[PPT] - Concussion Tara Rhine, MD MS 1 Lynn Babcock, MD MS 1 Mekibib Altaye, PowerPoint Presentation

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A National Review of Inpatient Admissions for Pediatric Concussion

Tara Rhine, MD MS 1 Lynn Babcock, MD MS1 Mekibib Altaye, PhD2

1Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center 2Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center

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Disclosures

The authors have no relevant financial relationships with the

manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.

I do not intend to discuss an unapproved/investigative use of a

commercial product/device in my presentation.

Funding Sources

R40 MC268060102 from the Maternal and Child Health Research

Program, Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services. (Rhine)

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Indications for admission and goals of

inpatient care for pediatric concussion are unclear

Significant inter-hospital variability in the

admission rates for pediatric concussion (5-72%) (Bourgeois 2014)

Background

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Evaluate national trends of pediatric hospitalizations for concussion from 2007-2013

Objective

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Design: Retrospective cohort Source: Pediatric Health Information System (PHIS) Database – 42 hospitals Study Period: 2007 - 2013 Participants: Children hospitalized with traumatic brain injury (TBI)

Methods

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Inclusion Criteria

Ages 0-18 years
Inpatient or observational unit charges
International Classification of Diseases, Clinical

Modification, Ninth revision (ICD9-CM) TBI-related codes

– “Concussion” patients

Subset of ICD9-CM diagnosis codes: 850.0–850.9
Head Abbreviated Injury Score* 1-2
Total Injury Severity Score* of ≤6
Calculated using ICDMAP-90 software (Tri-Analytics, Inc.)

Methods

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Outcome

Proportion of all TBI admissions for concussion

Analyses

Trend analysis over time using the Cochran-Armitage Trend Test

Data Elements

Age
Race
Gender
Payer type
Mechanism of injury
Hospital size

Analyses

Descriptive analysis of data elements
Trend analysis over time using the Cochran-Armitage Trend Test

Analysis

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Proportion of Concussion Admissions versus Overall TBI Admissions

Number of TBI Admissions

2000 4000 6000 8000 10000 12000 2007 2008 2009 2010 2011 2012 2013

All TBI Concussion Moderate/Severe TBI

Admissions for all TBI did not significantly change (p=0.587)

Results

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17 18 19 20 21 22 23 24 25 2007 2008 2009 2010 2011 2012 2013 Percent of All TBI Admissions Year

Concussion

23.7%

Proportion of TBI Admissions that were Concussions from 2007-2013

Proportion of concussions significantly increased (Z=10.41, p<0.0001)

Results

19.6%

Proportion of head injury NOS (~9%) did not significantly change over time (p=0.62)

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5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 0<4 4<9 9<14 16% 31% ≥14 21% 32% No Yes Concussion

All TBI Admissions

Age (Years) p=0.02* p<0.001* p<0.001* p<0.001*

Results

*All age groups demonstrated a significant increase in concussion admissions

Age of Children Admitted with TBI from 2007-2013 and Changes Over Time (N= 80,465) Age of Children Admitted with Concussion from 2007-2013 (N= 16,599) Median (IQR) Mean (±SD) Years 11 (6-14) 9.8 (5)

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Results

Characteristics of Children Admitted with Concussion from 2007-2013 and Changes Over Time (N= 16,599) Data Element % of Cohort Change over Time p-value* Race (N=16578)

Black 22% <0.001 White 63% 0.05 Other 15% <0.0001

Gender (N=16557)

Male 67% 0.28 *Based on Cochran-Armitage Trend Test Increasing Denoted significant p-values <0.05 Decreasing

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Results

Data Element % of Cohort Change over Time p-value*

Payer Type (N=16,599) Government

42% <0.0001

Non-Government

41% 0.43

Self Pay

14% <0.0001

Mechanism (14,431) Fall

32% <0.0001

Motor Vehicle Collision

25% <0.0001

Transport

7% 0.34

Struck by/against

9% 0.74

Sports

13%

<0.001

Other

12% <0.01 *Based on Cochran-Armitage Trend Test Increasing Denoted significant p-values <0.05. Decreasing

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25.4% 66.3% 8.3% 10 20 30 40 50 60 70 80 90 100

*p-values reflect changes in %

ver time

Percentage of Children Admitted with Concussion Based

n Hospital Size from 2007-2013 (N= 16,599)

Hospital Size (Based on Inpatient Beds) >400 <200 200 - 400 p = 0.75 p < 0.001 p < 0.001 Percent of Concussion Admissions

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Despite a stable rate of admissions for pediatric TBI, the

proportion of children admitted for concussion significantly increased to almost 24%

The majority of children admitted for concussion were male

(67%), white (63%), and had a median age of 11 years

Falls and motor vehicle collisions accounted for 55% of

concussion admissions – Sports increased from 10 to 15%

Summary

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Administrative database
Severity of TBI determined by ICD-9 codes
Generalizability

Limitations

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Concussions account for a substantial portion of

pediatric TBI admissions

Additional work is needed detailing the

interventions made during admissions – help understand outcomes following inpatient care – lead to the development of evidenced-based inpatient care guidelines Conclusions

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1. Faul M, Xu L, Wald MW, Coronado VG. Traumatic Brain Injury in the United States:

Emergency Department Visits, Hospitalizations, and Deaths 2002-2006. 2010

2. Mannix R, O'Brien MJ, Meehan WP 3rd. The epidemiology of outpatient visits for minor

head injury: 2005 to 2009. Neurosurgery. 2013 Jul;73(1):129-34; discussion 134.

3. Schneier AJ, Shields BJ, Hostetler SG, Xiang H, Smith GA. Incidence of pediatric

traumatic brain injury and associated hospital resource utilization in the United States.

Pediatrics. 2006 Aug;118(2):483-92.
4. Blinman TA, Houseknecht E, Snyder C, Wiebe DJ, Nance ML. Postconcussive

symptoms in hospitalized pediatric patients after mild traumatic brain injury. J Pediatr

Surg. 2009 Jun;44(6):1223-8.
5. Bourgeois FT, Monuteaux MC, Stack AM, Neuman MI. Variation in emergency

department admission rates in US children's hospitals. Pediatrics. 2014 Sep;134(3):539-45.

6. Tri-Analytics, Inc. and Johns Hopkins University. ICDMAP-90 Software User's Guide.

1997

References

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Thank you:
Dr. Lynn Babcock
Dr. Mekibib Altaye
Colleen Mangeot - Amy Liu
Dr. Shari Wade - Oliver Rhine
Questions?

Acknowledgments

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EXTRA SLIDES

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Inpatient Practices

Care Practices During Inpatient Pediatric Concussion Admission

Variable % of Cohort Nonnarcotic pain medication 56.6% Narcotic pain medication 30.1% Antiemetic medication 35.3% Maintenance IV fluids 48.1% Head CT 72.1%

Length of Stay for Inpatient Pediatric Concussion Admission

Median (IQR) Mean (±SD) Length of Stay (Days) 1 (1-2) 1.8 (3.5)

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Predictors of LOS

Predictors of Length of Stay for Inpatient Pediatric Concussion Admission (0-1 vs >1 Day)

Significant Variable Odds Ratio (95% Confidence Interval) Age 1.02 (1.01-1.03) Payer Type (Govt vs Self) 1.23 (1.09-1.39) Hospital Size (Large vs Small) 1.18 (1.01-1.38) Region (West vs Midwest) 1.41 (1.25-1.6) Region (West vs South) 1.16 (1.01-1.3) Mechanism (Motor Vehicle vs Sport) 3.64 (3.17-4.18) Mechanism (Transport vs Sport) 2.65 (2.22-3.15)

Length of Stay for Inpatient Pediatric Concussion Admission

Median (IQR) Mean (±SD) Length of Stay (Days) 1 (1-2) 1.8 (3.5)

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24% 0.02* 20% <0.0001* 36% 0.15 20% <0.0001*

*Significant changes over time are denoted by box color: Green increasing % and Red decreasing %

Percentage of Children Admitted with Concussion Based

n Hospital Region from 2007-2013 (N= 16,599)