Trends in Hospitalizations Associated With Pediatric Traumatic Brain Injuries Stephen M. Bowman, Tommy M. Bird, Mary E.

Aitken and John M. Tilford Pediatrics 2008;122;988 DOI: 10.1542/peds.2007-3511

The online version of this article, along with updated information and services, is located on the World Wide Web at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2008 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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ARTICLE

Trends in Hospitalizations Associated With Pediatric Traumatic Brain Injuries

Stephen M. Bowman, PhD, Tommy M. Bird, MS, Mary E. Aitken, MD, MPH, John M. Tilford, PhD Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
The authors have indicated they have no nancial relationships relevant to this article to disclose.

Whats Known on This Subject

TBI is the leading cause of death and disability among persons in the United States. Pediatric TBIs contribute substantially to the economic burden of health care, with an estimated $1 billion in annual hospital charges.

What This Study Adds

Our study provides national estimates of pediatric TBI hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies.

ABSTRACT
OBJECTIVES. The goals were to describe trends in pediatric traumatic brain injury hospitalizations in the United States and to provide national benchmarks for state and regional comparisons. METHODS. Analysis of existing data (19912005) from the Nationwide Inpatient Sample, the largest longitudinal, all-payer, inpatient care database in the United States, was performed. Children 0 to 19 years of age were included. Annual rates of traumatic brain injury-related hospitalizations, stratied according to age, gender, severity of traumatic brain injury, and outcome, were determined. RESULTS. From 1991 to 2005, the estimated annual incidence rate of pediatric hospi-

www.pediatrics.org/cgi/doi/10.1542/ peds.2007-3511 doi:10.1542/peds.2007-3511

Key Words traumatic brain injury, hospitalizations, incidence, trends Abbreviations TBItraumatic brain injury HCUPHealthcare Cost and Utilization Project CI condence interval E-code external-cause-of-injury code NISNationwide Inpatient Sample
Accepted for publication Jan 31, 2008 Address correspondence to Stephen M. Bowman, PhD, Department of Pediatrics, CARE/Peds Slot 512-26, Arkansas Childrens Hospital, 800 Marshall St, Little Rock, AR 72202-3591. E-mail: bowmanstephenm@ uams.edu

talizations associated with traumatic brain injury decreased 39%, from 119.4 to 72.7 hospitalizations per 100 000. The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point. Fatal hospitalization rates decreased from 3.5 deaths per 100 000 in 19911993 to 2.8 deaths per 100 000 in 20032005. The rate of mild traumatic brain injury hospitalizations accounted for most of the overall decrease, whereas nonfatal hospitalization rates for moderate and severe traumatic brain injuries remained relatively unchanged.

CONCLUSIONS. Although pediatric hospitalization rates for mild traumatic brain injuries PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2008 by the have decreased over the past 15 years, rates for moderate and severe traumatic brain American Academy of Pediatrics injuries are relatively unchanged. Our study provides national estimates of pediatric traumatic brain injury hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies. Pediatrics 2008;122:988993

7000 deaths, 60 000 hospitalizations, and 500 000 visits to an emergency department.1 TBI is the leading cause of death or disability among persons in the United States, with an estimated 2% of people living with a disability as a result of TBI.2 Injuries are the leading cause of death for persons 1 to 19 years of age, accounting for 62% of all deaths in this population, with up to 50% of injury-related deaths being linked to TBIs.3 Pediatric TBIs contribute substantially to the economic burden of health care, with an estimated $1 billion in annual hospital charges.4 Between 1980 and 1995, a changing pattern of TBI hospitalizations was reported by Thurman and Guerrero,5 with a sharp decrease in the rate of mild TBI hospitalizations and a modest increase in the rate of severe TBI hospitalizations among persons of all ages. During that period, the greatest decrease occurred among children 5 to 14 years of age (219 hospitalizations per 100 000 in 1980 1981, compared with 75 hospitalizations per 100 000 in 1994 1995). The study did not report trends in incidence according to age and TBI severity. To our knowledge, there is no published study describing national trends in pediatric TBI-related hospitalizations. The purposes of this study were to describe the trends in pediatric TBI-related hospitalizations in the United States, to examine trends according to age, gender, TBI severity, outcome, mechanism, and intent, to provide national benchmarks for state and regional comparisons, and to discuss the implications of noted trends for injury prevention policy and practice.
988 BOWMAN et al

ACH YEAR IN the United States, traumatic brain injuries (TBIs) in children (0 19 years of age) are associated with

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METHODS Our study used administrative discharge data from the 19912005 Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality (Rockville, MD). The NIS was created by the Agency for Healthcare Research and Quality from the state inpatient databases provided by public and private statewide data organizations from participating states, as part of a federal-state-private collaboration. The NIS is the largest, longitudinal, all-payer, inpatient care database in the United States, with an average of 7 million hospitalizations from 1000 hospitals each year. The NIS approximates a 20% stratied random sample of all shortterm US community hospitals. The sampling frame for the 2005 NIS included state inpatient data for 90% of all hospital discharges in the United States. Data were obtained from the HCUP Central Distributor, with approval from the institutional review board at the University of Arkansas for Medical Sciences. The NIS includes both patient-level data, such as demographic characteristics (eg, age and gender), admission type and source, up to 15 International Classication of Diseases, Ninth Revision, Clinical Modication diagnostic and procedural codes, insurance status, total hospital charges, length of stay, and discharge disposition, and hospital-level information, such as hospital ownership, number of beds, urban/rural location, geographic region, and teaching status. For this study, eligibility was limited to children who were 0 to 19 years of age at admission and were hospitalized with primary or secondary International Classication of Diseases, Ninth Revision, Clinical Modication diagnosis codes for TBI (codes 800.0 801.9, 803.0 804.9, and 850.0 854.1). The TBI case denition is consistent with the recommendations of the Centers for Disease Control and Prevention,1 as reported previously by Thurman and Guerrero.5 Patients who died while hospitalized were included. The NIS contains no unique identiers; therefore, to reduce the effects of doublecounting multiple hospitalizations attributable to the same injury, hospitalizations of patients who were discharged to another short-term care facility were not included in the analysis.6 The assumption was that we would likely capture the denitive care of such patients in the receiving hospital records. An Abbreviated Injury Scale score for the head was calculated for each record by using ICDMAP-90 software (Johns Hopkins University and Tri-Analytics, Baltimore, MD). The Abbreviated Injury Scale is widely accepted as a valid measure of injury severity and is used to stratify incidence rates.79 As described by Thurman et al,2 Abbreviated Injury Scale scores of 1 and 2 were considered mild, a score of 3 was considered moderate, and scores of 4, 5, and 6 were considered severe. The mechanism of injury was determined on the basis of external-cause-of-injury codes (E-codes). We categorized mechanisms of injury by using the Centers for Disease Control and Prevention-recommended framework for presenting injury morbidity data.10 Similarly, we determined intent of injury (ie, unintentional, intentional, or undetermined) by using available E-codes.

To generate national estimates of hospitalizations from the NIS, we used the appropriately scaled discharge weights provided by the HCUP. With these weights, national estimates of hospitalization rates are comparable across years, despite the varying numbers of states participating in each year of the HCUP. All analyses were performed with the appropriate weighted, stratied, sample design, by using the survey command options within Stata 10.0/MP (Stata, College Station, TX). For the incidence rate calculations, we used midyear US Census estimates for the national civilian population during this time period.11 We present estimated crude hospitalization incidence rates according to age, gender, outcome, and injury severity. Because E-codes were missing for up to 55% of hospitalizations before 1997, we compared 2-year aggregate data for the years 1998 1999 and 2004 2005, to evaluate changes in injury mechanism and intent over time. RESULTS Pediatric hospitalizations attributable to TBIs decreased from an estimated 86 312 hospitalizations in 1991 to 59 418 hospitalizations in 2005. From 1991 to 2005, the estimated annual incidence rate of pediatric hospitalizations associated with TBIs decreased 39%, from 119.4 to 72.7 hospitalizations per 100 000 (Fig 1). The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point (Table 1). In-hospital mortality rates decreased from an average of 2534 deaths per year between 1991 and 1993 to 2266 deaths per year in the 20032005 period; fatal hospitalization rates decreased from 3.5 deaths per 100 000 (95% condence interval [CI]: 3.13.9 deaths per 100 000) in 19911993 to 2.8 deaths per 100 000 (95% CI: 2.53.1 deaths per 100 000) in 20032005. The rate of mild TBI hospitalizations accounted for most of the overall decrease, with a decrease from 64.6 hospitalizations per 100 000 in 19911993 to 23.8 hospitalizations per 100 000 in 2003 2005; nonfatal hospitalization rates for moderate and severe TBIs remained unchanged over the 15 years, with the exception of older teen-aged girls (1519 years of age), who experienced a 16.7% increase in rate, from 25.8 to 30.1 hospitalizations per 100 000 (Table 2 and Fig 2). Fatal hospitalization rates among persons with moderate to severe TBIs decreased from 3.3 deaths per 100 000 in 19911993 to 2.7 deaths per 100 000 in 20032005. Figure 2 illustrates the substantial decrease in mild TBI hospitalization rates during the 1990s and the relatively stable hospitalization rates for moderate to severe TBIs. Because E-codes frequently were missing for TBI hospitalizations in the early years of the NIS (through 1997), we compared more-recent data years (1998 1999 versus 2004 2005), which included E-codes for 90% of TBI hospitalizations. We observed a signicant increase in pediatric TBI hospitalization rates for trafc-related motorcycle crashes, primarily among teen-aged boys 15 to 19 years of age (Table 3). The overall rate of other transport-related TBI hospitalizations (eg, involving nontrafc motorcycle crashes, off-road vehicles, or all-terrain
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FIGURE 1 Hospitalization rates for all TBIs (ages 0 19 years). Vertical lines indicate 95% CIs.

vehicles) increased by 65% during this time period, with signicant increases for children 5 to 19 years of age. Bicycle, pedestrian, and rearm TBI hospitalizations all seemed to have decreased during this time, whereas minimal changes were observed for motor vehicle crash occupants and fall-related hospitalizations. Table 4 presents the results according to injury intent (ie, unintentional, intentional, or uncertain). No signicant differences were observed according to overall intent. DISCUSSION We observed a major decrease in the rate of pediatric hospitalizations for mild TBI during the 1990s, although rates seemed to have stabilized in more-recent years. Thurman and Guerrero5 reported the declining trend in mild TBI hospitalizations among people of all ages in their review of 1980 1995 data, and they suggested that more-restrictive hospital admission criteria might ex-

plain part of this decrease. Our study of pediatric TBI hospitalizations offers some evidence that any major change in hospital practices for this population might have been completed by the end of the 1990s. Between 1989 and 1998, TBI-associated death rates decreased for children in all age groups between 0 and 19 years.12 We were unable to identify any published, national, TBI death rate data for the subsequent period, possibly because of the change to International Classication of Diseases, 10th Revision, codes for death certificates and the challenges of assessing trends across different coding schemes. Reductions in TBI mortality rates might be attributable in part to the successes of injury prevention efforts, improvements in the delivery of prehospital and/or hospital care, or the development of trauma systems in many states.1316 Over the 15-year period, we observed a reduction in fatal TBI hospitalization rates, particularly among patients with moderate/ severe TBIs, which offers some support for the contribu-

TABLE 1 National Trends in the Incidence of Pediatric TBI-Related Hospitalizations According to Fatality, Injury Severity, Gender, and Age
Rate, Estimate (95% CI), Hospitalizations per 100 000 19911993 Overall Fatality Nonfatal Fatal Injury severity Mild Moderate Severe Unknown Gender Male Female Age 04 y 59 y 1014 y 1519 y
a Statistically

19941996 83.0 (77.188.8) 79.6 (74.185.1) 3.4 (3.03.8) 44.9 (41.948.0) 20.4 (18.822.1) 14.1 (12.715.4) 3.5 (3.23.8) 109.0 (101.2116.7) 55.6 (51.759.6) 77.2 (69.884.5) 51.7 (47.156.4) 64.2 (59.269.2) 141.3 (131.1151.5)

19971999 78.0 (71.984.1) 74.9 (69.080.8) 3.0 (2.73.4) 34.1 (31.337.0) 21.2 (19.323.0) 14.4 (13.115.7) 8.3 (7.59.1) 101.1 (93.2109.0) 53.7 (49.358.1) 66.8 (59.074.7) 47.7 (42.852.7) 58.4 (52.963.8) 131.8 (120.9142.6)

20002002 65.9 (60.371.5) 63.4 (58.068.7) 2.5 (2.22.8) 26.0 (23.728.4) 18.6 (16.920.3) 11.7 (10.512.8) 9.6 (8.510.7) 88.1 (80.795.5) 45.9 (41.850.0) 76.6 (67.086.2) 37.3 (33.041.6) 47.4 (42.652.3) 113.6 (104.7122.5)

20032005 74.9 (68.881.0)a 72.0 (65.778.2)a 2.8 (2.53.1)a 23.8 (21.626.0)a 24.8 (22.327.4) 13.9 (12.415.3) 12.4 (11.313.5)a 98.0 (89.6106.5)a 51.4 (46.756.2)a 72.8 (66.179.5)a 43.2 (37.948.4)a 55.4 (49.461.4)a 126.2 (116.1136.3)a

107.2 (99.7114.6) 103.7 (96.6110.9) 3.5 (3.13.9) 64.6 (60.169.1) 22.5 (20.624.4) 14.5 (13.215.8) 5.6 (5.06.2) 140.0 (130.3149.7) 72.7 (67.578.0) 107.0 (96.0117.9) 78.7 (71.585.9) 85.6 (78.892.4) 160.3 (150.2170.5)

signicant difference between 19911993 and 20032005, P .05.

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TABLE 2 National Trends in the Incidence of Moderate and Severe TBI-Related Hospitalizations According to Fatality, Gender, and Age
Rate, Estimate (95% CI), Hospitalizations per 100 000 19911993 Overall Nonfatal Male 04 y 59 y 1014 y 1519 y Female 04 y 59 y 1014 y 1519 y Fatal Male 04 y 59 y 1014 y 1519 y Female 04 y 59 y 1014 y 1519 y
a Statistically

19941996 34.5 (31.637.4) 31.3 (28.733.9) 37.2 (33.141.3) 24.6 (21.727.5) 34.0 (30.637.4) 75.8 (69.981.7) 24.7 (21.627.7) 13.0 (11.514.5) 14.7 (13.116.3) 25.6 (23.327.9) 3.2 (2.93.6) 2.8 (2.23.3) 1.8 (1.32.2) 2.4 (1.92.8) 11.1 (9.812.4) 2.3 (1.82.7) 0.8 (0.61.1) 1.4 (1.11.8) 3.4 (2.83.9)

19971999 35.6 (32.538.6) 32.6 (29.835.5) 39.5 (34.644.5) 25.7 (22.628.9) 33.6 (30.237.1) 74.5 (68.680.3) 29.0 (25.132.9) 14.5 (12.716.4) 14.0 (12.415.5) 28.4 (25.831.1) 2.9 (2.63.2) 2.5 (2.13.0) 1.6 (1.32.0) 1.9 (1.62.3) 9.2 (8.110.4) 2.3 (1.82.9) 1.0 (0.71.2) 1.2 (0.91.5) 3.3 (2.83.9)

20002002 30.3 (27.533.1) 27.8 (25.230.4) 36.1 (31.141.0) 18.9 (16.221.5) 26.6 (23.429.9) 67.2 (61.972.6) 27.3 (23.631.0) 10.8 (9.312.2) 11.1 (9.712.6) 23.7 (21.426.0) 2.3 (2.12.6) 2.2 (1.82.7) 1.0 (0.71.3) 1.6 (1.22.0) 7.8 (6.88.8) 1.6 (1.22.1) 0.6 (0.40.8) 1.0 (0.71.2) 2.7 (2.33.2)

20032005 38.7 (34.742.7) 35.9 (32.239.6) 46.0 (39.152.8) 27.4 (23.431.4) 36.7 (32.041.4) 79.9 (73.186.7) 33.1 (28.038.1) 15.6 (13.118.2) 15.2 (13.117.3) 30.1 (27.332.8)a 2.7 (2.33.0)a 3.1 (2.53.7) 1.1 (0.81.4)a 1.7 (1.32.0)a 8.2 (7.19.3)a 2.2 (1.72.6) 0.7 (0.50.9)a 0.7 (0.50.9)a 3.3 (2.83.9)

37.0 (33.940.1) 33.8 (31.036.6) 39.3 (34.644.0) 31.2 (27.734.7) 36.9 (33.340.6) 74.0 (67.980.1) 30.1 (26.433.7) 16.5 (14.418.5) 15.5 (13.917.2) 25.8 (23.428.2) 3.3 (2.93.7) 3.0 (2.43.6) 2.1 (1.62.5) 2.8 (2.33.2) 10.6 (9.112.2) 2.3 (1.82.7) 1.2 (0.91.5) 1.1 (0.81.4) 3.3 (2.73.9)

signicant difference between 19911993 and 20032005, P .05.

tion of health care improvements to the reduction in TBI-related death rates. Our assessment of incidence trends according to mechanism was limited to 1998 2005 because of extensive missing data on the external cause of injury in the early years of the HCUP. By limiting the analysis to later years, however, we avoided potential confounding that might have occurred because of changing hospital admission practices for patients with mild TBIs. Between 1998 1999 and 2004 2005, we did not observe a difference in TBI hospitalization rates for pediatric motor vehicle occupants. One possible explanation for a lack of improvement might be that interventions such as safer car designs and increased child passenger restraint use might allow some children who otherwise would have

died at the scene to survive to reach the hospital. Without more-recent, TBI-related death data, we cannot substantiate this idea. The decrease in bicycle-related TBI hospitalizations offers some evidence in support of bicycle helmet interventions aimed at children. Nationally, the Youth Risk Behavior Surveillance System reported that the proportion of children who never wore a helmet while riding a bicycle decreased from 88.4% in 1997 to 83.4% in 2005.17 In addition, fewer youths reported carrying guns in the past 30 days and fewer reported carrying guns or weapons to school. This may explain some of the observed decrease in rearm-related TBI hospitalizations during this time period. Of concern is the observed increase in motorcycle-related TBI hospitalizations. Motorcycle registrations increased by 50%

FIGURE 2 Incidence rates of pediatric TBI-related hospitalizations in the United States according to injury severity category.

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TABLE 3 Aggregate Incidence of TBI-Related Hospitalizations According to Mechanism and Age, in 1998 1999 and 2004 2005
Rate, Estimate (95% CI), Hospitalizations per 100 000 19981999 All mechanisms Motor vehicle occupants and unspecied Overall 04 y 59 y 1014 y 1519 y Motorcycles Overall 04 y 59 y 1014 y 1519 y Bicycles Overall 04 y 59 y 1014 y 1519 y Pedestrians Overall 04 y 59 y 1014 y 1519 y Transport, other Overall 04 y 59 y 1014 y 1519 y Falls Overall 04 y 59 y 1014 y 1519 y Firearms Overall 04 y 59 y 1014 y 1519 y Struck by/against, cut/ pierce Overall 04 y 59 y 1014 y 1519 y Other injury Overall 04 y 59 y 1014 y 1519 y Missing E-code Overall 04 y 59 y 1014 y 1519 y
a Statistically b Not

TABLE 4 Aggregate Incidence of TBI-Related Hospitalizations According to Intent and Age in 1998 1999 and 2004 2005
Rate, Estimate (95% CI), Hospitalizations per 100 000 19981999 Unintentional Overall 04 y 59 y 1014 y 1519 y Intentional Overall 04 y 59 y 1014 y 1519 y Undetermined/ unknown Overall 04 y 59 y 1014 y 1519 y
a There

Change, % 4.8 15.0 23.1 6.7 19.4a 15.3 30.0 b b 25.0 33.3a 24.6a 28.6 31.4a 29.0a 4.7 19.2a 31.7a 28.3a 22.0 2.1 65.5a 10.0 88.2a 71.8a 56.9a 3.5 2.2 3.1 5.0 22.5a 27.3a b b 50.0a 24.2 5.7 0 7.1 7.8 13.0 2.7 15.3 9.1 10.0 9.8 0 5.0 12.8 18.0 7.9

Change, %a

20042005 76.0 (67.884.1)

20042005 62.2 (55.269.2) 59.5 (49.869.2) 40.0 (33.546.4) 48.5 (41.955.0) 99.5 (89.4109.5) 5.6 (4.96.3) 8.2 (6.410.1) 0.4 (0.30.6) 1.8 (1.42.2) 11.7 (10.313.2) 6.0 5.0 1.1 7.3 6.0 1.8 28.1 0.0 21.7 9.3

79.8 (72.087.6)

24.6 (21.627.6) 10.4 (8.212.6) 9.0 (7.410.6) 12.4 (10.614.2) 66.2 (57.674.9) 1.0 (0.81.1) b b 0.8 (0.61.0) 2.7 (2.23.1) 5.7 (5.06.4) 0.7 (0.50.9) 7.0 (6.07.0) 10.7 (9.012.3) 4.3 (3.74.9) 5.2 (4.46.0) 4.1 (3.25.0) 6.0 (4.97.2) 5.9 (4.97.0) 4.8 (4.15.5) 2.9 (2.63.3) 1.0 (0.71.3) 1.7 (1.32.0) 3.9 (3.24.5) 5.1 (4.45.8) 17.1 (14.919.3) 36.3 (31.041.6) 12.8 (10.714.8) 10.0 (8.511.5) 9.8 (8.711.0) 1.1 (0.91.3) b b 0.8 (0.61.0) 3.3 (2.74.0)

20.9 (18.623.3) 8.0 (6.39.7) 8.4 (6.710.2) 10.0 (8.511.6) 56.1 (49.662.6) 1.3 (1.11.5) b b 1.0 (0.81.3) 3.6 (3.04.2) 4.3 (3.74.9) 0.5 (0.30.6) 4.8 (3.95.8) 7.6 (6.58.7) 4.1 (3.54.7) 4.2 (3.54.8) 2.8 (2.23.3) 4.3 (3.45.1) 4.6 (3.85.5) 4.9 (4.25.7) 4.8 (4.25.5) 1.1 (0.81.4) 3.2 (2.53.8) 6.7 (5.67.9) 8.0 (6.99.1) 17.7 (15.220.1) 37.1 (31.043.2) 12.4 (10.414.4) 9.5 (8.011.1) 12.0 (10.713.4) 0.8 (0.60.9) b b 0.4 (0.20.5) 2.5 (2.03.0)

66.2 (59.373.1) 62.6 (53.571.7) 44.0 (38.049.9) 52.3 (45.858.8) 105.8 (93.9117.8) 5.5 (4.86.2) 6.4 (5.17.7) 0.4 (0.20.5) 2.3 (1.92.7) 12.9 (11.214.6)

8.1 (6.79.6) 8.8 (6.910.8) 4.0 (2.95.0) 5.2 (4.06.4) 14.6 (12.117.2)

8.2 (5.910.4) 8.6 (5.811.5) 4.5 (2.66.4) 6.0 (3.88.3) 13.2 (10.116.4)

1.2 2.3 12.5 15.4 9.6

were no signicant differences.

7.0 (6.27.7) 3.3 (2.63.9) 4.2 (3.54.8) 6.4 (5.57.3) 13.9 (12.115.8) 7.5 (6.38.7) 13.7 (11.316.0) 3.3 (2.64.0) 4.0 (3.24.8) 9.2 (7.311.1) 7.7 (6.29.2) 8.0 (6.19.9) 3.9 (2.95.0) 5.0 (3.86.2) 13.9 (11.416.5)

6.6 (5.97.3) 3.3 (2.73.9) 3.9 (3.24.5) 6.9 (5.97.9) 12.1 (10.913.8) 7.7 (6.29.1) 15.8 (12.419.2) 3.0 (2.23.9) 3.6 (2.54.6) 8.3 (6.99.7) 7.7 (5.510.0) 7.6 (4.810.4) 4.4 (2.66.3) 5.9 (3.78.2) 12.8 (9.715.9)

signicant, P .05. reported; unstable because of small numbers.

between 1998 and 2005, from 3.8 million to 6 million registered in the United States.18 At the same time, motorcycle-related crash fatalities doubled from 2294 to 4553 deaths per year.19 With increasing fuel prices, the growth in motorcycle use may continue into the future. Despite evidence supporting the effectiveness of motorcycle helmets in preventing TBIs, only 20 states have comprehensive motorcycle helmet laws.20 Rates of hospitalizations attributable to other transport modes, such as off-road motorcycles and all-terrain vehicles, also have increased. A lack of comprehensive helmet laws for these riders also places young people at excessive risk. Several limitations are worth noting. First, we relied on the ICDMAP-90 program to determine injury severity. Misclassication of TBI severity because of incomplete or inaccurate injury coding is possible. Shore et al21 studied the validity of administrative data for characterizing TBI-related hospitalizations and reported the potential for underreporting of mild TBIs in hospital discharge data. Therefore, some of the decrease in mild TBI incidence might have resulted from changes in coding over time. However, the consistency observed for moderate and severe TBI rates supports the use of administrative data for trend analysis. Second, the NIS does not include hospitalizations at federal hospitals (eg, military and Veterans Administration facilities). The true TBI hospitalization rates are likely to be greater because of the potential for admission to federal hospitals. This is likely to be less a factor in this analysis of pediatric TBIs than in studies of adult hospitalizations, however. Finally, our study does not include children with TBIs who died before reaching a hospital.

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CONCLUSIONS Although pediatric hospitalization rates for mild TBIs decreased over the past 15 years, we did not observe a decrease in hospitalization rates for children with moderate to severe TBIs. One possible explanation is that better prehospital care and improved access to trauma centers now allow some children who previously would have died at the scene to reach a hospital for denitive care. We did observe some improvement in hospital outcomes for critically ill children with TBIs. Given that the estimated lifetime medical costs for persons who experience TBIs exceed $9 billion annually, future efforts should focus on translating effective injury prevention strategies into public health practice.22 Primary seat belt laws, motorcycle helmet requirements for on-road and off-road vehicle users (including all-terrain vehicle users), and comprehensive, graduated, drivers licensing programs for young drivers offer the potential to reduce TBI-related hospitalization rates in the coming years. Our study provides national estimates of pediatric TBI hospitalization rates that can be used as benchmarks to inform injury prevention efforts through targeting of effective intervention strategies. Given the signicant burden of TBIs in real and human costs, additional monitoring of pediatric TBIs seems warranted. Currently, resources for comprehensive monitoring of pediatric TBIs seem to be lacking. Multiple, coordinated, surveillance systems are needed to improve knowledge of TBIs and to support injury prevention and treatment efforts. Building better data systems to conduct pediatric TBI research on health care quality in both prehospital and hospital settings could assist in reducing TBI-related mortality and morbidity rates for children. ACKNOWLEDGMENTS Support for Dr Bowman was provided in part by the Arkansas Biosciences Institute, a partnership of scientists from Arkansas Childrens Hospital, Arkansas State University, the University of Arkansas Division of Agriculture, the University of Arkansas, Fayetteville, and the University of Arkansas for Medical Sciences. The Arkansas Biosciences Institute is the major research component of the Tobacco Settlement Proceeds Act of 2000. REFERENCES
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PEDIATRICS Volume 122, Number 5, November 2008

993

Trends in Hospitalizations Associated With Pediatric Traumatic Brain Injuries Stephen M. Bowman, Tommy M. Bird, Mary E. Aitken and John M. Tilford Pediatrics 2008;122;988 DOI: 10.1542/peds.2007-3511
Updated Information & Services References including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/122/5/988.full.ht ml This article cites 11 articles, 1 of which can be accessed free at: http://pediatrics.aappublications.org/content/122/5/988.full.ht ml#ref-list-1 This article has been cited by 9 HighWire-hosted articles: http://pediatrics.aappublications.org/content/122/5/988.full.ht ml#related-urls This article, along with others on similar topics, appears in the following collection(s): Emergency Medicine http://pediatrics.aappublications.org/cgi/collection/emergency _medicine_sub Trauma http://pediatrics.aappublications.org/cgi/collection/trauma_su b Neurologic Disorders http://pediatrics.aappublications.org/cgi/collection/neurologic _disorders_sub Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2008 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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