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

A National Review of Inpatient Admissions for Pediatric Concussion Tara Rhine, MD MS 1 Lynn Babcock, MD MS 1 Mekibib Altaye, PhD 2 1 Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center 2 Division of Biostatistics & Epidemiology, Cincinnati Children’s Hospital Medical Center

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)

Background • 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)

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

Methods 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 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.)

Analysis Outcome • Proportion of all TBI admissions for concussion Analyses • Trend analysis over time using the Cochran-Armitage Trend Test Data Elements • Age • Payer type • Race • Mechanism of injury • Gender • Hospital size Analyses • Descriptive analysis of data elements • Trend analysis over time using the Cochran-Armitage Trend Test

Results Proportion of Concussion Admissions versus Overall TBI Admissions 12000 Number of TBI Admissions 10000 8000 Admissions for all TBI did not 6000 significantly change (p=0.587) 4000 2000 0 2007 2008 2009 2010 2011 2012 2013 All TBI Concussion Moderate/Severe TBI

Results Proportion of TBI Admissions that were Concussions from 2007-2013 Proportion of concussions significantly increased 25 (Z=10.41, p<0.0001) Percent of All TBI Admissions 24 Proportion of head injury NOS (~9%) did not 23.7% 23 significantly change over time (p=0.62) 22 21 Concussion 19.6% 20 19 18 17 2007 2008 2009 2010 2011 2012 2013 Year

Results Age of Children Admitted with Concussion from 2007-2013 (N= 16,599) Age of Children Admitted with TBI Median (IQR) Mean (±SD) from 2007-2013 and Changes Over Time (N= 80,465) Years 11 (6-14) 9.8 (5) 40,000 p=0.02* 35,000 16% *All age groups demonstrated a significant increase in concussion All TBI Admissions 30,000 admissions 25,000 20,000 p<0.001* p<0.001* 15,000 p<0.001* 21% 32% 31% 10,000 5,000 0 0<4 9<14 ≥14 Age 4<9 (Years) Yes No Concussion

Results Characteristics of Children Admitted with Concussion from 2007-2013 and Changes Over Time (N= 16,599) Change over Time Data Element % of Cohort 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 Denoted significant p-values <0.05 Increasing Decreasing

Results Change over Time Data Element % of Cohort 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 Denoted significant p-values <0.05. *Based on Cochran-Armitage Trend Test Increasing Decreasing

Percentage of Children Admitted with Concussion Based on Hospital Size from 2007-2013 (N= 16,599) 100 Percent of Concussion Admissions *p-values reflect 90 changes in % 80 over time p < 0.001 70 60 50 40 66.3% p < 0.001 30 20 p = 0.75 25.4% 10 8.3% 0 >400 200 - 400 <200 Hospital Size (Based on Inpatient Beds)

Summary • 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%

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

Conclusions • 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

References 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 3 rd . 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

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

EXTRA SLIDES

Inpatient Practices Length of Stay for Inpatient Pediatric Concussion Admission Median (IQR) Mean (±SD) Length of Stay (Days) 1 (1-2) 1.8 (3.5) 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%

Predictors of LOS Length of Stay for Inpatient Pediatric Concussion Admission Median (IQR) Mean (±SD) Length of Stay (Days) 1 (1-2) 1.8 (3.5) Predictors of Length of Stay for Inpatient Pediatric Concussion Admission (0-1 vs >1 Day) Odds Ratio Significant Variable (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)

Results Percentage of Children Admitted with Concussion Based on Hospital Region from 2007-2013 (N= 16,599) 20% <0.0001* 24% 20% 0.02* <0.0001* 36% 0.15 *Significant changes over time are denoted by box color: Green increasing % and Red decreasing %