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Hospitalizations for critically ill children with traumatic brain injuries: A longitudinal analysis*

Tilford, John M. PhD; Aitken, Mary E. MD, MPH; Anand, K J. S. MBBS; Green, Jerril W. MD; Goodman, Allen C. PhD; Parker, James G. MS; Killingsworth, Jeffrey B. MPH; Fiser, Debra H. MD; Adelson, P David MD

doi: 10.1097/01.CCM.0000171839.65687.F5
Pediatric Critical Care

Objective: This study examines the incidence, utilization of procedures, and outcomes for critically ill children hospitalized with traumatic brain injury over the period 1988–1999 to describe the benefits of improved treatment.

Design: Retrospective analysis of hospital discharges was conducted using data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample that approximates a 20% sample of U.S. acute care hospitals.

Setting: Hospital inpatient stays from all types of U.S. community hospitals.

Participants: The study sample included all children aged 0–21 with a primary or secondary ICD-9-CM diagnosis code for traumatic brain injury and a procedure code for either endotracheal intubation or mechanical ventilation.

Interventions: None.

Measurements and Main Results: Deaths occurring during hospitalization were used to calculate mortality rates. Use of intracranial pressure monitoring and surgical openings of the skull were investigated as markers for the aggressiveness of treatment. Patients were further classified by insurance status, household income, and hospital characteristics. Over the 12-yr study period, mortality rates decreased 8 percentage points whereas utilization of intracranial pressure monitoring increased by 11 percentage points. The trend toward more aggressive management of traumatic brain injury corresponded with improved hospital outcomes over time. Lack of insurance was associated with vastly worse outcomes. An estimated 6,437 children survived their traumatic brain injury hospitalization because of improved treatment, and 1,418 children died because of increased mortality risk associated with being uninsured. Improved treatment was valued at approximately $17 billion, whereas acute care hospitalization costs increased by $1.5 billion (in constant 2000 dollars). Increased mortality in uninsured children was associated with a $3.76 billion loss in economic benefits.

Conclusions: More aggressive management of pediatric traumatic brain injury appears to have contributed to reduced mortality rates over time and saved thousands of lives. Additional lives could be saved if mortality rates could be equalized between insured and uninsured children.

From the Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR (JMT, MEA, KJSA, JWG, JGP, JBK, DHF); Department of Economics, Wayne State University, Detroit MI (ACG); and Department of Neurosurgery, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA (PDA).

Supported, in part, by grant H34 MC 00105 from the Health Resources and Services Administration/Maternal and Child Health Bureau.

Address requests for reprints to: John M. Tilford, PhD, Center for Applied Research and Evaluation, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, 800 Marshall St., Little Rock, AR 72202–3591. Email:,

© 2005 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins