surveillance for Traumatic Brain Injury-Related Deaths
9
Figure 1
Age-Adjusted Rate of Traumatic Brain Injury Deaths (All Ages) By Race 1997-2007
Figure 2
Age-Adjusted Rate of Traumatic Brain Injury Deaths (All Ages) By Gender 1997-2007
10
Figure 3
Age-Adjusted Rate of Traumatic Brain Injury Deaths By Age 1997-2007
State Data
Table 4
The number and rate of Traumatic Brain Injury-Related Deaths by Age Group, Florida 1997-2007
Age Group
Year
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
0--4
Number
Rate
1,147
6.0
1,154
6.0
1,045
5.5
1,077
5.6
1,059
5.5
986
5.0
1,065
5.3
1,016
5.0
1,054
5.1
1,002
4.9
978
4.7
5--9
Number
640
664
633
624
568
503
455
447
440
438
382
Rate
3.2
3.2
3.1
3.0
2.8
2.5
2.3
2.3
2.2
2.2
1.9
10--14
Number
Rate
1,027
5.2
1,060
5.3
881
4.4
829
4.0
797
3.8
785
3.7
818
3.9
761
3.6
685
3.3
637
3.1
593
2.9
15--19
Number
Rate
4,996
25.8
4,802
24.2
4,627
23.0
4,539
22.4
4,265
20.9
4,345
21.2
4,062
19.7
4,002
19.2
3,964
18.8
3,877
18.1
3,547
16.4
From 1997-2007, the rate of traumatic brain injury-related deaths has decreased across all displayed age ranges.
Age 0-4: -1.3; Age 5-9: -1.3; Age 10-14: -2.3; Age 15-19: -9.4.
11
Figure 4
Non-Fatal Head Injury Hospitalization for Ages 12-18, Florida Department of Health, 1999-2009
Source: Florida Department of Health, Bureau of Vital Statistics (CHARTS)
Data Source: Florida Agency for Health Care Administration (AHCA).
The rate per 100,000 for non-fatal head injury hospitalizations of patients ages 12-18 decreased from the
1999-2001 rate of 79.2 to the 2007-2009 rate of 67.4, an 11.8 per 100,000 decrease.
12
Regional Outpatient (Emergency Department Visits) for
Traumatic Brain Injury (TBI)
Figure 5
Emergency Department Visits, TBI vs. Non-TBI,
Florida Agency for Health Care Administration, 2006-2009
TBI is defined as 850 through 850.9 or 900 through 900.9 or 959.01 or 854 through 854.19
Data is provided for a seven county region including Baker, Clay, Duval, Flagler, Nassau, St. Johns,
& Volusia Counties
Source: Florida Agency for Health Care Administration
There is a noticeable increase in the number of emergency department visits in 2009. Additionally, 2009 saw
the largest percentage of emergency department visits resulting from TBI, at 2.15%. In 2006: 1.97%; 2007: 2.09%;
2008: 1.85%.
13
Traumatic Brain Injury (TBI) Sports and Non-Sports Related
Figure 6
Emergency Department Visits, TBI, Sports vs. Non-Sports,
Sports Related is defined as E849.4 or E886.0 or E917.0 or E917.5
& Volusia Counties
From 2006 to 2009, Sports related Traumatic Brain Injuries (TBI) accounted for 15% of all TBIs reported during this
timeframe. There was an increase in the number of children 10 – 18 years of age who went to the ED for treatment
of a sport-related TBI between 2006 and 2009 from 154 to 269 people, a 75% increase but the overall number of
TBI for this period also increased.
14
Figure 7
Emergency Department Visits, TBI, Sports vs. Non-Sports, By Age
& Volusia Counties
The number of emergency department visits from 2006-2009 for patients with TBI increases steadily with age.
However, the percentage of those visits that are sports-related do not follow this pattern.
Table 5
Age
10
11
12
13
14
15
16
17
18
Percentage of TBI visits that are sports-related
13.8%
14.8%
14.8%
16.5%
20.1%
18.9%
17.8%
13.3%
5.0%
15
Figure 8
Emergency Department Visits, TBI, Sports vs. Non-Sports, By Gender
& Volusia Counties
Males make many more emergency department visits for TBI. Additionally, the percentage of visits that are
sports-related for males (17.8%) is higher than for females (8.8%). This disagrees with Covassin et al. Their
rate was higher in females.
16
Figure 9
Emergency Department Visits, TBI, Sports vs. Non-Sports, By Race
& Volusia Counties
While “White” resident emergency department visits with TBI are double “Black” and “Other” put together, they
have the lowest *value of sports-related TBI visits (14.3%). “Black”: 15.2% “Other”: 16.4%.
*This data was not statistically tested to see if chance could account for this variation.
17
Figure 10
Emergency Department Visits, TBI, Sports vs. Non-Sports, By Payor
& Volusia Counties
53% of all emergency department visits for patients with TBI was paid for with private insurance. The highest
proportion of sports-related TBI occurred in those who pay via military benefits (23.7%).
Table 6
Payor
Percentage of Sports-Related TBI
Commercial
17.5%
Medicaid
11.2%
Self-Pay
7.6%
Military
23.7%
Other
13.1%
18
Figure 11
Emergency Department Visits, TBI, Sports vs. Non-Sports, By County
& Volusia Counties
Duval County has the highest number of visits for patients with TBI (2,410). However, St. Johns County has the
highest proportion of those visits stemming from sports-related TBI (24.7%).
Table 7
County
Duval
Volusia
St. Johns
Clay
Flagler
Nassau
Baker
12.7%
15.0%
24.7%
14.9%
19.9%
11.6%
8.2%
19
Figure 12
Emergency Department Visits, TBI, Sports vs. Non-Sports, By Day of the Week
& Volusia Counties
Table 8
Total Cases
Sports-related %
Monday
869
13.0%
Tuesday
807
14.4%
Wednesday
840
14.5%
Thursday
839
15.4%
Friday
893
17.4%
Saturday
872
15.3%
Sunday
808
11.5%
There is limited variation in emergency department visits across day of the week (Min = 808, Max = 893). Friday
sees the largest percentage of sports-related visits with 17.4%.
20
Figure 13
Emergency Department Visits, TBI, Sports vs. Non-Sports, By Hospital
Data is provided for a seven county region including Baker, Clay, Duval, Flagler, Nassau, St. Johns, & Volusia Counties
Table 9
TBI Sports-Related and Non Sports-Related Hospital Data Throughout Seven Florida Counties
TBI Sports- TBI Non Sports% of Sports-Related
Hospital Name
Related
related
TBI
Florida Hospital, Ormond Hospital
37
121
30.6%
Baptist Medical Center- Nassau
25
136
18.4%
Florida Hospital, Flagler
39
169
23.1%
Baptist Medical Center - Beaches
49
195
25.1%
Florida Hospital - Deland
42
243
17.3%
Baptist Medical Center South
94
287
32.8%
Flagler Hospital
28
299
9.3%
Florida Hospital Fish Memorial
47
322
14.6%
Halifax Health Medical Center
86
367
23.4%
Orange Park Medical Center
60
377
15.9%
Baptist Medical Center -Downtown
143
592
24.2%
Shands Jacksonville
87
958
9.1%
Other (Hospitals with counts <25)
124
1001
12.4%
Total
861
5,067
17.0%
Shands sees the highest volume of patients with TBI (1,045), but Baptist Medical Center South sees the highest
percentage of sports-related TBI patients (32.8%).
21
Figure 14
Emergency Department Percentage of Visits, CT Scan for TBI, Sports vs. Non-Sports,
CT utilization is defined based on procedure codes: 70450, 70460, & 70470
& Volusia Counties
Of note, the numbers of ordered CT scans for sports and non-sports related TBI have decreased over the study
period (2006-2009) by 17.6% and 11.3% respectively. This could be due to recently published guidelines
for CT scan imaging in pediatric TBI (Osmond, 2010; Kupperman, et al, 2009).
In addition, the decrease in the number of ordered CT scans could be due the general awareness by parents and
ED physicians of the increase risk of subsequent malignancy in pediatric patients undergoing CT since children are
10 times more radiosensitive than adults (Brody, Frush, Huda, et al; American Academy of Pediatrics, 2007).
22
Regional Inpatient (Hospital Admissions) for Traumatic Brain
Injury (TBI) Sports and Non-Sports Related
Figure 15
Hospital Admissions for Patients with TBI and Non-TBI,
& Volusia Counties
There is a noticeable decrease in the number of hospital admission visits in 2009. Additionally, 2009 saw the
smallest percentage of hospital visits result from TBI, at 1.1% (In 2006: 1.4%; 2007: 1.5%; 2008: 1.2%).
23
Figure 16
Hospital Admissions for Patients with TBI Sports and Non-Sports Related TBI,
& Volusia Counties
From 2006-2009, TBI hospital admissions dropped by 15 patients. The percentage of those patients who had
sports-related TBI increased slightly over the same timeframe (2006: 5.1; 2009: 5.5). Additionally, 2007 saw
the highest number of admissions (99) and the highest percentage of sports-related TBI admissions (10.1%)
from 2006-2009.
24
Figure 17
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Age,
& Volusia Counties
Incidence of TBI increases overall with age. However, ages 12 and 14 have the highest proportion sports-related
TBI (15.8% and 15.4% respectively). The numbers are sport-related TBI are very small so these differences are
somewhat irrelevant.
Table 10
Age
10
11
12
13
14
15
16
17
18
6.7%
9.1%
15.8%
8.3%
15.4%
9.8%
4.6%
4.9%
1.2%
25
Figure 18
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Gender,
& Volusia Counties
Table 11
Gender
ED visits for
sports-related
TBI
Male
673
Female 188
ED visits for nonsports related TBI
3,107
1,960
Hospitalization
for sports-related
TBI
17
8
Hospitalization for
non- sports related
TBI
213
323
The percentage of hospitalizations of male patients presenting to the ED with TBI were as follow:
Sport-related TBI: 2.5%
Non-sport related TBI: 6.85%
On the other hand, the percentage of hospitalizations of female patients presenting to the ED with TBI
were as follow:
Sport-related TBI: 4.25%
Non-sport related TBI: 16.5%
Therefore, the hospitalization of female patients presenting to the ED with TBI was higher than males particularly in
non-sport related TBI.
26
Figure 19
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Race,
& Volusia Counties
“White” resident emergency department visits with TBI are double “Black” and “Other” put together. “Black”
patients have the lowest proportion of sports-related TBI visits (6.2%). “Other” patients have a very high
percentage (22.2%).
27
Figure 20
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Payor,
& Volusia Counties
Commercial payment was used for the most patients (242). The payment option with the highest percentage
of sports-related TBI was military (25.0%).
Table 12
Payor
Percentage of Sports-Related TBI
Commercial
6.6%
Medicaid
6.3%
Self-Pay
6.3%
Military
25.0%
Other
0.7%
28
Figure 21
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By County,
& Volusia Counties
Duval County saw the highest number of hospital admissions for patients with TBI (111).
Table 13
County
Duval
Volusia
St. Johns
Clay
Flagler
Nassau
Baker
5.4%
7.7%
0%
3.3%
18.2%
0%
8.3%
29
Figure 22
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Day of the Week,
& Volusia Counties
Table 14
Total Patients
Sports-related %
Monday
58
3.4%
Tuesday
43
9.3%
Wednesday
39
2.6%
Thursday
44
6.8%
Friday
44
18.2%
Saturday
66
6.1%
Sunday
54
5.6%
Saturday saw the highest number of admissions for TBI (66) from 2006-2009, but Friday had the highest
percentage of sports-related admissions (18.2%).
30
Figure 23
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Hospital,
Data is provided for a seven county region including Baker, Clay, Duval, Flagler, Nassau, St. Johns, &
Volusia Counties
Table 15
Hospital Name
Baptist Medical Center-Downtown
Halifax Health Medical Center
Shands Hospital Jacksonville
TBI Sports-Related
TBI Non Sports-related
5
15
4
% of Sports-Related TBI
23.8%
16
11.5%
116
2.2%
177
Shands has the highest volume of hospital admissions for patients with TBI (181) but Baptist Medical Center –
Downtown serves the highest percentage of sports-related TBI patients (23.8%).
Rates for the other hospitals were too small to report.
31
Figure 24
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, Mean Length of Stay (LOS),
Volusia Counties
Across each year between 2006-2009, sports-related TBI resulted in shorter length of stay than non-sports
related TBI. Both types of TBI have decreased in length of stay from 2006 (sports-related: -0.2; non-sports
related: -0.3)
32
Figure 25
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, Mean Gross Charges,
Volusia Counties
Mean gross charges are consistently higher for non-sports related TBI, possibly because their length of stay is
consistently longer.
33
Regional Inpatient Hospital Admissions) for Traumatic Brain
Figure 26
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, Discharge Status,
Volusia Counties
A substantial amount of patients with TBI were discharged “Home” (306) than “Other” (42). Additionally, only one
sports-related TBI patient was discharged to somewhere other than home.
34
Figure 27
Hospital Admissions for Patients with TBI Sports and Non-Sports Related, Admission Type,
Volusia Counties
Fewer TBI patients were admitted as “Emergency” than “Other”. However, a much larger proportion of those
admitted as “Emergency” were sports-related (Emergency: 12.3% Other: 2.7%).
35
Recommendations
Members of the study council and the Health Planning Council recommend the following actions steps:
1. Develop a Youth Sport-Related Concussion Task Force
It is recommended that a neutral, but topically qualified entity build on the momentum of this report and convene
the medical community, sport-related organizations, public and private school associations, researchers, athletic
trainers, advocates, parents and policy-makers and develop a Youth Sport-Related Concussion Task Force to:
Agree on the consistent use of the terms ―concussion‖ ―head injury‖, and ―traumatic brain Injury‖
Agree on a consistent, formalized, and ethical process for reporting incidence and prevalence of
traumatic brain injuries at all levels of sports and recreation, diagnosis, hospital discharge
procedures, treatment, follow up and return-to-play decisions
Develop a coordinated and comprehensive public awareness campaign to educate coaches,
hospital staff, parents, pediatricians, students and athletic trainers on the signs and symptoms of a
traumatic brain injury, treatment and follow up procedures
Identify funding (and leverage community assets) to execute study recommendations, measure results,
and invest in local bio-science research and development relating to sport related traumatic brain
injuries
2. Develop a Community-Based Research Agenda
Although the small numbers of sport related traumatic brain injury (TBI) limit the generalizability and interpretation
of the data provided, the following areas of research should be explored and or conducted:.
Examine the apparent disparity between gender and self- identified racial/ethnic group differences.
This includes exploring the barriers to health care access for such injuries. Proposed barriers are
parental and athletes limited knowledge of the clinical presentation of TBI as well as lower income
preventing parents from seeking care in either the ED or outpatient follow up of TBI symptoms.
Further studies should focus on the impact of sport related TBI on the athletes’ neuro-cognitive and
behavior changes and its consequences on quality of life and school performance
36
References
American Association of Neurological Surgeons. (Updated 2010, July). Sports-Related Head Injury. Retrieved June 22,
2011 from http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/SportsRelated%20Head%20Injury.aspx.
Bailes, J.E., Hudson, V. (2001). Classification of sport-related head trauma: a spectrum of mild to severe injury. Journal
of Athletic Training, 36(3), 236-243.
Brody AS, Frush DP, Huda W, et al; American Academy of Pediatrics Section on Radiology. Radiation risk to children
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Collie, A., McCrory, P., & Makdissi, M. (2006). Does history of concussion affect current cognitive status? British Journal
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school and collegiate athletes. Journal of Athletic Training, 42(4), 495-503.
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Kelly, K.D., Lissel, H.L., Rowe, B.H., Vincenten, J.A., & Voaklander, D.C. (2001). Sport and Recreation-related head
injuries treated in the emergency department. Clinical Journal of Sport Medicine, 11(2), 77-81.
Kupperman N, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a
prospective cohort study. Lancet. 2009;(374) 9696:1160-1170.
Langlois, J.A., Rutland-Brown, W., & Thomas, K.E. (2005). The incidence of traumatic brain injury among children in the
United States by Race. Journal of Head Trauma Rehabilitation, 20(3), 229-238.
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312-315.
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38
www.hpcnef.org
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and
Dr. Madeline Joseph- Associate Professor of Emergency Medicine and Pediatrics,
Assistant Chair of Pediatrics Emergency Medicine, Division Chief and Medial Director
39
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of
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Emergency Department and Hospital Admission

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