Measuring Inflicted Traumatic Brain Injury in Minnesota

Sara Seifert, M.P.H. & Debra HagelInjury & Violence Prevention Unit

Minnesota Department of Health

Nomenclature

If we can’t name it, how can we measure it?

Shaken Baby Syndrome Shaken Impact Syndrome Abusive Head Trauma Inflicted Traumatic Brain Injury

Overview Minnesota Trauma Data Bank

Data Sources for iTBI

Strengths & Weaknesses of each Data Source

Epidemiology of Severe iTBI in Minnesota

MMinnesota innesota TTrauma rauma DData ata BBankank

Pre-hospital

HOSPITALHOSPITAL

Post-hospital

Hospital Data

Codes assigned by medical records identify diagnoses, procedures, and injury causes.

Minnesota Hospital Association compiles billing data statewide. gender, age, inpatient / ED, date, zip code, charges

MDH abstracts data from medical records. relationship to perpetrator, circumstances of injury,

alcohol / drug use

Partners

Centers for Disease Control & Prevention Funding to: Identify additional cases Gather new information Assess CPS / public health cost differential

Department of Human Services Midwest Children’s Resource Center Shaken Baby Syndrome Task Force Minnesota Department of Health

Child Maltreatment in Minnesota

Central Nervous System Injuries

Fatalities

Hospital Treated Cases

Outpatient Cases

Substantiated Reports to CPS

Substantiated Injury Reports to CPS

Data Sources Deaths

Death Certificates Medical Examiner Reports Child Fatality Review Panel Supplemental Homicide Reports Femicide Report Newspaper Clippings

Death Certificates Strengths

Population-based Public data Have ICD 10 Codes

Weaknesses Often no perpetrator

information Often limited

information on circumstances

“Abdominal and head injuries”

“Multiple injuries of varying ages”

“Was injured by another person”

Medical Examiner Reports Don’t know. Anticipate much detail,

especially medical.

Child Fatality Review Panel Strengths

Lots of information Public data

Weaknesses Only obtain cases

that are reported to Child Protective Services

North Dakota Case

Supplemental Homicide Reports Strengths

Public data Often have

perpetrator and circumstances

Weaknesses Voluntary system Limited detail

Victim: 1 year old female, Asian, Non-HispanicOffender: 54 year old female, white, Non-Hispanic

Weapon: [blank]

Relationship: Day care provider

Circumstance: Victim violently shaken, causing shaken baby syndrome

Femicide Report Strengths

Public data Often have

perpetrator and circumstances

Weaknesses Based on voluntary

reporting and newspaper clippings

Femicide Report continued

11. Austin Olson, 8 months Otsego November 7

Cynthia Henderson of Rogers, 32, was charged with second-degree murder in connection with the death of Austin Olsonof Otsego, 8 months, for whom she was caring. Shortly afternoon on November 5, Henderson called 911 to report thatAustin had been injured when her own child threw a toy athim. She later told investigators . . . A CAT scan on Austinrevealed a skull fracture and other injuries consistent withblunt force trauma and shaking injuries. An autopsy also revealed rib fractures. Cynthia Henderson was sentenced inJune of 2002 to 12 ½ years in prison for unintentional second-degree murder.

Newspaper Clippings Strengths

Public data Often have

perpetrator and circumstances

Weaknesses Not all cases obtain

coverage Cost/time

“The boy’s brain injuries were consistent with violent shaking, but medical experts can’t rule out the possibility that the accidents played a role in his death.”

Data Sources continued

Inpatient Hospitalizations & ED Treated Minnesota Hospital Association TBI/SCI Registry Abstracted hospital data Lists from other sources

Minnesota Hospital Association Strengths

Identify potential cases Have ICD 9 codes

Weaknesses Cannot confirm cases Usually have no

circumstance or perpetrator information

Private data Cost

801.0 Fracture of base of skull, open with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness

TBI/SCI Registry Strengths

Identify cases Have ICD 9 codes Usually have

perpetrator and circumstances

Weaknesses May lack important

detail Private data

“Alleged fall from jungle gym (suspected child abuse).”

Abstracted Hospital Data Strengths

Identify cases Have ICD 9 codes Have most detail

Weaknesses Private data Cost May vary by facility May not be

conclusive

“Shaken baby syndrome with old tibia fracture. Large subdural hematoma with herniation seizure. Severe disability. Delay in seeking treatment for 16 hours although 1 month was unresponsive. Siblings removed from home. Suspected shaken baby syndrome by dad also old left tibia fracture. Child later became ward of state.”

Abstracted Hospital Data continued

“There is nothing here except 1) face sheet 2) order for full skeletal series with reason noted as suspected shaken baby syndrome 3) request from County Child Protective Services for all medical records. Lots of unknowns.”

“2 subdural hematomas of varying ages. County Social Services unable to prove anything, so child discharged to home.”

Child Protective Services Need to explore this data more. Identify TBIs, unclear if only due to iTBI

and how complete.

Clinic, Home or No Treatment

No data at this time.

Key Messages About Data Sources With some effort you can access death data

for iTBI cases The IVPU can provide summary data on

inpatient iTBI hospitalizations The IVPU can provide more limited

summary data on ED treated iTBI No data available on clinic or untreated

iTBI at this time

Major Limitations of iTBI Data Requires

Identification, Documentation, Coding & Submission of cases.

Have many unknown/unclear cases May not obtain cases treated out-of-state

Key Findings for Severe iTBI in Minnesota, 1999-2001 Small number of cases Majority are boys Majority are under one year of age Nearly half have documented previous

abuse Most perpetrators are a parent or parent’s

partner Majority of perpetrators are male

Severe iTBI RatesMN, 1999-2001, Ages 0-4

Note: Cases identified from Death Certificates, Abstracting TBI Cases, and TBI Registry. Actual N’s = 32, 35, and 46 respectively.

Rate of severe iTBI appears to be rising but that is likely due to incomplete data in 1999 and 2000

9.7510.44

13.5912.80

13.42 13.59

Actual Estimated

How does Minnesota compare?Ages 0-1

46.89

29.7

21.3

05

101520253035404550

Minnesota (n=32) North Carolina(n=71)

Wales (n=15)

Note: Different case definitions and data collection methods.

CI=(33.8, 60.0) CI=(22.9, 36.7) CI=(1.78, 40.82)

Deaths and Inpatient Hospitalizations by Gender and Age, MN, 1999-2001

Note: Information available only for TBI Registry and abstracted cases

58%

8%

0% 0% 0%3% 3% 3% 2%

24%

Under 1 Age 1 Age 2 Age 3 Age 4

Boys Girls

Perpetrator for Inpatient HospitalizationsMN, 1999-2001, Ages 0-4

Note: Information available only for abstracted cases

0% 0% 0% 0% 0%

21%

3%0% 0% 0% 0%

43%

2% 2%2%

29%

Parent(blood, step,

foster)

Day careprovider

Babysitter -non-family

Caregiver -sibling

Babysitter -other family

Other Parent'ssignificant

other

Unknown

Male Female

Previous Abuse for Inpatient HospitalizationsMN, 1999-2001, Ages 0-4

44%

31%

25%

Yes No UnknownNote: Information available only for abstracted cases

Hospital Charges, MN,1999-2001

iTBI, Inpatient Hospitalizations (n=66)

CM, Inpatient Hospitalizations (n=58)

CM, ED Treated (n=110)

Mean $36,219 $9,361 $776

Median $20,234 $5,461 $310

Sum $2,390,476 $541,912 $85,573

Note: Information available only for abstracted cases

Payer Source for Inpatient Hospitalizations, MN,1999-2001

Note: Information available only for abstracted cases

32%

52%

3%

12%

Medicaid Other Othergov Self-pay

Conclusions We can estimate incidence of severe iTBI in

Minnesota and provide descriptive information. Limited data at local level due to small numbers

and lack of access to data sources other than deaths.

The majority of severe iTBI victims in Minnesota are boys under age one. Nearly half have a documented history of previous hospital/ED treated abuse.