Epidemiology of Pediatric Trauma: Importance of Population-Based Statistics ByArthur
Cooper,
Barbara Barlow, Leslie Davidson, John Relethford, James O’Meara, New York, New York and Albany, New York
l To determine the validity of using hospital-based pediatric trauma registry data to draw specific inferences with regard to regional pediatric trauma system design, we compared statistical data on the incidence and mortality of
pediatric and adult injuries and burns calculated by the New York State Department of Health, based on legally mandated reports of injury deaths and hospital discharges for 1989. During this year, some 488 children, aged 0 to 14 years, died as a result of injuries, a rate of 13.8 per 100,000 annually, of whom 408 (11.8/ 100,000) died as a result of traumatic injuries or burns, a population-based rate 20% of that observed in adults. During the same period, 18,402 children were hospitalized for treatment of traumatic injuries and burns, a rate of 466 per 100,000 annually, a population-based rate 56% of that observed in adults; and of this number, some 90 children died, yielding an in-hospital mortality “rate” (ie, case fatality ratio) of 0.55%. and a populationbased rate of 2.6 per 100,000 annually. Thus, 9.0 of the 11.6 per 100,000 children who died in New York State in 1989 as a result of traumatic injuries and burns were not admitted to the hospital and, therefore, were unknown to the statewide hospital reporting system. Detailed analysis of data by specific cause of injury was limited by the fact that hospitals in New York State did not begin reporting data on etiology (ICD-9 E-codes) as well as anatomic nature (ICD-9 N-codes) of serious injury until 1990; however, although it appears that no single injury subtype is responsible for the large number of not-in-hospital deaths statewide, homicide predominates in the metropolitan area, and motor vehiclerelated injuries in others. Our results indicate that: (1) although death is a less common outcome of major trauma among children than adults, the need for in-hospital treatment of serious injuries approaches that of adults; and (2) in missing large numbers of not-in-hospital deaths (78% of the total in New York State in 1889), hospital-based data (on which most pediatric trauma registries throughout this nation are based) substantially underestimate the extent and severity of childhood traumatic injuries and burns as public health problems. We conclude that although pediatric trauma registry data are invaluable in judging treatment outcome, they should be used in guiding regional pediatric trauma system design only when considered together with population-based mortality and morbidity data derived from state or local vital statistics. Thus, collaboration with regional governmental health agencies is essential to ensure both proper data collection, and that the needs of the public for pediatric injury prevention education and pediatric trauma and burn care are optimally met.
Copyright (c)1992 by W.B. Saunders Company INDEX WORDS: Trauma, pediatric; epidemiology.
burns, pediatric; trauma,
T
RAUMA HAS LONG been known as the leading cause of death and disability in American children. However, coordinated national efforts to Journaloffediafric
Surgery, Vol 27, No 2 (February), 1992: pp 149-154
and Lawrence
Mottley
reduce this toll have been underway for little more than a decade. Hospital-based trauma registries have played an important role in determining the extent and consequences of injuries treated in our nation’s trauma centers, a fact that led to the creation of both the Multiple Trauma Outcome Study’ and the National Pediatric Trauma Registry.” To determine the validity of using hospital-based pediatric trauma registry data to draw specific inferences with regard to regional pediatric trauma system design, we compared vital statistical data on the mortality rates of traumatic injuries and burns in children in New York State with those generated from Uniform Hospital Discharge Summary data compiled by the statewide hospital reporting system. MATERIALS
AND METHODS
Reports of injury deaths and hospital discharges both are legally mandated in New York State.‘,4 The former are submitted to the Office of Vital Statistics of the New York State Department of Health for review by many agencies, including the Injury Control Program; the latter are submitted directly to the Statewide Planning and Research Cooperative (Hospital Reporting) System (SPARCS). For the purposes of this study we chose to review data from 1984 through 1989 (the last years for which complete statistics were available at the time of writing) for children under 15 years of age. From the Injury Control Program, we obtained mortality data for all injuries, including those due to trauma and burns, grouped by cause of injury, from 1984 through 1988; from SPARCS, we obtained both hospital discharge and mortality data for patients whose principal diagnoses were found under international Classifcation of Diseases5 (ICD-9) N-codes 800 through 957, 959. and 995.5, grouped by site of injury (Table l), for 1989. All data obtained were in the public domain: the former were obtained from Injury Mortality in New York State 1984-1988, a report prepared by the Injury Control Program,’ the latter via a SPARCS Nondeniable Data Request, ie, a request not requiring review by
From the Departments of Surgery and Pediatrics, Harlem Hospital Center, and the School of Public Health. College of Physicians and Surgeons of Columbia University, New York. NY; and Injury Control Program, Division of Epidemiology; Statewide Planning and Research Cooperative System, Information Systems and Health Statistics Group, Bureau of Production Systems Management, Division of Administration; and Bureau of Hospital Services, Division of Health Care Surveillance, New York State Department of Health, Albany, NY Presented at the 22nd Annual Meeting of the American Pediatric SurgicalAssociation, Lake Buena Vista, Florida, May 15-18, 1991. Address reprint requests to Arthur Cooper, MD, Chief of Pediatric Surgical Critical Care, Harlem Hospital Center, 506 Lenox Ave. New York, NY 1003 7. Copyright o 1992 by W.B. Saundenv Company 0022-346819212702-0003$03.00!0 149
150
COOPER ET AL
Table 1. Injury Groups by Principal Anatomic Diagnosis Injury Site
Table 3. Pediatric Injury Deaths in New York State-1989 (Estimated)
ICD-9 N-Code
Musculoskeletal
Mortality
805-849
Head (skull/brain)
800-804.850-854
Internal (torso/vessels)
860-869.900-904
Total, all ages
1984-l 988
Annualized
43,876
8,775
Per 100,000
External (open)
870-897
2,441
488
13.8*
External (closed)
910-924
Motor vehicle accidents
690
138
3.9
Crush
925-929
Homicide
420
84
2.4
Burns/smoke inhalation
940-949
Gunshots, stabs
135
27
Spine/nerves
950-957
Abuse
69
14
Injuries NOS
959
Hanging, strangulation
47
9
Child abuse*
995.5
173
37
414
83
405
81
Total, O-14 years
Other
*Does not include all cases of physical abuse or maltreatment.
Burns Fire, flame, inhalation Scald, corrosive, steam
the SPARCS Data Protection Board because all personal and institutional identifiers had been removed. Data were analyzed both for New York State as a whole, and separately for New York City and the rest of New York State. Population estimates were derived from the Annual Child and Adolescent Health profile’ of the New York State Department of Health (Table 2). Injury control data and SPARCS data were correlated directly whenever possible. Statistical comparisons were made on the overall rates using the x2 test, and were deemed significant when P < .05. RESULTS
Annualized injury mortality data for children aged 0 to 14 years from 1984 through 1988 in New York State are delineated in Table 3. Some 488 children now die each year as a result of injuries, a rate of 13.8 per 100,000 annually; 408 of these (11.6/100,000) die as a result of traumatic injuries or burns. Annualized mortality rates for New York City versus the rest of New York State are shown in Table 4. Although the overall mortality rates are not dissimilar, homicides and falls were far more common causes of death in New York City, whereas motor vehicle-related injuries were a less frequent cause. Hospitalizations for traumatic injuries and burns for children aged 0 to 14 years during 1989 in New York State are delineated in Table 5. In this year, 16,402 children were discharged from the hospital following treatment of traumatic injuries and burns, a rate of 465 per 100,000 annually; of this number, some 90 children died, yielding an in-hospital mortality “rate” (ie, case fatality ratio) of 0.55%, and a Table 2. Population of New York State-1987 Am Ivr)
New York State
New York City
(Estimated)
Rest of New York State
o-4
1.127.518
498,966
718,552
5-9
1,156,462
458,104
698,358
IO-14
1,153,884
448,530
705,354
O-14
3.527,864
1.405.600
2,122,264
All ages
17.844.900
7.313.100
10,531,800
Data from New York State Department of Health Bureau of Child and Adolescent Health.’
2.4
9
2
Drowning
215
43
1.2
Choking, suffocation
141
28
0.8
Falls
87
15
0.4
Suicide
57
11
0.3
417
83
Other
*Rate of 11.6 per 100,000 excluding deaths not due to trauma or burns. Data from New York State Department
of Health Injury Control
Program.6
population-based rate of 2.6 per 100,000 annually. Thus, 9.0 of the 11.6 per 100,000 children who died in New York State in 1989 as a result of serious injuries were not admitted to the hospital and, therefore, were unknown to the statewide hospital reporting system. Hospitalization and in-hospital mortality rates for New York City versus the rest of New York State are shown in Table 6. Hospitalization for treatment of injury occured 1.21 times more frequently in New York City, although hospitalization for head and/or skull injury occured 0.86 times less frequently. Inhospital mortality from head and/or skull injury was also somewhat lower in New York City than in the rest of New York State, possibly reflecting (1) fewer high-speed motor vehicle-related injuries, (2) the generally shorter transport time to definitive care, or (3) both. Detailed analysis of mortality data by specific cause of injury was limited by the fact that hospitals did not begin reporting data on etiology (ICD-9 E-codes) until 1990. However, although it appears that no single injury subtype is responsible for the large number of not-in-hospital deaths statewide, this observation does not pertain on a regional basis. Indeed, homicide (Table 7) particularly that due to gunshot wounds (Table 8), is a far more common cause of death among children than had previously been suspected: it is now the leading cause of traumatic injury death in New York City, and closely follows motor vehicle-related injuries in New York State as a whole. This corroborates the findings of a recent
EPIDEMIOLOGY
OF PEDIATRIC
TRAUMA
151
Table 4. Pediatric Trauma/Sum
Deaths in New York City Versus Rest of New York State-1989 New York City Mortality
1984.1988
Annualized
934
187 (100%)
204
Homicide Burns
Total,
O-14 years
Motor
vehicle
accidents
Fire, flame, inhalation Scald, corrosive, steam
(Estimated)
Rest of New York State Mortality Per 100,000
1984.1988
Annualized
13.3
1,151
230 (100%)
Per 100,000
41 (22%)’
2.9’
486
97 (42%)*
269
54 (29X)X
3.8*
151
30 (13%)X
1.4s
148
30 (16%)
2.1
266
53 (23%)
2.5
141
81
264
7
2
2
10.8 4.6*
53
Cooper,
Barbara Barlow, Leslie Davidson, John Relethford, James O’Meara, New York, New York and Albany, New York
l To determine the validity of using hospital-based pediatric trauma registry data to draw specific inferences with regard to regional pediatric trauma system design, we compared statistical data on the incidence and mortality of
pediatric and adult injuries and burns calculated by the New York State Department of Health, based on legally mandated reports of injury deaths and hospital discharges for 1989. During this year, some 488 children, aged 0 to 14 years, died as a result of injuries, a rate of 13.8 per 100,000 annually, of whom 408 (11.8/ 100,000) died as a result of traumatic injuries or burns, a population-based rate 20% of that observed in adults. During the same period, 18,402 children were hospitalized for treatment of traumatic injuries and burns, a rate of 466 per 100,000 annually, a population-based rate 56% of that observed in adults; and of this number, some 90 children died, yielding an in-hospital mortality “rate” (ie, case fatality ratio) of 0.55%. and a populationbased rate of 2.6 per 100,000 annually. Thus, 9.0 of the 11.6 per 100,000 children who died in New York State in 1989 as a result of traumatic injuries and burns were not admitted to the hospital and, therefore, were unknown to the statewide hospital reporting system. Detailed analysis of data by specific cause of injury was limited by the fact that hospitals in New York State did not begin reporting data on etiology (ICD-9 E-codes) as well as anatomic nature (ICD-9 N-codes) of serious injury until 1990; however, although it appears that no single injury subtype is responsible for the large number of not-in-hospital deaths statewide, homicide predominates in the metropolitan area, and motor vehiclerelated injuries in others. Our results indicate that: (1) although death is a less common outcome of major trauma among children than adults, the need for in-hospital treatment of serious injuries approaches that of adults; and (2) in missing large numbers of not-in-hospital deaths (78% of the total in New York State in 1889), hospital-based data (on which most pediatric trauma registries throughout this nation are based) substantially underestimate the extent and severity of childhood traumatic injuries and burns as public health problems. We conclude that although pediatric trauma registry data are invaluable in judging treatment outcome, they should be used in guiding regional pediatric trauma system design only when considered together with population-based mortality and morbidity data derived from state or local vital statistics. Thus, collaboration with regional governmental health agencies is essential to ensure both proper data collection, and that the needs of the public for pediatric injury prevention education and pediatric trauma and burn care are optimally met.
Copyright (c)1992 by W.B. Saunders Company INDEX WORDS: Trauma, pediatric; epidemiology.
burns, pediatric; trauma,
T
RAUMA HAS LONG been known as the leading cause of death and disability in American children. However, coordinated national efforts to Journaloffediafric
Surgery, Vol 27, No 2 (February), 1992: pp 149-154
and Lawrence
Mottley
reduce this toll have been underway for little more than a decade. Hospital-based trauma registries have played an important role in determining the extent and consequences of injuries treated in our nation’s trauma centers, a fact that led to the creation of both the Multiple Trauma Outcome Study’ and the National Pediatric Trauma Registry.” To determine the validity of using hospital-based pediatric trauma registry data to draw specific inferences with regard to regional pediatric trauma system design, we compared vital statistical data on the mortality rates of traumatic injuries and burns in children in New York State with those generated from Uniform Hospital Discharge Summary data compiled by the statewide hospital reporting system. MATERIALS
AND METHODS
Reports of injury deaths and hospital discharges both are legally mandated in New York State.‘,4 The former are submitted to the Office of Vital Statistics of the New York State Department of Health for review by many agencies, including the Injury Control Program; the latter are submitted directly to the Statewide Planning and Research Cooperative (Hospital Reporting) System (SPARCS). For the purposes of this study we chose to review data from 1984 through 1989 (the last years for which complete statistics were available at the time of writing) for children under 15 years of age. From the Injury Control Program, we obtained mortality data for all injuries, including those due to trauma and burns, grouped by cause of injury, from 1984 through 1988; from SPARCS, we obtained both hospital discharge and mortality data for patients whose principal diagnoses were found under international Classifcation of Diseases5 (ICD-9) N-codes 800 through 957, 959. and 995.5, grouped by site of injury (Table l), for 1989. All data obtained were in the public domain: the former were obtained from Injury Mortality in New York State 1984-1988, a report prepared by the Injury Control Program,’ the latter via a SPARCS Nondeniable Data Request, ie, a request not requiring review by
From the Departments of Surgery and Pediatrics, Harlem Hospital Center, and the School of Public Health. College of Physicians and Surgeons of Columbia University, New York. NY; and Injury Control Program, Division of Epidemiology; Statewide Planning and Research Cooperative System, Information Systems and Health Statistics Group, Bureau of Production Systems Management, Division of Administration; and Bureau of Hospital Services, Division of Health Care Surveillance, New York State Department of Health, Albany, NY Presented at the 22nd Annual Meeting of the American Pediatric SurgicalAssociation, Lake Buena Vista, Florida, May 15-18, 1991. Address reprint requests to Arthur Cooper, MD, Chief of Pediatric Surgical Critical Care, Harlem Hospital Center, 506 Lenox Ave. New York, NY 1003 7. Copyright o 1992 by W.B. Saundenv Company 0022-346819212702-0003$03.00!0 149
150
COOPER ET AL
Table 1. Injury Groups by Principal Anatomic Diagnosis Injury Site
Table 3. Pediatric Injury Deaths in New York State-1989 (Estimated)
ICD-9 N-Code
Musculoskeletal
Mortality
805-849
Head (skull/brain)
800-804.850-854
Internal (torso/vessels)
860-869.900-904
Total, all ages
1984-l 988
Annualized
43,876
8,775
Per 100,000
External (open)
870-897
2,441
488
13.8*
External (closed)
910-924
Motor vehicle accidents
690
138
3.9
Crush
925-929
Homicide
420
84
2.4
Burns/smoke inhalation
940-949
Gunshots, stabs
135
27
Spine/nerves
950-957
Abuse
69
14
Injuries NOS
959
Hanging, strangulation
47
9
Child abuse*
995.5
173
37
414
83
405
81
Total, O-14 years
Other
*Does not include all cases of physical abuse or maltreatment.
Burns Fire, flame, inhalation Scald, corrosive, steam
the SPARCS Data Protection Board because all personal and institutional identifiers had been removed. Data were analyzed both for New York State as a whole, and separately for New York City and the rest of New York State. Population estimates were derived from the Annual Child and Adolescent Health profile’ of the New York State Department of Health (Table 2). Injury control data and SPARCS data were correlated directly whenever possible. Statistical comparisons were made on the overall rates using the x2 test, and were deemed significant when P < .05. RESULTS
Annualized injury mortality data for children aged 0 to 14 years from 1984 through 1988 in New York State are delineated in Table 3. Some 488 children now die each year as a result of injuries, a rate of 13.8 per 100,000 annually; 408 of these (11.6/100,000) die as a result of traumatic injuries or burns. Annualized mortality rates for New York City versus the rest of New York State are shown in Table 4. Although the overall mortality rates are not dissimilar, homicides and falls were far more common causes of death in New York City, whereas motor vehicle-related injuries were a less frequent cause. Hospitalizations for traumatic injuries and burns for children aged 0 to 14 years during 1989 in New York State are delineated in Table 5. In this year, 16,402 children were discharged from the hospital following treatment of traumatic injuries and burns, a rate of 465 per 100,000 annually; of this number, some 90 children died, yielding an in-hospital mortality “rate” (ie, case fatality ratio) of 0.55%, and a Table 2. Population of New York State-1987 Am Ivr)
New York State
New York City
(Estimated)
Rest of New York State
o-4
1.127.518
498,966
718,552
5-9
1,156,462
458,104
698,358
IO-14
1,153,884
448,530
705,354
O-14
3.527,864
1.405.600
2,122,264
All ages
17.844.900
7.313.100
10,531,800
Data from New York State Department of Health Bureau of Child and Adolescent Health.’
2.4
9
2
Drowning
215
43
1.2
Choking, suffocation
141
28
0.8
Falls
87
15
0.4
Suicide
57
11
0.3
417
83
Other
*Rate of 11.6 per 100,000 excluding deaths not due to trauma or burns. Data from New York State Department
of Health Injury Control
Program.6
population-based rate of 2.6 per 100,000 annually. Thus, 9.0 of the 11.6 per 100,000 children who died in New York State in 1989 as a result of serious injuries were not admitted to the hospital and, therefore, were unknown to the statewide hospital reporting system. Hospitalization and in-hospital mortality rates for New York City versus the rest of New York State are shown in Table 6. Hospitalization for treatment of injury occured 1.21 times more frequently in New York City, although hospitalization for head and/or skull injury occured 0.86 times less frequently. Inhospital mortality from head and/or skull injury was also somewhat lower in New York City than in the rest of New York State, possibly reflecting (1) fewer high-speed motor vehicle-related injuries, (2) the generally shorter transport time to definitive care, or (3) both. Detailed analysis of mortality data by specific cause of injury was limited by the fact that hospitals did not begin reporting data on etiology (ICD-9 E-codes) until 1990. However, although it appears that no single injury subtype is responsible for the large number of not-in-hospital deaths statewide, this observation does not pertain on a regional basis. Indeed, homicide (Table 7) particularly that due to gunshot wounds (Table 8), is a far more common cause of death among children than had previously been suspected: it is now the leading cause of traumatic injury death in New York City, and closely follows motor vehicle-related injuries in New York State as a whole. This corroborates the findings of a recent
EPIDEMIOLOGY
OF PEDIATRIC
TRAUMA
151
Table 4. Pediatric Trauma/Sum
Deaths in New York City Versus Rest of New York State-1989 New York City Mortality
1984.1988
Annualized
934
187 (100%)
204
Homicide Burns
Total,
O-14 years
Motor
vehicle
accidents
Fire, flame, inhalation Scald, corrosive, steam
(Estimated)
Rest of New York State Mortality Per 100,000
1984.1988
Annualized
13.3
1,151
230 (100%)
Per 100,000
41 (22%)’
2.9’
486
97 (42%)*
269
54 (29X)X
3.8*
151
30 (13%)X
1.4s
148
30 (16%)
2.1
266
53 (23%)
2.5
141
81
264
7
2
2
10.8 4.6*
53
