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Traumatic Brain Injury–Related Emergency Department Visits, Hospitalizations, and Deaths — United States, 2007 and 2013

Surveillance Summaries / March 17, 2017 / 66(9);1–16


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Christopher A. Taylor, PhD1; Jeneita M. Bell, MD, MPH1; Matthew J. Breiding, PhD1; Likang Xu, MD, MS2 (View author affiliations)

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Abstract

Problem/Condition: Traumatic brain injury (TBI) has short- and long-term adverse clinical outcomes, including death and disability. TBI can be caused by a number of principal mechanisms, including motor-vehicle crashes, falls, and assaults. This report describes the estimated incidence of TBI-related emergency department (ED) visits, hospitalizations, and deaths during 2013 and makes comparisons to similar estimates from 2007.

Reporting Period: 2007 and 2013.

Description of System: State-based administrative health care data were used to calculate estimates of TBI-related ED visits and hospitalizations by principal mechanism of injury, age group, sex, and injury intent. Categories of injury intent included unintentional (motor-vehicle crashes, falls, being struck by or against an object, mechanism unspecified), intentional (self-harm and assault/homicide), and undetermined intent. These health records come from the Healthcare Cost and Utilization Project’s National Emergency Department Sample and National Sample. TBI-related death analyses used CDC multiple-cause-of-death public-use data files, which contain death certificate data from all 50 states and the District of Columbia.

Results: In 2013, a total of approximately 2.8 million TBI-related ED visits, hospitalizations, and deaths (TBI-EDHDs) occurred in the United States. This consisted of approximately 2.5 million TBI-related ED visits, approximately 282,000 TBI-related hospitalizations, and approximately 56,000 TBI-related deaths. TBIs were diagnosed in nearly 2.8 million (1.9%) of the approximately 149 million total injury- and noninjury-related EDHDs that occurred in the United States during 2013. Rates of TBI-EDHDs varied by age, with the highest rates observed among persons aged ≥75 years (2,232.2 per 100,000 population), 0–4 years (1,591.5), and 15–24 years (1,080.7). Overall, males had higher age-adjusted rates of TBI-EDHDs (959.0) compared with females (810.8) and the most common principal mechanisms of injury for all age groups included falls (413.2, age-adjusted), being struck by or against an object (142.1, age-adjusted), and motor-vehicle crashes (121.7, age-adjusted). The age-adjusted rate of ED visits was higher in 2013 (787.1) versus 2007 (534.4), with fall-related TBIs among persons aged ≥75 years accounting for 17.9% of the increase in the number of TBI-related ED visits. The number and rate of TBI-related hospitalizations also increased among persons aged ≥75 years (from 356.9 in 2007 to 454.4 in 2013), primarily because of falls. Whereas motor-vehicle crashes were the leading cause of TBI-related deaths in 2007 in both number and rate, in 2013, intentional self-harm was the leading cause in number and rate. The overall age-adjusted rate of TBI-related deaths for all ages decreased from 17.9 in 2007 to 17.0 in 2013; however, age-adjusted TBI-related death rates attributable to falls increased from 3.8 in 2007 to 4.5 in 2013, primarily among older adults. Although the age-adjusted rate of TBI-related deaths attributable to motor-vehicle crashes decreased from 5.0 in 2007 to 3.4 in 2013, the age-adjusted rate of TBI-related ED visits attributable to motor-vehicle crashes increased from 83.8 in 2007 to 99.5 in 2013. The age-adjusted rate of TBI-related hospitalizations attributable to motor-vehicle crashes decreased from 23.5 in 2007 to 18.8 in 2013.

Interpretation: Progress has been made to prevent motor-vehicle crashes, resulting in a decrease in the number of TBI-related hospitalizations and deaths from 2007 to 2013. However, during the same time, the number and rate of older adult fall-related TBIs have increased substantially. Although considerable public interest has focused on sports-related concussion in youth, the findings in this report suggest that TBIs attributable to older adult falls, many of which result in hospitalization and death, should receive public health attention.

Public Health Actions: The increase in the number of fall-related TBIs in older adults suggests an urgent need to enhance fall-prevention efforts in that population. Multiple effective interventions have been identified, and CDC has developed the STEADI initiative (Stopping Elderly Accidents Deaths and Injuries) as a comprehensive strategy that incorporates empirically supported clinical guidelines and scientifically tested interventions to help primary care providers address their patients’ fall risk through the identification of modifiable risk factors and implementation of effective interventions (e.g., exercise, medication management, and Vitamin D supplementation).

Introduction

CDC conducts surveillance of traumatic brain injury (TBI) to understand the public health burden, to monitor trends, and to identify groups at greatest risk for TBI. TBI is a major cause of mortality in the United States, contributing to approximately 30% of all injury-related deaths (1). The burden on the health care system is also substantial; in 2010, approximately 2.5 million emergency department (ED) visits, hospitalizations, or deaths were associated with TBI (2). From 2001 to 2010, the rates of ED visits increased by 70%, and rates of hospitalization and death increased by 11% and 7%, respectively (2).

Historically, CDC’s national estimates of TBI-related hospitalizations and ED visits have been based on data from two sources: the National Hospital Discharge Survey (NHDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), respectively. These databases have been useful in identifying broad groups affected by TBI and the most common principal mechanisms of injury resulting in TBI. However, the relatively small sample sizes of these databases have not allowed for the calculation of stable annual estimates by subgroups of interest, such as estimates stratified by both age group and principal mechanism of injury. As a result, pooled years of data were required to achieve stability; for example, data published by CDC in 2010 included estimates of TBI-related medical encounters from NHDS and NHAMCS that were pooled for 2002–2006. This limits the ability of researchers to document changes in TBI incidence over time, especially for subgroups of particular risk (e.g., falls among children and older adults and sports-related TBIs among youth). To improve TBI estimation, CDC identified alternative databases that were large enough to provide annual estimates of TBI within subgroups. CDC uses the Healthcare Cost and Utilization Project (HCUP) databases to estimate the incidence of TBI in the United States (3–5). The findings in this report can be used by public health officials to understand trends in TBI-related medical events (e.g., emergency department visits, hospitalizations and deaths) and to identify priority areas for prevention programs.

Methods

To estimate the incidence of TBI-related emergency department (ED) visits, hospitalizations, and deaths (TBI-EDHDs) during 2013 compared to 2007, CDC analyzed the latest data from two HCUP databases and the National Vital Statistics System (NVSS). The findings are reported by principal mechanism of injury, age group, sex, and medical event type (i.e., ED visits, hospitalizations, deaths) for 2013. In addition, estimates from 2007 and 2013 were compared to describe changes in TBI incidence since CDC’s most recent detailed report examining data during 2002–2006 (1). Traumatic brain injury-related deaths were analyzed using the multiple-cause-of-death files from the 2007 and 2013 NVSS.

Data Sources

The HCUP Nationwide Emergency Department Sample (NEDS) and HCUP National Inpatient Sample (NIS) are visit-based databases that contain sample sizes large enough to provide stable annual estimates of TBI for subgroups (3,4). Previous work has found that the frequencies of TBI-related hospitalizations and ED visits in these HCUP databases are comparable to those observed in NHDS and NHAMCS (5). NVSS includes data for all deaths registered in all 50 U.S. states and the District of Columbia (6).

Data used to describe TBI-related ED visits were obtained from the 2007 and 2013 NEDS. NEDS is the largest all-payer ED record database in the United States; in 2013, it contained 29,581,718 records representing 134,869,015 ED visits nationally (4). NEDS is designed to represent a 20% stratified sample of U.S. hospital-based EDs with records drawn from non-Federal, short-term, general, and other specialty hospitals from participating states (30 states in 2013) (4).

TBI-related inpatient hospitalizations were analyzed using data from the 2007 and 2013 NIS. Similar to NEDS, NIS is the largest all-payer inpatient hospitalization database; in 2013, it contained data from 7,119,563 records, representing 35,597,792 hospital discharges nationally (3). Throughout the report, NIS discharges are referred to as hospitalizations. The 2013 data represent a 20% sample of hospital discharges from community hospitals, excluding rehabilitation and long-term acute care facilities (3).

Records from both NEDS and NIS do not include individual patient identifiers and, unlike the mortality data, might contain more than one record per person (i.e., multiple ED visits for the same injury or multiple medical event types for different injuries). Certain records were excluded to reduce the possibility of counting multiple encounters for the same injury. In-hospital deaths were excluded from the hospitalization counts (because these would be included in the mortality data), as were hospital transfers and hospital admissions that occurred directly from the ED (because each would be included in the hospitalization data).

Surveillance Definition

For TBI-related ED visits and hospitalizations, cases were identified using codes from the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) using an established definition (7). Records were included and classified as TBI-related if any of the following ICD-9-CM codes were included in the record as a diagnosis code, regardless of its position (i.e., both primary and secondary diagnoses were included):

  • 800: fracture of vault of skull;

  • 801: fracture of the base of skull;

  • 803: other and unqualified skull fractures;

  • 804: multiple fractures involving skull or face with other bones;

  • 850: concussion;

  • 851: cerebral laceration and contusion;

  • 852: subarachnoid, subdural, and extradural hemorrhage, following injury;

  • 853: other and unspecified intracranial hemorrhage following injury;

  • 854.0, 854.1: intracranial injury of other and unspecified nature;

  • 950.1–950.3: injury to the optic nerve and pathways;

  • 959.01: head injury, unspecified; and

  • 995.55: shaken infant syndrome.

For TBI-related deaths, cases were included if the record contained a TBI-related code from the International Classification Diseases, Tenth Revision (ICD-10) in any position of the NVSS mortality record. This coding definition has been used previously in the identification of TBI-related mortality records (1). These codes included:

  • S01: open wound of the head;

  • S02.0, S02.1, S02.3, S02.7–S02.9: fracture of the skull and facial bones;

  • S04.0: injury to optic nerve and pathways;

  • S06: intracranial injury;

  • S07.0, S07.1, S07.8, S07.9: crushing injury of head;

  • S09.7–S09.9: other unspecified injuries of head;

  • T01.0: open wounds involving head with neck;

  • T02.0: fractures involving head with neck;

  • T04.0: crushing injuries involving head with neck;

  • T06.0: injuries of brain and cranial nerves with injuries of nerves and spinal cord at neck level; and

  • T90.1, T90.2, T90.4, T90.5, T90.8, T90.9: sequelae of injuries of head.

Variables

Data were stratified by age, sex, principal mechanism of injury, and injury intent. Age groups included ages 0–4, 5–14, 15–24, 25–34, 35–44, 45–54, 55–64, 65–74, and ≥75 years. Principal mechanisms of injury included motor-vehicle crashes, falls, being struck by or against an object, mechanism unspecified, and other. Categories of injury intent included unintentional (motor-vehicle crashes, falls, being struck by or against an object, mechanism unspecified), intentional (self-harm and assault/homicide), and undetermined intent. Estimates of intentional self-harm were suppressed for the 0–4 and 5–14 year age groups because it is unclear whether children aged <10 years are truly able to form suicidal intent (8). For ED visits and hospitalizations, these categories were based on CDC’s recommended framework for grouping external cause-of-injury codes (E-codes) using ICD-9-CM (9). Up to four E-codes can be recorded per ED visit or hospitalization in NEDS or NIS. The first-listed E-code should correspond to the most serious diagnosis assigned (10). Therefore, only the first-listed valid E-code was used in this analysis, and this assigned code was assumed to be the principal mechanism of injury for the TBI. Valid injury mechanism E-codes (E800–E966 and E968–E999) are those that are correct in syntax (i.e., they exist as stated within ICD-9-CM) and correspond to a principal mechanism of injury rather than an activity (code E000), place of occurrence (E001–E030), or perpetrator of abuse (E967). Principal mechanism of injury and injury intent for TBI-related deaths were categorized on the basis of the CDC-recommended external cause of injury mortality matrix for ICD-10 (11).

Statistical Analysis

For ED visits and hospitalizations, data were weighted to provide national estimates of annual numbers and rates per 100,000 population. These rates and 95% confidence intervals around each rate were based on U.S. bridged-race population estimates of the resident population released and maintained by CDC for individual years (12). Age-adjusted rates were standardized to the U.S. census population estimates for 2000 by the direct method (1). Estimates were considered unreliable and not reported if the relative standard error was >30% or the standard error = 0. Chi-square or t-tests were used to analyze between-group differences for number and rates, respectively, of TBI-related ED visits, hospitalizations, and deaths. Only selected comparisons were tested for statistical significance. Differences with p values <0.05 were considered statistically significant. All statistical analyses were performed using SAS Systems for Windows, version 9.3 (SAS Institute, Cary, North Carolina).

The sampling frame for NIS data changed in 2012. Before 2012, NIS data were derived from a sample of hospitals with all discharges included. Beginning in 2012, NIS data were based on a sample of discharges from all NIS-participating hospitals. Revised weights for trend analyses using 2011 NIS data and earlier were used to calculate estimates comparable to the new design in accordance with NIS guidance (13).

Results

In 2013, a total of 2.8 million TBI-EDHDs occurred in the United States (Table 1). This consisted of approximately 2.5 million TBI-related ED visits, approximately 282,000 TBI-related hospitalizations, and approximately 56,000 TBI-related deaths. Of the 149 million total injury and noninjury-related EDHDs that occurred in the United States in 2013, TBIs were diagnosed in 1.9% of these. The proportion of TBI-related injuries accounted for approximately one of every 50 ED visits (2.2%). TBI-related deaths accounted for 2.2% of all deaths in the United States.

TBI-Related ED Visits, Hospitalizations, and Deaths by Age Group

Rates of TBI-EDHD varied by age, with the highest rates observed among those aged ≥75 years (2,232.2 per 100,000 population), 0–4 years (1,591.5), and 15–24 years (1,080.7) (Table 2). With respect to TBI-related ED visits only, the age groups with the highest rates were those aged ≥75 years (1,701.7), 0–4 years (1,541.1), and 15–24 years (1,001.9). Rates of TBI-related hospitalizations and deaths were highest among the oldest age groups. For hospitalizations, the age groups with the highest rates were those aged ≥75 years (454.4), 65–74 years (139.4), and 55–64 years (86.0). The same pattern was observed for TBI-related deaths with the highest rates found among those aged ≥75 years (76.1), 65–74 years (24.3), and 55–64 years (18.8). In terms of overall numbers, persons aged 15–24 years accounted for 17.9% of all TBI-related ED visits, more than any other age group. Those aged ≥75 years comprised the largest proportion of both TBI-related hospitalizations (31.4%) and deaths (26.5%).

TBI-Related ED Visits, Hospitalizations, and Deaths by Age Group and Principal Mechanism of Injury

Rates of TBI-EDHDs varied by principal mechanism of injury, and by age group within principal mechanism of injury (Table 3). Overall, the most common principal mechanisms of injury were falls (413.2 per 100,000 population, age-adjusted), being struck by or against an object (142.1, age-adjusted), and motor-vehicle crashes (121.7, age-adjusted). These principal mechanisms represented 47.2%, 15.4%, and 13.7% of all TBI-EDHDs, respectively. Examining each principal mechanism by age group reveals a different pattern. Those aged ≥75 years had the highest rate of fall-related TBI-EDHDs (1,859.0), followed by 0–4 years (1,119.3), and 65–74 years (539.8). For TBI-EDHDs attributable to being struck by or against an object, the age groups with the highest rate include those aged 5–14 years (291.9), 0–4 years (262.7), and 15–24 years (243.3). Finally, for TBI-EDHDs attributable to motor-vehicle crashes, those aged 15–24 years (258.3), 25–34 years (182.9), and 35–44 years (126.5) had the highest rates.

TBI-Related ED Visits, Hospitalizations, and Deaths by Sex and Principal Mechanism of Injury

Differences in age-adjusted rates were found for each principal mechanism when comparing rates of TBI-EDHDs by sex (Table 4). Overall, males had higher age-adjusted rates of TBI-EDHDs (959.0 per 100,000 population) compared with females (810.8. Males had higher age-adjusted rates of being struck by or against an object compared with females (167.3 versus 115.6), a higher age-adjusted rate of motor-vehicle crash–related TBI-EDHDs (128.2 versus 115.5), a more than fivefold higher age-adjusted rate of intentional self-harm-related TBI-EDHDs (11.7 versus 2.3), a higher age-adjusted rate of assault-related TBI-EDHDs (96.0 versus 54.8) (Table 4). Females had a significantly higher age-adjusted rate of fall-related TBI-EDHDs compared to men (417.7 versus 400.7).

Comparison of TBI-Related ED Visits Between 2007 and 2013 by Age Group and Principal Mechanism of Injury

Age-adjusted rates of TBI-related ED visits increased from 534.4 per 100,000 in 2007 to 787.1 in 2013 (Table 2). Further, this increase in TBI-related ED visit rates has occurred for nearly all of the major principal mechanism categories: a 65% increase for falls (from 222.6 per 100,000 to 366.5, age-adjusted); a 55% increase in being struck by or against an object (from 90.3 to 139.8, age-adjusted); a 75% increase for TBIs as a result of intentional self-harm (from 0.4 to 0.7, age-adjusted); a 20% increase for assaults (from 56.8 to 68.2, age-adjusted); and a 19% increase for motor-vehicle crashes (from 83.8 to 99.5, age-adjusted) (Table 5).

The number of TBI-related ED visits increased from approximately 1.6 million in 2007 to approximately 2.5 million in 2013, representing an increase of more than 50%, or an increase of more than 850,000 ED visits (Table 2). The key contributors to the increase are falls (accounting for 57.3% of the increase); being struck by or against an object (accounting for 18.2% of the increase); and motor-vehicle crashes (accounting for 7.0% of the increase). With respect to both principal mechanism and age, the key contributors to the increase are fall-related TBIs among those aged ≥75 years (accounting for 17.9% of the increase), aged 65–74 years (accounting for 7.7% of the increase), aged 55–64 years (accounting for 6.7% of the increase), and aged 0–4 years (accounting for 6.1% of the increase) and being struck by or against an object among those aged 5–14 years (accounting for 5.7% of the increase) and 15–24 years (accounting for 4.2% of the increase).

Comparison of TBI-Related Hospitalizations Between 2007 and 2013 by Age Group and Principal Mechanism of Injury

Approximately 75% of TBI-related hospitalizations in 2013 were attributable to two principal mechanisms: falls (50.4%) and motor-vehicle crashes (21.5%) (Table 6). Overall, the total number of TBI-related hospitalizations in 2013 (281,555) was similar to the number of TBI-related hospitalizations in 2007 (267,350) and rates of TBI-related hospitalizations remained nearly the same (Table 2). The age-adjusted rate of TBI-related hospitalizations attributable to motor-vehicle crashes decreased from 2007 to 2013 (from 23.5 to 18.8 per 100,000) (Table 6). In addition, the age-adjusted rate of TBI-related hospitalizations attributable to falls increased from 33.9 in 2007 to 42.2 in 2013.

Age was an important factor contributing to the TBI-related hospitalization rate change from 2007 to 2013. The overall decrease in rates of TBI-related hospitalizations attributable to motor-vehicle crashes was evidenced most prominently among those aged 15–24 years as the rate decreased from 47.3 in 2007 to 31.8 in 2013 (Table 6). The overall increase in rates of TBI-related hospitalizations attributable to falls was observed most prominently among those aged ≥75 years (from 257.3 in 2007 to 354.8 in 2013).

Comparison of TBI-Related Deaths Between 2007 and 2013 by Age Group and Principal Mechanism of Injury

Overall, the number of TBI-related deaths increased from 54,699 in 2007 to 55,920 in 2013 (Table 2). However, age-adjusted rates of TBI-related deaths decreased slightly during that period (from 17.9 to 17.0 per 100,000). This decrease is largely attributable to an overall decrease in the age-adjusted rate of TBI-related deaths attributable to motor-vehicle crashes (5.0 in 2007 to 3.4 in 2013) (Table 7). Despite the overall decrease in rates, there were increases in the age-adjusted rate of TBI-related deaths attributable to falls (from 3.8 in 2007 to 4.5 in 2013) and intentional self-harm (from 4.8 in 2007 to 5.6 in 2013). Whereas motor-vehicle crashes were the leading cause of TBI-related death in 2007, in both number and rate, intentional self-harm was the leading cause, in number and rate, in 2013. Increases between 2007 and 2013 in the number of TBI-related deaths attributable to self-harm were found among all age groups examined (i.e., those aged ≥15 years). In 2013, of TBI-related deaths attributable to self-harm, 86.9% were among males; in 96.9% of these cases, a firearm was the principal mechanism (data not shown). Although leading causes of TBI-related deaths for all other age groups are either falls, motor-vehicle crashes, or unintentional self-harm, the leading cause among those aged 0–4 years in 2007 and 2013 was assault/homicide (Table 7).

The overall decrease in the rate of TBI-related deaths attributable to motor-vehicle crashes was found among all age groups, with the most pronounced decrease being among those aged 15–24 years (from 10.0 in 2007 to 5.7 in 2013). The increased rate of TBI-related deaths attributable to falls was not evenly spread among all ages as those aged ≥75 years had the largest increase (from 39.7 in 2007 to 50.3 in 2013).

Discussion

In 2013, approximately 2.8 million TBI-EDHDs occurred in the United States. Most were TBI-related ED visits (87.9%), and only 2.0% of the total were TBI-related deaths. Males continue to have higher rates of TBI-EDHDs compared with females (1,14). Although the total number of TBI-EDHDs has increased over time, the increases are not uniform across all age groups or principal mechanisms of injury, and this suggests priority areas for TBI-related prevention.

Several hypotheses might explain the increase in TBI-EDHDs over time. First, heightened public awareness about sports-related concussions might have translated to greater public concern about the effects of TBI generally, leading people of all ages to more readily seek care. Second, heightened awareness among health care providers, and the broader dissemination of validated assessment tools, might have resulted in more TBI diagnoses. Although increases among youth were found for TBI-related ED visits, there were significant increases in the number of ED visits, hospitalizations, and deaths attributable to TBIs resulting from older adult falls. This across-the-board increase over a relatively short time, suggests the need to address preventing and reducing the number of older adult falls resulting in TBI.

The highest rates of TBI-EDHDs were among the oldest or youngest age groups. TBIs in these age groups are notable for several reasons. In children aged <7 years, TBIs can impair neurologic development and the ability to meet developmental milestones (15). Impaired development might lead to further challenges as a child ages, such as declines in academic functioning and psychosocial sequelae such as emotional and behavioral disorders (e.g., depression or attention-deficit hyperactivity disorder) (16–19). In older adults, TBIs are associated more often with hospitalization and death. Cognitive and physical reserve are diminished at older ages, so TBIs might have a greater impact on daily living. TBIs in older adults are more likely to lead to hospitalization and these hospitalizations can be complicated by the presence of comorbidities. Furthermore, more frequent use of anticoagulants among older adults can result in a greater likelihood of secondary effects because of an increased likelihood of intracranial hemorrhage (20,21).

The most common principal mechanisms of injury for TBI-EDHDs were falls, being struck by or against an object, and motor-vehicle crashes. Although these three principal mechanisms accounted for approximately 70% of all TBI-EDHDs, particular age groups were disproportionally affected by specific principal mechanisms, similar to previous studies (1,14,22,23). Approximately half of all fall-related TBI-EDHDs occurred among those aged 0–4 years and ≥75 years. Codes defining whether a TBI was fall-related are heterogeneous. In addition to falls attributable to tripping and slipping, the codes also capture falls on stairs or from ladders, falls from one level to another (e.g., from a bed or chair), and falls into openings such as swimming pools. This analysis did not examine the individual contribution of each fall-related code. Future analyses could examine these individual codes to delineate better how activities leading to fall-related TBI vary by age group.

Certain prevention strategies have been identified for older adult falls, many of which have been demonstrated in randomized controlled trials to be effective (24). These include multicomponent physical exercise programs, Tai chi, Vitamin D supplementation (which might be effective among those who are Vitamin D deficient), surgical interventions (e.g., pacemakers and cataract surgery where indicated), and strategies to reduce home hazards (e.g., increased lighting and removal of tripping hazards). CDC has developed the STEADI initiative (Stopping Elderly Accidents Deaths and Injuries) as a comprehensive strategy to reduce falls in older adults. STEADI incorporates empirically supported clinical guidelines and scientifically tested interventions to help primary care providers address patient fall risk through the identification of modifiable risk factors and implementation of effective interventions (e.g., medication management) (25).

A number of strategies have been suggested for preventing injuries in children in general, including those resulting from falls. These include the use of safety gates at the top and bottom of stairways; ensuring that children aged <6 years do not sleep in the top bunk of a bunk bed; seat belt use in a shopping cart; use of an appropriate helmet for activities such as bicycle riding, skateboarding, and horseback riding; and age- and activity-appropriate supervision by adult caregivers (26–28). To prevent TBIs related to motor-vehicle crashes among infants and children, children should sit in the back seat until aged 13 years and be seated in age- and size-appropriate car seats (29). Unrestrained children aged 4–15 years are three times more likely to sustain a TBI than children who were restrained (30). The American Academy of Pediatrics (AAP) recommends that infants and toddlers remain in a rear-facing car safety seat until aged 2 years or until they reach the height and weight limit designated by the manufacturer of the car seat, then be restrained in forward-facing car seats (until they reach the height/weight limits on their car seats) (29). AAP recommends that children sit in a booster seat once they outgrow child safety seats and can fit appropriately into an adult seat belt (29).

The leading cause of TBI-related death among those aged 0–4 years was assault/homicide, including abusive head trauma by inflicted blunt impact or violent shaking, and other causes, such as firearm-related injuries (31). A number of strategies have been developed to prevent child abuse and neglect. To help communities make use of the best available evidence for prevention, CDC has released a technical package that describes a set of strategies and examples of specific approaches that enhance safe, stable, nurturing relationships and environments for children and families to reduce abuse and neglect and promote health (32).

The highest rates of TBI-EDHDs occurring after being struck by or against objects were among those aged 0–24 years. Sports- and recreation-related activities likely contribute to these types of injuries, especially for those aged 4–24 years. However, this analysis did not look at specific E-codes as a means to identify sports- and recreation-related TBIs. Although E-codes have been used to identify sports-related injuries (33), it is challenging to describe all activities associated with sports and recreation using these data due to differences in coding policies among health care providers, limited documentation in medical records, and limited utility of E-codes. To obtain greater detail about the nature of “struck by or against” related injuries and identify targets for prevention, use of other data sources would be needed. For example, the National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP) includes narratives with each record that provide a short description of the injury event. Sometimes this includes what the person was doing at the time of injury and additional parties involved. Such information has been more useful in identifying risk factors for strike-related TBI incidence (22).

The most common principal mechanism of TBI-EDHDs among persons aged 15–24 and 25–34 years was motor-vehicle crashes. This corresponds with the age groups that are known to be at higher risk for a motor-vehicle crash (34). Several factors have contributed to increased motor vehicle-related injuries in teens and young adult drivers compared to older drivers, including a reduced ability to recognize driving hazards and unsafe road conditions (35), low frequency of seat belt use (36), and higher levels of alcohol-impaired driving (37). The motor vehicle mechanism category used in the analysis includes injuries to pedal cyclists and pedestrians by motor vehicles. However, previous research has shown that approximately 70% of the motor-vehicle–related TBIs in persons aged 15–34 years involve occupants of a vehicle, approximately 12% involve motorcycle passengers, and approximately 8% involve pedestrians (1).

Compared to 2007, in 2013 the overall age-adjusted rate of TBI-related hospitalizations attributable to motor-vehicle crashes decreased, with the largest decreases occurring among those aged 15–24 years. This may be due to the implementation of programs and policies focused on young and inexperienced drivers. Programs such as graduated drivers licensing focus on young drivers as a way to increase safety awareness and reduce driving under high-risk driving conditions when the driver is still relatively inexperienced (38). All states have instituted zero tolerance for alcohol and driving among young drivers (i.e., those aged <20 years) (39). Overall decreases in these motor-vehicle–related hospitalizations were likely the result of both behavioral and vehicle improvements such as the increased use of seatbelts and vehicle safety measures such as airbags and electronic stability control (40–42). These advances have helped to reduce the incidence of motor-vehicle crashes but might also contribute to decreased injury severity, resulting in fewer TBIs that require hospitalization.

Although the number of TBI-related deaths increased from 2007 to 2013, the age-adjusted rate of TBI-related deaths decreased. This decrease was largely attributable to a decrease in the rate of fatal TBIs in motor-vehicle crashes. However, to some extent, this decrease has masked increases during the same period in fatal TBIs caused by falls, particularly among older adults, and an increase in fatal TBIs attributable to intentional self-harm. Fatal TBIs attributable to intentional self-harm were found predominantly among males; firearms were the predominant principal mechanism of injury. The increase in fatal TBIs attributable to intentional self-harm is consistent with an overall increase in suicide rates in the United States and underscores the importance of comprehensive and coordinated prevention efforts, including efforts to enhance social support and connectedness, reduce stigma for help-seeking, and provide support for those at greatest risk (43,44).

The increase in the overall number of TBI-related hospitalizations and deaths attributable to older adult falls might be in some part attributable to increased life expectancy combined with the increased risk of falls among older adults (45). However, the increase in life expectancy during the relatively short period of time covered by this analysis (from 78.1 years in 2007 to 78.8 in 2013) cannot explain such a large increase in the rate of TBI-related hospitalizations and deaths attributable to falls among older adult age groups. The reason or reasons for this increase are unknown.

Limitations

The findings in this report are subject to at least three limitations. First, these findings might overestimate the incidence of TBI-related ED visits and hospitalizations because the data are collected at the visit-level only. Thereby multiple records might exist for a single injury as persons might present more than once for treatment. However, steps were taken to reduce the number of records that were double-counted, including removing in-hospital deaths (that would be included in the mortality data) and excluding hospital transfers but residual double counting for multiple encounters/readmissions cannot be ruled out. Second, clinical severity cannot be ascertained from hospital administrative data that are not primarily designed for public health surveillance. Although TBIs are included as a diagnosis in the HCUP NIS and NEDS records, the severity of these injuries is unknown, nor is it known if hospital admissions with multiple diagnoses were attributable to the head injury or to another diagnosis. Third, this study does not include data on persons who did not seek care for their TBI or those who sought care in an outpatient setting. As a result, the TBI-EDHDs described in this report are not a complete accounting of all TBIs occurring in the United States and likely an undercount of TBIs that are milder in severity.

Conclusion

In 2013, approximately 2.8 million TBI-related ED visits, hospitalizations, and deaths occurred in the United States, representing an increase since 2007 that was largely attributed to an increase in the number and rate of TBI-related ED visits. Although much public interest has been devoted to sports-related concussion in youth, the findings in this report indicate that older adult falls account for a much larger proportion of the increase in TBI-related ED visits during this period. In addition, although the modest increases in ED visits that might be attributed to youth sports concussion do not extend to increases in TBI-related hospitalizations and deaths, the same cannot be said for TBIs attributable to older adult falls. From 2007 to 2013, increases in TBI-related hospitalizations and deaths attributable to older adult falls suggest the need for greater attention to preventing older adult falls. Empirically validated prevention measures can help reduce the incidence of older adult falls.

The decrease in TBI-related deaths caused by motor-vehicle crashes from 2007 to 2013 is likely attributable to efforts to prevent motor-vehicle crashes. Nevertheless, more can be done to further reduce motor-vehicle crashes. The United States lags behind other high-income countries in the rate of motor-vehicle crash deaths; in 2013, the rate of motor-vehicle crash deaths in the United States was more than double the average rate of other high-income comparison countries (46). Redoubling efforts to increase restraint use and reduce alcohol-impaired driving, among other proven interventions, are critical to the continued reduction of motor-vehicle crashes and motor-vehicle crash–related TBIs.

Corresponding author: Matthew J. Breiding, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control. Telephone: 770-488-1396; E-mail: dvi8@cdc.gov.

1Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control; 2Division of Analysis, Research, and Practice Integration, National Center for Injury Prevention and Control

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Return to your place in the textTABLE 1. Estimated number of emergency department visits,* hospitalizations,† and deaths,§ and the number and proportion that were attributable to injury and traumatic brain injury — United States, 2013
Event Total Injuries TBIs
No. No. % of total events No. % of injuries % of total events
Emergency department visit 113,370,448 24,597,345 21.7 2,460,420 10.0 2.2
Hospitalization 33,288,183 1,554,104 4.7 281,610 18.1 0.9
Death 2,596,993 192,945 7.4 55,927 29.9 2.2
Total 149,255,624 26,344,394 17.7 2,797,957 10.6 1.9

Sources: For emergency department visits, Healthcare Cost and Utilization Project’s (HCUP) Nationwide Emergency Department Sample; for hospitalizations, HCUP’s National Inpatient Sample; for deaths, CDC’s National Vital Statistics System.
Abbreviation: TBIs = traumatic brain injuries.
* Persons who were hospitalized, died, or transferred to another facility were excluded.
† In-hospital deaths and patients who transferred from another hospital were excluded.
§ Record-Axis Condition codes were used (usually included both Part I and Part II of Entity-Axis Condition codes).

Return to your place in the textTABLE 2. Estimated number* and rate of traumatic brain injury–related emergency department visits, hospitalizations, and deaths, by age group — United States, 2007 and 2013
Age group (yrs) Year Emergency department visits† Hospitalizations§ Deaths Total
No. Rate** (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI)
0–4 2007 234,003 1,118.5 (996.3–1,240.7) 10,935 52.3 (39.2–65.4) 978 4.7 (4.4–5.0) 245,916 1,175.4 (1,052.7–1,298.1)
2013 305,969 1,541.1 (1,389.9–1,692.3) 9,250 46.6 (40.2–53.0) 760 3.8 (3.6–4.1) 315,979 1,591.5 (1,440.4–1,742.6)
5–14 2007 227,848 564.5 (515.5–613.6) 12,475 30.9 (24.2–37.6) 975 2.4 (2.3–2.6) 241,298 597.9 (548.4–647.3)
2013 335,966 814.8 (744.3–885.4) 8,680 21.1 (18.2–23.9) 724 1.8 (1.6–1.9) 345,370 837.6 (767.1–908.1)
15–24 2007 340,846 792.8 (749.5–836.1) 40,862 95.0 (80.3–109.8) 8,550 19.9 (19.5–20.3) 390,258 907.7 (862.1–953.4)
2013 441,187 1,001.9 (951.2–1,052.7) 28,330 64.3 (59.0–69.6) 6,359 14.4 (14.1–14.8) 475,876 1,080.7 (1,029.7–1,131.6)
25–34 2007 190,565 473.4 (443.9–502.9) 28,067 69.7 (59.2–80.3) 6,862 17.0 (16.6–17.5) 225,494 560.2 (528.9–591.4)
2013 279,583 651.7 (614.2–689.3) 25,990 60.6 (55.7–65.4) 6,605 15.4 (15.0–15.8) 312,178 727.7 (689.9–765.5)
35–44 2007 156,763 367.1 (344.4–389.8) 27,074 63.4 (54.0–72.8) 6,650 15.6 (15.2–15.9) 190,487 446.0 (421.5–470.6)
2013 206,628 509.7 (481.1–538.2) 20,545 50.7 (46.8–54.5) 5,688 14.0 (13.7–14.4) 232,861 574.4 (545.6–603.1)
45–54 2007 140,709 322.8 (303.0–342.7) 31,795 73.0 (63.3–82.6) 7,774 17.8 (17.4–18.2) 180,278 413.6 (391.6–435.7)
2013 218,968 499.4 (471.6–527.2) 31,360 71.5 (66.8–76.2) 7,440 17.0 (16.6–17.4) 257,768 587.9 (559.8–616.1)
55–64 2007 90,074 275.9 (259.6–292.2) 25,590 78.4 (69.7–87.1) 5,917 18.1 (17.7–18.6) 121,581 372.4 (353.9–390.8)
2013 186,186 473.2 (447.7–498.8) 33,815 86.0 (81.1–90.8) 7,401 18.8 (18.4–19.2) 227,402 578.0 (552.0–604.0)
65–74 2007 66,740 343.2 (321.8–364.6) 24,597 126.5 (115.5–137.5) 4,742 24.4 (23.7–25.1) 96,079 494.1 (470.0–518.1)
2013 154,668 613.3 (577.1–649.4) 35,160 139.4 (132.9–145.9) 6,137 24.3 (23.7–24.9) 195,965 777.0 (740.3–813.7)
≥75 2007 155,574 841.9 (778.1–905.8) 65,955 356.9 (331.1–382.8) 12,251 66.3 (65.1–67.5) 233,780 1,265.2 (1,196.4–1,333.9)
2013 331,122 1,701.7 (1,578.2–1,825.2) 88,425 454.4 (436.7–472.1) 14,806 76.1 (74.9–77.3) 434,353 2,232.2 (2,107.7–2,356.8)
Total 2007 1,603,124 531.9 (502.7–561.1) 267,350 88.7 (79.4–98.0) 54,699 18.1 (18.0–18.3) 1,925,173 638.8 (608.1–669.4)
2013 2,460,278 777.5 (736.8–818.2) 281,555 89.0 (84.8–93.2) 55,920 17.7 (17.5–17.8) 2,797,753 884.2 (843.3–925.0)
Adjusted†† 2007 534.4 (519.8–549.0) 87.6 (83.7–91.6) 17.9 (17.7–18.0) 639.9 (624.7–655.0)
2013 787.1 (767.4–806.9)§§ 85.4 (83.5–87.3) 17.0 (16.9–17.2)§§ 889.6 (869.7–909.4)

Sources: For emergency department visits, Healthcare Cost and Utilization Project’s (HCUP) Nationwide Emergency Department Sample; for hospitalizations, HCUP’s National Sample; for deaths, CDC’s National Vital Statistics System.
Abbreviation: CI = confidence interval.
* Visits with missing age were excluded. Numbers subject to rounding error.
†Persons who were hospitalized, died, or transferred to another facility were excluded.
§ In-hospital deaths and patients who transferred from another hospital were excluded.
Record-Axis Condition codes were used (usually included both Part I and Part II of Entity-Axis Condition codes).
**Per 100,000 population.
†† Age-adjusted to the 2000 U.S. standard population.
§§Significant difference in rate compared to 2007 based on t-test (p<0.05). Only selected comparisons were tested for statistical significance.

Return to your place in the textTABLE 3. Estimated number* and rate of traumatic brain injury–related emergency department visits,† hospitalizations,§ and deaths, by age group and mechanism of injury — United States, 2013
Age group (yrs) Unintentional motor-vehicle crashes Unintentional falls** Unintentionally struck by or against an object Other unintentional injury, mechanism unspecified†† Intentional self-harm Assault or homicide Other or no mechanism specified§§
No. Rate¶¶ (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI)
0–4 6,335 31.9 (28.7–35.2) 222,233 1,119.3 (1,007.8–1,230.9) 52,148 262.7 (235.3–290.0) 13,485 67.9 (56.6–79.3) —*** — 1,979 10.0 (8.7–11.3) 19,756 99.5 (54.9–144.1)
5–14 21,308 51.7 (47.4–56.0) 132,190 320.6 (291.2–350.0) 120,375 291.9 (264.7–319.2) 33,623 81.5 (74.4–88.6) — — 10,109 24.5 (22.0–27.0) 27,414 66.5 (41.6–91.4)
15–24 113,743 258.3 (243.2–273.4) 100,364 227.9 (214.3–241.5) 107,138 243.3 (228.4–258.3) 39,520 89.7 (83.6–95.9) 3,254 7.4 (7.0–7.8) 72,787 165.3 (154.2–176.4) 39,072 88.7 (67.9–109.6)
25–34 78,451 182.9 (171.8–194.0) 72,345 168.6 (158.5–178.8) 43,865 102.3 (96.0–108.5) 25,311 59.0 (53.6–64.4) 3,577 8.3 (8.0–8.7) 62,832 146.5 (136.0–157.0) 25,796 60.1 (45.5–74.8)
35–44 51,271 126.5 (118.4–134.5) 69,714 172.0 (162.5–181.4) 32,814 80.9 (76.0–85.9) 19,566 48.3 (44.1–52.5) 3,269 8.1 (7.8–8.4) 37,386 92.2 (85.7–98.8) 18,842 46.5 (35.7–57.3)
45–54 48,286 110.1 (103.5–116.7) 103,051 235.0 (222.8–247.2) 29,894 68.2 (64.0–72.4) 22,167 50.6 (46.2–54.9) 3,903 8.9 (8.7–9.1) 30,056 68.6 (63.6–73.5) 20,411 46.6 (35.7–57.4)
55–64 33,777 85.9 (80.7–91.0) 122,637 311.7 (296.8–326.7) 19,804 50.3 (47.1–53.6) 16,582 42.1 (37.5–46.8) 3,429 8.7 (8.5–8.9) 13,058 33.2 (30.9–35.5) 18,114 46.0 (36.3–55.8)
65–74 17,725 70.3 (65.9–74.6) 136,140 539.8 (511.7–567.9) 11,493 45.6 (42.4–48.8) 9,655 38.3 (33.4–43.2) 2,254 8.9 (8.8–9.1) 3,168 12.6 (11.4–13.7) 15,531 61.6 (50.7–72.5)
≥75 12,397 63.7 (59.3–68.1) 361,738 1,859.0 (1,747.4–1,970.7) 13,305 68.4 (62.6–74.1) 11,051 56.8 (48.3–65.3) 2,189 11.2 (11.0–11.5) 1,468 7.5 (6.7–8.4) 32,205 165.5 (137.1–193.9)
Total 383,293 121.1 (114.4–127.9) 1,320,411 417.3 (395.9–438.6) 430,836 136.2 (127.5–144.8) 190,959 60.3 (55.3–65.4) 22,270 7.0 (6.9–7.2) 232,842 73.6 (68.9–78.3) 217,141 68.6 (53.2–84.1)
Adjusted††† 121.7 (118.6–124.9) 413.2 (401.4–425.0) 142.1 (137.1–147.2) 61.3 (59.2–63.4) 6.8 (6.7–7.0) 75.5 (73.0–77.9) 68.9 (62.3–75.6)

Sources: For emergency department visits, Healthcare Cost and Utilization Project’s (HCUP) Nationwide Emergency Department Sample; for hospitalizations, HCUP’s National Sample; for deaths, CDC’s National Vital Statistics System.
Abbreviations: CI = confidence interval; TBI = traumatic brain injury.
*Visits with missing age were excluded. Numbers subject to rounding error.
†Persons who were hospitalized, died, or transferred to another facility were excluded.
§In-hospital deaths and patients who transferred from another hospital were excluded.
Record-Axis Condition codes were used (usually included both Part I and Part II of Entity-Axis Condition codes).
**Includes falls of undetermined intent to maintain consistency with past data releases.
††E-codes specify that the injury was unintentional but do not specify the actual mechanism of injury.
§§Includes TBIs in which the intent was not determined as well as those due to legal intervention or war. Includes TBIs in which no mechanism was specified in the record. Does not include falls of undetermined intent.
¶¶Age-adjusted to the 2000 U.S. standard population (per 100,000 population).
***Estimates suppressed for the age groups 0–4 and 5–14 years because it is unclear whether children aged <10 years are able to form suicidal intent.
†††Age-adjusted to the 2000 U.S. standard population (per 100,000 population).

Return to your place in the textTABLE 4. Estimated number* and age-adjusted rate of traumatic brain injury–related emergency department visits,† hospitalizations,§ and deaths, by sex and mechanism of injury — United States, 2013
Sex Unintentional motor-vehicle crashes Unintentional falls** Unintentionally struck by or against an object Other unintentional injury, mechanism unspecified†† Intentional self-harm Assault or homicide Other or no mechanism specified§§
No. Rate¶¶ (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI)
Male 201,012 128.2 (124.8–131.5) 603,444 400.7 (388.7–412.8) 253,848 167.3 (160.9–173.7) 119,637 77.4 (74.9–79.9) 18,509 11.7 (11.5–12.0) 149,271 96.0 (92.8–99.1) 118,904 77.7 (70.1–85.2)
Female 182,220 115.5 (112.3–118.8)*** 716,915 417.7 (405.9–429.4)*** 176,975 115.6 (111.7–119.5)*** 71,306 45.1 (43.3–47.0) 3,760 2.3 (2.2–2.4)*** 83,554 54.8 (52.7–57.0)*** 98,225 59.8 (53.8–65.7)
Total 383,231 121.7 (118.6–124.9) 1,320,360 413.2 (401.4–425.0) 430,822 142.1 (137.1–147.2) 190,944 61.3 (59.2–63.4) 22,270 6.8 (6.7–7.0) 232,828 75.4 (73.0–77.9) 217,129 68.9 (62.3–75.6)

Sources: For emergency department visits, Healthcare Cost and Utilization Project’s (HCUP) Nationwide Emergency Department Sample; for hospitalizations, HCUP’s National Sample; for deaths, CDC’s National Vital Statistics System.
Abbreviations: CI = confidence interval; TBI = traumatic brain injury.
*Visits with missing age were excluded. Numbers subject to rounding error.
†Persons who were hospitalized, died, or transferred to another facility were excluded.
§In-hospital deaths and patients who transferred from another hospital were excluded.
Record-Axis Condition codes were used (usually included both Part I and Part II of Entity-Axis Condition codes).
**Includes falls of undetermined intent to maintain consistency with past data releases.
††E-codes specify that the injury was unintentional but do not specify the actual mechanism of injury.
§§Includes TBIs in which the intent was not determined as well as those due to legal intervention or war. Includes TBIs in which no mechanism was specified in the record. Does not include falls of undetermined intent.
¶¶Per 100,000 population.
***Significant difference in rate compared to men based on t-test (p<0.05). Only selected comparisons were tested for statistical significance.

Return to your place in the textTABLE 5. Estimated number* and rate of traumatic brain injury–related emergency department visits,† by age group and mechanism of injury — Healthcare Cost and Utilization Project’s Nationwide Emergency Department Sample, United States, 2007 and 2013
Age group (yrs) Year Unintentional motor-vehicle crashes Unintentional falls§ Unintentionally struck by or against an object Other unintentional injury, mechanism unspecified Intentional self-harm Assault or homicide Other or no mechanism specified**
No. Rate†† (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI)
0–4 2007 5,582 26.7 (23.0–30.4) 165,093 789.1 (691.6–886.7) 38,850 185.7 (162.0–209.4) 10,317 49.3 (42.7–56.0) §§ §§ 624 3.0 (2.3–3.6) 13,528 64.7 (40.1–89.2)
2013 5,251 26.4 (23.1–29.8) 217,280 1,094.4 (973.5–1,215.3) 51,517 259.5 (230.0–288.9) 12,592 63.4 (51.8–75.1) §§ §§ 590 3.0 (2.3–3.6) 18,696 94.2 (49.5–138.8)
5–14 2007 17,009 42.1 (37.7–46.6) 87,804 217.6 (193.6–241.5) 70,501 174.7 (156.6–192.8) 29,924 74.1 (66.9–81.4) §§ §§ 8,826 21.9 (19.4–24.3) 13,710 34.0 (22.2–45.8)
2013 18,459 44.8 (40.1–49.4) 129,599 314.3 (282.0–346.6) 119,535 289.9 (259.9–319.9) 31,887 77.3 (69.6–85.0) §§ §§ 9,852 23.9 (21.1–26.7) 26,447 64.1 (39.1–89.2)
15–24 2007 88,161 205.1 (187.3–222.8) 64,574 150.2 (138.5–161.9) 70,128 163.1 (150.6–175.6) 29,338 68.2 (63.3–73.2) 427 1.0 (0.7–1.2) 63,320 147.3 (135.9–158.7) 24,899 57.9 (39.7–76.2)
2013 97,214 220.8 (203.0–238.5) 96,202 218.5 (202.0–234.9) 106,066 240.9 (222.6–259.1) 36,272 82.4 (75.4–89.3) 808 1.8 (1.4–2.2) 68,210 154.9 (141.6–168.2) 36,417 82.7 (61.3–104.1)
25–34 2007 49,088 121.9 (110.2–133.7) 40,199 99.9 (92.0–107.7) 28,207 70.1 (64.5–75.7) 16,359 40.6 (37.3–43.9) 279 0.7 (0.5–0.9) 40,813 101.4 (92.3–110.5) 15,620 38.8 (28.1–49.6)
2013 65,034 151.6 (138.6–164.6) 67,492 157.3 (145.1–169.6) 43,121 100.5 (92.8–108.2) 22,650 52.8 (46.9–58.7) 485 1.1 (0.8–1.4) 57,537 134.1 (122.0–146.3) 23,263 54.2 (39.2–69.2)
35–44 2007 35,299 82.7 (74.7–90.6) 41,668 97.6 (90.1–105.0) 23,222 54.4 (50.0–58.7) 14,435 33.8 (31.1–36.5) 264 0.6 (0.4–0.8) 29,200 68.4 (61.7–75.1) 12,676 29.7 (21.2–38.2)
2013 42,402 104.6 (95.4–113.8) 64,113 158.1 (146.4–169.8) 32,203 79.4 (73.3–85.5) 17,156 42.3 (37.8–46.8) 392 1.0 (0.7–1.2) 33,568 82.8 (75.2–90.4) 16,795 41.4 (30.4–52.4)
45–54 2007 28,481 65.3 (59.0–71.7) 51,091 117.2 (108.0–126.4) 17,521 40.2 (36.9–43.5) 12,433 28.5 (26.2–30.8) 138 0.3 (0.2–0.4) 19,928 45.7 (41.0–50.5) 11,116 25.5 (18.8–32.2)
2013 37,838 86.3 (78.8–93.8) 90,421 206.2 (190.9–221.5) 29,036 66.2 (61.0–71.4) 18,410 42.0 (37.3–46.7) 176 0.4 (0.3–0.5) 26,176 59.7 (54.0–65.4) 16,911 38.6 (27.6–49.6)
55–64 2007 15,797 48.4 (43.6–53.1) 46,823 143.4 (132.5–154.3) 8,739 26.8 (24.3–29.2) 6,680 20.5 (18.6–22.3) ¶¶ ¶¶ 5,136 15.7 (14.0–17.5) 6,873 21.0 (15.5–26.6)
2013 25,477 64.8 (59.0–70.5) 103,924 264.2 (245.2–283.1) 19,007 48.3 (44.4–52.2) 13,130 33.4 (28.5–38.2) 135 0.3 (0.2–0.5) 10,828 27.5 (24.9–30.2) 13,684 34.8 (24.9–44.6)
65–74 2007 7,410 38.1 (34.3–41.9) 45,635 234.7 (216.3–253.0) 4,266 21.9 (19.6–24.3) 3,302 17.0 (15.3–18.7) ¶¶ ¶¶ 1,209 6.2 (5.3–7.2) 4,908 25.2 (18.6–31.8)
2013 12,582 49.9 (45.4–54.4) 111,531 442.2 (408.6–475.8) 10,810 42.9 (39.3–46.5) 7,236 28.7 (23.7–33.6) ¶¶ ¶¶ 2,420 9.6 (8.4–10.8) 10,052 39.9 (29.0–50.7)
≥75 2007 5,631 30.5 (27.2–33.7) 129,618 701.5 (638.0–764.9) 5,740 31.1 (27.6–34.6) 3,847 20.8 (18.1–23.5) ¶¶ ¶¶ 582 3.1 (2.5–3.8) 10,132 54.8 (40.9–68.8)
2013 7,791 40.0 (35.8–44.3) 282,912 1,453.9 (1,327.1–1,580.8) 12,182 62.6 (56.3–68.9) 7,775 40.0 (31.4–48.5) ¶¶ ¶¶ 1,040 5.3 (4.5–6.2) 19,403 99.7 (71.5–128.0)
Total 2007 252,459 83.8 (76.5–91.1) 672,504 223.1 (206.1–240.2) 267,175 88.6 (81.7–95.6) 126,635 42.0 (39.1–44.9) 1,254 0.4 (0.3–0.5) 169,638 56.3 (51.6–60.9) 113,460 37.6 (27.0–48.3)
2013 312,048 98.6 (90.7–106.6) 1,163,473 367.7 (341.2–394.1) 423,477 133.8 (123.4–144.2) 167,107 52.8 (47.3–58.4) 2,284 0.7 (0.6–0.8) 210,220 66.4 (60.8–72.1) 181,668 57.4 (41.7–73.1)
Adjusted*** 2007 83.8 (80.3–87.2) 222.6 (213.6–231.6) 90.3 (86.6–94.0) 42.7 (41.1–44.2) 0.4 (0.4–0.5) 56.8 (54.4–59.2) 37.8 (33.5–42.0)
2013 99.5 (95.9–103.2)††† 366.5 (353.4–379.7)††† 139.8 (134.1–145.5)††† 54.0 (51.8–56.2) 0.7 (0.7–0.8)††† 68.2 (65.3–71.1)††† 58.3 (51.6–65.0)

Abbreviations: CI = confidence interval; TBI = traumatic brain injury.
*Visits with missing age were excluded. Numbers subject to rounding error.
†Persons who were hospitalized, died, or transferred to another facility were excluded.
§Includes falls of undetermined intent to maintain consistency with past data releases.
E-codes specify that the injury was unintentional but do not specify the actual mechanism of injury.
**Includes TBIs in which the intent was not determined as well as those due to legal intervention or war. Includes TBIs in which no mechanism was specified in the record. Does not include falls of undetermined intent.
††Per 100,000 population.
§§Estimates suppressed for the age groups 0–4 and 5–14 years because it is unclear whether children aged <10 years are able to form suicidal intent.
¶¶The relative standard error was >30% or the standard error = 0, the value of the estimate was considered unreliable and was not reported.
***Age-adjusted to the 2000 U.S. standard population (per 100,000 population).
†††Significant difference in rate compared to 2007 based on t-test (p<0.05). Only selected comparisons were tested for statistical significance.

Return to your place in the textTABLE 6. Estimated number* and rate of traumatic brain injury–related hospitalizations,† by age group and mechanism of injury — Healthcare Cost and Utilization Project’s National Sample, United States, 2007 and 2013
Age group (yrs) Year Unintentional motor-vehicle crashes Unintentional falls§ Unintentionally struck by or against an object Other unintentional injury, mechanism unspecified Intentional self-harm Assault or homicide Other or no mechanism specified**
No. Rate†† (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI)
0–4 2007 1,345 6.4 (4.1–8.8) 5,333 25.5 (19.3–31.7) 610 2.9 (1.9–3.9) 657 3.1 (2.1–4.2) §§ §§ 1,166 5.6 (3.4–7.8) 1,819 8.7 (4.5–12.9)
2013 880 4.4 (3.5–5.4) 4,925 24.8 (21.3–28.3) 600 3.0 (2.3–3.7) 765 3.9 (3.0–4.7) §§ §§ 1,065 5.4 (4.2–6.5) 1,015 5.1 (3.5–6.7)
5–14 2007 3,917 9.7 (6.9–12.5) 2,823 7.0 (5.4–8.6) 1,278 3.2 (2.4–4.0) 2,515 6.2 (4.7–7.8) §§ §§ 302 0.7 (0.5–1.0) 1,608 4.0 (1.8–6.2)
2013 2,515 6.1 (5.1–7.1) 2,585 6.3 (5.3–7.2) 825 2.0 (1.6–2.4) 1,615 3.9 (3.2–4.6) §§ §§ 155 0.4 (0.2–0.5) 955 2.3 (1.6–3.1)
15–24 2007 20,318 47.3 (37.9–56.6) 4,522 10.5 (8.5–12.6) 1,540 3.6 (2.9–4.2) 4,009 9.3 (7.7–11.0) 277 0.6 (0.4–0.9) 5,120 11.9 (9.8–14.0) 5,075 11.8 (6.4–17.2)
2013 14,025 31.8 (28.6–35.1)*** 4,035 9.2 (8.3–10.0) 1,045 2.4 (2.0–2.7) 2,950 6.7 (5.9–7.5) 365 0.8 (0.6–1.0) 3,360 7.6 (6.7–8.5) 2,550 5.8 (4.6–7.0)
25–34 2007 11,760 29.2 (23.3–35.1) 3,697 9.2 (7.7–10.7) 842 2.1 (1.7–2.5) 2,364 5.9 (4.9–6.9) 252 0.6 (0.4–0.8) 4,657 11.6 (9.5–13.6) 4,494 11.2 (6.7–15.7)
2013 11,400 26.6 (23.8–29.3) 4,680 10.9 (10.0–11.9) 705 1.6 (1.4–1.9) 2,315 5.4 (4.7–6.0) 390 0.9 (0.7–1.1) 4,130 9.6 (8.6–10.7) 2,370 5.5 (4.4–6.7)
35–44 2007 9,962 23.3 (18.3–28.4) 5,756 13.5 (11.6–15.4) 781 1.8 (1.5–2.2) 2,495 5.8 (4.9–6.8) 253 0.6 (0.4–0.8) 3,860 9.0 (7.3–10.8) 3,967 9.3 (5.6–13.0)
2013 7,465 18.4 (16.4–20.4) 5,280 13.0 (12.0–14.1) 570 1.4 (1.1–1.7) 2,040 5.0 (4.4–5.6) 265 0.7 (0.5–0.8) 3,035 7.5 (6.6–8.3) 1,890 4.7 (3.8–5.5)
45–54 2007 9,895 22.7 (18.0–27.4) 9,349 21.5 (18.8–24.1) 788 1.8 (1.5–2.2) 2,835 6.5 (5.4–7.6) 259 0.6 (0.4–0.8) 3,561 8.2 (6.6–9.8) 5,109 11.7 (8.1–15.3)
2013 8,925 20.4 (18.3–22.5) 11,725 26.7 (25.0–28.4) 805 1.8 (1.5–2.1) 3,145 7.2 (6.5–7.9) 320 0.7 (0.5–0.9) 3,230 7.4 (6.6–8.2) 3,210 7.3 (6.2–8.4)
55–64 2007 6,453 19.8 (16.0–23.5) 10,686 32.7 (29.3–36.2) 647 2.0 (1.6–2.4) 2,117 6.5 (5.4–7.6) 97 0.3 (0.2–0.4) 1,311 4.0 (3.1–4.9) 4,279 13.1 (9.5–16.7)
2013 7,040 17.9 (16.0–19.8) 17,205 43.7 (41.3–46.1) 735 1.9 (1.6–2.2) 2,875 7.3 (6.6–8.0) 150 0.4 (0.2–0.5) 1,770 4.5 (3.9–5.1) 4,040 10.3 (9.0–11.5)
65–74 2007 3,562 18.3 (14.9–21.7) 14,600 75.1 (68.0–82.2) 419 2.2 (1.6–2.7) 1,144 5.9 (4.9–6.9) ¶¶ ¶¶ 348 1.8 (1.2–2.4) 4,464 23.0 (18.4–27.5)
2013 4,395 17.4 (15.6–19.2) 22,390 88.8 (84.5–93.0) 650 2.6 (2.1–3.0) 1,985 7.9 (7.0–8.8) 75 0.3 (0.2–0.4) 540 2.1 (1.7–2.6) 5,125 20.3 (18.2–22.4)
≥75 2007 4,063 22.0 (18.4–25.6) 47,553 257.3 (235.4–279.3) 779 4.2 (3.4–5.0) 1,618 8.8 (7.5–10.0) 57 0.3 (0.1–0.5) 322 1.7 (1.3–2.2) 11,563 62.6 (52.7–72.5)
2013 3,820 19.6 (17.7–21.6) 69,030 354.8 (340.1–369.4)*** 1,075 5.5 (4.7–6.3) 2,390 12.3 (11.0–13.5) 70 0.4 (0.2–0.5) 235 1.2 (0.9–1.6) 11,805 60.7 (54.6–66.7)
Total 2007 71,274 23.6 (19.2–28.1) 104,319 34.6 (31.5–37.7) 7,684 2.5 (2.2–2.9) 19,754 6.6 (5.7–7.5) 1,293 0.4 (0.3–0.5) 20,648 6.9 (5.7–8.0) 42,378 14.1 (10.2–18.0)
2013 60,465 19.1 (17.4–20.8) 141,855 44.8 (43.1–46.6) 7,010 2.2 (2.1–2.4) 20,080 6.3 (5.9–6.8) 1,665 0.5 (0.5–0.6) 17,520 5.5 (5.1–6.0) 32,960 10.4 (9.3–11.5)
Adjusted††† 2007 23.5 (21.5–25.4) 33.9 (32.3–35.5) 2.6 (2.4–2.8) 6.5 (6.1–7.0) 0.4 (0.4–0.5) 6.9 (6.3–7.4) 13.9 (12.4–15.4)
2013 18.8 (18.1–19.6)*** 42.2 (41.1–43.2)*** 2.2 (2.1–2.3) 6.2 (5.9–6.4) 0.5 (0.5–0.6) 5.6 (5.3–5.9) 9.9 (9.4–10.4)

Abbreviations: CI = confidence interval; TBI = traumatic brain injury.
*Visits with missing age were excluded. Numbers subject to rounding error.
†In-hospital deaths and patients who transferred from another hospital were excluded.
§Includes falls of undetermined intent to maintain consistency with past data releases.
E-codes specify that the injury was unintentional but do not specify the actual mechanism of injury.
**Includes TBIs in which the intent was not determined as well as those due to legal intervention or war. Includes TBIs in which no mechanism was specified in the record. Does not include falls of undetermined intent.
††Per 100,000 population.
§§Estimates suppressed for the age groups 0–4 and 5–14 years because it is unclear whether children aged <10 years are able to form suicidal intent.
¶¶The relative standard error was >30% or the standard error = 0, the value of the estimate was considered unreliable and was not reported.
***Significant difference in rate compared to 2007 based on t-test (p< .05). Only selected comparisons were tested for statistical significance.
†††Age-adjusted to the 2000 U.S. standard population (per 100,000 population).

Return to your place in the textTABLE 7. Number* and rate of traumatic brain injury-related deaths,† by age group and mechanism of injury — CDC’s National Vital Statistics System, United States, 2007 and 2013
Age group (yrs) Year Unintentional motor-vehicle crashes Unintentional falls§ Unintentionally struck by or against an object Other unintentional injury, mechanism unspecified Intentional self-harm Assault or homicide Other or no mechanism specified**
No. Rate†† (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI) No. Rate (95% CI)
0–4 2007 317 1.5 (1.3–1.7) 41 0.2 (0.1–0.3) 35 0.2 (0.1–0.2) 150 0.7 (0.6–0.8) —¶¶ — 402 1.9 (1.7–2.1) 33 0.2 (0.1–0.2)
2013 204 1.0 (0.9–1.2)§§ 28 0.1 (0.1–0.2) 31 0.2 (0.1–0.2) 128 0.6 (0.5–0.8) — — 324 1.6 (1.5–1.8) 45 0.2 (0.2–0.3)
5–14 2007 576 1.4 (1.3–1.5) 16 0 (0–0.1) 22 0.1 (0–0.1) 170 0.4 (0.4–0.5) — — 130 0.3 (0.3–0.4) 16 0 (0–0.1)
2013 334 0.8 (0.7–0.9)§§ 6 0 (0–0) 15 0 (0–0.1) 121 0.3 (0.2–0.3) — — 102 0.2 (0.2–0.3) 12 0 (0–0)
15–24 2007 4,287 10.0 (9.7–10.3) 144 0.3 (0.3–0.4) 30 0.1 (0–0.1) 480 1.1 (1.0–1.2) 1,794 4.2 (4.0–4.4) 1,686 3.9 (3.7–4.1) 129 0.3 (0.2–0.4)
2013 2,504 5.7 (5.5–5.9)§§ 127 0.3 (0.2–0.3) 27 0.1 (0–0.1) 298 0.7 (0.6–0.8) 2,081 4.7 (4.5–4.9)§§ 1,217 2.8 (2.6–2.9) 105 0.2 (0.2–0.3)
25–34 2007 2,611 6.5 (6.2–6.7) 201 0.5 (0.4–0.6) 45 0.1 (0.1–0.1) 431 1.1 (1.0–1.2) 2,092 5.2 (5.0–5.4) 1,362 3.4 (3.2–3.6) 120 0.3 (0.2–0.4)
2013 2,017 4.7 (4.5–4.9)§§ 173 0.4 (0.3–0.5) 39 0.1 (0.1–0.1) 346 0.8 (0.7–0.9) 2,702 6.3 (6.1–6.5)§§ 1,165 2.7 (2.6–2.9) 163 0.4 (0.3–0.4)
35–44 2007 2,114 5.0 (4.7–5.2) 371 0.9 (0.8–1.0) 47 0.1 (0.1–0.1) 514 1.2 (1.1–1.3) 2,462 5.8 (5.5–6.0) 960 2.2 (2.1–2.4) 182 0.4 (0.4–0.5)
2013 1,404 3.5 (3.3–3.6)§§ 321 0.8 (0.7–0.9) 41 0.1 (0.1–0.1) 370 0.9 (0.8–1.0) 2,612 6.4 (6.2–6.7)§§ 783 1.9 (1.8–2.1) 157 0.4 (0.3–0.4)
45–54 2007 2,127 4.9 (4.7–5.1) 875 2.0 (1.9–2.1) 67 0.2 (0.1–0.2) 724 1.7 (1.5–1.8) 2,923 6.7 (6.5–6.9) 765 1.8 (1.6–1.9) 293 0.7 (0.6–0.7)
2013 1,523 3.5 (3.3–3.6)§§ 905 2.1 (1.9–2.2) 53 0.1 (0.1–0.2) 612 1.4 (1.3–1.5) 3,407 7.8 (7.5–8.0)§§ 650 1.5 (1.4–1.6) 290 0.7 (0.6–0.7)
55–64 2007 1,279 3.9 (3.7–4.1) 1,139 3.5 (3.3–3.7) 46 0.1 (0.1–0.2) 497 1.5 (1.4–1.7) 2,281 7.0 (6.7–7.3) 405 1.2 (1.1–1.4) 270 0.8 (0.7–0.9)
2013 1,260 3.2 (3.0–3.4)§§ 1,508 3.8 (3.6–4.0) 62 0.2 (0.1–0.2) 577 1.5 (1.3–1.6) 3,144 8.0 (7.7–8.3)§§ 460 1.2 (1.1–1.3) 390 1.0 (0.9–1.1)
65–74 2007 775 4.0 (3.7–4.3) 1,650 8.5 (8.1–8.9) 44 0.2 (0.2–0.3) 415 2.1 (1.9–2.3) 1,408 7.2 (6.9–7.6) 171 0.9 (0.7–1.0) 279 1.4 (1.3–1.6)
2013 748 3.0 (2.8–3.2)§§ 2,219 8.8 (8.4–9.2) 33 0.1 (0.1–0.2) 434 1.7 (1.6–1.9) 2,141 8.5 (8.1–8.8)§§ 208 0.8 (0.7–0.9) 354 1.4 (1.3–1.5)
≥75 2007 994 5.4 (5.0–5.7) 7,344 39.7 (38.8–40.7) 40 0.2 (0.1–0.3) 990 5.4 (5.0–5.7) 1,828 9.9 (9.4–10.3) 177 1.0 (0.8–1.1) 878 4.8 (4.4–5.1)
2013 786 4.0 (3.8–4.3)§§ 9,796 50.3 (49.3–51.3)§§ 48 0.2 (0.2–0.3) 886 4.6 (4.3–4.9) 2,100 10.8 (10.3–11.3)§§ 193 1.0 (0.9–1.1) 997 5.1 (4.8–5.4)
Total 2007 15,080 5.0 (4.9–5.1) 11,781 3.9 (3.8–4.0) 376 0.1 (0.1–0.1) 4,371 1.5 (1.4–1.5) 14,833 4.9 (4.8–5.0) 6,058 2.0 (2.0–2.1) 2,200 0.7 (0.7–0.8)
2013 10,780 3.4 (3.3–3.5)§§ 15,083 4.8 (4.7–4.8) 349 0.1 (0.1–0.1) 3,772 1.2 (1.2–1.2) 18,321 5.8 (5.7–5.9) 5,102 1.6 (1.6–1.7) 2,513 0.8 (0.8–0.8)
Adjusted*** 2007 5.0 (4.9–5.0) 3.8 (3.7–3.9) 0.1 (0.1–0.1) 1.4 (1.4–1.5) 4.8 (4.7–4.9) 2.0 (2.0–2.1) 0.7 (0.7–0.7)
2013 3.4 (3.3–3.4)§§ 4.5 (4.4–4.5)§§ 0.1 (0.1–0.1) 1.1 (1.1–1.2) 5.6 (5.5–5.6)§§ 1.6 (1.6–1.7) 0.7 (0.7–0.8)

Abbreviations: CI = confidence interval; TBI = traumatic brain injury.
*Visits with missing age were excluded. Numbers subject to rounding error.
†Record-Axis Condition codes were used (usually included both Part I and Part II of Entity-Axis Condition codes).
§Includes falls of undetermined intent to maintain consistency with past data releases.
E-codes specify that the injury was unintentional but do not specify the actual mechanism of injury.
**Includes TBIs in which the intent was not determined as well as those due to legal intervention or war. Includes TBIs in which no mechanism was specified in the record. Does not include falls of undetermined intent.
††Per 100,000 population.
§§Significant difference in rate compared to 2007 based on t-test (p<0.05). Only selected comparisons were tested for statistical significance.
¶¶Estimates suppressed for the age groups 0–4 and 5–14 years because it is unclear whether children aged <10 years are able to form suicidal intent.
***Age-adjusted to the 2000 U.S. standard population (per 100,000 population).

Suggested citation for this article: Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic Brain Injury–Related Emergency Department Visits, Hospitalizations, and Deaths — United States, 2007 and 2013. MMWR Surveill Summ 2017;66(No. SS-9):1–16. DOI: http://dx.doi.org/10.15585/mmwr.ss6609a1.

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