Hospital care of childhood traumatic brain injury in the United States, 1997-2009: a neurosurgical perspective

Abstract

Object: The goal in this paper was to study hospital care for childhood traumatic brain injury (TBI) in a nationwide population base.

Methods: Data were acquired from the Kids' Inpatient Database (KID) for the years 1997, 2000, 2003, 2006, and 2009. Admission for TBI was defined by any ICD-9-CM diagnostic code for TBI. Admission for severe TBI was defined by a principal diagnostic code for TBI and a procedural code for mechanical ventilation; admissions ending in discharge home alive in less than 4 days were excluded.

Results: Estimated raw and population-based rates of admission for all TBI, for severe TBI, for death from severe TBI, and for major and minor neurosurgical procedures fell steadily during the study period. Median hospital charges for severe TBI rose steadily, even after adjustment for inflation, but estimated nationwide hospital charges were stable. Among 14,932 actual admissions for severe TBI captured in the KID, case mortality was stable through the study period, at 23.9%. In a multivariate analysis, commercial insurance (OR 0.86, CI 0.77-0.95; p = 0.004) and white race (OR 0.78, CI 0.70-0.87; p < 0.0005) were associated with lower mortality rates, but there was no association between these factors and commitment of resources, as measured by hospital charges or rates of major procedures. Increasing median income of home ZIP code was associated with higher hospital charges and higher rates of major and minor procedures. Only 46.8% of admissions for severe TBI were coded for a neurosurgical procedure of any kind. Fewer admissions were coded for minor neurosurgical procedures than anticipated, and the state-by-state variance in rates of minor procedures was twice as great as for major procedures. Possible explanations for the "missing ICP monitors" are discussed.

Conclusions: Childhood brain trauma is a shrinking sector of neurosurgical hospital practice. Racial and economic disparities in mortality rates were confirmed in this study, but they were not explained by available metrics of resource commitment. Vigilance is required to continue to supply neurosurgical expertise to the multidisciplinary care process.