THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE 2017 Biennial Report on the Incidence of Traumatic Brain Injury in Ohio
Presented to the Brain Injury Advisory Committee | Jan. 1, 2018 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Acknowledgements This report was prepared in accordance with the requirement set forth in ORC 3335 60,. which states that the Brain Injury Program of Ohio will prepare a biennial report on the impact of brain injury in the state of Ohio . It was developed by the staff of the Ohio Brain Injury Program and the Data Work Group of the Brain Injury Advisory Committee . The staff of the Ohio Brain Injury Program appreciates the work and commitment of the Brain Injury Advisory Committee for charting a direction and providing the energy to develop a robust brain injury program for the people of Ohio and looks forward with anticipation to the work ahead .
As chair of the Data Work Group, Stephanie Ramsey, BSN, MPH, from the Brain Injury Association of Ohio, has been the driving force behind preparation of this report . Without her gentle yet unrelenting leadership, this report would not have been completed .
We wish to acknowledge a past author and editor for his contribution in the development and preparation of previous reports, which was the basis for the format and development of this current production . F . Barry Knotts, MD, PhD, is gratefully acknowledged by the Brain Injury Advisory Committee for his dedication to brain injury in the state of Ohio and his distinguished contributions to the Brain Injury Advisory Committee that date from its inception through July 2017 .
We also wish to acknowledge the contributions of the Ohio Department of Public Safety Division of Emergency Medical Services and the Ohio Department of Health as well as other members of the Data Work Group for their selfless effort to complete this reporting requirement:
• Sue A . Morris, BA, paramedic and continuing education instructor with the Brain Injury Advisory Committee Data Work Group and the Ohio Department of Public Safety
• Abraham Yohannes, MA, MPH, epidemiologist with the Ohio Department of Public Safety
• Kara Manchester, MS, with the Brain Injury Advisory Committee Data Work Group and the Ohio Department of Health Table of Contents • Gregory Wagner with the Brain Injury Advisory Committee Data Work Group and the Brain Injury Association of Ohio
ACKNOWLEDGEMENTS...... 3 SELECTION CRITERIA...... 23 • Jeffrey Leonard, MD, with Nationwide Children’s Hospital
PREFACE...... 4 DATA FROM THE OHIO TRAUMA Special gratitude is extended to John Corrigan, PhD, and Monica Lichi, MS Ed, PC, MBA, from the Ohio Brain REGISTRY...... 23 Injury Program and the Ohio Valley Center for Brain Injury Prevention and Rehabilitation at The Ohio State EXECUTIVE SUMMARY: HOW BIG IS University Wexner Medical Center for their outstanding leadership and guidance in the development and THE PROBLEM IN OHIO?...... 5 LIMITATIONS OF THE DATA...... 28 production of this report . We present this report with the deepest respect to the Brain Injury Advisory Committee . 10 TAKEAWAYS FROM THIS REPORT ...... 6 SECTION 3: OHIO TRAUMATIC BRAIN INJURY PREVALENCE DATA FROM THE BEHAVIORAL RISK Copies of this report will be distributed by the Ohio Brain Injury Program staff to members of the Ohio Brain FACTORS SURVEILLANCE SURVEY, OHIO VALLEY PROLOGUE: TRAUMATIC BRAIN INJURY Injury Advisory Committee as required by ORC 3335 60. for information and review . Additional copies of CENTER FOR BRAIN INJURY PREVENTION IS ALWAYS A PERSONAL STORY...... 7 AND REHABILITATION AT THE OHIO STATE this report as well as previous reports may be obtained by contacting Monica Lichi at 614-293-3802 or UNIVERSITY WEXNER MEDICAL CENTER...... 29 [email protected] . SECTION 1: OHIO DEPARTMENT OF HEALTH DATA FROM DEATH CERTIFICATES, HOSPITALIZATIONS DATA COLLECTION ...... 30 AND EMERGENCY DEPARTMENT VISITS...... 9
SECTION 4: THE COSTS OF TRAUMATIC BRAIN INJURY: SECTION 2: OHIO TRAUMA REGISTRY DATA FROM CAN THEY BE REDUCED?...... 36 THE OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES...... 21 SUPPORTING RESEARCH...... 37
INCLUSION CRITERIA...... 22 CONCLUSIONS...... 40
2 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 3 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Preface This report fulfills the requirement of the Ohio Revised Code 3335 60. for the Brain Injury Program of Ohio to produce a statewide biennial report on the impact of traumatic brain injury (TBI) in Ohio . It is the seventh report prepared using data from the Ohio Trauma Registry (OTR) collected by the Ohio Department of Public Safety . It is the second report to include data on inpatient hospital discharges, emergency room visits and deaths from Ohio hospital discharge data collected by the Ohio Hospital Association and compiled by the Ohio Department of Health . It is the first report to include data on the prevalence of TBI in the state collected from the Ohio Behavioral Risk Factor Surveillance System by the Ohio Department of Health .
These different data sources are included to provide a more comprehensive overview of the significant impact of TBI across the spectrum of human and financial loss as seen through such measures as incidence, prevalence, severity, cost and resource consumption . Considerations of death, short- and long- term disability, and the implications for public policy are brought together to provide a foundation for the development of a system of statewide services and supports to meet the needs of the people of Ohio living with the consequence of brain injury .
Specific data collection methodologies are described in each section of this report . The following is a brief overview of the distinctions between the three primary sources of empirical data:
• Data from the OTR were collected from hospital-mandated reports on specific International Classification of Diseases-10 (ICD-10) categories of injury .
• Data from the Ohio Department of Health were collected from hospital inpatient stays, emergency department visits and deaths .
• Ohio Behavioral Risk Factor Surveillance System data were drawn from a telephone survey conducted by the Ohio Department of Health .
Because the data collection criteria and methodology of the data sets differ, direct comparison of the data is not always possible . Rather, all sets are presented and correlated when possible to provide a more comprehensive picture of the incidence and impact of TBI over time on Ohio citizens . Data may at times Executive Summary: How Big Is the Problem in Ohio? show parallel trends or suggest similar conclusions . To maintain clarity, the data sets are reported in separate sections in this report . In Ohio, injury is the leading cause of death and disability in people between the ages of 1 and 44 and the third-leading cause of death behind heart disease and cancer . Traumatic brain injury (TBI) is involved in over This report uses the Centers for Disease Control and Prevention (CDC)’s definition of TBI: an injury caused by 30 percent of injury cases in Ohio and increasing . a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain . Each year, emergency rooms and hospitals across Ohio see almost 120,000 Ohioans for TBI . As many as The Traumatic Brain Injury Model Systems National Data and Statistical Center provides a more detailed two to three times more Ohioans experience concussions (mild TBIs) that are either evaluated outside the definition: TBI is defined as damage to brain tissue caused by an external mechanical force as evidenced by hospital or not evaluated at all . medically documented loss of consciousness or post-traumatic amnesia due to brain trauma or by objective neurological findings that can be reasonably attributed to TBI on physical examination or mental status In addition to this, TBI is the signature injury of the Afghanistan and Iraq conflicts, which are responsible for examination . bringing thousands of new cases of TBI home to Ohio . As stated in the 2015 CDC report to Congress (http://www.cdc.gov/traumaticbraininjury/pdf/TBI_Report_to_Congress_Epi_and_Rehab-a.pdf), “Military For purposes of this report, these definitions are considered equivalent . service members and veterans from recent conflicts and combat are a population of special concern . However, of all new cases of TBI among military personnel, approximately 80 percent occur in non-deployed settings ”.
4 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 5 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
10 Takeaways From This Report Prologue: Traumatic Brain Injury Is Always a Personal Story 1 . In 2014 – the most recent year for which data are available – 2,300 Ohioans died from a traumatic brain The report that follows provides numbers that are intended to offer comprehensive information on the injury (TBI), and 118,000 injuries were treated in emergency departments or required hospitalization . frequency of traumatic brain injury (TBI); the who, what and where of the occurrences; and the impact on [Sources: Ohio Department of Health (ODH) Vital Statistics and Ohio Hospital Association (OHA)] the population as a result of persistent disabilities and deficits . However, TBI is principally a human story of 2 . Falls remained the most common cause of TBI . In 2014, twice as many injuries resulted from falls versus sudden loss, fear, pain, unknowns, financial strain and altered lives . While it is true that each TBI is different, motor vehicle crashes, the second-most-common cause . [Source: Ohio Trauma Registry (OTR)] these elements are part of each story, and the challenges they present affect both the individuals who are injured and the families who walk the path with them . 3 . From 2013 to 2014, the number of emergency department visits increased by 1 percent, and deaths increased by 4 percent . However, inpatient hospital admissions declined by 2 .5 percent . [Sources: ODH Therefore, before we look at the numbers, we need to look at what the numbers represent in terms of the Vital Statistics and OHA] human story . Below is one family’s story .
4 . In 2014, almost 4,000 children were treated in emergency departments for sports-related TBIs – twice as many injuries as 10 years earlier . [Source: OHA] Erica’s Journey of Hope 5 . Among hospitalizations for TBI in 2014, 65 percent involved mild TBIs . Moderate, severe or penetrating injuries comprised the rest and totaled 2,400 . [Source: OHA] In the summer of 2013, our 20-year-old daughter Erica suffered a severe TBI as a result of an auto accident . She would not be alive if not for the great response from the paramedics, trauma team and dedicated 6 . Among hospitalizations for TBI in 2014, 65 percent of patients went directly home – most without medical professionals entrusted with her care . The paramedics responded in less than 15 minutes and found services . Twenty-one percent of patients were discharged from the hospital to inpatient rehabilitation or Erica unresponsive with a severe head injury . Their protocol allowed them to invoke the trauma response skilled nursing facilities . [Source: OTR] team so that Erica was on the table in a Level I trauma center in well under an hour . 7 . More than one in five (1 .8 million) adult Ohioans have incurred at least one TBI in their lifetime that was The neurosurgeon operated and removed road debris from Erica’s brain, including part of her right frontal severe enough to cause loss of consciousness . Almost 220,000 have had a moderate or severe TBI . lobe . She also suffered from several brain bleeds and shearing of axons throughout multiple areas of her [Source: ODH Behavioral Risk Factor Surveillance System (BRFSS)] brain (known as a diffuse axonal injury) . Even with all the miraculous medical effort, we still weren’t sure she 8 . Among the 2 million adults in Ohio who identified as having a disability in 2014, more than 635,000 had would live, enduring the worst weeks any parents can go through . After 27 days in a coma, the medical team a TBI that caused loss of consciousness sometime in their life . Almost 100,000 had a moderate or severe determined that Erica would survive, but they were very concerned, as she was still nonresponsive and TBI . [Source: ODH BRFSS] completely dependent on a ventilator and feeding tube .
9 . Appalachian regions of Ohio have more than twice the rate of residents who have had at least one The question remained: What to do with a nonresponsive young lady in a coma? We did the only thing any moderate or severe TBI in their lifetime . [Source: ODH BRFSS] parent can do . We prayed, cried and relied heavily on the tremendous support from family, friends, neighbors and, just as critically, the medical personnel who cared for her and us . 10 .The TBIs that occurred in 2014 will cost Ohio $4 3. billion in medical expenses and lost wages . [Source: CDC’s Web-based Injury Statistics Query and Reporting System cost of injury reports, ODH Vital Statistics Through it all, there was no clear way to know how to proceed through the murky world of TBI . As parents, and OHA] we were in shock, trying to navigate not only what it was but also what options existed and how to achieve the best care for Erica . We investigated options and contacted friends who knew people who knew people In short, TBI remains a major public health problem that exacts a high personal and financial cost for the who knew people . We literally guessed at the next steps . Erica went from an intensive care unit (ICU) at a citizens of Ohio . The findings presented in this report indicate a troubling trend of increased incidence and major hospital to an ICU at a step-down hospital, because we were told that should be done . Education human and economic cost among all strata of the population and emphasize the critical need for prevention from the hospital on the process or about brain injury was very scarce . Fortunately, it was a good step-down among all age and gender groups . hospital that knew a bit about the care of TBI patients .
Furthermore, while prevention is a hallmark objective, the obvious corollary is the need for a system of Erica progressed from the ICU to the special care rooms over the six weeks, but she was still nonresponsive . services available to meet the care, treatment and rehabilitation needs of individuals and their families who We saw some signs that we interpreted as responses, but we were told it was probably wishful thinking . have experienced brain injury and are currently facing the challenges of residual disabilities or impairments Our insurance coverage for the step-down hospital was running out, placing us in a huge dilemma: If our that can limit or threaten resumption of a full and productive future course . daughter didn’t wake up soon, she would have to go to a nursing home for likely a lifetime of care .
Thankfully, with the help of a bold doctor and the off-label use of medicine, she came around and became partially responsive (able to give yes/no indications), and the nursing home was avoided at the very last day . We now had to find the right rehab hospital that would take a nonambulatory person – she could do virtually nothing for herself .
With each of these moves, we received little or no notice as to what the process was for a patient with a TBI . This is a huge issue that most families we met had to deal with . The trauma alone of dealing with the critical severity of TBI is devastating . Families are not able to make good health choices for their loved ones with little or no information . Nor is it reasonable for the family to be responsible for researching the process,
6 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 7 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
especially with no free time while managing the impact of this trauma . Further, what happens to those who do not have family or support to help navigate this opaque system? The hospital staff and hospital social staff should understand and cover this care process, or they should have access to a resource that can help provide the necessary guidance .
At the rehabilitation hospital, Erica began the painstaking process of regaining her functions . She had to relearn nearly every life skill – the ability to swallow, eat food, sit up in bed, stand and walk . She needed the Section 1 help of three therapists to learn how to walk again . She partially regained her speech (limited words, short sentences in short bursts), and she began to remember who she was and recall her life . Those six weeks were challenging, and all the while, the insurance meter was running .
Though Erica was making continued progress, getting more than 30 days of rehabilitation is nearly impossible, and after those few short weeks, we soon had another decision to make . We needed to determine the next step for a young lady who could not walk, feed, bathe or otherwise care for herself . Again, providence shined on us, and a path forward was identified . We would be taking her to a residential neurorehabilitation facility .
Training at the new facility included a routine of speech, occupational and physical therapy along with relearning life skills . She progressed over two months to feeding herself, walking very slowly with assistance and a walker, and using more words, including short sentences . Her ability to care for herself improved, but she still needed someone there for her during all waking hours to help her get out of bed or a chair, to help her sit down, and to help with her personal needs . She needed help with and had to relearn all the things we take for granted .
Four hospitals and six months after her accident, Erica was released from the residential rehabilitation facility and returned home . Erica still required 24-hour care, the use of a wheelchair and assistance with nearly every life skill . Realizing the incredible amount of time and care our daughter required, my wife resigned her position with her company to become Erica’s full-time caregiver . Even though we later learned that Erica qualified for help with home health care, we bore that burden as a family .
Our home needed modifications at significant costs to us in order to care for Erica . We were not at any time made aware that the state had programs to help with these modifications . Erica continued with outpatient speech, occupational and physical therapy for months . At home, my wife scheduled time for reading, writing, math, puzzles and other cognitive and life skills . We made sure that Erica was not homebound and felt part of the world again with trips to the mall and movies and dinner out and visits with friends and family . These efforts increased as Erica’s stamina and strength increased .
A year after her accident, Erica was able to go for a concentrated month to the Shepherd Center in Atlanta for intense rehab . There she gained greater strength and flexibility and learned a new way to approach rehab . She progressed from barely able to move to a wheelchair, then to a walker and then to a cane . She now is able to walk slowly and independently (though a bit shakily) in a controlled environment .
As we approach four years after her accident, our daughter is back in college, doing well and earning mostly A’s and B’s on a limited class schedule . She enjoys going to the gym four to five days a week along Ohio Department of Health Data From Death with Pilates twice a week to improve her walking . Erica has a wonderful group of friends that she regularly meets with . Erica’s drive and positive, never-give-up attitude is amazing . We know we are blessed, and our Certificates, Hospitalizations and Emergency daughter is a miracle thanks to the help from a thousand hands .
Department Visits
8 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Ohio Death Certificate Data: • Injury deaths were defined as a death with the underlying cause of death listed as an injury . Traumatic brain injury (TBI) deaths were defined as deaths with an injury as underlying cause of death and a TBI listed in one of the multiple cause-of-death fields . Injury underlying cause of death International Classification of Diseases-10 (ICD-10) Codes include V01-Y36, Y85-Y87, Y89,*U01-*U03 and ICD-10 codes in any field of the multiple cause-of-death file (S01 0-S01. .9, S02 0,. S02 1,. S02 .3, S02 7-S02. .9, S04 0,. S06 0-S06. .9, S07 0,. S07 1,. S07 .8, S07 .9, S09 7-S09. .9, T01 0,. T02 0,. T04 0,. T06 0,. T90 1,. T90 .2, T90 .4, T90 .5, T90 .8 and T90 .9) .
• Deaths included in this report were restricted to Ohio residents .
• Rates were calculated by dividing the number of injuries by the number of Ohio residents . Population estimates were based on estimates from the National Center for Health Statistics . Rates were age-adjusted to the 2000 U .S . standard population .
• The data source is Ohio Vital Statistics, Ohio Department of Health . Ohio Hospitalizations: • The hospital discharge data set includes nonfederal, acute care and inpatient facilities . The data set does not include the U .S . Department of Veterans Affairs and other federal hospitals, rehabilitation centers or psychiatric hospitals .
• Injury hospitalization visits were defined as an inpatient visit with an injury listed in the principal diagnosis codes (ICD-9-CM codes 800-909 .2, 909 .4, 909 .9, 995 .5-995 .59 or 995 .80-995 85). . TBI emergency department visits were defined as injury visits with any of the following TBI ICD-9-CM codes in any diagnosis field: 800 00-801. .99, 803 00-804. .99, 850 0-854. 19,. 950 1-950. .3, 959 01. or 995 .55 . Mild TBI is defined as ICD-9-CM with the first four digits 800 0,. 800 .5, 801 0,. 801 .5, 803 0,. 803 .5, 804 0,. 804 .5, 850 0,. 850 1,. 850 .5 or 850 .9 and a fifth digit of 0, 1, 2, 6, 9 or missing; or ICD-9-CM with the first four digits 854 0. and a fifth digit of 1, 2, 6, 9 or missing; or ICD-9-CM 959 01. .
• The external cause-of-injury code used in the analysis was the first listed cause of the discharge diagnosis Ohio Emergency Department Visits: fields . If the codes E000-E030, E849, E967, E869 .4, E870E879 or E930-E949 were the first listed codes, • The emergency department (ED) visits data set includes nonfederal, acute care and inpatient facilities . The then the next valid external cause code was used . data set does not include the Department of Veterans Affairs and other federal hospitals, rehabilitation • Data sets include readmissions, transfers and deaths occurring in the hospital . centers or psychiatric hospitals .
• Hospitalizations included in this report were restricted to Ohio residents . • Injury ED visits were defined as an ED visit with an injury listed in the principal diagnosis codes (ICD-9- CM codes 800-909 .2, 909 .4, 909 .9, 995 5-995. 59. or 995 80-995. 85). or a valid external cause-of-injury • Rates were calculated by dividing the number of injuries by the number of Ohio residents . Population code in any of the discharge diagnosis fields . TBI ED visits were defined as an injury visit with any of the estimates were based on estimates from the National Center for Health Statistics . Rates were age-adjusted following TBI ICD-9-CM codes in any diagnosis field: 800 00-801. .99, 803 00-804. .99, 850 0-854. 19,. 950 1-. to the 2000 U .S . standard population . 950 .3, 959 01. or 995 55. . Mild TBI is defined as ICD-9-CM with the first four digits 800 0,. 800 .5, 801 0,. 801 .5, 803 0,. 803 5,. 804 0,. 804 5,. 850 0,. 850 1,. 850 .5 or 850 .9 and a fifth digit of 0, 1, 2, 6, 9 or missing; or ICD-9- • The source of the data is the Ohio Hospital Association . CM with the first four digits 854 0. and a fifth digit of 1, 2, 6, 9 or missing; or ICD-9-CM 959 01. .
• The external cause-of-injury code used in the analysis was the first listed cause of the discharge diagnosis fields . If the codes E000-E030, E849, E967, E869 .4, E870E879 or E930-E949 were the first listed codes, then the next valid external cause code was used .
• ED visits included in this report were restricted to Ohio residents .
• Persons who were treated at an ED and later admitted to a hospital were removed from the ED data set and, therefore, were not included in any analysis of ED data .
• Rates were calculated by dividing the number of injuries by the number of Ohio residents . Population estimates were based on estimates from the National Center for Health Statistics . Rates were age-adjusted to the 2000 U .S . standard population .
• The source of the data set is the Ohio Hospital Association .
10 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 11 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Figure 1: Traumatic Brain Injury Pyramid, Ohio, 2014 Figure 3: Traumatic Brain Injury Death Rates by Age and Gender, Ohio, 2014 Males Females 220 Males Females 204 200 220 204 180 200
160 180 140 160 120 140 104 95 100 120 104 95 80 100 80 Rate Per 100,000 60 45 38 Rate Per 100,000 60 30 45 40 24 29 26 24 38 40 24 29 26 24 16 30 20 7 9 6 8 7 16 9 8 7 0 20 7 6 15‐24 25‐340 35‐44 45‐54 55‐64 65‐74 75‐84 85+ 15‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84 85+ Age in Years Age in Years Source: Ohio Department of Health, Vital Statistics
Source: 1Ohio Department of Health, Vital Statistics Source: 2Ohio Hospital Association While the overall death rate for TBI was 18 6. per 100,000 in 2014, rates vary greatly by gender and age . Rates were approximately three times higher among males than females for all age groups except for adults The pyramid graph above shows all cases of TBI in Ohio in 2014 broken down by deaths, hospitalizations 85 and older where the rate was approximately two times higher for males than females . The death rates and ED visits . In that year, 2,330 people died as a result of a TBI, 6,768 people were hospitalized, and 111,757 for both genders were somewhat consistent through age 64 and then began to increase significantly with people visited the ED . age . The rate for males 85 and older was 204 per 100,000 . For females, it was 95 per 100,000, showing a significant increased risk of death for males over the age of 85 who sustain a TBI . Note: The number of deaths for males and females in this age group was similar – 159 for females compared to 169 for males . Figure 2: Number and Age-Adjusted Death Rates for Traumatic Brain Injuries by Year, Ohio, 2000-2014 Number Rate Figure 4: Traumatic Brain Injury Deaths by Mechanism and Intent, Ohio, 2014 Number Rate 2,500 17.5 17.8 17.8 17.4 18.4 18.4 18.1 18.6 20.0 17.3 17.1 18.6 Struck By/Against… 2,500 16.7 17.5 16.617.8 17.8 16.617.4 18.4 18.4 18.1 20.0 18.0 Struck By/Against… 15.9 15.6 17.3 17.1 16.6 16.6 2,00015.9 16.7 18.0 16.0 15.6 t r 2,000 16.0 t r 14.0 1,500 14.0 12.0 nint nti na a s
100,000 nint nti na a s 1,500 12.0 2,260 2,268 2,238 2,330 10.0
100,000 2,136 2,156 2,330 10.0 1,000 1,921 1,999 2,009 2,060 1,986 2,023 2,1052,260 2,268 2,238 8.0 Suici 1,818 1,825 2,136 2,156 Suici 1,000 1,921 1,999 2,009 2,060 1,986 2,023 2,105 8.0 6.0 1,825 Per Rate Number of Deaths Number of 1,818 6.0 500 4.0 Per Rate Number of Deaths Number of 500 4.0 2.0 t r ic 0 2.0 0.0 t r ic ras s 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 0.0 ici ras s 2000 2001 2002 2003 2004 2005 2006 2007Year 2008 of Death 2009 2010 2011 2012 2013 2014 ici Year of Death Source: Ohio Department of Health, Vital Statistics Source: Ohio Department of Health, Vital Statistics Data from death certificates indicate that TBI deaths among Ohio residents fluctuated somewhat between 2000 and 2014 . However, there was an overall increase in both the rates and number of TBI deaths in 2014 Data show that unintentional falls (33 percent) were the foremost mechanism of injury for TBI deaths in 2014 . compared to 2000 . From 2000 to 2014, the death rate for TBI increased nearly 17 percent from 15 .9 per Suicide (28 percent) was the second-most-common injury followed by motor vehicle crashes (21 percent) . 100,000 to 18 6. per 100,000, and the number of deaths increased by 28 percent .
12 12 12 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 13 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Figure 5: Number and Age-Adjusted Rate for Traumatic Brain Injury Related Figure 7: Traumatic Brain Injury Hospitalizations by Mechanism and Intent, Ohio, 2014 1 8 Hospitalizations by Year, Ohio, 2002-201467 66 8 63 3 64 8 65 6 64 7 6 7 62 5 61 1 8 57 1 58 7 57 1
55 1 6 1 8 6 67 66 8 63 3 64 8 65 6 64 7 nint nti na 6 7 62 5 61 1 8 57 1 58 7 57 1 4 a s
55 1 6 4 7 2 7 7 5 4 7 612 7 35 7 855 7 641 7 413 7 336 Struck 6 541 6 83 7 3 6 51 6 768
6 1 By/Against 2 t r 2 4
4 7 612 7 35 7 855 7 2 7 7 5 4 7 641 7 413 7 3 7 336 t r ic 6 541 6 83 6 51 6 768 Suici
1 ras s 2 Att ts 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 2 1 2 11 2 12 2 13 2 14 2
Assau ts 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 2 1 2 11 2 12 2 13 2 14 Source: Ohio Hospital Association Source: Ohio Hospital Association Unintentional falls are the leading mechanism for TBIs that result in hospitalizations (37 percent) followed by The above figure shows that the hospitalization rates increased gradually from 2002 until 2007 when the motor vehicle crashes (24 percent) . The mechanism could not be determined for 24 percent of TBI-related rate was 67 .9 per 100,000 persons . Since 2007, the rate has decreased to 55 1. per 100,000 persons in 2014 . hospitalizations because an external cause of injury code (E-Code) was not reported . Although this appears to be a positive trend, it should be considered in light of a rising death rate and persistent rising number of ED visits .
Figure 6: Hospitalization Rates for Traumatic Brain Injuries by Gender and Age, Ohio, 2014
35
3 35 25 2
3 25 15 2 1 1 15 5 1
1 1 1‐4 5‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84 85 5 Source: Ohio Hospital 1 Association1‐4 5‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84 85 Hospitalization rates for TBI are lowest for both males and females ages 5 to 14 (23 .5 per 100,000 and 11 .8 per 100,000 respectively) . The highest rates are seen among those age 75 and older . Rates are higher among males than females for all age groups except for adults 85 and older, in which the female rate (334 per 100,000) is higher than the male rate (324 .2 per 100,000) .
13
14 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 13 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 15 14 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Table 1: Hospitalizations for Mild Traumatic Brain Injury (TBI) and All Other TBIs by Table 2: Hospitalizations for Mild Traumatic Brain Injury (TBI) and All Other TBIs by Demographic Characteristics, Ohio, 2014 Geographic Regions, Ohio, 2014
s ita i ati ns s ita i ati ns gra ic i B A t r ta gra ic i B A t r ta aract ristics u r rc nt u r rc nt u r rc nt aract ristics u r rc nt u r rc nt u r rc nt
ta gra ic gi n e 1 333 7 6 17 7 2 5 3 7 4 n r e 2 1 7 2 4 56 2 4 163 2 4 1 832 41 7 754 31 7 2 586 38 2 e 3 218 5 1 7 4 5 325 4 8 2 55 58 3 1 61 68 1 4 178 61 7 e 4 685 15 6 437 18 4 1122 16 6 4 2 4 1 e 5 782 17 8 324 13 6 11 6 16 3 e 6 386 8 8 1 4 8 2 58 8 6 Ag e 7 155 3 5 71 3 226 3 3 1 21 5 44 1 65 1 e 8 684 15 6 326 13 7 1 1 14 1‐4 Years 87 2 78 3 3 165 2 4 e 338 7 7 211 8 54 8 1 5‐14 Years 156 3 6 1 8 4 5 264 3 e 1 333 7 6 2 4 12 4 627 3 15‐24 Years 543 12 4 286 12 82 12 2 e 11 1 7 2 4 58 2 4 165 2 4 25‐34 Years 544 12 4 271 11 4 815 12 e 12 14 3 2 67 2 8 2 7 3 1 35‐44 Years 437 1 212 8 64 6 e 13 52 1 2 32 1 3 84 1 2 45‐54 5 2 11 4 2 4 12 4 7 6 11 8 e 14 71 1 6 3 1 3 1 1 1 5 55‐64 Years 517 11 8 34 14 7 866 12 8 65‐74 Years 431 8 211 8 642 5 Source: Ohio Hospital Association 75‐84 Years 564 12 8 282 11 846 12 5 85 58 13 4 242 1 2 831 12 3 Region 1 Defiance, Fulton, Henry, Lucas, Paulding, Williams, Wood Region 2 Allen, Auglaize, Hancock, Hardin, Mercer, Putnam, Van Wert ac / t nicity Region 3 Crawford, Erie, Huron, Ottawa, Richland, Sandusky, Seneca, Wyandot 3 45 78 6 1 81 76 1 5 26 77 7 Region 4 Cuyahoga, Geauga, Lake, Lorain 558 12 7 274 11 5 832 12 3 Region 5 Ashland, Holmes, Medina, Stark, Summit, Wayne 2 2 1 4 1 22 5 8 3 3 4 Region 6 Ashtabula, Columbiana, Mahoning, Portage, Trumbull 51 1 2 43 1 8 4 1 4 Region 7 Delaware, Knox, Marion, Morrow, Union 3 8 7 24 1 1 548 8 1 Region 8 Fairfield, Franklin, Licking, Madison, Pickaway Source: Ohio Hospital Association Region 9 Champaign, Clark, Darke, Greene, Logan, Miami, Montgomery, Preble, Shelby Region 10 Butler, Clermont, Clinton, Hamilton, Warren Region 11 Adams, Brown, Fayette, Highland, Pike, Ross, Scioto Of the 6,768 hospitalizations for TBI, 64 .9 percent (4,391 hospitalizations) were identified as mild . While males were more likely to be hospitalized for TBI than females overall; the proportion of hospitalizations for Region 12 Coshocton, Guernsey, Morgan, Muskingum, Noble, Perry, Tuscarawas males in the All Other category is greater than in the Mild TBI category, suggesting males had more severe Region 13 Belmont, Carroll, Harrison, Jefferson, Monroe, Washington injuries than females . The proportion of hospitalizations of persons age 65 and older was higher for mild TBI Region 14 Athens, Gallia, Hocking, Jackson, Lawrence, Meigs, Vinton compared to more severe injury .
16 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 17 16 15 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Figure 8: Number and Age-Adjusted Rate for Traumatic Brain Injury-Related Emergency Figure 10: Traumatic Brain Injury Emergency Department Visits by Mechanism, Ohio, 2014 Department Visits by Year, Ohio, 2002-2014 er a e 73 78 4 12 52 4 1 er a e 875 73 78 4 12 81 4 81 8 52 4 1 1 875 8
81 8 667 3 81 4 nint nti na Struck 1 634 7 a s 8 58 6 8 By/Against 667 3 527 6 6 5 8 3 634 7 8 461 2 468 3 58 6 6 5 nint nti na 527 6 6 Struck t r 5 8 3 1 7 585 111 757 a s 461 2 468 3 135 11 566 4 By/Against ic 6 1 576 2 6 8 5 4 1 7 585 111 757 ras s 71 562 75 4 135 11 566 3 a e er 1 t r er er s s 66 25 1 576 2 6 8 4 4 57 32 5 416 t r
52 878 a e er 1 51 53 71 562 75 4 3 2 er er s s 2 66 25 ic Assau ts 57 32 5 416 51 53 52 878 2 1 ras s 2 t r 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 2 1 2 11 2 12 2 13 2 14 Assau ts 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 2 1 2 11 2 12 2 13 2 14 Source: Ohio Hospital Association Source: Ohio Hospital Association Unintentional falls are the leading mechanism for TBI-related ED visits (41 percent) followed by struck by/against The rate of TBI-related ED visits increased steadily from 2002 (461 .2 per 100,000) to 2014 (978 .4 per (16 percent) and then motor vehicle crashes (12 percent) . The mechanism could not be determined for 19 100,000) . The youth athlete concussion law that was signed into legislation at the end of 2012 and put into percent of TBI-related ED visits because an external cause of injury code (E-code) was not reported . effect in 2013 is likely to account for some of the increase in TBI awareness, evaluation and treatment .
Figure 11: Number of Emergency Department Visits for Sports- and Recreation-Related Figure 9: Rates of Emergency Department Visits for Traumatic Brain Injuries by Gender Traumatic Brain Injuries by Cause of Injury, 18 Years of Age and Younger, Ohio, 2002-2014 and Age, Ohio, 2014 a es e a es 5 a es e a es 35 45 35 5 4 3
3 45 35
25
4 25 3 2 35 25 2 15 3 2 15 25 1 15 a e er 1 1 2 a e er 1 1 5 5 15 5 1 1 1‐4 5‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84 85 5 1 1‐4 5‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84 85 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 2 1 2 11 2 12 2 13 2 14 e e Years Years Source: Ohio Hospital Association 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 2 1 2 11 2 12 2 13 2 14 ED visits for TBI are highest at either end of the age spectrum, with the highest rates among adults 85 years The number of ED visits due to TBI for recreation-related activities among children age 0 to 18 remained stable of age and older followed by children age 1 to 4 . In 2014, females age 85 years and older led the number from 2002 to 2014, while TBIs related to sports activities increased during this time . It is not clear if this is due to of ED visits with approximately 2,500 visits per 100,000 . ED rates were higher among males than females an actual increase of occurrence, a greater recognition for the need for medical care, or improved reporting . for younger age groups (under age 25), and females had higher rates among the older age groups (55 and older) compared to males .
18 18 18 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 19 17 17 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Table 3: Emergency Department Visits for Mild Traumatic Brain Injury (TBI) and All Table 4: Emergency Department Visits for Mild Traumatic Brain Injury (TBI) and All Other TBIs by Demographic Characteristics, Ohio, 2014 Other TBIs by Geographic Regions, Ohio, 2014
rg ncy art nt isits rg ncy art nt isits i B A t r ta gra ic i B A t r ta gra ic aract ristics u r rc nt u r rc nt u r rc nt aract ristics u r rc nt u r rc nt u r rc nt
gra ic gi n ta e 1 7 55 6 4 42 4 6 7 7 6 4 e 2 2246 2 31 3 4 2277 2 n r e 3 5 2 4 5 62 6 8 5 1 4 6 55 446 5 355 38 8 55 8 1 4 e 4 1872 16 13 14 2 1885 16 55 3 3 5 558 61 1 55 51 5 1 e 5 143 12 1 6 11 6 144 6 12 4 1 1 5 e 6 8767 7 56 6 1 8823 7 e 7 3388 3 1 36 3 3424 3 1 Ag e 8 1452 13 1 4 1 3 14614 13 1 1 1 16 1 22 2 4 1 182 1 1 e 13848 12 5 1 3 11 3 13 51 12 5 1‐4 Years 1 758 7 45 4 1 8 3 7 e 1 13715 12 4 141 15 4 13856 12 4 5‐14 Years 15 6 14 1 7 7 7 15 67 14 e 11 3 48 2 7 34 3 7 3 82 2 8 15‐24 Years 2 66 18 6 121 13 2 2 7 18 6 e 12 28 2 2 5 36 3 2838 2 5 e 13 2115 1 2 2 2 2135 1 25‐34 Years 13 575 12 2 1 2 11 2 13 677 12 2 e 14 1281 1 2 23 2 5 13 4 1 2 35‐44 Years 862 8 1 2 11 2 64 8 45‐54 Years 511 8 6 1 2 11 2 613 8 6 Source: Ohio Hospital Association 55‐64 Years 8 485 7 7 8 1 7 8 583 7 7 65‐74 Years 6 785 6 1 7 8 6 6 864 6 1 Region 1 Defiance, Fulton, Henry, Lucas, Paulding, Williams, Wood 75‐84 Years 7 27 6 6 2 1 1 7 371 6 6 Region 2 Allen, Auglaize, Hancock, Hardin, Mercer, Putnam, Van Wert 85 7 15 6 5 81 8 7 231 6 5 Region 3 Crawford, Erie, Huron, Ottawa, Richland, Sandusky, Seneca, Wyandot Region 4 Cuyahoga, Geauga, Lake, Lorain ac / t nicity Region 5 Ashland, Holmes, Medina, Stark, Summit, Wayne 85 165 76 8 734 8 3 85 8 76 Region 6 Ashtabula, Columbiana, Mahoning, Portage, Trumbull 16 182 14 6 81 8 16 263 14 6 Region 7 Delaware, Knox, Marion, Morrow, Union 75 1 75 1 Region 8 Fairfield, Franklin, Licking, Madison, Pickaway 53 5 7 8 537 5 Region 9 Champaign, Clark, Darke, Greene, Logan, Miami, Montgomery, Preble, Shelby 2 241 2 2 2 2 2 261 2 6 65 6 72 7 6 722 6 Region 10 Butler, Clermont, Clinton, Hamilton, Warren Source: Ohio Hospital Association Region 11 Adams, Brown, Fayette, Highland, Pike, Ross, Scioto Region 12 Coshocton, Guernsey, Morgan, Muskingum, Noble, Perry, Tuscarawas
Region 13 Belmont, Carroll, Harrison, Jefferson, Monroe, Washington Region 14 Athens, Gallia, Hocking, Jackson, Lawrence, Meigs, Vinton
1 20 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 21 2 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Inclusion Criteria The following are the inclusion criteria used by each hospital to determine which injury cases shall be submitted to the Ohio Trauma Registry (OTR):
1 . It is the first time the patient has been admitted for the injury, and the patient meets one of the below Section 2 inclusion criteria; OR
2 . The patient was transferred into or out of any hospital, regardless of the length of stay, and the patient meets one of the below inclusion criteria; OR
3 . The patient was dead on arrival and meets one of the below inclusion criteria; OR
4 . The patient died after receiving any evaluation or treatment while on hospital premises, and the patient meets one of the below inclusion criteria .
International Classification of Diseases-9-Clinical Modification (ICD-9-CM) Diagnosis Codes on Discharge From Acute Care Hospital
iagn sis iagn sis s s iagn sis iagn sis scri ti ns scri ti ns
ractur s ractur s ractur s ractur s is cati ns/s rains is cati ns/s rains intracrania intracrania in ury in ury int rna int rna in uryin ury t ra t ra a na n an an is is n n un s un s in uryin ury t t ss s ss s A rasi ns/ ricti nA rasi ns/ ricti n urns urns t t trunk trunk s u rs u r an an u ru r ar ar A rasi ns/ ricti nA rasi ns/ ricti n urns urns t t i i t ig t ig g g ank ank t r t r r r u ti u ti sit ssit s ntusi ns ntusi ns an an crus crus in uri sin uri s Burns Burns in uryin ury t t n r sn r s an an s ina s ina c r c r trau atictrau atic c icati nsc icati ns an an uns ci i uns ci i in uryin ury S k S k in a ati nin a ati n r st it r st it y t r ia y t r ia an an t rna t rna cts cts c c As y iati n As y iati n strangu ati n strangu ati n r ning r ning an an ctr cuti n ctr cuti n i i a tr at nt a tr at nt an an a us a us Ohio Trauma Registry Data From the Ohio Exclusion c usi n c usi n Criteria: rit ria rit ria Excluded c u c u iagn s s iagn s s Diagnoses an an and ICD-9-CM s s Codes
Department of Public Safety Division of s at s at i i ractur ractur Emergency Medical Services at at cts cts in uryin ury Su r icia Su r icia a rasi ns a rasi ns ist rs ist rs an an ins ctins ct it s it s r ign r ign i s i s
2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 23 2222 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Selection Criteria Figure 13: Traumatic Brain Injury Records by Mechanism of Injury, Ohio, 2014* This report is based on Ohio Trauma Registry (OTR) data on patients with traumatic brain injury (TBI) who were discharged from any acute care hospital in Ohio . Appropriate cases for this report were selected based on the OTR patient inclusion criteria defined above as well as the following ICD-9-CM codes: • 800 0-801. .9 – Fracture of vault or base of the skull • 803 0-804. 0. – Other and unqualified and multiple fractures of the skull • 850 0-854. 1. – Intracranial injury, including concussion, contusion, laceration, and subarachnoid, subdural, extradural and other hemorrhage(s)
• 959 01. – Unspecified head injury
Data From the Ohio Trauma Registry
Overall, TBI-related hospitalizations increased between 2003 and 2014 . However, in 2013, Ohio removed the “48-hour rule,” which excluded patients from the reporting data set of TBI patients if their admission to Other Cause ‐ Unspecified a hospital or acute care facility was less than 48 hours . This change resulted in the addition of reported cases of patients who presented with less severe injuries necessitating shorter lengths of stay . Such cases Other Cause ‐ were not counted in prior periods due to the 48-hour rule . Because the additional case counts extend to individuals with less severe injuries, the number of survivors has increased .
The change in data collection methodology in 2013 makes it difficult to make direct comparisons . However, what remains clear is that more people are surviving TBIs . Whether this is due to severity of injury, age of the injured party or improved trauma-care measures, the fact remains that, as more individuals survive, the 1 4 5 demand for additional treatment and rehabilitation services becomes greater . Figure 12: Number of Traumatic Brain Injury Records by Age Group and Gender, Ohio, 2014* Source: Ohio Department of Public Safety Division of Emergency Medical Services, Ohio Trauma Registry 14 *12 records where the injury mechanism was not recorded (blank, N/A or unknown) were excluded a e **Other Cause - Specified also includes inhalation, overexertion, submersion/suffocation, poisoning, fire/burn and natural/environmental
12 e a e Falls were responsible for 54 percent of all TBIs in 2014 . Falls continue to lead all mechanisms of TBI in Ohio . Both falls and motor vehicle collisions accounted for about 75 percent of all TBIs in 2014 .
1 The vast majority of TBI-related records reported were due to blunt force trauma, which accounted for more than 95 percent of all TBI injuries in 2014 . Blunt trauma has been the leading injury type of all TBI- related hospitalizations since 2007 . Although the number of TBI incidences caused by penetrating trauma is 8 comparatively small, this type of injury is the leading cause of TBI-related death, and it accounted for a case fatality rate of 35 3. percent in 2014 . 6
er er e r s
4
2
‐4 5‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84 ≥ 85 e r s Source: Ohio Department of Public Safety Division of Emergency Medical Services, Ohio Trauma Registry *29 TBI records where age group and gender were not recorded (blank or unknown) were excluded
Of the records reported in 2014, the incidence of TBI was high among the male population, especially for those age 15 to 64 years old . In the female population, the incidence of TBI was higher among those age 75 and older .
5 24 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 25
24 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Figure 14: Number of Traumatic Brain Injury Records by Injury Location, Ohio, 2014* Figure 15: Traumatic Brain Injury Records by Hospital Discharge Disposition, Ohio, 2014*
e ith ut er ices i ed ursin aci it npatient eha r esi nated Unit eceased
e ith er ices Another Type of Rehabilitation or Long‐Term Care aci it
spice eft ainst edica d ice r isc ntinued Care
u er f u er f ec rds Long‐Term Care Hospital (LTCH) ransferred t n ther spita nter ediate Care aci it C urt a nf rce ent s chiatric spita r s chiatric istinct art f a spita
ercenta e f ec rds
Source: Ohio Department of Public Safety Division of Emergency Medical Services, Ohio Trauma Registry *3,246 records where the discharge destination was not recorded (blank) were excluded Source: Ohio Department of Public Safety Division of Emergency Medical Services, Ohio Trauma Registry *422 records where the injury location was not recorded (blank) were excluded In 2014, the majority of discharges from acute care hospitals after TBI were to home (64 7. percent, with or without services) . Most people discharged to home were not provided further services . More than 15 percent The majority of TBI incidences reported occurred in the home . In 2014, 40 1. percent of TBI injuries occurred were discharged to a skilled nursing facility, and nearly 6 percent were discharged to some sort of inpatient at home . This correlates with the fact that falls are the leading mechanism of injury among TBI patients . The rehabilitation facility . second-most-common site of injury is streets . This relates to the second-most-common mechanism of injury, motor vehicle accidents .
26 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 27 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Limitations of the Data As with any large data set, OTR data have inherent limitations and weaknesses . Identified limitations and weaknesses include:
• All hospitals that provide initial treatment to persons with traumatic injury are required by law to submit Section 3 data to the Ohio Trauma Registry . However, as no enforcement authority was provided in this law, not all hospitals contribute . To date, approximately 85 percent of hospitals required to report data to the OTR did so during the time period covered in this report .
• For various administrative reasons, hospitals that routinely submit the required data to the OTR are unable to identify or submit all cases meeting inclusion criteria .
• Prior to 2013, the trauma data set excluded patients with TBI who had a hospital length of stay of less than 48 hours . However, these patients are now included . Consideration of this point is particularly relevant to all case fatality rates discussed within this document and discussion of age groups at high risk for TBI .
• Evaluation of injury severity scoring (ISS) data in relation to TBI would add considerable value to the study topic, but because there is no statewide consistency in the application of ISS (largely due to the lack of formal and standardized training), the information was excluded from this report .
• Data collection requirements for the Ohio Department of Public Safety data set do not include prevalence data but are limited to incidence data only . As a result, the current registry data can provide only an indication of the occurrence of new TBI cases . In addition, the data set does not address the ultimate post-discharge outcome for patients who have sustained a TBI, nor does it address eventual cognitive or functional capacity or the quality of life for those with TBI in Ohio .
• Financial data are excluded from this report, because information is not reliably reported to the OTR . Charges billed are not consistently reported throughout the state, and the data are considered flawed . Payer data, while reported more reliably than charges billed, are still considered suspect . This is largely because payer data are collected based on how the patient expects to pay for the treatment at the time of registration . Final determination of the true primary payer frequently remains undetermined for periods of time that may reach six months to a year following discharge .
• Indviduals who die of TBI before transport to a hospital are not included in this data set . It would be necessary to include statewide coroners’ data to complete the picture of all deaths due to TBI .
Ohio Traumatic Brain Injury Prevalence Data From the Behavioral Risk Factor Surveillance
Survey, Ohio Valley Center for Brain Injury Prevention and Rehabilitation at The Ohio
28 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Data Collection Table 5: Lifetime Prevalence of Traumatic Brain Injury With Loss of Consciousness (LOC) by Demographic Characteristics, Ohio, 2014 The Traumatic Brain Injury Identification Method was developed by the Ohio Valley Center for Brain Injury Prevention and Rehabilitation at The Ohio State University Wexner Medical Center . It was adapted for ra B it the state of Ohio’s Behavioral Risk Factor Surveillance System (BRFSS) survey in 2014 in order to provide gra ic aract ristics Sa vital information on the lifetime prevalence of traumatic brain injury (TBI) in the Ohio adult population . It is particularly important, because while population estimates of the annual incidence of TBI are available from Sa i sti at hospital discharge and trauma registry data (as provided in previous sections of this report), there are no data available on how many Ohioans have had a TBI and whether there is an association with health and ta function . This is a critical piece of information in terms of defining the current societal impact of TBI . S The BRFSS was developed by the Centers for Disease Control and Prevention (CDC) to allow continuous ale 24.3‐29.6 surveying of health issues in every state . The Ohio Department of Health oversees Ohio’s BRFSS survey . emale 15.0‐18.7 Data are collected through random digit dialing of adult, noninstitutionalized Ohio residents . Ag 18‐24 19.4‐32.7 The TBI module, which was included in the 2014 Ohio survey, was designed to estimate the prevalence of a 25‐34 20.4‐30.9 lifetime history of TBI among adult Ohioans according to these dimensions: 35‐44 20.8‐30.0 45‐64 19.4‐23.6 • The number of Ohio adults who have experienced a mild, moderate or severe TBI as their most severe TBI 11.9‐15.7 • The number of Ohio adults who experienced their first TBI in childhood ac / t nicity hite 20.6‐24.1 • The proportion of mild, moderate and severe TBIs that have resulted from specific etiologies la 10.6‐21.6 ther 15.2‐26.4 • The proportion of childhood TBIs that have resulted from specific etiologies arita Status • The relationships between history of TBI and risk factors for poor health and quality of life arrie 17.2‐21.0 e er arrie 22.4‐31.6 All lse 19.7‐25.4 i r n i ing in ur us 18.9‐22.6 20.0‐29.9 14.3‐24.3 20.1‐33.7 ig st ucati n t High hool 17.9‐28.9 H egree or 18.5‐23.9 Some Post‐High School 21.6‐28.2 College egree or ore 15.3‐19.9 y nt Status Employed/Self‐Employed 19.4‐23.8 ee ing mployment 18.4‐34.0 Retire 13.3‐18.0 nable to or 30.7‐42.3 Homema er 11.7‐22.7 t ent 12.2‐33.3 Annua us nc 23.6‐35.0 $15,000‐$24,999 22.1‐31.1 $25,000‐$34,999 16.8‐26.3 $35,000‐$49,999 14.7‐23.1 17.1‐22.1 Source: Behavioral Risk Factor Surveillance System, including module on lifetime history of traumatic brain injury
30 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 31 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Table 6: Lifetime Traumatic Brain Injury With Loss of Consciousness (LOC) by Current Figure 16: Health Conditions and Behaviors, Ohio, 2014
ri nc u r B s S rity rst B Ag irst B a i ti ra i it i it ist ry rat B r A t r in urr nt a t n iti ns an B a i rs B t S r Ag Ag in
sti at sti at sti at s sti at sti at sti at sti at sti at sti at sti at sti at u r
hio 8,366,791 100.0 21.7 13.5 4.5 3.7 10.7 4.9 2.7 9.1 12.3
y is ility 1,984,904 23.7 35.0 29.7 44.8 42.1 27.5 41.0 44.2 34.0 35.6
Disability ‐ Vision 349,554 5.2 9.1 7.5 10.5 13.7 6.8 8.0 13.5 10.6 7.8 Disability ‐ Cognition 968,341 13.2 25.7 20.2 36.0 33.5 19.0 31.0 35.7 25.5 25.4 Disability ‐ Mobility 1,220,267 16.1 24.7 20.7 31.5 31.9 19.0 28.8 34.1 20.9 27.6
Disability ‐ Self‐Care 320,736 4.8 10.2 7.3 13.5 17.7 5.7 13.4 18.3 9.0 11.2 Disability ‐ Independent Living 618,215 8.8 16.4 10.4 27.4 25.6 10.7 22.1 21.3 17.2 16.1
i o Poo e e l He lth 1,537,232 18.4 25.9 22.8 25.8 37.4 22.1 27.5 29.4 24.1 27.0
1‐7 Days of Physical Health Not Good 1,823,387 21.8 23.4 22.4 28.2 21.1 25.4 23.3 23.4 21.5 25.2 8‐30 Days of Physical Health Not Good 1,333,267 15.9 23.7 20.0 26.2 34.0 19.3 26.5 27.1 24.9 23.4
1‐7 Days of Poor Health Keeping From Activities 973,800 11.6 13.5 13.5 17.1 8.8 13.8 16.7 12.7 12.1 14.7
8‐30 Days of Poor Health Keeping From Activities 935,458 11.2 19.0 15.4 23.1 27.0 14.6 25.2 22.2 22.4 16.9 h o ic He lth P o lem1 4,846,432 57.9 65.8 64.4 69.0 67.0 60.2 66.4 76.1 67.1 64.9
Sleepi g 7 Ho s o e ge Pe y 3,195,472 38.5 48.2 43.4 54.5 57.8 45.7 51.9 48.7 49.6 46.4 i ge i i g2 25.5 22.3 28.8 33.0 29.5 26.3 19.4 24.0 25.3
He y i i g3 10.2 10.0 7.9 13.8 10.9 11.3 7.3 9.3 9.3
Smo e 29.4 22.5 42.3 38.9 23.6 38.1 36.0 30.8 28.2 ep essi e iso de 30.8 27.2 37.4 35.7 24.7 34.9 39.9 34.8 27.3 Figure 17: e t l He lth ot ood4 27.3 23.9 34.3 31.1 22.7 33.1 26.3 31.9 23.5
Source: Behavioral Risk Factor Surveillance System, including module on lifetime history of traumatic brain injury
1 Chronic Health Problem includes heart attack; angina or coronary health disease; stroke; asthma; skin cancer; other types of cancer; chronic obstructive pulmonary disease, emphysema or chronic bronchitis; some form of arthritis, rheumatoid arthritis, gout, lupus or fibromyalgia; depressive disorder, including depression, major depression, dysthymia or minor depression; and kidney disease and diabetes (not pregnancy-related) . 2 Binge Drinking is defined as males having five or more drinks on one occasion and females having four or more drinks on one occasion . 3 Heavy Drinking is defined as males having more than two drinks per day and females having more than one drink per day . 4 Mental Health Not Good reflects mental health reported as not good on more than five days in the past 30 days .
32
32 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 3333 33 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
Table 6: Lifetime Prevalence of Traumatic Brain Injury With Loss of Consciousness Data from the lifetime history of the TBI module of the BRFSS have produced significant insight into the (LOC) by Region, Ohio, 2014 prevalence of TBI in the Ohio population and the impact of injuries over time in terms of long-term disability, behavioral problems, employment and quality of life .
u r B s S rity rst B Ag irst B Findings from the 2014 survey include: ri nc a i ra i ti i it it rat B r A t r • The number of adults in Ohio who have had at least one TBI with loss of consciousness is . ist ry B in 1.8 million gi n in t S r Ag Ag • Even a brief loss of consciousness once in a lifetime is associated with subsequent health problems, Sa sti at sti at s sti at sti at sti at sti at sti at sti at sti at sti at including smoking, heavy alcohol consumption, chronic illness, emotional disturbances and chronic pain . u r u r • The number of adults in Ohio who have sustained at least one moderate or severe TBI is 219,000 .
hio 8 8 3 7 1 1 7 13 3 7 10 7 1 1 3 • The number of people who sustained at least one TBI with loss of consciousness before age 15 is egion 1 01 8 7 1 3 3 13 3 7 1 7 1 750,000 . egion 71 7 71 1 7 10 0 3 1 1 8 1 0 8 8 7 • There is a relationship between the level of education achieved, the age of injury, and the worst TBI egion 3 330 7 1 1 7 3 8 0 8 1 0 7 3 11 8 sustained by an individual, suggesting that injuries in childhood could have influenced educational egion 1 7 37 1 0 1 7 3 7 3 8 7 11 attainment . egion 1 11 1 11 10 3 7 1 8 11 • More severe TBI is correlated with less chance of gaining a college degree . egion 1 31 7 17 0 8 13 7 7 1 7 1 11 8 • Those with the lowest incomes are more likely to have had a severe TBI . egion 7 77 8 18 1 1 3 1 1 3 0 7 11 egion 8 1 1 0 8 3 1 13 1 3 8 11 3 0 13 1 • The chance of having a chronic disease doubles when a person experiences a TBI with loss of egion 1 8 8 30 1 7 1 1 1 3 8 13 consciousness . egion 10 1 0 1 781 1 1 0 0 7 3 1 7 3 11 • A history of TBI more than doubles the likelihood of having a disability as an adult . egion 11 0 7 8 3 3 13 3 8 7 3 7 1 17 0 • Almost one in three adults (636,000) with a disability in Ohio have had a TBI with loss of consciousness . 08 7 118 0 1 0 3 10 3 7 1 egion 1 Almost one in 20 adults (97,000) with a disability in Ohio have had a moderate or severe TBI . egion 13 0 33 10 18 3 3 13 0 0 10 1 3 egion 1 78 1 8 33 7 1 11 3 8 1 1 • Appalachian regions of Ohio have more than twice the rate of residents who have had at least one moderate or severe TBI . Source: Behavioral Risk Factor Surveillance System, including module on lifetime history of traumatic brain injury These remarkable findings demonstrate that TBI is not just a problem of incidence . The prevalence of TBI in Region 1 Defiance, Fulton, Henry, Lucas, Paulding, Williams, Wood the population expands the magnitude and impact of this injury in both numbers and complexity, as these Region 2 Allen, Auglaize, Hancock, Hardin, Mercer, Putnam, Van Wert injuries are associated with poorer living situations, health and disability . Region 3 Crawford, Erie, Huron, Ottawa, Richland, Sandusky, Seneca, Wyandot Region 4 Cuyahoga, Geauga, Lake, Lorain Region 5 Ashland, Holmes, Medina, Stark, Summit, Wayne Region 6 Ashtabula, Columbiana, Mahoning, Portage, Trumbull Region 7 Delaware, Knox, Marion, Morrow, Union Region 8 Fai rfield, Franklin, Licking, Madison, Pickaway Region 9 Champaign, Clark, Darke, Greene, Logan, Miami, Montgomery, Preble, Shelby Region 10 Butler, Clermont, Clinton, Hamilton, Warren Region 11 Adams, Brown, Fayette, Highland, Pike, Ross, Scioto Region 12 Coshocton, Guernsey, Morgan, Muskingum, Noble, Perry, Tuscarawas Region 13 Belmont, Carroll, Harrison, Jefferson, Monroe, Washington Region 14 Athens, Gallia, Hocking, Jackson, Lawrence, Meigs, Vinton 3
34 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 35 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
The previous report sections describe the scope and impact of the incidence and prevalence of traumatic brain injury (TBI) in the Ohio population, primarily in a single year: 2014 . As alarming as the incidence figures may be, they only begin to convey the real impact of TBI on individuals, families and society . Due to functional changes that frequently follow the more severe injuries, long-term disability results from impairments in cognition, affect, behavior and/or motor abilities . These disabilities affect the long-term health and well-being of individuals and frequently reduce or eliminate the earning capacity of individuals who Section 4 are injured or family members who have to assume care-taking responsibilities . Lost wages to the family compound economic consequences from massive expenditures for medical care and support services .
The following table shows the financial impact of the 2014 TBI experience in Ohio as estimated by the CDC .
Table 7: Estimated Total Lifetime Costs of Traumatic Brain Injury for Deaths, Hospitalizations and Emergency Department Visits*
u r ica st rk ss st in st n uri s at s 330 7 3 000 1 0 000 s ita i ati ns 7 8 73 7 000 1 31 1 3 000 rg ncy 111 7 7 7 701 000 8 011 000 art nt isits A
*Source of cost data: CDC Web-based Injury Statistics Query and Reporting System cost of injury reports 1Source for number of deaths: Ohio Department of Health, Vital Statistics 2Source for number of hospitalizations and emergency department visits: Ohio Hospital Association
These costs represent the long-term burden to both families and society for each person injured in 2014 . If additional indirect costs (for example, public assistance, Medicaid, long-term care and assisted living) were added, the ultimate costs would be staggering . While additional research is needed to define the financial model with precision, there is evidence building that the societal burden of TBI can be reduced by the introduction of measures commonly accepted in the long-term management of chronic disease . That is, providing the right treatment at the right time according to the right method and carefully watching for signs of progression or deterioration .
Methodologies to apply such principles to the long-term management of TBI in a cost-effective manner are beginning to emerge from much needed research studies and practical models . The results they produce are compelling in offering solutions to the societal costs generated by the TBI experience .
The Costs of Traumatic Brain Injury: Supporting Research The research studies below show how implementing treatment guidelines and support services help Can They Be Reduced? reduce the costs of TBI. 2007 Cost-Benefit Study A study conducted by a team of CDC researchers and published in the Journal of Trauma Injury, Infection, and Critical Care looked at whether a set of clinical treatment guidelines from the Brain Trauma Foundation would reduce the costs of treatment for adults with severe TBI . The cost points included were direct medical costs (hospital and rehabilitation) and societal costs (lost wages) . The study found that the treatment guidelines affected outcomes and costs in the following ways: • Reduced deaths for severely injured patients age 12 and older by 15 percent . • Increased the proportion of patients with good outcomes from 35 percent to 66 percent . • Decreased the proportion of patients with poor outcomes from 34 percent to 19 percent . 37
2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 37 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE
The researchers concluded that these improved outcomes influenced the associated short- and long-term costs as follows: • Medical costs were reduced by $11,280 per person . • Total direct medical costs were reduced by $262 million . • Annual rehabilitation costs were reduced by $43 million . • Lifetime societal costs were reduced by $3 .84 billion .
2013 Literature Review An extensive literature review published in the peer-reviewed journal ClinicoEconomics and Outcomes Research analyzed nine online journal databases to estimate the long-term costs of TBI . The researchers focused on cost-impact factors and mitigating factors such as the implementation of Brain Trauma Foundation treatment guidelines and post-acute TBI rehabilitation . The review cited significant immediate and long-term personal, familial and societal costs due to the persistent residual or progressive effects of TBI . Conclusions from the review to highlight include: • At one year post-injury, 52 percent of 3,000 cases of serious TBI remained moderately to severely disabled . • At four years post-injury, most of these survivors neither worked nor attended school . • There was a marked risk of social isolation and psychological distress and unemployment . • Annual life care costs for a survivor without rehabilitation were 77 percent higher than for a survivor placed in supervised home care .
2011 Economic Impact Study and 2016 Controlled Study Conclusions
A 2011 study published by the Ball State University Center for Business and Economic Research estimated These statistics represent the staggering human and societal impact that is traumatic brain injury (TBI) . The that providing a package of specific support and coordination services designed to help TBI survivors number of individuals and families who must cope with both the short- and long-term consequences of TBI in Indiana return to work and community living could help avoid over $31 million in annual lost wages grows yearly, as does the challenge to all aspects of society, including the education system, the workplace, when applied to the Indiana population average salary of $30,925 . The authors pointed out that their public financing of medical and support services and quality of life . In short, TBI is a major public health methodologies do not address the additional societal costs of lost business and personal tax revenues, enemy that requires a concentrated public policy solution . which eventually affect public health systems like Medicare and Medicaid . Many other states have invested in programs that assist individuals and their families with care, treatment In 2016, a controlled study published in the Archives of Physical Medicine and Rehabilitation found a and support as they make their journey to recovery . Regrettably, Ohio has yet to take similar action . The significant improvement in return-to-work and community living after this same package of support and Brain Injury Advisory Committee concludes this report with the strong recommendation that Ohio adopt a coordination services was provided to TBI survivors in Indiana . The survivors who received support services public policy initiative that brings a comprehensive action plan to improve access and quality of care for achieved a 64 percent return-to-work rate, while the study control group who did not receive these services Ohioans with brain injury and their families . only achieved a 40 and 50 percent rate . In addition, TBI survivors who received support services had a seven times higher chance of achieving productive participation in the community (defined as competitive employment, return to school, or volunteering) .
The significant improvement in return-to-work moved the state of Indiana to support a Resource Facilitation Program through the Rehabilitation Hospital of Indiana . The program gives the TBI survivor a return-to- work or return-to-school goal as well as an individualized package of services to identify likely employment opportunities and community resources .
Although research concerning the societal costs of TBI needs to be expanded, the work done thus far shows immense opportunities to substantially reduce societal costs by recognizing the value of established best practices as well as specific support systems designed to meet the physical, educational and psychosocial needs of TBI survivors . The TBI cost paradigm presents a “pay me now or pay me later” scenario . We advocate a prevention strategy that establishes cost avoidance by promoting optimal recovery and function .
38 | 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO 2017 BIENNIAL REPORT ON THE INCIDENCE OF TRAUMATIC BRAIN INJURY IN OHIO | 39 THE OHIO BRAIN INJURY PROGRAM AND THE BRAIN INJURY ADVISORY COMMITTEE