Emergency department visits for mild traumatic brain injury in early childhood
a b s t r a c t
Background: Brain injury during early childhood may disrupt key periods of neurodevelopment. Most research regarding mild traumatic brain injury has focused on school-age children. We sought to characterize the incidence and healthcare utilization for mTBI in young children presenting to U.S. emergency departments (ED).
Methods: The Nationwide Emergency Department Sample was queried for children age 0-6 years with mTBI from 2016 to 2019. Patients were excluded for focal or diffuse TBI, drowning or abuse mechanism, death in the ED or hospital, Injury Severity Score > 15, neurosurgical intervention, intubation, or blood product transfusion. Results: National estimates included 1,372,291 patient visits: 63.5% were two years or younger, 57.5% were male, and 69.4% were injured in falls. The most common head injury diagnosis was “unspecified injury of head” (83%); this diagnosis decreased in frequency as age increased, in favor of a concussion diagnosis. Most patients were seen at low pediatric volume EDs (64.5%) and non-children’s hospital EDs (86.2%), and 64.9% were seen at a non-teaching hospital. Over 98% were treated in the ED and discharged home. Computed tomography of the head and cervical spine were performed in 18.7% and 1.6% of patients, respectively, less often at children’s hos- pitals (OR = 0.55, 95%CI = 0.41-0.76 for head and OR = 0.19, 95%CI = 0.11-0.34 for cervical spine). ED charges resulted in $540-681 million annually, and more than half of patients utilized Medicaid.
Conclusions: Early childhood mTBI is prevalent and results in high financial burden in the U.S. There is wide var- iation in diagnostic coding and Computed tomography scanning amongst EDs. More focused research is needed to identify optimal diagnostic tools and management strategies.
(C) 2023
mild traumatic brain injury , or concussion, is a leading public health issue, with an estimated 1.1-1.9 million sports and recreation- related head injuries in children annually in the United States [1]. Mild
Abbreviations: CDC, Centers for Disease Control and Prevention; CPT, current procedural terminology; CT, computed tomography; ED, emergency department; ISS, injury severity score; mTBI, mild traumatic brain injury.
* Corresponding author at: Nationwide Children’s Hospital and The Ohio State University College of Medicine, 700 Children’s Drive, Columbus, OH 43205, United States.
E-mail address: [email protected] (S.C. Rose).
1 Contributed equally as co-senior authors.
TBI can occur through various mechanisms, and only half of children with mTBI presenting to the Emergency Department (ED) are due to sports injuries [2]. In children age 0-4 years, approximately 70% of mTBIs are caused by falls, and <20% are sports-related [3].
Brain injury during early childhood is of particular concern due to the rapid development and changing morphology of the brain. Eighty percent of maximum gray matter and white matter volumes are reached by about 1 year and 6-8 years, respectively [4], and radio- graphic myelination of the white matter occurs largely in the first 2 years of life [5]. Brain development in early childhood drives the rapid acquisition of motor, cognitive, and social skills, and injury during this period can affect long-term outcomes. Although moderate-severe inju- ries often lead to significant sequelae [6,7], mTBI can result in persistent manifestations including social and behavioral difficulties [8-10].
https://doi.org/10.1016/j.ajem.2022.12.035
0735-6757/(C) 2023
Most existing research on mTBI has focused on school-age children, especially those playing sports. However, infants, toddlers and pre- schoolers are at highest risk for all-severity TBI, and the reported rate of TBI in this age group has increased over time [11]. Due to the limited self-report of symptoms, mTBI can be difficult to diagnose in early child- hood. Young children may experience somatic, sleep, emotional, or visual-vestibular symptoms typically seen in older children, but they may also experience symptoms not included on concussion symptom checklists such as behavioral difficulties, decreased participation in ac- tivities, clinginess, and change in appetite [12,13]. Until recently [14], symptom checklists were only validated down to 5 years of age [15,16]. Due to these diagnostic challenges, little is known about the in- cidence of mTBI in children prior to entering elementary school. Under- standing the incidence and public health burden of ED visits for mTBI in this age group will help inform future research initiatives and public policy. We sought to describe mTBI in children age 0-6 years from a national sample of ED visits in the United States.
- Methods
- Data source
We conducted a cross-sectional study of a national administrative limited dataset. This study was exempt from review by the institutional review board at our institution. We examined ED visits using the Nation- wide Emergency Department Sample (NEDS), generated for the Healthcare Cost and Utilization Project (HCUP) and sponsored by the Agency for Healthcare Research and Quality [17]. NEDS is the largest da- tabase of ED visits in the United States, including data from 37 states, over 950 EDs, and 32-35 million ED visits each year representing all ages and all payers. NEDS Sample weights allow for the generation of na- tional estimates of approximately 144 million ED visits per year. The 10th Revision of the International Statistical Classification of Diseases and Re- lated Health Problems, clinical modification, (ICD-10-CM) was adopted in October 2015 and impacted head injury diagnoses, so we chose to ex- amine data from 2016 to 2019. ICD-10-CM codes and Current Procedural Terminology (CPT) codes were used in this study. NEDS data from 2019 was the most current year available at the time of data analysis.
Patient and hospital characteristics were obtained from the NEDS database. The database includes both adult and pediatric EDs. To classify hospitals, we defined a high pediatric volume ED as one seeing at least 20,000 patients <18 years per year. We also defined children’s hospitals
protect the confidentiality of patients, HCUP requires that cell sizes with fewer than 10 patients be excluded or grouped to form larger cell sizes. Therefore, after initial review of the dataset, we grouped the head injury diagnoses into five categories (Table 1). We considered inclusion of patients with focal TBI and diffuse TBI Diagnostic codes (S06301A, S062X0A, and S062X1A). However, these codes were consistently associ- ated with higher ISS, suggesting that these codes are commonly used for patients with moderate to severe TBI; therefore, these codes were ex- cluded from the analysis. Patients were also excluded for the following reasons: abuse diagnosis code, death in the ED or death during the asso- ciated hospital admission, ISS >15, or a drowning/submersion mecha- nism of injury. Finally, patients were excluded if they had procedures indicative of moderate to severe TBI in the following CPT code groups: Group 1 (incision and excision of central nervous system), Group 2 (insertion, replacement, or removal of extracranial Ventricular shunt), Group 216 (respiratory intubation and mechanical ventilation), or Group 222 (blood and blood product transfusion).
2.4. Data analysis
Descriptive statistics were calculated for patient visit characteristics and hospital characteristics. If a patient visit contained more than one eligible mTBI diagnostic code, the visit was included in analyses for each of the relevant mTBI groups, but only counted once in the total visit count. Two-tailed Rao-Scott chi-square tests were used to assess injury diagnoses between children’s hospitals and non-children’s hospitals. To analyze the weighted data and obtain p-values and 95% confidence intervals for the Rao-Scott chi-square tests, we used the “proc surveyfreq” function. The “proc surveylogistic” function was used to conduct a logistic regression to assess head and cervical spine CT usage between children’s hospitals and non-children’s hospitals, controlling for age, primary payer, and median Household income. Sta- tistical analysis was performed using SAS Enterprise Guide version 8.1.
- Results
A total of 326,704 (national estimate 1,391,730) head injury ED visits in children 0-6 years were identified in the four-year study period. After exclusionary criteria were applied, 322,235 (national estimate 1,372,291) were included (Fig. 1). Characteristics of the included patient
Table 1
Head injury diagnoses included.
Grouping Diagnostic Codes
by median patient age. The median age for children’s hospitals was <10 years, and the median age for non-children’s hospitals was >20 years. No hospitals in the NEDS dataset had a median patient age between 10 and 20 years. Injury severity score (ISS), mechanism of injury group- ings, and intent were generated using the “icdpicr” injury categorization package version 1.0.0 for R [18]. The ISS assesses trauma severity, with higher scores generated based on the severity of injury to each body re- gion or trauma to multiple body regions. An ISS cutoff of 15 (out of 75 total) has previously been used to distinguish mild from severe brain in- jury [19]. The Clinical Classifications Software Refined (CCSR), included in the HCUP datasets (version 2020.1), was used to identify groups of CPT codes for exclusionary purposes. The 100 most frequently used CPT codes during the ED encounter for each year of age and the 25 most frequently used CPT codes for each head injury diagnosis were de- scribed. Rates of computed tomography (CT) of the head and cervical spine were obtained for the included patients.
We included ED visits for patients age 0-6 years with a head injury diagnosis listed as one of the first 15 diagnoses for the patient visit. To
Unspecified injury of head
Other specified injury of head
Concussion group
Post-traumatic headache group
Other head injury group
Unspecified injury of head (S0990XA) Other specified injuries of head (S098XXA)
concussion without loss of consciousness, initial encounter (S060X0A)
concussion with loss of consciousness of 30 min or less, initial encounter (S060X1A)
concussion with loss of consciousness of unspecified duration, initial encounter (S060X9A)
acute post-traumatic headache, intractable (G44311) acute post-traumatic headache, not intractable (G44319) post-traumatic headache, unspecified, intractable (G44301)
post-traumatic headache, unspecified, not intractable (G44309)
other biomechanical lesions of head region (M9980) unspecified Intracranial injury without loss of consciousness, initial encounter (S069X0A)
unspecified intracranial injury with loss of consciousness of 30 min or less, initial encounter (S069X1A) unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter (S069X9A) encounter for screening for traumatic brain injury (Z13850)
Fig. 1. Emergency department visits for patients age 0-6 years presenting with a head in- jury diagnosis after applying inclusion and exclusion criteria (sampled visits, US national estimates).
visits and hospitals are shown in Table 2 (national estimates) and Sup- plementary Table 3 (sampled visits). Unspecified injury of head, initial encounter (S0990XA) was the most commonly used diagnosis, repre- senting 83% of all visits. Mean, median, and Total charges for ED care and inpatient care are included in Table 2.
The use of each head injury diagnosis category varied by age (Fig. 2). With increasing age, the unspecified injury of head diagnosis decreased while concussion diagnoses increased. Similarly, post-traumatic head- ache diagnoses increased with age, although remained uncommon (0.0% of patients <1 year and 1.3% of patients 6 years old). As shown in Table 3, children’s hospitals used the unspecified injury of head diagnosis at a similar rate as non-children’s hospitals (85.1% vs 82.7%, respectively, p = 0.09). Children’s hospitals also used a concussion diagnosis at a sim- ilar rate as non-children’s hospitals (9.5% vs 9.6%, respectively, p = 0.94). Head CT.was obtained in 18.7% of patients, while cervical spine CT was obtained in 1.6% of patients. Patients treated at children’s hospitals were less likely to receive a head CT (OR = 0.55, 95%CI = 0.41-0.76) or a cervical spine CT (OR = 0.19, 95%CI = 0.11-0.34).
For each year of age, the rate of CPT code usage for level of medical complexity, repair of superficial wounds, imaging, medication adminis- tration, venipuncture, labs, and other interventions are summarized in Supplementary Table 1. ED visits were mostly of low or moderate med- ical complexity: 32% low complexity (CPT codes 99281 and 99282), 65% moderate complexity (CPT codes 99283 and 99284), and 3% high complexity (CPT code 99285). The rate of CPT code usage for each head injury diagnosis is shown in Supplementary Table 2.
Most research on pediatric mTBI has focused on school-age children and athletes, leaving a gap in knowledge regarding the epidemiology,
diagnosis, management, and consequences of these injuries in young children. Our study showed that mTBI is highly prevalent in children 6 years or younger, with approximately 343,000 ED visits annually in the U.S.
To our knowledge, this is the first study to identify mTBI specifically in young children from a nationally Representative sample. The Centers for Disease Control and Prevention’s (CDC) 2021 report on the incidence of all-severity TBI used ICD codes for Skull fracture, facial fracture, crushing injury of skull, injury of the optic nerves or specific brain re- gions, intracranial injury, and shaken infant syndrome [20]. Given that the majority of TBIs are known to be mild in nature, we included only diagnostic codes that suggest concussion or mild TBI. We did not include codes for fractures or specific intracranial injuries because these indi- cate a more focal or severe brain injury.
To meet the unique challenge of identifying young children with mTBI, we included the “unspecified injury of head” diagnosis. A study of all-severity pediatric head trauma using NEDS data from 2006 to 2010 included the “head injury, unspecified” diagnosis but did not dis- tinguish its incidence from other head injury diagnoses [21]. Others have excluded this diagnosis from surveillance data based on the as- sumption that it does not reflect clinical TBI [20]. Two studies evaluated the characteristics of adults and children diagnosed with “unspecified injury of head” in the ED. Peterson and colleagues found that almost half of patients had moderate to high clinical evidence of TBI, based on traumatic neuroimaging findings or classic signs and symptoms of mTBI [22]. Bazarian and colleagues found that 25% of patients met their clinical definition of mTBI, which required loss of consciousness, amnesia, or Mental status change [23]. However, these previous studies included older children and adults, and the criteria they used may have underestimated the number of children age 0-6 years with mTBI, who are unable to report amnesia, have difficulty reporting most symptoms, and often have negative Neuroimaging studies.
Over 80% of the children in our sample were diagnosed with “un- specified injury of head”. The use of this diagnosis was similar between children’s hospitals and non-children’s hospitals. We saw a prominent decline in the use of this diagnosis as age increases, in favor of a concus- sion diagnosis, suggesting that health care professionals are more comfortable with the concussion diagnosis at older ages. This is not sur- prising due to the common association of the term “concussion” with sport-related injuries found more commonly in older children. limited resources are available to guide clinicians in the diagnosis and manage- ment of mTBI in early childhood.
Due to the absence of symptom reporting and limited observable signs of mTBI, health care professionals lack validated and reliable methods to diagnose mTBI in children age 0-6 years. Most mTBI assess- ment tools are validated only in school-age children and adults, making the diagnosis of mTBI in early childhood particularly challenging. For ex- ample, the Child SCAT-5 and Post-Concussion Symptom Inventory use self- and parent-reported symptoms checklists and are only validated down to age 5 years [15,16]. The assessment of young children suspected of having a mTBI may require a more developmentally- appropriate tool based on signs and symptoms, such as the recently pro- posed Report of Early Childhood Traumatic Injury Observations & Symptoms (REACTIONS), developed for children age 0-8 years [14]. The diagnostic and Prognostic accuracy of this assessment tool needs to be further studied.
Head and spine imaging are not recommended for the routine diag-
nosis of children with mTBI [24]. The Pediatric Emergency Care Applied Research Network prediction rules to identify children at higher risk for clinically important TBI were published in 2009 [25]. This tool aids the clinician in determining if head imaging is indicated after head trauma. We found that 18.7% of children age 0-6 years re- ceived a head CT. Adoption of these prediction rules may have contrib- uted to the lower imaging rates seen in this study, as compared with that seen in 2011, when 37.4% of patients age 0-11 diagnosed with mTBI received a head CT in the ED [26]. In our sample, head CT and
Characteristics of emergency department patient visits from 2016 to 2019, national estimates.
|
2016 |
2017 |
2018 |
2019 |
Total |
||||||||
|
Variable |
Subcategory |
N |
N |
N |
N |
N |
Percentage |
|||||
|
Total |
370,112 |
343,292 |
353,161 |
305,726 |
1,372,291 |
100.0 |
||||||||||||
|
Unspecified injury of head (S0990XA) |
309,092 |
283,670 |
293,494 |
252,799 |
1,139,056 |
83.0 |
||||||||||||
|
Other specified injuries of head (S098XXA) |
21,626 |
22,860 |
22,109 |
18,813 |
85,407 |
6.2 |
||||||||||||
|
Head Injury Diagnosisa |
Concussion groupb |
34,995 |
33,341 |
33,207 |
29,749 |
131,292 |
9.6 |
|||||||||||
|
Post-traumatic headache groupc |
1310 |
1226 |
1145 |
1047 |
4728 |
0.3 |
||||||||||||
|
Other head injury groupd |
7485 |
5884 |
5568 |
5172 |
24,110 |
1.8 |
||||||||||||
|
<1 |
79,981 |
72,615 |
78,902 |
69,067 |
300,565 |
21.9 |
||||||||||||
|
1 |
76,995 |
71,664 |
71,729 |
61,843 |
282,230 |
20.6 |
||||||||||||
|
2 |
81,709 |
70,355 |
74,126 |
61,316 |
287,506 |
21.0 |
||||||||||||
|
Age (years) |
3 |
39,639 |
39,440 |
39,655 |
34,424 |
153,158 |
11.2 |
|||||||||||
|
4 |
33,248 |
32,407 |
31,446 |
28,128 |
125,229 |
9.1 |
||||||||||||
|
5 |
29,996 |
29,316 |
30,004 |
26,092 |
115,408 |
8.4 |
||||||||||||
|
6 |
28,461 |
27,448 |
27,264 |
24,715 |
107,888 |
7.9 |
||||||||||||
|
Gender |
Male |
212,855 |
198,680 |
202,865 |
174,166 |
788,566 |
57.5 |
|||||||||||
|
Female |
157,243 |
144,590 |
150,260 |
131,528 |
583,621 |
42.5 |
||||||||||||
|
Large central metropolitan |
127,064 |
102,075 |
110,755 |
89,900 |
429,794 |
31.4 |
||||||||||||
|
Patient’s Residence |
Small metropolitan |
191,737 |
192,077 |
194,191 |
170,635 |
748,639 |
54.7 |
|||||||||||
|
Micropolitan |
32,577 |
32,434 |
31,162 |
28,818 |
124,990 |
9.1 |
||||||||||||
|
Not metropolitan or micropolitan |
17,700 |
15,828 |
16,294 |
15,663 |
65,484 |
4.8 |
||||||||||||
|
Patient treated and released |
364,546 |
337,355 |
348,003 |
300,863 |
1,350,767 |
98.4 |
||||||||||||
|
Disposition from ED |
Patient admitted to same hospital |
2029 |
2073 |
1938 |
1887 |
7927 |
0.6 |
|||||||||||
|
patient transferred to a short-term hospital |
3366 |
3265 |
2902 |
2927 |
12,460 |
0.9 |
||||||||||||
|
Patient not admitted, destination unknown |
172 |
599 |
318 |
37 |
1127 |
0.1 |
||||||||||||
|
Mean |
1727 |
1836 |
1959 |
2244 |
1940 |
|||||||||||||
|
ED Charges (dollars) |
Median |
1000 |
1034 |
1157 |
1308 |
1116 |
||||||||||||
|
Total |
539,751,868 |
548,417,948 |
598,656,794 |
681,391,250 |
2,368,217,860 |
|||||||||||||
|
Mean |
32,632 |
24,529 |
35,886 |
29,162 |
30,464 |
|||||||||||||
|
Inpatient Charges (dollars) |
Median |
19,050 |
16,194 |
21,069 |
21,318 |
19,053 |
||||||||||||
|
Total |
70,708,551 |
54,268,394 |
72,448,363 |
56,411,314 |
253,836,623 |
|||||||||||||
|
Medicare |
2725 |
1074 |
1087 |
1756 |
6642 |
0.5 |
||||||||||||
|
Medicaid |
199,208 |
187,029 |
191,580 |
164,672 |
742,489 |
54.2 |
||||||||||||
|
Primary Payer |
Private insurance |
134,350 |
127,305 |
129,140 |
110,384 |
501,178 |
36.6 |
|||||||||||
|
Self-pay |
19,587 |
16,076 |
18,835 |
17,603 |
72,101 |
5.3 |
||||||||||||
|
No charge |
187 |
279 |
304 |
466 |
1235 |
0.1 |
||||||||||||
|
Other |
13,771 |
10,700 |
11,995 |
10,301 |
46,767 |
3.4 |
||||||||||||
|
2016 |
2017 |
2018 |
2019 |
Total |
||||||||||||||
|
Variable |
Subcategory |
N |
N |
N |
N |
N |
Percentage |
|||||||||||
|
0%-25% |
107,000 |
99,157 |
105,187 |
87,820 |
399,165 |
29.4 |
||||||||||||
|
Median household income Quartile by Zip Code 25%-50% |
94,693 |
92,337 |
93,968 |
79,130 |
360,129 |
26.5 |
||||||||||||
|
50%-75% |
85,367 |
81,537 |
79,312 |
73,599 |
319,815 |
23.5 |
||||||||||||
|
75%-100% |
79,081 |
67,043 |
71,535 |
62,680 |
280,339 |
20.6 |
||||||||||||
|
Fall |
260,426 |
240,815 |
235,596 |
216,087 |
952,924 |
69.4 |
||||||||||||
|
Struck by, against |
58,137 |
52,268 |
50,910 |
47,992 |
209,307 |
15.3 |
||||||||||||
|
MVA groupe |
10,187 |
9229 |
8886 |
7908 |
36,210 |
2.6 |
||||||||||||
|
Pedal cyclist, other |
3306 |
2940 |
2617 |
2410 |
11,271 |
0.8 |
||||||||||||
|
Mechanism of Injury Pedestrian, other |
400 |
365 |
314 |
275 |
1354 |
0.1 |
||||||||||||
|
Natural/environmental |
855 |
881 |
980 |
859 |
3575 |
0.3 |
||||||||||||
|
Cut/pierce |
584 |
609 |
535 |
607 |
2334 |
0.2 |
||||||||||||
|
Miscellaneous groupf |
132 |
174 |
174 |
164 |
643 |
0.0 |
||||||||||||
|
Other groupg |
36,086 |
36,013 |
53,150 |
29,424 |
154,672 |
11.3 |
||||||||||||
|
Unintentional |
340,266 |
312,804 |
304,744 |
280,683 |
1,238,497 |
90.3 |
||||||||||||
|
Assault |
735 |
635 |
724 |
728 |
2821 |
0.2 |
||||||||||||
|
Intent Self-inflicted |
22 |
22 |
19 |
38 |
101 |
0.0 |
||||||||||||
|
Undetermined |
310 |
256 |
275 |
160 |
1000 |
0.1 |
||||||||||||
|
NA |
28,780 |
29,576 |
47,399 |
24,117 |
129,872 |
9.5 |
||||||||||||
|
0 |
688 |
725 |
684 |
630 |
2728 |
0.2 |
||||||||||||
|
Injury Severity Score 1-3 |
270,906 |
251,315 |
265,534 |
230,567 |
1,018,322 |
74.2 |
||||||||||||
|
4-8 |
89,720 |
84,633 |
80,728 |
68,982 |
324,063 |
23.6 |
||||||||||||
|
9-15 |
8798 |
6620 |
6214 |
5547 |
27,179 |
2.0 |
||||||||||||
|
Children’s Hospital Children’s hospital |
49,353 |
35,364 |
66,843 |
37,339 |
188,899 |
13.8 |
||||||||||||
|
Non-Children’s hospital |
320,760 |
307,928 |
286,318 |
268,387 |
1,183,393 |
86.2 |
||||||||||||
|
Teaching Hospital Teaching hospital |
230,472 |
217,078 |
242,035 |
200,481 |
482,226 |
35.1 |
||||||||||||
|
Non-teaching hospital grouph |
139,641 |
126,214 |
111,126 |
105,245 |
890,065 |
64.9 |
||||||||||||
|
Northeast |
67,077 |
59,912 |
60,741 |
54,645 |
242,374 |
17.7 |
||||||||||||
|
Hospital Region Midwest |
79,339 |
87,798 |
90,377 |
69,277 |
326,791 |
23.8 |
||||||||||||
|
South |
132,762 |
112,656 |
131,921 |
112,248 |
489,586 |
35.7 |
||||||||||||
|
West |
90,934 |
82,927 |
70,122 |
69,557 |
313,540 |
22.8 |
||||||||||||
|
1-1799 |
11,634 |
12,924 |
12,557 |
14,115 |
51,230 |
3.7 |
||||||||||||
|
Number of Patients < 18 Treated at Hospital Annually 1800-4999 |
55,715 |
52,523 |
54,328 |
52,466 |
215,031 |
15.7 |
||||||||||||
|
5000-9999 |
75,452 |
84,745 |
74,270 |
75,573 |
310,041 |
22.6 |
||||||||||||
(continued on next page)
|
2016 |
2017 |
2018 |
2019 |
Total |
|||||||
|
Variable Subcategory |
N |
N |
N |
N |
N |
Percentage |
|||||
|
10,000-19,999 |
85,347 |
76,018 |
71,656 |
75,141 |
310,041 |
22.5 |
|||||
|
20,000-49,999 |
79,654 |
65,309 |
63,669 |
57,650 |
266,283 |
19.4 |
|||||
|
>= 50,000 |
62,310 |
51,773 |
76,680 |
30,781 |
221,545 |
16.1 |
ED, emergency department; MVA, motor vehicle accident; NA, not applicable. a: some patient visits may be classified in multiple sub-categories.
b: Concussion group: concussion without loss of consciousness, initial encounter (S060X0A), concussion with loss of consciousness of 30 min or less, initial encounter (S060X1A), concus-
sion with loss of consciousness of unspecified duration, initial encounter (S060X9A).
c: Post-traumatic headache group: acute post-traumatic headache, intractable (G44311), acute post-traumatic headache, not intractable (G44319), post-traumatic headache, unspecified, intractable (G44301), post-traumatic headache, unspecified, not intractable (G44309).
d: Other head injury group: other biomechanical lesions of head region (M9980), unspecified intracranial injury without loss of consciousness, initial encounter (S069X0A), unspecified intracranial injury with loss of consciousness of 30 min or less, initial encounter (S069X1A), unspecified intracranial injury with loss of consciousness of unspecified duration, initial en- counter (S069X9A), encounter for screening for traumatic brain injury (Z13850).
e: MVA group: motor vehicle traffic and transport.
f: Miscellaneous group: adverse effects, fire/burn, firearm machinery, overexertion.
g: Other group: other specified classifiable, other specified not elsewhere classifiable, unspecified, NA. h: Non-teaching hospital group: metropolitan non-teaching and non-metropolitan.
cervical spine CT were used more frequently at non-children’s hospitals. Additional education of clinicians regarding evidence-based indications for CT after head injury in young children is warranted and may further reduce the rate of CT usage for mTBI.
Although most of the head injury visits in this sample are of low or moderate medical complexity, they result in significant financial bur- den, incurring almost 600 million dollars per year for ED care plus 63 million dollars per year for inpatient care. More than half of the visits were covered by Medicaid, indicating a high burden on public payers.
-
- Limitations
There are several limitations to the current study. First, the NEDS da- tabase is based on billing and diagnostic codes, which are limited by the
input accuracy of the health care professionals and billing department of the hospital. Second, using the “unspecified injury of head” diagnosis may have resulted in the inclusion of patients with very mild injuries, not meeting the clinical definition of concussion that has been estab- lished for older children and adults [27]. However, we believe that this diagnosis should be included in estimates of the incidence of mTBI in young children due to the limited guidelines available to clinicians to make a more specific diagnosis. Third, information regarding race, eth- nicity, neuroImaging results, outpatient medications, and past medical history are not available in the NEDS database. repeat visits to the ED and follow-up outpatient visits are also not available in NEDS, so we were unable to track patients over time to determine recovery. Fourth, many children with mTBI are seen in the outpatient setting or do not seek medical care. However, 87% of young children diagnosed with
Fig. 2. Percentage of patient visits to the emergency department using each head injury diagnosis category. Percentages for the “other head injury” and “post-traumatic headache” groups were all <2.5%, so exact percentages are not shown for these categories.
Injury diagnosis rates by hospital type, national estimates.
Children’s Hospital Non-Children’s Hospital P-value
|
Diagnosis |
N |
Percent |
95% CI |
N |
Percent |
95% CI |
||
|
Unspecified injury of head (S0990XA) |
160,780 |
85.1 |
82.5-87.0 |
978,276 |
82.7 |
81.8-83.5 |
0.09 |
|
|
Other specified injuries of head (S098XXA) |
7650 |
4.1 |
2.6-5.5 |
77,758 |
6.6 |
5.9-7.2 |
0.08 |
|
|
Concussion groupa |
17,949 |
9.5 |
7.6-11.5 |
113,343 |
9.6 |
9.2-10.0 |
0.94 |
|
|
Post-traumatic headache groupb |
639 |
0.3 |
0.2-0.5 |
4088 |
0.4 |
0.3-0.4 |
0.92 |
|
|
Other head injury groupc |
2870 |
1.5 |
1.1-1.9 |
21,240 |
1.8 |
1.6-2.0 |
0.26 |
|
|
Total |
188,899 |
100 |
1,183,393 |
100 |
Comparisons made using two-tailed Rao-Scott Chi-Square tests.
a Concussion group: concussion without loss of consciousness, initial encounter (S060X0A), concussion with loss of consciousness of 30 min or less, initial encounter (S060X1A), concussion with loss of consciousness of unspecified duration, initial encounter (S060X9A).
b Post-traumatic headache group: acute post-traumatic headache, intractable (G44311), acute post-traumatic headache, not intractable (G44319), post-traumatic headache, unspeci-
fied, intractable (G44301), post-traumatic headache, unspecified, not intractable (G44309).
c Other head injury group: other biomechanical lesions of head region (M9980), unspecified intracranial injury without loss of consciousness, initial encounter (S069X0A), unspecified intracranial injury with loss of consciousness of 30 min or less, initial encounter (S069X1A), unspecified intracranial injury with loss of consciousness of unspecified duration, initial en- counter (S069X9A), encounter for screening for traumatic brain injury (Z13850).
mTBI are seen in the ED or urgent care [12]. Our study assessed the subset of patients presenting to the ED for care.
-
- Conclusions
Approximately 343,000 children ages 0-6 years present to U.S. EDs each year with concussion or mTBI, incurring over $650 million in ED and inpatient charges. Most are diagnosed with “unspecified injury of head”, highlighting the diagnostic uncertainty clinicians face in this age group. There are limited diagnostic tools and no clinical practice guidelines tailored to this young age. Future research should focus on the diagnostic accuracy of mild TBI in early childhood and the develop- ment of effective treatments.
Funding
Emergency Medicine at Nationwide Children’s Hospital supported the statistical analysis.
Declaration of Competing Interest
The authors report no conflicts of interest related to this article.
We thank Tammy Lozan and Jody Streitenberger for their help obtaining descriptions of CPT codes. We thank Emergency Medicine at Nationwide Children’s for funding the statistical analysis.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2022.12.035.
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