Burden of traumatic brain injury in North Carolina

              THE BURDEN OF
Traumatic Brain Injury (TBI)
in
North Carolina
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 1 of 29
THE BURDEN OF
Traumatic Brain Injury
in North Carolina
May 2010
Katherine J. Harmon, MPH
State of North Carolina • Beverly Eaves Perdue, Governor
Department of Health and Human Services
Lanier M. Cansler, Secretary
Division of Public Health • Jeffrey P. Engel, State Health Director
Injury and Violence Prevention Branch
www.ncdhhs.gov • www.ncpublichealth.com • www.injuryfreenc.ncdhhs.gov
The North Carolina Department of Health and Human Services is an equal opportunity employer and provider. 05/10
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 2 of 29
Acknowledgements:
Contributors and Reviewers
Scott K. Proescholdbell, MPH
Head, Epidemiology and Surveillance Unit
Injury and Violence Prevention Branch, North Carolina Division of Public Health
Janice (Jan) K. White, M. Ed.
Traumatic Brain Injury Program Manager
Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
Sharon Schiro, PhD
Injury Surveillance Consultant
Injury and Violence Prevention Branch, North Carolina Division of Public Health
Associate Professor, Department of Surgery, University of North Carolina-Chapel Hill
We would like to acknowledge and thank our colleagues who contributed their time in reviewing and commenting on
early drafts of this report. This includes Becca Byrd and Jennifer Woody of the North Carolina Injury and Violence
Prevention Branch; Joan Kaye of the Division of Mental Health; Developmental Disabilities, and Substance Abuse Services;
Kathleen Jones-Vessey and Dianne Enright of the North Carolina State Center for Health Statistics; Sandra Farmer of the
Brain Injury Association of North Carolina; and Marilyn Lash and Carol Ornitz of the Brain Injury Advisory Council.
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 3 of 29
Table of Contents:
Section One: Overview and Trends of Traumatic Brain Injuries (TBIs) in North Carolina 5
Figure 1: Percent of Injury Deaths due to TBIs 5
Figure 2: The Injury Iceberg—TBI Injuries 6
Figure 3: Rates of TBI Deaths 7
Section Two: Demographics of TBI Deaths 8
Table 1: Gender, Race, Hispanic-Ethnicity, and Age of Deaths due to TBIs 9
Figure 4: Rates of TBI Deaths by Gender and Age 10
Section Three: TBI Deaths by County from 2006 to 2008 11
Figure 5: Rates of TBI Deaths by County 11
Section Four: Demographics of TBI Hospitalizations and Emergency Department (ED) Visits 12
Table 2: Gender and Age of Deaths, Hospital Discharges, and Emergency
Department (ED) Visits due to TBI 12
Section Five: Manner of Injury 13
Figure 6: Reported Manner of Injury of TBI Deaths, Hospital Discharges, and ED Visits 13
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 4 of 29
Section Six: Causes of TBI Injuries 14
Figure 7: Leading Causes of TBI Deaths 14
Figure 8: Leading Causes of TBI Deaths by Gender 15
Figure 9: Male Deaths by Age and Cause of TBI 16
Figure 10: Female Deaths by Age and Cause of TBI 17
Figure 11: Percent Difference in Rates of Leading Causes of TBI Death between
2000 and 2008 18
Figure 12: Leading Causes of TBIs—Hospitalizations 19
Figure 13: Leading Causes of TBIs—ED Visits 20
Section 7: Conclusions 21
Section 8: Additional Sources of Information 22
Section 9: Notes 23
Section 10: Glossary 24
Section 11: References 26
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 5 of 29
Figure 1: Percent of Injury Deaths due to Traumatic
Brain Injuries (TBI): North Carolina Residents, 2008
Data: NC Center for Health Statistics, 2008
Analysis: Injury Epidemiology and Surveillance Unit
Overview and Trends of Traumatic
Brain Injuries (TBI) in North Carolina:
Injury is the third-leading cause of death in North
Carolina; only heart disease and cancer cause
more deaths in the state1. Injury is the leading
cause of death in individuals between the ages of
one and 442. In 2008 alone, injury was cited as the
primary cause of death in 6,275 deaths.
One of the more common forms of injury in North
Carolina is traumatic brain injury (TBI). Although
TBI is not a manner or specific cause of injury, its
frequency and potential for both disability and
death warrant attention. In 2008, 1,903 deaths
were due to TBI. TBIs accounted for about 30
percent of all injury deaths (Figure 1).
American Indians have the highest rate of
death due to TBIs in North Carolina.
In 2008, the rate of death due to TBIs
increased with increasing age. Individuals
over the age of 84 have the highest
mortality rates for all age groups.
The three most common causes of TBI
deaths were firearms, motor vehicle-traffic
(MVT) crashes, and falls.
Highlights:
In 2008, 1,903 North Carolina residents died
after sustaining a traumatic brain injury
(TBI).
TBIs accounted for 30 percent of all injury
deaths in 2008.
The rate of TBI deaths is 20.6 per 100,000
North Carolina residents.
Males are nearly three times as likely to die
from TBIs as females.
SECTION 1
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 6 of 29
SECTION 1
TBIs occur when acute trauma damages the brain and may lead to a closed or penetrating head injury3. The
Centers for Disease Control and Prevention refer to TBI as the “silent epidemic”, because many of the signs,
symptoms, and sequelae of TBI, such as memory loss, are not readily recognized by the public. TBIs vary in
severity from mild injuries that require minimal medical attention to severe injuries that may cause death or
life-long disability. In the United States, approximately 50,000 people die, 235,000 people are hospitalized,
and 1.1 million people visit an emergency department (ED) due to a TBI each year4. These numbers do not
reflect the untold thousands who visit a primary care physician or seek no medical attention. Of the many
who survive their injuries, about 80,000 will suffer some form of disability3.
The Injury Iceberg illustrates the overall burden that TBI has on the population of North Carolina. Deaths
account for only the “tip” of the iceberg in regards to TBI injuries. For each death, there are 3.9
hospitalizations and 26.9 ED visits5, 6, 7. Surveillance data are not available for outpatient clinics or for TBIs
that are not medically attended; however, these numbers are likely to be far higher than the number of ED
visits (Figure 2).
Figure 2: The Injury Iceberg—TBI Injuries: North Carolina Residents, 2007 and 2008
1,903
Deaths*
7,441
Hospitalizations†
51,259 Emergency
Department Visits*
???Outpatient Visits???
?????Medically Unattended Injuries
(Home, Work, School)?????
Ratio
1.0
3.9
26.9
???
?????
Data: NC Center for Health Statistics, 2007, 2008; NC DETECT, 2008
Analysis: Injury Epidemiology and Surveillance Unit
*Data is from 2008.
†Data is from 2007.
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 7 of 29
SECTION 1
Figure 3: Rates of TBI Deaths: North Carolina Residents, 2000-2008
Deaths from TBIs have remained relatively stable over the last decade. The average rate of death from TBI
between 2000 and 2008 was 21.6 (95 percent confidence interval (CI) 21.3-21.9; see Notes). In 2008, the
rate of TBI death was 20.6, slightly less than the average rate observed between 2000 and 2008 for North
Carolina residents (Figure 3).
Although national TBI data are not available for 2008, the fatality rate for the most recent year available
(2005) was 18.28. Nationally, TBI deaths and hospitalizations appear to have declined over the past few
decades, although this trend is not uniform for all causes of TBI9, 10.
Data: NC Center for Health Statistics, 2008
Analysis: Injury Epidemiology and Surveillance Unit
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 8 of 29
In the Notes section.
Definitions:
The CDC defines a TBI as a “blow or jolt to the head or a
penetrating head injury that disrupts the function of the
brain11.”
Not all blows to the head result in a TBI.
Severity of TBIs may range from mild to severe.
One measure of TBI severity is the Glasgow Coma
Scale (GCS). The GCS is based on best eye, verbal,
and motor response12.
In general, mild TBIs (often concussions) are
associated with a complete recovery, although
short-term memory loss and other neurologic
disorders may be present12. Loss of consciousness
does not necessarily accompany a mild TBI. Adult
populations, particularly the elderly, may have
slower and less complete recovery than their
younger counterparts13.
Moderate TBIs are associated with transient loss of
consciousness. An individual with a moderate TBI
will suffer more serious symptoms than a mild TBI ,
such as persistent headache, repeated vomiting or
nausea, seizures, memory loss, confusion, and
etc3.
Sufferers of severe TBIs demonstrate a complex
combination of physical, cognitive, and behavioral
challenges. Severe TBIs may result in a coma and
carry a substantial risk for long-term disability or
death12.
All TBI deaths and injuries are classified using the
World Health Organization’s International
Classification of Disease codes ICD-10 (deaths) and ICD-
9-CM (nonfatal injuries). Supplemental information is
provided in the Notes (page 22) and Glossary sections
(page 24).
SECTION 2
Demographics of TBI Deaths:
In 2008, over 1,900 North Carolina residents died
after sustaining a TBI. Table 1 provides
demographic characteristics of these deaths. In
North Carolina, certain populations are at a
greater risk of suffering a fatal TBI:
Men are considerably more likely to die
from a TBI then women. Over two-thirds
of all TBI deaths occur in the male
population (71%). The rate of deaths from
TBI in men is 30.0 (95% CI 28.4-31.6). The
rate of deaths of TBI in women is 11.6
(95% CI 10.6-12.6).
Hispanics (15. 9, 95% CI 12.9-18.9) have
lower rates of TBI death than non-
Hispanics (21.0, 95% CI 20.0-22.0).
American Indians have the highest rate of
death due to TBI of all racial groups.
American Indians have a rate of 34.1 (95%
CI 23.7-44.5). This is nearly 1.6 times
higher than the rate of death in whites
(21.8, 95% CI 20.7-22.9).
Adults older than 84 have the highest rate
of death due to TBI of all age groups
(116.8, 95% CI 99.4-134.2). Adults in this
age group have a rate that is 33.4 times
higher than children ages 10-14.
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 9 of 29
Table 1: Gender, Race, Hispanic-Ethnicity, and Age of
TBI Deaths: North Carolina Residents, 2008
Number Percent Rate†
95% Confidence
Interval
Lower Upper
Gender
Male 1,356 71.3% 30.0 28.4 31.6
Female 547 28.7% 11.6 10.6 12.6
Hispanic Ethnicity
Hispanic 109 5.7% 15.9 12.9 18.9
Non-Hispanic 1,791 94.3% 21.0 20.0 22.0
Race§
Asian 15 0.8% * * *
American Indian 41 2.2% 34.1 23.7 44.5
Black 343 18.0% 16.9 15.1 18.7
Other 2 0.1% * * *
White 1,501 78.9% 21.8 20.7 22.9
Age Group¥
00-04 39 2.1% 6.0 4.1 7.9
05-09 9 0.5% * * *
10-14 21 1.1% 3.5 2.0 5.0
15-19 117 6.2% 18.6 15.2 22.0
20-24 160 8.4% 25.5 21.5 29.5
25-34 261 13.7% 21.1 18.5 23.7
35-44 257 13.5% 19.2 16.9 21.5
45-54 273 14.4% 20.6 18.2 23.0
55-64 218 11.5% 20.7 18.0 23.4
65-74 151 7.9% 24.4 20.5 28.3
75-84 221 11.6% 59.3 51.5 67.1
85+ 173 9.1% 116.8 99.4 134.2
Total 1,903 100.0% 20.6 19.7 21.5
*Rate is based on fewer than 20 deaths and is considered statistically unreliable.
†All rates are per 100,000 North Carolina residents.
§Missing 1 of unknown race.
¥Missing 3 of unknown age.
Data: NC Center for Health Statistics, 2008
Analysis: Injury Epidemiology and Surveillance Unit
SECTION 2
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North Carolina Division of Public Health – May 2010 Page 10 of 29
SECTION 2
TBI rates differ considerably between different age groups and sexes. These trends are not unique to North
Carolina. Nationally, males have higher rates of death from TBIs in comparison to females for all age groups.
Additionally, young adult males and the elderly of both sexes are at an increased risk of a TBI fatality4. Figure
4 presents TBI deaths in North Carolina by age and gender:
Males exhibit a small peak in deaths between the ages of 20 and 24 and a larger peak over the age of
84. These rates parallel trends observed nationally4.
The female population does not exhibit a large uptick in the rate of death until the age of 75, although
this peak is noticeably less than the peak observed in males.
Rates of TBIs are the same or lower for females than males for all age groups.
Figure 4: Rates of TBI Deaths by Gender and Age: North Carolina Residents, 2008
Data: NC Center for Health Statistics, 2008
Analysis: Injury Epidemiology and Surveillance Unit
Missing 3 of unknown age.
*Rate is based on fewer than 20 deaths and is
considered statistically unreliable.
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North Carolina Division of Public Health – May 2010 Page 11 of 29
SECTION 3
T TBI Deaths by County from 2006 to 2008 (Pooled Population):
The rates of fatal TBIs are not distributed equally across the state of North Carolina. Figure 5 presents the
rates of TBI death by county for the years 2006 through 2008. The rates should be interpreted with caution,
however; counties with fewer than 20 deaths may have statistically unreliable rates. Additionally, differences
in rates between counties are due to an array of factors including population, infrastructure, and geographic
differences.
During the years 2006-2008, North Carolina had 5,633 deaths and an average TBI mortality rate of
20.8 (95% CI 20.3-21.3).
Of the 75 counties with greater than 20 deaths, Robeson County had the highest mortality rate due to
TBI (39.3, 95% CI 33.0-45.6). Columbus County (38.2, 95% CI 28.7-47.7) and Anson County (37.0, 95%
CI 23.3-50.7) had the second and third highest mortality rates, respectively.
Of the counties with greater than 20 deaths, Wake (12.9, 95% CI 11.5-14.3), Orange (12.9, 95% CI 9.3-
16.5), and Durham Counties (14.5, 95% CI 11.8-17.2) had the lowest rates of TBI mortality.
Figure 5: Rates of TBI Deaths by County: North Carolina Residents, 2006-2008
* Indicates < 20 deaths
Data: NC Center for Health Statistics, 2006-2008
Analysis: Injury Epidemiology and Surveillance Unit
NC Overall: 20.8 deaths
per 100,000 NC Residents
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North Carolina Division of Public Health – May 2010 Page 12 of 29
Demographics of TBI Hospitalizations and
Emergency Department (ED) Visits:
Deaths make up only a small portion of TBIs; nonfatal injuries are far more
common. Hospital discharge records and data from emergency departments
(EDs) provide additional insight into the extent of TBIs in North Carolina.
Unfortunately, this study provides only a rough approximation of the full extent of nonfatal injuries in the
state; injuries that are treated in outpatient clinics and in the home will not be captured by this study. Table
2 presents hospital discharge and ED data:
North Carolina residents are three times more likely to be hospitalized and nearly 30 times more likely
to visit the ED than to die from a TBI1, 5, 6, 7.
Although children between the ages of zero and four do not constitute a large percentage of deaths,
they have high rates of hospitalization (47.4) and even higher rates of ED visits (919.9).
Adults over the age of 84 have the highest rates of TBI deaths, hospitalizations, and ED visits.
Death§ Hospital Discharge¥ ED Visits§
Number Rate† Number Rate† Number Rate†
Gender£
Male 1,356 30.0 4,520 102.3 28,319 626.9
Female 547 11.6 2,921 63.2 22,931 487.3
Age Group¤
00-04 39 6.0 301 47.4 6,005 919.9
05-09 9 * 139 22.8 2,931 470.1
10-14 21 3.5 175 29.6 3,074 516.9
15-19 117 18.6 515 83.0 5,501 874.6
20-24 160 25.5 608 99.6 4,501 717.8
25-34 261 21.1 740 60.9 6,300 510.3
35-44 257 19.2 789 59.0 5,308 395.8
45-54 273 20.6 835 64.3 4,681 353.2
55-64 218 20.7 718 70.3 3,238 306.9
65-74 151 24.4 750 126.8 2,768 447.8
75-84 221 59.3 1,057 286.0 3,811 1,022.3
85+ 173 116.8 814 572.4 3,112 2,101.9
Total 1,903 20.6 7,441 82.3 51,259 555.5
Table 2: Gender and Age of Deaths, Hospital Discharges, and Emergency Department (ED) Visits due to TBI:
North Carolina Residents, 2007 and 2008
SECTION 4
Data: NC Center for Health Statistics, 2007, 2008; NC DETECT, 2008
Analysis: Injury Epidemiology and Surveillance Unit
*Rate is based on fewer than 20 deaths and is considered statistically unreliable.
†All rates are per 100,000 North Carolina residents.
§Data are from 2008; ¥Data are from 2007
£ED: 9 missing gender ; ¤Deaths: 3 missing age; ED: 29 missing age.
For 2007, the median hospital
bill for all hospital discharges
due to TBI was about $20,000
($150 - $2, 519, 191) and the
total hospital charges for North
Carolina were over $300 million.
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 13 of 29
SECTION 5
Manner of Injury:
TBI injuries can be either intentional (self-inflicted or assault), unintentional, or undetermined. As with most
types of injury, unintentional injuries are the most common manner of injury. Unintentional injuries account
for 59 percent of deaths, 88 percent of hospitalizations, and 87 percent of ED visits. However, the manner of
injury is distributed more equitably in deaths than in hospitalizations and ED visits (Figure 6).
Figure 6: Reported Manner of Injury of TBI Deaths*, Hospital Discharges†, and ED Visits*: North Carolina
Residents, 2007 and 2008
*Data are from 2008.
†Data are from 2007.
Data: NC Center for Health Statistics, 2007, 2008; NC DETECT, 2008
Analysis: Injury Epidemiology and Surveillance Unit
12%
8%
13%
28%
1%
59%
88%
1%
3%
<1%
87%
<1%
0%
20%
40%
60%
80%
100%
Deaths Hospital Discharges ED Visits
Percent
Assault
Self-Inflicted
Unintentional
Other/Undetermined
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 14 of 29
Mechanism(s) of Injury:
Deaths:
TBIs may be due to any of a wide assortment of causes. Causes of death are classified using the International
Classification of Disease, Version 10 (ICD-10) using codes established by the CDC State Injury Indicators
Report14. Figures 7 through 11 present leading mechanisms of death. For additional information regarding these
figures, including specific coding used to generate these figures, please see the Notes and Glossary sections.
The leading mechanism of TBI deaths in North Carolina is firearms with 690 deaths. Firearm-related
deaths account for over 36 percent of all TBI deaths. Most of these deaths are either due to assault or
self-inflicted injuries (Figure 7). Firearms are also the leading cause of TBI deaths nationally. Nine out of
10 TBIs due to firearms will end in death15.
Motor vehicle-traffic crashes (MVT) are the second leading mechanism of death with 567 deaths (30%,
Figure 7).
The third leading mechanism of TBI deaths was falls with 338 deaths in 2008 (18%, Figure 7).
The
Figure 7: Leading Mechanism of TBI Deaths: North Carolina Residents, 2008
Data: NC Center for Health Statistics, 2008
Analysis: Injury Epidemiology and Surveillance Unit
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North Carolina Division of Public Health – May 2010 Page 15 of 29
SECTION 6
Data: NC Center for Health Statistics, 2008
Analysis: Injury Epidemiology and Surveillance Unit
Figure 8: Leading Mechanisms of TBI Deaths by Gender: North Carolina Residents, 2008
For all mechanisms of death, there are more male than female deaths due to TBI (Figure 8).
The three leading mechanisms of TBI deaths in males are: 1) firearm-suicide, 2) MVT crashes, and 3)
falls (Figure 8).
The three leading mechanisms of TBI deaths in females are: 1) falls, 2) MVT crashes, and 3) firearm-suicide
(Figure 8).
Males are five times more likely to die from a TBI associated with firearm-suicide and three times more
likely to die from a TBI associated with firearm-homicide than females.
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SECTION 6
At various stages in life, different mechanisms of injury are more prevalent in certain age groups than others. In
2008, causes of TBI differed considerably by both age and gender. Figures 9 and 10 display these trends.
Male TBI deaths were relatively low in number until the age of fifteen.
MVT (86 deaths) and firearm deaths (98 deaths) peaked in males between the ages of 25 and 34. Deaths
from MVT crashes dropped off more sharply than firearm-related deaths (Figure 9).
The number of male deaths due to falls rose in middle-age when deaths due to MVT crashes and
firearms dropped sharply (Figure 9).
Figure 9: Top Three Mechanisms of TBI Death in Males: North Carolina Residents, 2008
Data: NC Center for Health Statistics, 2008
Analysis: Injury Epidemiology and Surveillance Unit
Missing 3 of unknown age.
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SECTION 6
In 2008, female deaths displayed different trends than male deaths. In contrast to males, females
displayed a small peak in MVT-related deaths between the ages of 15 and 19 (26 deaths; Figure 10).
Unlike males, females did not exhibit a peak in TBI deaths between the ages of 25 and 34 (Figure 10).
MVT (31 deaths) and firearm deaths (31 deaths) peaked in females between 35 and 44 (Figure 10).
Similar to males, female TBI deaths due to falls rose sharply in individuals older than 55 years of age
(Figure 10).
Figure 10: Top Three Mechanisms of TBI Death in Females: North Carolina Residents, 2008
Data: NC Center for Health Statistics, 2008
Analysis: Injury Epidemiology and Surveillance Unit
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SECTION 6
Since 2000, trends regarding the causes of TBI deaths have changed (Figure 11).
In 2000, the leading cause of TBI death was MVT crashes with 662 deaths and a rate of 8.2 (95% CI
7.6-8.8). In 2008, the number of MVT deaths had dropped to 567 deaths and a rate of 6.1 (95% CI
5.6-6.6). Between 2000 and 2008 the rate of MVT deaths due to TBI decreased by over 25 percent.
In 2008, the leading cause of TBI death was firearms with a rate of 7.5 (95% CI 6.9-8.1). The rate of
firearm-related deaths has not changed considerably since 2000.
The rate of TBI-related falls in North Carolina residents has increased by over 42 percent since 2000.
In 2000, the rate of TBI deaths due to falls was 2.6 (95% 2.2-3.0). In 2008, this rate had increased to
3.7 (95% CI 3.3-4.1). This trend mirrors the increase in all fall-related deaths in North Carolina over
the last decade16.
Figure 11: Percent Difference in Rates of Leading Mechanisms of TBI Death: North Carolina Residents,
2000 versus 2008
Data: NC Center for Health Statistics, 2008
Analysis: Injury Epidemiology and Surveillance Unit
Falls, +42.3%
MVT, -25.6%
Firearms, -1.3%
-50 -25 0 25 50
Percent Difference in Rates
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
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Figure 12: Leading Causes of TBI Injuries--Hospitalizations: North Carolina Residents, 2007
Data: NC Center for Health Statistics, 2007
Analysis: Injury Epidemiology and Surveillance Unit
Mechanism(s) of Injury:
Hospitalizations:
Hospitalizations due to TBIs are more common than deaths. Unfortunately, many persons with TBIs will
require long-term medical care following a TBI17. Nationally, an estimated 70,000-90,000 individuals will
require long-term care post-TBI18. As the average life-expectancy of an individual who survives a severe TBI is
50 years post-injury, the burden on the health care system may be quite extensive19. Figure 12 presents
leading causes of TBI hospitalizations for 20075:
Unlike deaths, the leading mechanism of hospitalization in North Carolina is falls (2,800
hospitalizations).
MVT crashes are the second leading mechanism of hospitalizations (2,420 hospitalizations).
After MVT crashes, there is a large drop between the second and third leading mechanisms of TBI
hospitalizations. TBI hospitalizations due to being struck by an object accounted for only 468
hospitalizations; about one-fifth of the number of MVT crashes.
SECTION 6
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SECTION 7
Data: NC DETECT, 2008
Analysis: Injury Epidemiology and Surveillance Unit
Mechanism(s) of Injury:
Emergency Department (ED) Visits:
There are more ED visits due to TBIs than all hospitalizations and deaths combined. ED data capture some of the
less severe TBIs. Even mild and moderate TBIs may result in disability, especially in children and the elderly13. For
example, TBIs in early adulthood may increase the risk of developing Alzheimer’s disease and Parkinson’s disease
later in life3. Also, individuals with a history of a TBI may be at an increased risk of suffering from a future TBI20.
Unfortunately, TBIs may be underreported in the ED; especially in patients presenting acute life-threatening
injuries21. Figure 13 presents leading causes of ED visits6:
Similar to hospitalizations, falls were the leading mechanism of ED visits (15, 316 visits).
In 2008, nearly twice as many North Carolina residents visited the ED due to TBIs relating to falls than TBIs
relating to being struck.
In 2008, being struck was the seconding leading mechanism of TBI (8,434 visits) and MVT was the third
leading mechanism of TBI (6,857 visits).
Figure 13: Leading Causes of TBI Injuries - ED Visits: North Carolina Residents, 2008
6,857
801 630
15,316
8,434
1,445 1,133
0
4,000
8,000
12,000
16,000
Fall Struck MVT Unspecified Transport-
Other
Other-Not
Classifiable
Pedal Cyclist
Cause No. of ED Visits
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Conclusions:
Traumatic brain injury (TBI) is a significant source of morbidity and mortality for North Carolina residents and
exacts a heavy toll on the life, health, and economic security of the individual, family unit, community, and state.
TBI is a complex problem in that it affects all age groups, from the very young to the very old, all races, and
encompasses a large number of causes, many of which are unrelated. In order to fully address this complicated
public health issue, disparate organizations with backgrounds in health, advocacy, research, education, law
enforcement, and policy must partner in order to relieve the burden that TBIs place on North Carolina.
Additionally, continuing population-based surveillance is necessary to provide data on changing trends regarding
TBI. Hopefully the data provided in this document and upcoming publications will be used to aid in TBI prevention
and to spur future research priorities.
SECTION 8
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SECTION 9
Additional Sources of Information:
North Carolina:
North Carolina Division of Public Health, Injury and Violence Prevention Branch
Phone: (919) 707-5425
Email: beinjuryfreenc@dhhs.nc.gov
Website: www.injuryfreenc.ncdhhs.gov
North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse
Traumatic Brain Injury Program
Phone: (919) 715-5989
Email: TBIContact@dhhs.nc.gov
Website: www.dhhs.state.nc.us/mhddsas/tbi/index.htm
Brain Injury Association of North Carolina
Phone: (800) 377-1464
Email: bianc@bianc.net
Website: www.bianc.net
National:
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control
Phone: (800) 232-4636
Email: cdcinfo@cdc.gov
Website: www.cdc.gov/ncipc/tbi/TBI.htm
National Institute of Neurological Disorders and Stroke
Phone: (800) 352-9424
Website: www.ninds.nih.gov/disorders/tbi/tbi.htm
Brain Injury Association of America
Phone: (800) 444-6443
Email: braininjuryinfo@biausa.org
Website: www.biausa.org
Brain Trauma Foundation
Phone: (212) 772-0608
Website: www.braintrauma.org
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 23 of 29
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Notes:
Rates: All rates (unless documented otherwise) are per 100,000 North Carolina residents. Rates are not
age-adjusted, unless labeled as such.
95 Percent Confidence Intervals: Data are frequently reported as point estimates with an associated 95
percent confidence interval. A confidence interval is the range of values within which the expected “true”
value falls 95 percent of the time. In general, a rate with a large numerator will have a narrower 95
percent confidence interval than a rate with a small numerator22.
Population Estimates: The North Carolina State Center for Health Statistics provided population data for
the years 1990-2008. These estimates originate from the National Center of Health Statistics’ Bridged
Population Files.
Death Data: The North Carolina State Center for Health Statistics provided death certificate data for every
death in North Carolina. Only North Carolina residents with a North Carolina county address were
considered in our analyses. Deaths were limited to events in which the primary cause of death was
identified as an injury. Primary cause of death was assigned with the International Classification, 10th
Revision (ICD-10) codes. The coding used to classify traumatic brain injury fatalities was: 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.
Hospital Discharge Data: The North Carolina Center for Health Statistics provided hospital discharge data
for every hospital discharge of North Carolina residents. A hospital discharge occurs after a patient leaves
a hospital following admission. This data does not represent number of patients, but number of discharges
(multiple discharges per patient are possible). Cause of injury was assigned with International
Classification, 9th Revision, Clinical Modification (ICD-9-CM) External Causes of Injury codes (E Codes). The
coding used to classify traumatic brain injuries was: 800.0-801.9, 803.0-804.9, 850.0-854.19, 950.1-950.3,
959.01, and 995.55.
Emergency Department Data: The North Carolina Disease Event Tracking and Epidemiologic Collection
Tool (NC DETECT) is a state system that collects and monitors emergency department (ED) for public health
purposes. NC DETECT receives data on at least a daily basis from hospital emergency departments
statewide to provide early detection and timely public health surveillance. As of 01/2007, NC DETECT was
receiving data from 90 of the 112 hospital EDs. The ED data and the hospital discharge data are not
mutually exclusive. Cause of injury was assigned with International Classification, 9th Revision, Clinical
Modification (ICD-9-CM) External Causes of Injury codes (E Codes). The coding used to classify traumatic
brain injuries was: 800.0-801.9, 803.0-804.9, 850.0-854.19, 950.1-950.3, 959.01, and 995.55.
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 24 of 29
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Glossary23:
Adult: Person 18 years of age or older at date of death/injury.
Adverse effects: An injury caused by complications following the administration of a medication or medical
procedure.
Assault: Injury resulting from an act of violence where physical force by one or more persons is used with
the intent of causing harm, injury, or death to another person.
Child: Person less than 18 years of age at date of death/injury.
Fall: An injury caused by descending rapidly and striking a surface.
Firearm: An injury caused by a projectile shot by a powder-charged gun. Firearm-related injuries include
hand-guns, shot-guns, and rifles. Firearm-related injuries do not include paint, nail, or air guns.
Intent of injury: Whether or not an act that caused an injury was committed on purpose.
Intentional injury: An injury caused by a purposeful act by oneself (self-inflicted) or another individual
(assault).
Mechanism (cause) of death: The reason or event that precipitates the death/injury.
Motor vehicle-traffic (MVT): A crash involving a motor vehicle on a highway, street, or road.
North Carolina resident: A resident of North Carolina with a verifiable county of residence. All deaths and
injuries reported in this report are North Carolina residents.
Other-not classifiable: An injury by a known cause that does not fit into an established category.
Pedal cyclist: An injury to a pedal cyclist caused by a collision with a human, animal, or inanimate object
such as a vehicle.
Pedestrian: An injury to a person caused by a collision with a vehicle including a motor vehicle, bicycle,
train, and etc.
Rate: Calculated as count x 100,000/population.
Self-inflected injury: An injury caused by an act to deliberately harm oneself.
Struck: An injury caused by being hit or crushed by a human, animal, or inanimate object other than a
vehicle or machinery.
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
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Transport-other: An injury caused by a person boarding or riding a vehicle other than a motor vehicle or
bicycle such as animal-drawn vehicles, ATVs, ski-lifts, and etc.
Traumatic brain injury (TBI): An injury caused by a blow to the head or a penetrating head injury that disrupts
the function of the brain.
Undetermined Intent: An injury in which the medical examiner/hospital/emergency department did not have
enough information to describe the intent of injury.
Unintentional injury: An injury that is not caused by an act with intent to harm oneself or another
individual.
Unspecified injury: An injury in which the medical examiner/hospital/emergency department did not have
enough information to describe the cause of injury.
N.C. Injury and Violence Prevention Branch | The Burden of Traumatic Brain Injury in North Carolina
North Carolina Division of Public Health – May 2010 Page 26 of 29
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SECTION 12
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