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The Epidemiology of Pediatric Head Injury Treated Outside of Hospital Emergency Departments

Zogg, Cheryl, K.a,b,c; Haring, R., Sterlingb,c,d; Xu, Likange; Canner, Joseph, K.c; AlSulaim, Hatim, A.c; Hashmi, Zain, G.b,c; Salim, Alib,f; Engineer, Lilly, D.c,g; Haider, Adil, H.b,f; Bell, Jeneita, M.e; Schneider, Eric, B.b,c,h

doi: 10.1097/EDE.0000000000000791
Perinatal and Pediatric Epidemiology

Background: Although head trauma–related deaths, hospitalizations, and emergency department visits are well characterized, few studies describe pediatric patients presenting outside of emergency departments. We compared the epidemiology and extent of healthcare-seeking pediatric (0–17 years) patients presenting in outpatient settings with those of patients seeking nonhospitalized emergency department care.

Methods: We used MarketScan Medicaid and commercial claims, 2004–2013, to identify patients managed in two outpatient settings (physician’s offices/clinics, urgent care) and the emergency department. We then examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention–defined head trauma diagnoses, the extent of and reasons for post-index visit ambulatory care use within 30/90/180 days, and annual and monthly variations in head trauma trends. Outpatient incidence rates in 2013 provided estimates of the nationwide US outpatient burden.

Results: A total of 1,683,097 index visits were included, representing a nationwide burden in 2013 of 844,660 outpatient cases, a number that encompassed 51% of healthcare-seeking head trauma that year and that substantially increased in magnitude from 2004 to 2013. Two-thirds (68%) were managed in outpatient settings. While demographic distributions varied with index-visit location, injury-specific factors were comparable. Seasonal spikes appeared to coincide with school sports.

Conclusions: There is an urgent need to better understand the natural history of head trauma in the >800,000 pediatric patients presenting each year for outpatient care. These outpatient injuries, which are more than double the number of head trauma cases recorded in the hospital-affiliated settings, illustrate the potential importance of expanding inclusion criteria in surveillance and prevention efforts designed to address this critical issue.

From the aYale School of Medicine, New Haven, CT; bCenter for Surgery and Public Health: Harvard Medical School, Harvard T.H. Chan School of Public Health, and the Department of Surgery, Brigham & Women’s Hospital, Boston, MA; cJohns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; dDepartment of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; eNational Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; fDivision of Trauma, Burn, and Surgical Critical Care, Brigham & Women’s Hospital, Boston, MA; gDepartment of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and hDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Submitted May 12, 2017; accepted December 12, 2017.

The data are not available for replication because MarketScan is a proprietary database owned by Truven Health Analytics. Inquires about code can be directed to Cheryl K. Zogg at

No funding specifically for this work was provided. C.K.Z. is supported by NIH Medical Scientist Training Program Training Grant T32GM007205. She is the Primary Investigator of a grant from the Emergency Medical Foundation and American College of Emergency Physicians entitled, “Understanding Emergency Medicine Providers’ Perceptions of the ACA in a Renewed Era of Healthcare Reform: National Survey and Qualitative Mixed-Methods Approach.” A.H.H. is the Primary Investigator of a contract (AD-1306–03980) with PCORI entitled “Patient-Centered Approaches to Collect Sexual Orientation/Gender Identity in the ED,” a Harvard Surgery Affinity Research Collaborative (ARC) Program Grant entitled “Mitigating Disparities Through Enhancing Surgeons’ Ability To Provide Culturally Relevant Care,” and a collaborative research grant from the Henry M. Jackson Foundation for the Advancement of Military Medicine in conjunction with the Uniformed Services University of the Health Sciences entitled “The Comparative Effectiveness and Provider Induced Demand Collaboration.” He is also a co-founder and equity-shareholder of the company Patient Doctor Technologies, Inc., which owns and operates the website

Disclosure: The findings and conclusion of this research are those of the authors and do not represent the official views of the US Department of Health and Human Services (DHHS) and the Centers for Disease Control and Prevention (CDC). The inclusion of individuals, programs, or organizations in this article does not constitute endorsement by the US federal government, DHHS, or CDC. Two of the study’s co-authors, L.X. and J.M.B., are employees of the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. The other authors have no conflicts to report.

C.K.Z., R.S.H., L.X., and E.S.B. made substantial contributions to the conception or design of the work; C.K.Z., R.S.H., L.X., J.K.C., and E.S.B. participated in the acquisition and analysis of the data; C.K.Z., R.S.H., L.X., J.K.C., H.A.A., Z.G.H., A.L., L.D.E., A.H.H., J.M.B., and E.B.S. contributed toward the interpretation of data for the work; C.K.Z., R.S.H., and E.B.S. drafted the manuscript; and L.X., J.K.C., H.A.A., Z.G.H., A.L., L.D.E., A.H.H., and J.M.B. critically revised the manuscript for intellectual content. All authors provided final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Presented as an oral presentation at the American College of Surgeons Clinical Congress Scientific Forum, October 16–20, 2016, Washington, DC.

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Correspondence: Cheryl K. Zogg, Yale School of Medicine, 67 Cedar Street, Room 316 ESH, New Haven, CT 06510. E-mail:

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