Youth Sport Related Concussion Study FINAL

7/29/2019 Youth Sport Related Concussion Study FINAL

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1ED and Hospital Admission Rates for Youth Sport Related Concussions

(c) Copyright (October 20, 2011) All Rights Reserved

Emergency Department and Hospital Admission Ratesfor Youth Sports-Related Concussions:A Northeast Florida Utilization Study

ContentsTables and Figures p. 2

About the Health Planning Council p. 4Background p. 4

Literature Review p. 5

Research Questions p. 7

Data Collection p. 7

Findings p. 8

National p. 9

State p. 11

Regional p. 13

Recommendations p. 36

References p. 37

A Smart People Project


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Tables and Figures

ble 1 Top 20 Sports/Recreational Activities that Lead to Head Injuries----------------------------------------------------------6ble 2 Top 10 Sports-Related Head Injury Categories Among Children Ages 14 and Younger------------------------6ble 3 Numbers and age-adjusted rates per 100,000 population for traumatic brain

injury deaths, by year, sex, and race/ethnicity 19972007------------------------------------------------------------------- 9gure 1 Age-Adjusted Rate of Traumatic Brain Injury Deaths (All Ages) By Race 1997-2007--------------------------1gure 2 Age-Adjusted Rate of Traumatic Brain Injury Deaths (All Ages) By Gender 1997-2007----------------------10gure 3 Age-Adjusted Rate of Traumatic Brain Injury Deaths By Age 1997-2007---------------------------------------------1ble 4 The number and rate of Traumatic Brain Injury-Related Deaths by Age Group, Florida

1997-2007________________________________________________________________________11gure 4 Non-Fatal Head Injury Hospitalization for Ages 12-18, Florida Department of Health,

1999-2009------------------------------------------------------------------------------------------------------------------------------------------------ 12gure 5 Emergency Department Visits, Patients with TBI versus Non-TBI, 2006-2009------------------------------------1gure 6 Emergency Department Visits for Patients with TBI, Sports versus Non-Sports

Related, 2006-2009---------------------------------------------------------------------------------------------------------------------------------14gure 7 Emergency Department Visits for Patients with TBI, Sports versus Non-Sports

Related, By Age, 2006-2009--------------------------------------------------------------------------------------------------------------------1ble 5 Emergency Department Visits for Patients with TBI, Sports Versus Non-Sports

Related, By Age, 2006-2009 Percentage of TBI Visits that are Sports-Related-----------------------------------1gure 8 Emergency Department Visits for Patients with TBI, Sports and Non-Sports

Related, By Gender, 2006-2009--------------------------------------------------------------------------------------------------------------1gure 9 Emergency Department Visits for Patients with TBI, Sports and Non-Sports

Related, By Race, 2006-2009------------------------------------------------------------------------------------------------------------------1gure 10 Emergency Department Visits for Patients with TBI, Sports and Non-Sports

Related, By Payor, 2006-2009-----------------------------------------------------------------------------------------------------------------1ble 6 Emergency Department Visits for Patients with TBI, Sports and Non-Sports

Related, By Payor, 2006-2009 Percentage of TBI Visits that are Sports-Related--------------------------------1gure 11 Emergency Department Visits for Patients with TBI, Sports and Non-Sports

Related, By County, 2006-2009--------------------------------------------------------------------------------------------------------------19ble 7 Emergency Department Visits for Patients with TBI, Sports and Non-Sports

Related, By County, 2006-2009 Percentage of TBI Visits that are Sports-Related-----------------------------19gure 12 Emergency Department Visits for Patients with TBI, Sports and Non-Sports

Related, By Day of the Week, 2006-2009----------------------------------------------------------------------------------------------20ble 8 Emergency Department Visits for Patients with TBI, Sports and Non-Sports Related,

By Day of the Week, 2006-2009 Percentage of TBI Visits that are Sports-Related----------------------------20gure 13 Emergency Department Visits for Patients with TBI, Sports and Non-Sports

Related, By Hospital, 2006-2009------------------------------------------------------------------------------------------------------------21ble 9 Emergency Department Visits for Patients with TBI, Sports and Non-Sports Related,

By Hospital, 2006-2009 Percentage of TBI Visits that are Sports-Related------------------------------------------21gure 14 Emergency Department Percentage of Visits Receiving a CT Scan for TBI

Sports and Non-Sports Related, 2006-2009----------------------------------------------------------------------------------------- 22gure 15 Hospital Admissions for Patients with TBI and Non-TBI, 2006-2009--------------------------------------------------- 2gure 16 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,2006-2009----------------------------------------------------------------------------------------------------------------------------------------------- 24gure 17 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Age, 2006-2009----------------------------------------------------------------------------------------------------------------------------------25ble 10 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Age, 2006-2009 Percentage of TBI Visits that are Sports-Related-------------------------------------------------25gure 18 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Gender, 2006-2009----------------------------------------------------------------------------------------------------------------------------26ble 11 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,


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By Gender, 2006-2009, Percentage of TBI, ED and Hospitalizations, by Gender_______________ 26gure 19 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Race, 2006-2009--------------------------------------------------------------------------------------------------------------------------------27gure 20 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Payor, 2006-2009------------------------------------------------------------------------------------------------------------------------------- 2ble 12 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Payor, 2006-2009 Percentage of TBI Visits that are Sports-Related-----------------------------------------------2gure 21 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By County, 2006-2009------------------------------------------------------------------------------------------------------------------------------2ble 13 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By County, 2006-2009 Percentage of TBI Visits that are Sports-Related---------------------------------------------2gure 22 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Day of the Week, 2006-2009--------------------------------------------------------------------------------------------------------------3ble 14 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Day of the Week, 2006-2009 Percentage of TBI Visits that are Sports-Related-----------------------------3gure 23 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Hospital, 2006-2009----------------------------------------------------------------------------------------------------------------------------3ble 15 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

By Hospital, 2006-2009 Percentage of TBI Visits that are Sports-Related-------------------------------------------3gure 24 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

Mean LOS, 2006-2009-----------------------------------------------------------------------------------------------------------------------------3gure 25 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

Mean Gross Charges, 2006-2009-----------------------------------------------------------------------------------------------------------33gure 26 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

Discharge Status, 2006-2009-----------------------------------------------------------------------------------------------------------------34gure 27 Hospital Admissions for Patients with TBI Sports and Non-Sports Related,

Admission Type, 2006-2009--------------------------------------------------------------------------------------------------------------------3


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bout the Healthlanning CouncilThe Health Planning Council is a non-

profit agency and one of 11 Local

Planning Councils mandated by Florida

State Statute 408.033 to dedicate

resources and expertise to regional

community-based health needsassessments, healthcare utilization

studies, management of health-related

quality of life indicators and the

development of effective collaborative

partnerships. For over 40 years, weve

been making the region healthier by

providing assessment services to our

service delivery area: Baker, Clay,

Duval, Flagler, Nassau, St. Johns and

Volusia Counties. As a neutral regional

planning entity with offices in both

Duval and Volusia Counties, we

provide a range of health planning

expertise without bias or conflicts of

interest. We serve the region by

actively participating and influencing

outcomes to protect and create

healthy, sustainable communities.

Our core focus areas address:Healthy Communities- Assessprevalence of disease and issues

impacted by biological, behavioral,

social and environmental

determinants of healthHappy and Healthy Places-Influence policy that improves

quality of life and the built

environmentSmart People-Equip decision-makers and the public with the

information they need to make

informed decisionsVibrant Partnerships-Develop andleverage effective collaborations,

networks, systems & health-

related organizations

ackgroundIn October 2010, the Health Planning

Council announced the topic for the

2011 Utilization Study: The Youth

Sport-Related Concussion Study.

After selecting the topic, the Health

Planning Council worked on

assembling and convening a group

of regional representatives from

area hospitals and sport-related

organizations to form the study

council. The study council would be

charged with determining the

research questions, collecting and

analyzing the local data, and making

formal recommendations. The

group consists of representatives

from Agency for Health Care

Administration (AHCA), Baker County

Hospital Authority, Baptist

Health,Brooks Rehabilitation, Duval

County Medical Society, the Florida

Association of High School Athletics,

Florida Hospital, Halifax Medical

Center, Jacksonville Jaguars,

Jacksonville Sports Medicine

Program, Mayo Clinic, MemorialHealth, Nemours Childrens Clinic,

Office of Research Affairs Center for

Healthy Equity and Quality Research

UF-Shands, Orange Park Medical

Center, Shands Jacksonville, St.

Vincents Health, Wolfson Childrens

Hospital, the University of North

Florida, the University of Florida

Emergency Department in

Jacksonville, and a local neuro-

psychologist.

The study council developed the

following areas of concern regarding

sport-related concussions in children

between the ages of 10-18:

The need to ensure children

safety during sport activities. The

disconnect among community

stakeholders regarding local

expertise and stewardship,

outreach efforts, education,

clinical research, reporting,

treatment, neuro-imaging,

etcregarding sport related

concussion in children

Communities have a difficult

time identifying and

understanding valid,

quantifiable, baseline data for

incidence and prevalence of

youth sport related concussions

The absence of a formalized

process for reporting youth-rela

concussions, which occurs in

community sports associations

and schools

The vital need to educate the

community on how to tell when

head injury has occurred (terme

signs and symptoms), treatme

and follow up procedures for yo

sport concussions- i.e. coaches

hospital staff, parents,

pediatricians, students and

athletic trainers

Concussions are difficult to

diagnose; There are hidden sign

and symptoms are often

misdiagnosed or completely

overlooked and missed

Concussion treatment, hospital

discharge procedures, andensuring appropriate follow up a

challenges for ED physicians,

primary care physicians,

pediatricians, parents, and

coaches

The need to better understand t

long-term outcomes of the 1st

subsequent concussive episode

1, 2, 3 years post concussion

including school performance

The community needs to develo

and agree to the ethicalconsiderations for allowing

children to return to play after a

concussion to avoid significant

health consequences and death

There is a need to better

understand the indications for

utilizing CT scans or other imag

procedures in the management

children with minor injury with o

without symptoms of concussio


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he Health Planning Council assembled 23 peer reviewed articles to assist with selecting initial research questions. The

rticles were plotted on a matrix to classify the information for further analysis. Many of the articles were dated within in

he last 10 years and related to head injuries, concussions caused by sports, CT (computed tomographic) scan utilization

nd signs and symptoms. The Health Planning Council looked to the expertise of the Study Council to finalize the resear

uestions for the study.

port-related traumatic brain injuries (TBIs) have received an increase in national and local attention over the last severa

ears with state and federal governments leading the implementation of laws directing a set of standards and guidelines

uspected brain injury (Centers for Disease Control and Prevention, 2011) . This is evident by the 60% increase in the

ediatric ED visits of concussion over the last 8 years. The recommendations from the Third International Conference on

Concussion in Sports were to reinforce an individualized evaluation of an athletes neurocognitive functioning, symptoms

nd balance and a step wise approach in the return to play process. There is also a need for a standardized and objectiv

ool to aid in the initial evaluation and management of brain injuries (Cohen, Gioia, Atabaki, & Teach, 2009). Despite the

eed for a standard grading scale to determine the severity of the head injury, it is important to determine return to plaased on a clinical evaluation of the individual athlete (Collie, McCrory, Makdissi, 2006). Substantial knowledge now exis

hat will help in evaluating an injured athlete and the most appropriate management scheme in order to prevent perman

erebral dysfunction and to establish return to play guidelines (Bailes & Hudson, 2001).

Often times players will suffer from a head injury and never report it. Players and coaches need to be educated on the s

nd symptoms of head injuries as well as proper care procedures. Having a certified athletic trainer at high school sport

vents would greatly aide in the proper diagnosis and treatment of head injuries during these events. It is also vital for t

oaches and athletic trainers to agree upon what concussion grading scale and return to play guidelines will be used

American Academy of Neurology, Colorado Medical Society, Cantu) (Logan, Bell, & Leonardt, 2001). Often times when a

atient doesnt fully understand concussions, they will continue to participate in high risk activities despite having

ymptoms of a concussion. This can lead to further concussions and Second Impact Syndrome (Delaney, Abuzeyad, Cor

& Foxford, 2005).

ven though the actual number of head injuries varies between ice hockey, football and soccer, the annual rate for each

port is comparable (Delaney, 2004). Females sustained a higher rate of concussions than males during sport related

ctivities (Covassin, Swanik, & Sachs, 2003). Concussion rates tend to be higher among collegiate athletes but they

epresent a high proportion of the injuries reported in high school athletes (Gessel, Fields, Collins, Dick, & Cornstock, 200

atients presenting to the emergency department (ED) because of a head injury from a sport-related activity are commo

nd are typicallymore severe than other types of sport related injuries treated in the ED (Kelly, Lissel, Rowe, Vincenten, &oaklander, 2001). Concussion injury is 6 times more likely to happen during organized sports activity than in other

ctivities for children ages 6 to 14 (Lovell & Fazio, 2008).

Hospital stays for patients with a traumatic brain injury (TBI) tend to be longer and more costly than hospitalizations for nBI injuries. TBI hospitalizations are also more likely to occur among younger patients and males. Patients admitted for

lso have a higher in-hospital death rate than other injuries(Russo & Steiner, 2007).The American Association ofNeurological Surgeons reports that the leading cause of death from sports-related injuries is TBI. They define TBI as a b

r jolt to the head or a penetrating head injury that disrupts the normal function of the brain. According to an AANS stud

hat utilized Consumer Product Safety Commission (CPSC) data, 446,788 sports-related head injuries were treated in U.S

mergency departments in 2009. The actual incidence of these injuries could in fact be larger due to the exclusion of da

or product categories with 1,200 injuries or less. Additionally, not all head injuries are treated in emergency department


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Table 2

The following 20 sports/recreational activities represent the categories contributing to the

highest number of estimated head injuries treated in U.S. hospital emergency rooms in 2009 (All ages).

Source: American Association of Neurological SurgeonsThe top 10 sports-related head injury categories among children ages 14 and younger:

Source: American Association of Neurological Surgeons

Sport Estimated Number ofHead InjuriesCycling 85,389

Football 46,948

Baseball and Softball 38,394

Basketball 34,692

Water Sports (Diving, Scuba Diving, Surfing, Swimming, Water Polo, Water Skiing,

Water Tubing)

28,716

Powered Recreational Vehicles (ATVs, Dune Buggies, Go-Carts, Mini bikes, Off-road) 26,606

Soccer 24,184

Skateboards/Scooters 23,114

Fitness/Exercise/Health Club 18,012

Winter Sports (Skiing, Sledding, Snowboarding, Snowmobiling) 16,948

Horseback Riding 14,466

Gymnastics/Dance/Cheerleading 10,223

Golf 10,035

Hockey 8,145

Other Ball Sports and Balls, unspecified 6,883

Trampolines 5,919

Rugby/Lacrosse 5,794Roller and Inline Skating 3,320

Ice Skating 4,608

Sport Estimated Number of Head InjuriesCycling 40,272

Football 21,878

Baseball and Softball 18,246

Basketball 14,952Skateboards/Scooters 14,783

Water Sports 12,843

Soccer 8,392

Powered Recreational Vehicles 6,818

Winter Sports 6,750

Trampolines 5,025

Table 1


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Injury is the leading cause of morbidity and mortality for youths aged 10-19 years. (Laraque, Barlow, & Durkin, 1999,

p.551). Establishing preventive measures is going to play a key role in reducing the number of sport related head injuri

In order to establish these measures there needs to be an increase in knowledge of concussion rates, patterns and risk

factors (Gessel, et al., 2007). Continual analysis of the available data will also help reduce the number of sport related

head injuries (Mueller, 2001). Injury prevention activities should utilize both data and sound theoretical frameworks to

reduce the injury mortality and morbidity in youth (Laraque, et al., 1999).

Additionally, after a robust discussion, testimony from sport-related concussion experts, literature extracted from peer-

reviewed journals, and the careful narrowing of the studys scope, The Study Council agreed upon four core research

questions to pursue:

RQ1: How prevalent were Emergency Department visits for sport-related and non-sports related Traumatic BrainInjuries (TBI) in children between the ages of 10-18 in a seven county region in Northeast Florida between 2006

2009?

RQ2: How prevalent were Hospital Admissions for sport-related and non-sports related Traumatic Brain Injuries(TBI) in children between the ages of 10-18 in a seven county region in Northeast Florida between 2006-2009?

RQ3: What were the demographic characteristics of children between the ages of 10-18 with sport-related andnon-sports related Traumatic Brain Injuries (TBI) in a seven county region in Northeast Florida between 2006-

2009?

RQ4: What was the utilization pattern for neuro-imaging (i.e. CT scans) for children between the ages of 10-18presenting in Emergency Departments in Northeast Florida between the years 2006-2009?

The Health Planning Council requested and received an IRB study exemption from the University of Floridas Institutiona

Review Board. An IRB number was assigned by the University of Floridas Executive Committee and is available for revie

upon request. Based on the four core research questions, members of the Study Council identified and collected severa

secondary qualified healthcare utilization data from Floridas Agency for Health Care Administration (AHCA). This is

aggregate utilization data; no personal identifying information or patient level data was retrieved or included in the data

The Center for Healthy Equity and Quality Research at the University of Florida, College of Medicine Jacksonville (CHEQ

developed an analysis plan to ensure a complete and valid data analysis process. Throughout this report, you will see t

terms concussion, head injury, and traumatic brain injury (TBI) used interchangeably. This is due, in large part, by

inconsistent definition and use of the word concussion between the local, state and national medical communities,

levels of government, sport-related organizations, and researchers. For this report, the study council attempted to use th

term traumatic brain injury or TBI where ever appropriate, while trying to maintain the validity of the national and sta

reported data.

The following information outlines the analysis plan and the secondary data requested from AHCA:

Population: Children 10 18

2006-2009 trends

959.01 - Head Injury without LOC

854 through 854.19 - Intracranial Injury of Other and Unspecified Nature

850 through 850.9 - Concussion


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2. Sports related was defined as including one or more of the following ECodes:

E849.4 - Occurrence Sports/Recreational Related Injury Codes

E886.0 - In sports

o

Tackles in sportsE917.0 - In sports without subsequent fallo Kicked or stepped on during game (football) (rugby)o Struck by hit or thrown ballo Struck by hockey stick or puck

E917.5 - Object in sports with subsequent fall

o Knocked down while boxing

3. CPT Scans was defined as including any of the following Procedure Codes for CT scan:70450 - CT Head/Brain w/o Contrast

70460 - CT Brain with Contrast

70470 - CT Brain w/o Without Contrast

Outpatient- Emergency Department (ED) visits:

Data was analyzed for Emergency Department visits for a seven county region includingBaker, Clay, Duval, Flagler,Nassau, St. Johns, & Volusia counties. Patients who visited the ED and received an ICD9 code in any of the first 9diagnoses for Traumatic Brain Injury (TBI) were first compared against all ED visits, and then classified into sports and no

ports related TBI. Analysis examined demographic characteristics of patients with TBI sports and non-sports related inju

Demographic characteristics included the patients age, gender, race, method of ED payment, county of residence, and t

day of the week they come to the ED. Information was also analyzed by hospital and by procedure code to examine CT

utilization rates.

npatient Hospital Admissions:

Data was analyzed for Hospital Admissions for a seven county region includingBaker, Clay, Duval, Flagler, Nassau, St

ohns, & Volusia counties. Patients who were admitted to the hospital and received an ICD9 code in any of their diagnategories (primary the 9th diagnosis) for Traumatic Brain Injury (TBI) were first compared against all hospital admissio

and then by sports and non-sports related TBI. Analysis was then completed to examine demographic characteristics of

patients with TBI sports and non-sports related injuries. Demographic characteristics included the patients age, gender

ace, method of hospital payment, county of residence, and the day of the week they came to the hospital. Information w

also analyzed by hospital and by hospitalization characteristics including length of stay (LOS), gross charges, and source

admission and discharge status.

Additional data for the seven-county region of Northeast Florida was gathered from the Florida Community Health

Assessment Resource Tool Set (CHARTS) and the Florida Department of Health. Data on the state level was collected fro

CHARTS and the Well Florida Council. National data was collected from the Centers for Disease Control (CDC), the Journa

Head Trauma Rehabilitation, and the Well Florida Council.

FindingsThe following section reports comprehensive data collected from all sources, progressing from a national scope, to a

tatewide scope, and finally data concerning the seven counties of Northeast Florida: Baker, Clay, Duval, Flagler, Nassau

ohns, and Volusia.


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National DataNumbers and age-adjusted rates per 100,000 population for traumatic brain injury

deaths, by year, sex, and race/ethnicity 1997--2007

Year SexWhite, non-

HispanicBlack, non-

Hispanic

American

Indian/Alaska

Native

Hispanic Other/Unknown

Total

No. Rate No. Rate No. Rate No. Rate No. No. Rate

1997

M 28,165 30 5,571 37.2 465 50.7 3,468 24.8 854 38,523 30.5

F 10,887 9.9 1,707 10 153 15.4 836 6.3 357 13,940 9.6

Total 39,052 19.3 7,278 22.4 618 32 4,304 15.3 1,211 52,463 19.3

1998

M 28,293 30 5,334 35.7 423 41.6 3,444 23.9 842 38,336 30.1

F 11,143 10 1,598 9.2 179 16.6 887 6.7 363 14,170 9.6

Total 39,436 19.3 6,932 21.2 602 28.5 4,331 15.1 1,205 52,506 19.1

1999

M 27,884 29.4 5,166 34.4 441 43.4 3,445 23.8 829 37,765 29.3

F 11,145 9.8 1,638 9.4 165 15.7 870 6.3 358 14,176 9.4Total 39,029 18.9 6,804 20.7 606 29 4,315 14.7 1,187 51,941 18.7

2000

M 27,357 28.6 4,947 31.7 421 40 3,656 23.2 808 37,189 28.3

F 10,528 9.4 1,502 8.4 170 14.7 939 6.6 352 13,491 8.9

Total 37,885 18.3 6,449 19 591 26.6 4,595 14.8 1,160 50,680 18

2001

M 28,634 29.6 5,028 32 437 40.3 3,921 23.3 855 38,875 29.2

F 10,883 9.5 1,457 8.2 190 16.7 989 6.7 366 13,885 9

Total 39,517 18.9 6,485 19 627 28 4,910 14.9 1,221 52,760 18.5

2002

M 28,519 29.2 4,909 30.9 485 42.8 3,968 23 890 38,771 28.7

F 10,897 9.5 1,467 8 174 14.9 989 6.2 386 13,913 9

Total 39,416 18.7 6,376 18.4 659 28.4 4,957 14.4 1,276 52,684 18.2

2003

M 28,394 28.9 5,030 31 503 45.3 4,023 22.4 825 38,775 28.4

F 10,937 9.4 1,539 8.4 166 14.7 1,068 6.7 398 14,108 8.9

Total 39,331 18.5 6,569 18.8 669 29.4 5,091 14.5 1,223 52,883 18.1

2004

M 28,502 28.7 4,934 30.6 439 38.5 3,996 21.3 755 38,626 27.9

F 11,391 9.7 1,510 8.2 166 13.4 1,040 6.3 417 14,524 9.1

Total 39,893 18.6 6,444 18.3 605 25.3 5,036 13.8 1,172 53,150 18

2005

M 29,497 29.4 5,229 31.5 478 39.6 4,324 22.7 884 40,412 28.8

F 11,340 9.5 1,514 8.2 160 13.2 1,091 6.2 389 14,494 8.9

Total 40,837 18.9 6,743 18.9 638 26 5,415 14.4 1,273 54,906 18.3

2006M 29,119 28.7 5,296 31.2 460 38.5 4,322 21.7 832 40,029 28.1F 11,385 9.4 1,446 7.6 154 12.3 1,057 5.9 394 14,436 8.8

Total 40,504 18.6 6,742 18.4 614 24.9 5,379 13.7 1,226 54,465 17.9

2007

M 29,593 28.9 5,069 29 429 36.3 4,197 20.8 884 40,172 27.9

F 11,462 9.3 1,441 7.5 145 11.7 1,086 5.8 410 14,544 8.7

Total 41,055 18.6 6,510 17.5 574 23.6 5,283 13.3 1,294 54,716 17.8

Source: Centers for Disease Control and Prevention, Surveillance for Traumatic Brain Injury-Related Deaths

Table 3


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Age-Adjusted Rate of Traumatic Brain Injury Deaths (All Ages) By Race 1997-2007


Age-Adjusted Rate of Traumatic Brain Injury Deaths (All Ages) By Gender 1997-2007


Figure 1

Figure 2


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Table 4

Age-Adjusted Rate of Traumatic Brain Injury Deaths By Age 1997-2007

Source: Centers for Disease Control and Prevention, Surveillance for Traumatic Brain Injury-Related DeathsState Data

The number and rate of Traumatic Brain Injury-Related Deaths by Age Group, Florida 1997-2007

From 1997-2007, the rate of traumatic brain injury-related deaths has decreased across all displayed age ranges

Age 0-4: -1.3; Age 5-9: -1.3; Age 10-14: -2.3; Age 15-19: -9.4.

Age Group0--4 5--9 10--14 15--19

Year Number Rate Number Rate Number Rate Number Rate1997 1,147 6.0 640 3.2 1,027 5.2 4,996 25.81998 1,154 6.0 664 3.2 1,060 5.3 4,802 24.21999 1,045 5.5 633 3.1 881 4.4 4,627 23.02000 1,077 5.6 624 3.0 829 4.0 4,539 22.42001 1,059 5.5 568 2.8 797 3.8 4,265 20.92002 986 5.0 503 2.5 785 3.7 4,345 21.22003 1,065 5.3 455 2.3 818 3.9 4,062 19.72004 1,016 5.0 447 2.3 761 3.6 4,002 19.22005 1,054 5.1 440 2.2 685 3.3 3,964 18.82006 1,002 4.9 438 2.2 637 3.1 3,877 18.12007 978 4.7 382 1.9 593 2.9 3,547 16.4


Figure 3


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Non-Fatal Head Injury Hospitalization for Ages 12-18, Florida Department of Health, 1999-2009

Source: Florida Department of Health, Bureau of Vital Statistics (CHARTS)

Data Source: Florida Agency for Health Care Administration (AHCA).

The rate per 100,000 for non-fatal head injury hospitalizations of patients ages 12-18 decreased from the

1999-2001 rate of 79.2 to the 2007-2009 rate of 67.4, an 11.8 per 100,000 decrease.

Figure 4


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Figure 5

Emergency Department Visits, TBI vs. Non-TBI,

Florida Agency for Health Care Administration, 2006-2009

There is a noticeable increase in the number of emergency department visits in 2009. Additionally, 2009 saw

the largest percentage of emergency department visits resulting from TBI, at 2.15%. In 2006: 1.97%; 2007: 2.09

2008: 1.85%.

TBI is defined as 850 through 850.9 or 900 through 900.9 or 959.01 or 854 through 854.19

Data is provided for a seven county region including Baker, Clay, Duval, Flagler, Nassau, St. Johns,

& Volusia Counties

Source: Florida Agency for Health Care Administration

Regional Outpatient (Emergency Department Visits) forTraumatic Brain Injury (TBI)


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Emergency Department Visits, TBI, Sports vs. Non-Sports,


From 2006 to 2009, Sports related Traumatic Brain Injuries (TBI) accounted for 15% of all TBIs reported during this

timeframe. There was an increase in the number of children 10 18 years of age who went to the ED for treatment

of a sport-related TBI between 2006 and 2009 from 154 to 269 people, a 75% increase but the overall number of

TBI for this period also increased.

Figure 6


Sports Related is defined as E849.4 or E886.0 or E917.0 or E917.5


& Volusia Counties


Regional Outpatient (Emergency Department Visits) forTraumatic Brain Injury (TBI) Sports and Non-Sports Related


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Table 5

Emergency Department Visits, TBI, Sports vs. Non-Sports, By Age


The number of emergency department visits from 2006-2009 for patients with TBI increases steadily with age.

However, the percentage of those visits that are sports-related do not follow this pattern.

Age Percentage of TBI visits that are sports-related

10 13.8%

11 14.8%12 14.8%

13 16.5%

14 20.1%

15 18.9%

16 17.8%

17 13.3%

18 5.0%

Figure 7


Sports Related is defined as E849.4 or E886.0 or E917.0 or E917.5Data is provided for a seven county region including Baker, Clay, Duval, Flagler, Nassau, St. Johns,

& Volusia Counties




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Emergency Department Visits, TBI, Sports vs. Non-Sports, By Gender


Males make many more emergency department visits for TBI. Additionally, the percentage of visits that are

sports-related for males (17.8%) is higher than for females (8.8%). This disagrees with Covassin et al. Their

rate was higher in females.

Figure 8




& Volusia Counties




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Emergency Department Visits, TBI, Sports vs. Non-Sports, By Race


While White resident emergency department visits with TBI are double Black and Other put together, they

have the lowest *value of sports-related TBI visits (14.3%). Black: 15.2% Other: 16.4%.

*This data was not statistically tested to see if chance could account for this variation.

Figure 9



Data is provided for a seven county region including Baker, Clay, Duval, Flagler, Nassau, St. Johns,& Volusia Counties




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Emergency Department Visits, TBI, Sports vs. Non-Sports, By Payor


53% of all emergency department visits for patients with TBI was paid for with private insurance. The highest

proportion of sports-related TBI occurred in those who pay via military benefits (23.7%).

Payor Percentage of Sports-Related TBI

Commercial 17.5%

Medicaid 11.2%

Self-Pay 7.6%

Military 23.7%

Other 13.1%

Figure 10

TBI is defined as 850 through 850.9 or 900 through 900.9 or 959.01 or 854 through 854.19Sports Related is defined as E849.4 or E886.0 or E917.0 or E917.5


& Volusia Counties


Table 6



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Emergency Department Visits, TBI, Sports vs. Non-Sports, By County


Duval County has the highest number of visits for patients with TBI (2,410). However, St. Johns County has the

highest proportion of those visits stemming from sports-related TBI (24.7%).

County Percentage of TBI visits that are sports-related

Duval 12.7%

Volusia 15.0%

St. Johns 24.7%

Clay 14.9%

Flagler 19.9%

Nassau 11.6%

Baker 8.2%

Figure 11




& Volusia Counties


Table 7



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Emergency Department Visits, TBI, Sports vs. Non-Sports, By Day of the Week


There is limited variation in emergency department visits across day of the week (Min = 808, Max = 893). Friday

sees the largest percentage of sports-related visits with 17.4%.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Total Cases 869 807 840 839 893 872 808

Sports-related % 13.0% 14.4% 14.5% 15.4% 17.4% 15.3% 11.5%

Figure 12




& Volusia Counties


Table 8



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Data is provided for a seven county region including Baker, Clay, Duval, Flagler, Nassau, St. Johns, & Volusia Counties


Table 9

Emergency Department Visits, TBI, Sports vs. Non-Sports, By Hospital


TBI Sports-Related and Non Sports-Related Hospital Data Throughout Seven Florida CountiesHospital Name

TBI Sports-

Related

TBI Non Sports-

related

% of Sports-Related

TBI

Florida Hospital, Ormond Hospital 37 121 30.6%

Baptist Medical Center- Nassau 25 136 18.4%

Florida Hospital, Flagler 39 169 23.1%

Baptist Medical Center - Beaches 49 195 25.1%

Florida Hospital - Deland 42 243 17.3%

Baptist Medical Center South 94 287 32.8%

Flagler Hospital 28 299 9.3%

Florida Hospital Fish Memorial 47 322 14.6%

Halifax Health Medical Center 86 367 23.4%

Orange Park Medical Center 60 377 15.9%

Baptist Medical Center -Downtown 143 592 24.2%

Shands Jacksonville 87 958 9.1%

Other (Hospitals with counts


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Figure 14

Emergency Department Percentage of Visits, CT Scan for TBI, Sports vs. Non-Sports,


Of note, the numbers of ordered CT scans for sports and non-sports related TBI have decreased over the study

period (2006-2009) by 17.6% and 11.3% respectively. This could be due to recently published guidelines

for CT scan imaging in pediatric TBI (Osmond, 2010; Kupperman, et al, 2009).

In addition, the decrease in the number of ordered CT scans could be due the general awareness by parents and

ED physicians of the increase risk of subsequent malignancy in pediatric patients undergoing CT since children are

10 times more radiosensitive than adults (Brody, Frush, Huda, et al; American Academy of Pediatrics, 2007).



CT utilization is defined based on procedure codes: 70450, 70460, & 70470





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Hospital Admissions for Patients with TBI and Non-TBI,


There is a noticeable decrease in the number of hospital admission visits in 2009. Additionally, 2009 saw the

smallest percentage of hospital visits result from TBI, at 1.1% (In 2006: 1.4%; 2007: 1.5%; 2008: 1.2%).

Figure 15




& Volusia CountiesSource: Florida Agency for Health Care Administration

Regional Inpatient (Hospital Admissions) for Traumatic BrainInjury (TBI) Sports and Non-Sports Related


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Hospital Admissions for Patients with TBI Sports and Non-Sports Related TBI,


From 2006-2009, TBI hospital admissions dropped by 15 patients. The percentage of those patients who had

sports-related TBI increased slightly over the same timeframe (2006: 5.1; 2009: 5.5). Additionally, 2007 saw

the highest number of admissions (99) and the highest percentage of sports-related TBI admissions (10.1%)

from 2006-2009.

Figure 16







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Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Age,


Incidence of TBI increases overall with age. However, ages 12 and 14 have the highest proportion sports-related

TBI (15.8% and 15.4% respectively). The numbers are sport-related TBI are very small so these differences are

somewhat irrelevant.

Age Percentage of TBI visits that are sports-related

10 6.7%

11 9.1%12 15.8%

13 8.3%

14 15.4%

15 9.8%

16 4.6%

17 4.9%

18 1.2%

Figure 17



& Volusia Counties


Table 10



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& Volusia Counties


Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Gender,


The percentage of hospitalizations of male patients presenting to the ED with TBI were as follow:Sport-related TBI: 2.5%

Non-sport related TBI: 6.85%

On the other hand, the percentage of hospitalizations of female patients presenting to the ED with TBI

were as follow:

Sport-related TBI: 4.25%

Non-sport related TBI: 16.5%

Therefore, the hospitalization of female patients presenting to the ED with TBI was higher than males particularly in

non-sport related TBI.

Gender ED visits for

sports-related

TBI

ED visits for non-

sports related TBI

Hospitalization

for sports-related

TBI

Hospitalization for

non- sports related

TBI

Male 673 3,107 17 213

Female 188 1,960 8 323

Figure 18


Table 11


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Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Race,


White resident emergency department visits with TBI are double Black and Other put together. Black

patients have the lowest proportion of sports-related TBI visits (6.2%). Other patients have a very high

percentage (22.2%).

Figure 19




& Volusia Counties




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Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Payor,


Commercial payment was used for the most patients (242). The payment option with the highest percentage

of sports-related TBI was military (25.0%).

Payor Percentage of Sports-Related TBI

Commercial 6.6%Medicaid 6.3%

Self-Pay 6.3%

Military 25.0%

Other 0.7%

Figure 20



& Volusia Counties


Table 12



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& Volusia Counties


Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By County,


Duval County saw the highest number of hospital admissions for patients with TBI (111).

County Percentage of TBI visits that are sports-related

Duval 5.4%

Volusia 7.7%

St. Johns 0%

Clay 3.3%

Flagler 18.2%

Nassau 0%

Baker 8.3%

Figure 21

Table 13



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Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Day of the Week,


Saturday saw the highest number of admissions for TBI (66) from 2006-2009, but Friday had the highest

percentage of sports-related admissions (18.2%).

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Total Patients 58 43 39 44 44 66 54

Sports-related % 3.4% 9.3% 2.6% 6.8% 18.2% 6.1% 5.6%

Figure 22




& Volusia CountiesSource: Florida Agency for Health Care Administration

Table 14



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Hospital Admissions for Patients with TBI Sports and Non-Sports Related, By Hospital,


Hospital Name TBI Sports-Related TBI Non Sports-related % of Sports-Related TBI

Baptist Medical Center-Downtown 5 16 23.8

Halifax Health Medical Center 15 116 11.5

Shands Hospital Jacksonville 4 177 2.2

Shands has the highest volume of hospital admissions for patients with TBI (181) but Baptist Medical Center

Downtown serves the highest percentage of sports-related TBI patients (23.8%).

Rates for the other hospitals were too small to report.

Figure 23



Data is provided for a seven county region including Baker, Clay, Duval, Flagler, Nassau, St. Johns, &

Volusia Counties


Table 15



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Hospital Admissions for Patients with TBI Sports and Non-Sports Related, Mean Length of Stay (LOS),


Across each year between 2006-2009, sports-related TBI resulted in shorter length of stay than non-sports

related TBI. Both types of TBI have decreased in length of stay from 2006 (sports-related: -0.2; non-sports

related: -0.3)

Figure 24




Volusia Counties




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Hospital Admissions for Patients with TBI Sports and Non-Sports Related, Mean Gross Charges,


Mean gross charges are consistently higher for non-sports related TBI, possibly because their length of stay is

consistently longer.

Figure 25




Volusia Counties




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Hospital Admissions for Patients with TBI Sports and Non-Sports Related, Discharge Status,


A substantial amount of patients with TBI were discharged Home (306) than Other (42). Additionally, only one

sports-related TBI patient was discharged to somewhere other than home.

Figure 26




Volusia Counties


Regional Inpatient Hospital Admissions) for Traumatic BrainInjury (TBI) Sports and Non-Sports Related


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Figure 27

Hospital Admissions for Patients with TBI Sports and Non-Sports Related, Admission Type,


Fewer TBI patients were admitted as Emergency than Other. However, a much larger proportion of those

admitted as Emergency were sports-related (Emergency: 12.3% Other: 2.7%).




Volusia Counties




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Recommendations

Members of the study council and the Health Planning Council recommend the following actions steps:

1. Develop a Youth Sport-Related Concussion Task ForceIt is recommended that a neutral, but topically qualified entity build on the momentum of this report and convene

the medical community, sport-related organizations, public and private school associations, researchers, athletic

trainers, advocates, parents and policy-makers and develop a Youth Sport-Related Concussion Task Force to:

Agree on the consistent use of the terms concussion head injury, and traumatic brain Injury

Agree on a consistent, formalized, and ethical process for reporting incidence and prevalence of

traumatic brain injuries at all levels of sports and recreation, diagnosis, hospital discharge

procedures, treatment, follow up and return-to-play decisions

Develop a coordinated and comprehensive public awareness campaign to educate coaches,

hospital staff, parents, pediatricians, students and athletic trainers on the signs and symptoms of a

traumatic brain injury, treatment and follow up procedures

Identify funding (and leverage community assets) to execute study recommendations, measure results,

and invest in local bio-science research and development relating to sport related traumatic brain

injuries

2. Develop a Community-Based Research AgendaAlthough the small numbers of sport related traumatic brain injury (TBI) limit the generalizability and interpretation

of the data provided, the following areas of research should be explored and or conducted:.

Examine the apparent disparity between gender and self- identified racial/ethnic group differences.

This includes exploring the barriers to health care access for such injuries. Proposed barriers are

parental and athletes limited knowledge of the clinical presentation of TBI as well as lower income

preventing parents from seeking care in either the ED or outpatient follow up of TBI symptoms.

Further studies should focus on the impact of sport related TBI on the athletes neuro-cognitive and

behavior changes and its consequences on quality of life and school performance


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References

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Related%20Head%20Injury.aspx.

Bailes, J.E., Hudson, V. (2001). Classification of sport-related head trauma: a spectrum of mild to severe injury. Journa

of Athletic Training, 36(3), 236-243.

Brody AS, Frush DP, Huda W, et al; American Academy of Pediatrics Section on Radiology. Radiation risk to children

from computed tomography. Pediatrics. 2007;120(3):677-82.

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Kelly, K.D., Lissel, H.L., Rowe, B.H., Vincenten, J.A., & Voaklander, D.C. (2001). Sport and Recreation-related head

injuries treated in the emergency department. Clinical Journal of Sport Medicine, 11(2), 77-81.

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prospective cohort study. Lancet. 2009;(374) 9696:1160-1170.

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unreported episodes of head trauma. Journal of Athletic Training, 36(4), 433-436.

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Reports 7(1):12-15.

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Jacksonville Office

644 Cesery Boulevard Suite 210

Jacksonville, Florida 32211

(904)-723-2162

Daytona Beach Office

101 South Palmetto Avenue, Suite 5

Daytona Beach, Florida 32114

(386) 323-2046

www.hpcnef.org

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[email protected]

Special thanks to:The Office of Research Affairs, Center for Healthy Equity and Quality Research UF-Shand

Dr. David Wood, Katryne Lukens Bull, MPH, Dr. Dale Kraemer, Carmen Smotherman, an

Dr. Ryan Butterfield

and

Sponsored by:
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