Skip to content

Advertisement

You're viewing the new version of our site. Please leave us feedback.

Learn more

BMC Neurology

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Children and youth with non-traumatic brain injury: a population based perspective

  • Vincy Chan1, 2, 3Email author,
  • Jason D. Pole3, 4,
  • Michelle Keightley2, 5,
  • Robert E. Mann4, 6 and
  • Angela Colantonio1, 2, 4
BMC NeurologyBMC series – open, inclusive and trusted201616:110

https://doi.org/10.1186/s12883-016-0631-2

Received: 7 November 2015

Accepted: 1 July 2016

Published: 20 July 2016

Abstract

Background

Children and youth with non-traumatic brain injury (nTBI) are often overlooked in regard to the need for post-injury health services. This study provided population-based data on their burden on healthcare services, including data by subtypes of nTBI, to provide the foundation for future research to inform resource allocation and healthcare planning for this population.

Methods

A retrospective cohort study design was used. Children and youth with nTBI in population-based healthcare data were identified using International Classification of Diseases Version 10 codes. The rate of nTBI episodes of care, demographic and clinical characteristics, and discharge destinations from acute care and by type of nTBI were identified.

Results

The rate of pediatric nTBI episodes of care was 82.3 per 100,000 (N = 17,977); the average stay in acute care was 13.4 days (SD = 25.6 days) and 35 % were in intensive care units. Approximately 15 % were transferred to another inpatient setting and 6 % died in acute care. By subtypes of nTBI, the highest rates were among those with a diagnosis of toxic effect of substances (22.7 per 100,000), brain tumours (18.4 per 100,000), and meningitis (15.4 per 100,000). Clinical characteristics and discharge destinations from the acute care setting varied by subtype of nTBI; the proportion of patients that spent at least one day in intensive care units and the proportion discharged home ranged from 25.9 % to 58.2 % and from 50.6 % to 76.4 %, respectively.

Conclusions

Children and youth with nTBI currently put an increased demand on the healthcare system. Active surveillance of and in-depth research on nTBI, including subtypes of nTBI, is needed to ensure that timely, appropriate, and targeted care is available for this pediatric population.

Keywords

Non-traumatic brain injuryInternational Classification of DiseasesPediatrics

Background

Acquired brain injury (ABI) is “an insult to the brain that affects its structure or function, resulting in impairments of cognition, communication, physical function, or psychosocial behavior” and “does not include brain injuries that are congenital, degenerative, or induced by birth trauma” [1]. To date, much attention has been placed on brain injuries from traumatic causes (i.e., a traumatic brain injury, TBI). However, it is important to recognize that brain injuries from non-traumatic causes (i.e., non-traumatic brain injury, nTBI) can also result in negative and long-term consequences [2]. These nTBI include anoxia, vascular insults, toxic effect of substances, brain tumours, meningitis, metabolic encephalopathy, encephalitis, and other brain disorders [1].

Comprehensive information on the health service use among the nTBI population is currently only available for adult and older adult populations [312]. These studies found that the direct cost of healthcare services for nTBI was higher than that of TBI ($120.7 vs. $368.7 million) [6]. In Ontario, Canada, between the fiscal years of 2003/04 and 2009/10, approximately 10 % of nTBI cases in the acute care setting were among patients aged 18 years and under [9]. An understanding of this pediatric population is important because healthcare, in particular rehabilitation, for the pediatric nTBI population often occurs in similar or identical programs and facilities as those of TBI [13, 14]. However as a group, nTBI are often overlooked with regard to the potential for long lasting sequelae and the need for healthcare services post-injury [15].

Equally important is the need to understand each subtype of nTBI, as nTBI includes diverse health conditions that may require a targeted approach to resource allocation and healthcare planning. Unfortunately, there is currently a lack of population based research and data on subtypes of pediatric nTBI with regard to their healthcare use. For example, even though primary brain tumours are the leading causes of cancer death in children and youth aged 19 years and under [16, 17], there lacks a general epidemiological profile and healthcare utilization information for this population. Research on childhood cancer indicate that there is no clear end to the duration of healthcare need among survivors and these patients continue to use substantial healthcare resources that are not accounted for in resource allocation [18]. As such, children and youth with brain tumors may be candidates for increased healthcare use. Similarly, a systematic review of out-of-hospital pediatric cardiac arrest and drowning, which are common causes of anoxic brain injuries [19, 20], showed that, while less than 7 % of children with cardiac arrest survive to hospital discharge, only 2.2 % survive without neurological sequelae. A fifth of patients with anoxic brain injuries due to near drowning survive to hospital discharge, but survival can be as high as 80 % if timely and appropriate actions are taken [19]. This suggests that this population is also likely to be users of acute-care services and in particular, post-hospitalization services such as homecare or rehabilitation. NTBI from infectious causes (e.g., meningitis, encephalitis) are most common among pediatric age groups, with persisting sequelae often reported, including fatigue, epilepsy, and impairments in cognition, memory, and motor [2124]. As such, despite the diversity of causes of nTBI, the neurological sequelae and need for health services are evident across subtypes of nTBI.

The objectives of this study are to provide population-based information on (1) the burden of nTBI on healthcare services by identifying the rate of nTBI episodes of care in the province of Ontario in Canada and (2) the demographic and clinical characteristics and discharge destinations of hospitalized children and youth aged 19 years and under with nTBI. Recognizing the diverse conditions captured as nTBI, this paper additionally aimed to provide data on subtypes of nTBI that can be used to guide additional research on each type of nTBI. An understanding of the epidemiological profile and healthcare use of this group of individuals can greatly assist to appropriately, adequately, and effectively plan healthcare services for this population to ensure that their needs are met. This study is a first step towards a greater understanding of children and youth with nTBI and the patterns of their healthcare use.

Methods

The Canadian Institute for Health Information (CIHI) National Ambulatory Care Reporting System (NACRS) and the Discharge Abstract Database (DAD) were used. The NACRS is a mandated data collection system that collects emergency department (ED) and ambulatory care data [25]. A reabstraction study of the NACRS data that compared 7,500 charts from 15 hospitals in Ontario from 2004 to 2005 indicated up to 80 % agreement for International Classification of Diseases Version 10 (ICD-10) codes for patients’ main problem (i.e., the health condition responsible for the patient’s visit, requiring evaluation and/or treatment/management) [25]. The DAD contains demographic and clinical information on all hospital admissions and discharges, including transfers and deaths, using standard diagnosis and procedure/intervention codes [26]. A reabstraction study of the DAD found high sensitivity and near perfect specificity for demographic variables and moderate to substantial agreement for diagnoses (kappa value 0.41 to 0.80) [27]. As residents of Ontario have universal access to ED and hospital-based care, these data sources allow for the identification of all children and youth with a nTBI diagnoses in the ED and/or acute care setting during our study period.

NTBI was categorized by the presence of specified ICD-10 codes in any of the 10 diagnosis fields in the NACRS and the 25 diagnosis fields in the DAD. These ICD-10 codes represent conditions that are captured as a nTBI as defined by the Commission on Accreditation of Rehabilitation Facilities (CARF) International [1] and through stakeholder consultation in Ontario, Canada. This included members from the Ontario Ministry of Health and Long-Term Care, Ontario Agency for Protection and Promotion, SMARTRISK, and the Ministry of Transportation to advise on the creation of a neurotrauma surveillance system to inform prevention in the province of Ontario [28] (Table 1). Stroke captured in national studies were excluded from our case definition for vascular insults to reflect current research and clinical practice in Ontario, Canada. For example, various national rehabilitation information systems [29, 30] and centres [31, 32] classify stroke separately from nTBI and some definitions of nTBI include vascular conditions that are not captured in major stroke studies [33]. As such, these vascular insults were included in this study. All subtypes of nTBI across the 10 diagnosis fields in the NACRS and 25 diagnosis fields in the DAD were counted.
Table 1

International Classification of Diseases version 10 (ICD-10) case definitions for non-traumatic brain injury

Type of Non-Traumatic brain injury

ICD-10 Codes

Toxic effect of substances

T40.5, T42.6, T51, T56, T57.0, T57.2, T57.3, T58, T64, T65.0

Anoxia

G93.1, T71, T75.1, R09.0

Vascular insults (not captured in other national studies of stroke)

I62.0, I62.9

Brain tumours

C70, C71, C79.3, C79.4, D32.0, D33.0, D33.1, D33.2, D33.3, D42.0, D43, D43.2

Encephalitis

A81.1, A83.0, A83.2, A86.0, B00.4, B01.1, B02.0, B05.0, B94.1, G04.0, G04.2, G04.8, G04.9, G05, G09

Metabolic encephalopathy

E10.0, E11.0, E13.0, E14.0, E15, G92, G93.4

Meningitis

A87, B01.0, B37.5, G00, G01, G02, G03

Other brain disorders

G91.0, G91.1, G91.2, G93.2, G93.5, G93.6, G93.8, G93.9, G99.8, R29.1

Demographic variables included age and sex. Children and youth aged 19 years and under were categorized into five-year age groups [0 to 4 years (infants), 5 to 9 years (children), 10 to 14 years (youth), and 15 to 19 years (adolescents)] consistent with categories commonly used in the ABI literature [34], Statistics Canada [35], and the World Health Organization [36].

Clinical variables included the Charlson Comorbidity Index, length of stay (LOS) in acute care, and special care days. The Charlson Comorbidity Index is widely accepted as a useful tool for measuring comorbidity disease status, has been shown to have a consistent correlation to in-hospital mortality, and is used to assess the severity of comorbid health conditions [37, 38]. The score is derived using the sum of the standard weights (1 to 6) that are assigned for each condition in the index [39]. As most patients identified in this study have few Charlson comorbidities, the categories of 0 – 1 and 2+ were used to avoid the risk of re-identification of any patients in the acute care setting. LOS in acute care was defined as the number of days between admission and discharge. Special care days were defined as the cumulative number of days spent in all intensive care units.

Discharge disposition from acute care included death in acute care, home, home with support services (e.g., homecare, home making supportive housing), inpatient rehabilitation, complex continuing care (CCC; e.g., chronic care facility), long term care (LTC; e.g., nursing home), and transferred to another inpatient setting.

NTBI episodes of care between fiscal years 2003/04 and 2009/10 were used to determine the number and rate of healthcare utilization, which has been shown to provide a more accurate description of the utilization of healthcare services compared to data on just hospitalizations [40]. This was accomplished by linking the DAD to the NACRS via an unique encoded identifier, which is complete for all cases in the NACRS and the DAD and ensured that each episode was only captured once. The number of nTBI episodes of care by age group, sex, and type of nTBI were identified. The rate of nTBI episodes of care per 100,000 children and youth in Ontario, Canada, was calculated by dividing the total number of nTBI episodes by the population counts for the specific age group and sex in Ontario, Canada during the fiscal year of study. These numbers indicate the total number of nTBI episodes of care for every 100,000 children and youth in Ontario, Canada, during the study period.

A patient-level analysis of the patient’s initial hospitalization for a nTBI between 2004/05 and 2009/10 was used to examine patient and clinical characteristics, and discharge destination from acute care. This was chosen to distinguish between a readmissions profile, which may differ from the initial admission. Patients included in this analysis must be initial hospitalizations between fiscal years 2003/04 and 2009/10. A look-back window of at least one year was used to ensure that patients included were the initial hospitalization record between fiscal years 2003/04 and 2009/10. Due to the lack of data to look back one year for fiscal year 2003/04, this fiscal year was eliminated from the patient level analysis. This ensured that patients identified between fiscal years 2004/05 and 2009/10 were index hospitalizations during this study period.

Results

Between fiscal years 2003/04 and 2009/10, there were 17,977 nTBI episodes of care (82.3 per 100,000 children and youth 19 years and under in Ontario, Canada). Males had a higher rate (87.2 per 100,000) compared to females (77.2 per 100,000). By age group, the highest rates were among infants aged 0 to 4 years (130.8 per 100,000), followed by adolescents aged 15 to 19 years (92.9 per 100,000), youth aged 10 to 14 years (56.1 per 100,000), and children aged 5 to 9 years (54.1 per 100,000) (Table 2, Fig. 1).
Table 2

nTBI episodes of care (n and rate per 100,000 children and youth aged 19 years and under) in Ontario between fiscal years 2003/04 and 2009/10 by age, fiscal year of discharge, and sex

 

Overall

0 – 4

5 – 9

10 – 14

15 – 19

Overall

n

rate

Male

n

rate

Female

n

rate

Overall

n

rate

Male

n

rate

Female

n

rate

Overall

n

rate

Male

n

rate

Female

n

rate

Overall

n

rate

Male

n

rate

Female

n

rate

Overall

n

rate

Male

n

rate

Female

n

rate

2003/04

2591

82.7

1437

89.7

1154

75.5

932

136.3

553

158.4

379

113.3

477

61.0

242

60.7

235

61.3

432

51.6

252

58.9

171

41.8

759

91.6

390

91.5

369

91.6

2004/05

2606

83.2

1406

87.7

1200

78.5

893

131.0

522

149.4

371

111.7

445

58.0

247

63.2

198

52.7

500

59.4

267

62.1

233

56.6

768

91.3

370

85.5

398

97.3

2005/06

2635

84.2

1455

90.8

1180

77.3

922

135.1

539

153.8

383

115.4

385

51.4

226

59.1

159

43.3

494

58.9

278

64.9

216

52.6

834

97.2

412

93.5

422

101.1

2006/07

2419

77.3

1327

82.8

1092

71.6

808

116.4

441

123.6

367

108.8

379

51.8

242

64.6

137

38.4

440

53.0

228

53.9

212

52.2

792

90.7

416

92.9

376

88.4

2007/08

2328

74.7

1269

79.5

1059

69.7

794

114.1

433

120.9

361

106.8

300

41.6

176

47.5

124

35.3

439

53.8

233

55.9

206

51.6

795

90.3

427

94.8

368

85.6

2008/09

2717

87.5

1453

91.3

1264

83.4

975

139.5

578

160.8

397

116.9

424

59.1

240

65.2

184

52.7

488

60.8

245

59.8

243

62.0

830

93.6

390

86.1

440

101.4

2009/10

2681

86.3

1404

88.3

1277

84.2

986

143.5

561

159.1

425

127.1

399

55.1

228

61.6

171

48.3

459

56.2

218

52.3

241

60.2

837

95.3

397

88.1

440

102.9

2003/04 – 2009/10

17977

82.3

9751

87.2

8226

77.2

6310

130.8

3627

146.5

2683

114.3

2809

54.1

1601

60.3

1208

47.6

3243

56.1

1721

58.3

1522

53.8

5615

92.9

2802

90.4

2813

95.5

Fig. 1

nTBI episodes of care by age groups and fiscal year of discharge

Patient level analyses showed that there were 6,102 patients with nTBI between fiscal years 2004/05 and 2009/10. The average LOS in acute care was 13.4 days (SD = 25.6 days) and among those with at least one special care days (35 %), the average stay in intensive care units was 12.5 days (SD = 22.9 days). Approximately 12 % of patients had a Charlson Comorbidity Index Score of 2 or higher. Most of the patients (77 %) were discharged home from acute care, of which 9 % were discharged home with support services. Approximately 14 % of patients were transferred to another inpatient setting, less than 1 % to inpatient rehabilitation, 1 % to CCC or LTC, and 6 % died in acute care (Table 3, Fig. 2).
Table 3

Patient characteristics among children and youth with a nTBI diagnostic code in acute care in Ontario between fiscal years 2004/05 and 2009/10 by type of nTBI

Characteristics

Overalla

Toxic effect of substances

Anoxia

Vascular insults

Brain tumours

Encephalitis

Metabolic encephalopathy

Meningitis

Other brain disorders

N

Col %

N

Col %

N

Col %

N

Col %

N

Col %

N

Col %

N

Col %

N

Col %

N

Col %

Overall

6102

100

713

100

903

100

182

100

745

100

438

100

325

100

2094

100

1077

100

Age Groups

0 – 4

2713

44.5

59

8.3

530

58.7

108

59.3

174

23.4

177

40.4

117

36.0

1301

62.1

387

35.9

5 – 9

819

13.4

13

1.8

123

13.6

18

9.9

182

24.4

98

22.4

55

16.9

225

10.7

165

15.3

10 – 14

872

15.9

97

13.6

99

11.0

31

17.0

190

25.5

77

17.6

70

21.5

220

10.5

249

23.1

15 – 19

1598

26.2

544

76.3

151

16.7

25

13.7

199

26.7

86

19.6

83

25.5

303

14.5

276

25.6

Sex

Males

3358

55.0

321

45.0

539

59.7

114

62.6

410

55.0

224

51.1

172

52.9

1163

56.8

595

55.3

Females

2744

45.0

392

55.0

364

40.3

68

37.4

335

45.0

214

48.9

153

47.1

886

43.2

482

44.8

Length of Stay (Days)

Average Length of Stay (Mean, SD)

13.4 (25.6)

4.0 (6.4)

15.2 (36.4)

26.7 (44.1)

14.0 (22.4)

16.7 (23.9)

20.2 (41.0)

13.8 (21.6)

16.0 (25.9)

1 – 2

1278

20.9

390

54.7

287

31.8

16

8.8

108

14.5

58

13.2

48

14.8

209

10.2

195

18.1

3 – 5

1835

30.1

224

31.4

234

25.9

40

22.0

195

26.2

107

24.4

73

22.5

699

34.1

326

30.3

6 – 11

1296

21.2

61

8.6

153

16.9

42

23.1

217

29.1

109

24.9

78

24.0

482

23.5

212

19.7

12+

1693

27.8

38

5.3

229

25.4

84

46.2

225

30.2

164

37.4

126

38.8

659

32.2

344

31.9

Charlson Comorbidity Index Score

0 – 1

5355

87.8

NR

.

855

94.7

143

78.6

241

32.4

411

93.8

278

85.5

2005

97.9

908

84.3

2+

747

12.2

<5

.

48

5.3

39

21.4

504

67.7

27

6.2

47

14.5

44

2.1

169

15.7

Special Care Days

Average Number of Days (Mean, SD)

12.5 (22.9)

1.9 (2.4)

14.6 (28.8)

16.1 (22.5)

4.7 (12.8)

13.7 (18.0)

10.2 (15.0)

21.6 (27.8)

11.4 (20.4)

None

3970

65.1

475

66.6

522

57.8

76

41.8

377

50.6

327

74.7

181

55.7

1519

74.1

591

54.9

1 – 2

865

14.2

197

27.6

117

13.0

21

11.5

247

33.2

25

5.7

35

10.8

114

5.6

185

17.2

3 – 5

370

6.1

36

5.1

70

7.8

19

10.4

69

9.3

25

5.7

43

13.2

70

3.4

94

8.7

6 – 11

315

5.2

<5

.

70

7.8

NR

.

22

3.0

20

4.6

34

10.5

97

4.7

81

7.5

12+

582

9.5

<5

.

124

13.7

NR

.

30

4.0

41

9.4

32

9.9

249

12.2

126

11.7

Discharge Disposition

Home

4175

68.4

545

76.4

554

61.4

92

50.6

487

65.4

259

59.1

206

63.4

1490

72.7

653

60.6

Home with Support

544

8.9

11

1.5

73

8.1

35

19.2

132

17.7

71

16.2

45

13.9

131

6.4

121

11.2

Rehabilitation

47

0.8

<5

.

9

1.0

<5

.

9

1.2

8

1.8

<5

.

<5

.

15

1.4

Complex Continuing Care or Long Term Care

81

1.3

0

0

14

1.6

7

3.9

13

1.7

15

3.4

NR

.

NR

.

32

2.9

Transferred

870

14.3

151

21.2

78

8.6

24

13.2

80

10.7

76

17.4

28

8.6

372

18.2

99

9.2

Death

385

6.3

<5

.

175

19.4

NR

.

24

3.2

9

2.1

32

9.9

44

2.2

157

14.6

Note: aAll multiple nTBI diagnoses were counted for and as such, the overall N will not add up

NR = not reportable due to small cell sizes

Fig. 2

Patient characteristics by type of nTBI

Across the types of nTBI diagnoses, toxic effect of substance episodes of care was found to be the highest (22.7 per 100,000), followed by brain tumour episodes of care (18.4 per 100,000), and meningitis episodes of care (15.4 per 100,000) (Table 4, Fig. 3). Patient and clinical characteristics and discharge destinations varied by type of nTBI diagnosis; 76 % of individuals presenting with toxic effects of substances were adolescents, however, 86 % of anoxic brain injury cases were infants (Fig. 4). More than half of the patients with a toxic effect of substance stayed in acute care for less than 2 days. However, 46 % of cases with vascular insult stayed in acute care for 12 days or longer. Almost 60 % of cases with vascular insult stayed in the intensive care unit for at least one day, compared to approximately a quarter of cases with encephalitis and meningitis. Overall, there was a small percentage of deaths in acute care, however, 19 % of all patients with anoxic brain injury died in acute care (Table 3).
Table 4

nTBI episodes of care (n and rate per 100,000 children and youth aged 19 years and under) in Ontario between fiscal years 2003/04 and 2009/10 by type of nTBI and sex

 

Toxic effects of substance

n

rate

Anoxia

n

rate

Vascular insults

n

rate

Brain tumours

n

rate

Encephalitis

n

rate

Metabolic encephalopathy

n

rate

Meningitis

n

rate

Other brain disorders and infections

n

rate

Overall

2003/04

709

22.6

293

9.4

58

1.9

605

19.3

138

4.4

106

3.4

461

14.7

333

10.6

2004/05

809

25.8

294

9.4

43

1.4

557

17.8

125

4.0

84

2.7

453

14.5

312

10.0

2005/06

742

23.7

323

10.3

60

1.9

569

18.2

109

3.5

112

3.6

475

15.2

322

10.3

2006/07

691

22.1

317

10.1

48

1.5

562

18.0

130

4.2

84

2.7

392

12.5

264

8.4

2007/08

711

22.8

251

8.1

64

2.1

492

15.8

116

3.7

86

2.8

421

13.5

272

8.7

2008/09

681

21.9

299

9.6

66

2.1

602

19.4

164

5.3

123

4.0

579

18.6

332

10.7

2009/10

625

20.1

305

9.8

42

1.4

635

20.4

181

5.8

98

3.2

585

18.8

306

9.9

2003/04 – 2009/10

4968

22.7

2082

9.5

381

1.7

4022

18.4

963

4.4

693

3.2

3366

15.4

2141

9.8

Males

2003/04

336

21.0

172

10.7

36

2.2

364

22.7

72

4.5

50

3.1

281

17.5

188

11.7

2004/05

365

22.8

173

10.8

28

1.7

331

20.7

55

3.4

43

2.7

266

16.6

175

10.9

2005/06

351

21.9

203

12.7

33

2.1

360

22.5

59

3.7

54

3.4

255

15.9

185

11.5

2006/07

338

21.1

196

12.2

32

2.0

334

20.8

56

3.5

40

2.5

217

13.5

158

9.9

2007/08

349

21.9

151

9.5

41

2.6

257

16.1

71

4.4

46

2.9

251

15.7

147

9.2

2008/09

308

19.4

188

11.8

42

2.6

345

21.7

86

5.4

76

4.8

317

19.9

168

10.6

2009/10

273

17.2

185

11.6

29

1.8

322

20.2

97

6.1

58

3.6

327

20.6

167

10.5

2003/04 – 2009/10

2320

20.7

1268

11.3

241

2.2

2313

20.7

496

4.4

367

3.3

1914

17.1

1188

10.6

Females

2003/04

373

24.4

121

7.9

22

1.4

241

15.8

66

4.3

56

3.7

180

11.8

145

9.5

2004/05

444

29.0

121

7.9

15

1.0

226

14.8

70

4.6

41

2.7

187

12.2

137

9.0

2005/06

391

25.6

120

7.9

27

1.8

209

13.7

50

3.3

58

3.8

220

14.4

137

9.0

2006/07

353

23.1

121

7.9

16

1.0

228

14.9

74

4.9

44

2.9

175

11.5

106

6.9

2007/08

362

23.8

100

6.6

23

1.5

235

15.5

45

3.0

40

2.6

170

11.2

125

8.2

2008/09

373

24.6

111

7.3

24

1.6

257

17.0

78

5.1

47

3.1

262

17.3

164

10.8

2009/10

352

23.2

120

7.9

13

0.9

313

20.6

84

5.5

40

2.6

258

17.0

139

9.2

2003/04 – 2009/10

2648

24.8

814

7.6

140

1.3

1709

16.0

467

4.4

326

3.1

1452

13.6

953

8.9

Fig. 3

nTBI episodes of care by type of nTBI and sex

Fig. 4

Distribution of age by type of nTBI

Discussion

This study is the first study, to the best of our knowledge, providing a comprehensive overview of the burden of pediatric nTBI on healthcare services. Consistent with the trends seen in the overall nTBI population in Ontario [9], the number of nTBI episodes of care among children and youth increased from 2003/04 to 2009/10. However, differences were observed in discharge patterns. Of note is that the majority of children and youth were discharged home post-acute care, of which 9 % were discharged home with support services. This differs from findings on the overall nTBI population in Ontario, where less than 40 % were discharged home and 20 % died in acute care [3, 9]. This finding on discharge home is in line with studies that indicate a preference to discharge children and youth home post injury [41]. Given these differences in the healthcare use of the pediatric population compared to the general population, a specific focus on the health service use of this pediatric population is needed.

The pediatric nTBI population also differs from the TBI population; although the rate of nTBI episodes of care in this study was not as high as the rates reported for the TBI population, which ranged from 125 to 1,337 per 100,000 [34, 42, 43], the health service use of the nTBI population is just as high as the TBI population. For example, it was reported that the average LOS for a TBI related hospitalization in Canada was 5 days [44]; this paper showed that that the average LOS for a nTBI related hospitalization was approximately 13 days. Further, death in acute care for the TBI population was reported to be 9 % in Canada [44]. However, among those with anoxic brain injury, up to 19 % died in acute care. Although nTBI is not as common as TBI, this population puts an increased burden and demand on the healthcare system. Moreover, there is relatively little data suggesting how we can effectively and appropriately allocate the resources and support for these patients. Given that patients with TBI and nTBI are often treated in similar settings [13, 14] and that they use almost triple the amount of services, data pertaining specifically to the nTBI population is crucial.

Equally important is an understanding of the profile and use of healthcare services associated with each subtype of nTBI. For example, despite an overall increasing rate of nTBI episodes of care, differences were observed between types of nTBI, which may be due to the improvement in diagnosis or treatment, prevention, or coding practices. For example, there was an overall decrease in the rate of toxic effect of substances episodes of care, which may be attributed to increased prevention efforts against hazardous drinking, particularly in adolescents. Conversely, the slight increase in brain tumour episodes of care may reflect better detection of brain tumours while the increase in encephalitis may reflect trend towards a diagnosis/coding of “unspecified” or “unknown” cause of encephalitis [4548], a diagnosis that is captured in this study. These preliminary data on subtypes of nTBI highlight the importance of stratifying the nTBI population by subtype. Also, consistent with studies on anoxic brain injury among the pediatric population [19, 20], nearly one in five patients died in acute care. Data stratified by cause of anoxic brain injury can inform the prevention of anoxic brain injuries and preparation of healthcare for this population, as it has been reported that outcomes of anoxic brain injury from a cardiac arrest vs. near drowning are significantly different [20]. Furthermore, the differences in discharge destinations across types of nTBI reflect the complexities and diversity of this group. While very few patients with a diagnosis of toxic effect of substances are discharged home with support services, more than a fifth are transferred to another inpatient facility. Centres that receive these patients, including addiction treatment centres, should be aware of and consider the effects of a brain injury on these patients when assessing treatment options. Finally, the distribution of age group across each subtype of nTBI is also varied, presenting opportunities for targeted interventions by age. These data by subtype of nTBI provide the foundation needed for further in-depth research on each type of nTBI to inform targeted resource allocation and healthcare planning.

Limitations associated with this study include a lack of consistent, agreed upon case definition for nTBI. The importance of this is highlighted in a comparison of data presented by Wong and colleagues in 2001 on non-traumatic coma. Despite similar goals on informing healthcare resources for this population, the method used to identify patients were different, resulting in higher rates of nTBI episodes of care (82.3 per 100,000) reported in this study compared to data presented by Wong and colleagues (30.8 per 100,000) [49]. Specifically, Wong and colleagues restricted participants to only those with “significantly depression of conscious level as defined by the Glasgow Coma Score of 12” and, among those under the age of 5 years, at least 6 h of unconsciousness. Conversely, this paper identified nTBI using ICD-10 codes and the codes included in this study likely captured patients with a less severe nTBI. Limitations related to the data source are also recognized. First, the DAD only captures individuals that are admitted to an acute care setting and thus, deaths that occur outside of the hospital are missed, which is considered a limitation in neurotrauma research [50]. Second, the use of all 10 diagnosis fields in the NACRS and 25 diagnosis fields in the DAD resulted in counting of all multiple nTBI diagnoses, as a patient may have more than one type of nTBI. This is an important methodological issue to consider for future studies involving statistical analyses between and/or across each type of nTBI. Third, the use of only the DAD and the NACRS to identify cases of brain tumours may result in underestimates, as brain tumours may not be readily identified or captured in the ED and/or acute care setting. The inclusion of the Ontario Cancer Registry [51], which captures information on all newly diagnosed cases of invasive neoplasia, may result in a higher number of brain tumour cases captured. As such, it is acknowledged that estimates of brain tumours in this study are likely underestimates. Nonetheless, effort to capture all potential cases that may present in the emergency department or acute care was made by using episodes of care to assess the burden of healthcare services. For example, toxic effects of substances are likely to present in the emergency department, however, this diagnosis may not be made in the acute care setting. As such, the linkage of the DAD to the NACRS helped ensure that cases that are not coded as ‘toxic effects of substances’ in the DAD were captured in the NACRS and that double counting did not occur. The data sources used in this study are also population based and Ontario has publicly funded healthcare. Therefore, data presented here are less likely to have been influenced by access supplemental health insurance. Finally, it is acknowledged that the Charlson Comorbidity Index may not be ideal for comorbidity information in the children and youth population. However, this was chosen to provide consistency for comparison with published population based data on the adult and older adult ABI populations in Ontario, Canada [3, 4, 7, 8]. It was also used to assess the severity of comorbid health conditions, which has been used previously in research looking at the pediatric population [39]. Future studies should consider exploring comorbidities through ICD-10 Chapter Headings [52] or the John Hopkins Aggregated Diagnostic Grouping (ADG) [53].

Conclusions

To the best of our knowledge, this is the first population-based study to provide an overview of children and youth with nTBI in Ontario, Canada. Findings from this study provide a foundation for further in-depth research on nTBI and its subtypes that are critical for resource allocation and support for children and youth with nTBI. The availability of accurate and timely information on nTBI is crucial for the planning of healthcare services, resource allocation, and prevention. Children and youth are at a critical developmental period of their lives in which a nTBI can result in negative and lasting consequences. Some types of nTBI identified in this study are preventable; a focus on nTBI and in-depth research on each subtypes of nTBI is encouraged.

Abbreviations

ABI, acquired brain injury; CCC, complex continuing care; CIHI, Canadian Institute for Health Information; DAD, Discharge Abstract Database; ICD-10, International Classification of Diseases Version 10; LOS, length of stay; LTC, long-term care; NACRS, National Ambulatory Care Reporting System; nTBI. non-traumatic brain injury; TBI, traumatic brain injury

Declarations

Funding

VC received support from the Jane Gillett Pediatric ABI Studentship through the Ontario Neurotrauma Foundation, the Doctoral Research Award from the Canadian Institutes of Health Research (CIHR) and Pediatric Oncology Group of Ontario, and a Brain Canada-CIBC Brain Cancer Training Award from Brain Canada and CIBC. AC received support through a CIHR Research Chair in Gender, Work and Health (#CGW-126580). The authors have no conflicts of interest.

Availability of data and materials

We would like to thank the Ontario Ministry of Health and Long-Term Care for providing us with the data. The views expressed are those of the Principal Researchers and do not necessarily reflect those of the Ontario or the Ministry. Data sharing is currently unavailable, as data can only be released in a manner consistent with the Ontario Privacy Commissioner approved by the Ontario Ministry of Health and Long-Term Care policies and procedures.

Authors’ contribution

VC and AC conceptualized the study. VC formulated the methods for statistical analysis and carried out the analysis using SAS software. VC drafted the paper, conducted the literature review, and interpreted the results that formulated the foundation of the paper. VC, AC, JP, MK, and RM all had significant input into the editing process of this paper and additional interpretation of results. All authors approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Consent from patients is not possible as the data sources for this study are de-identified healthcare administrative databases.

Ethics approval and consent to participate

Ethics approval for this study was obtained from the Toronto Rehabilitation Institute, University Health Network Research Ethics Board. Informed consent from patients is not possible as the data sources for this study are de-identified healthcare administrative databases.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Toronto Rehabilitation Institute, University Health Network
(2)
Rehabilitation Sciences Institute, University of Toronto
(3)
Pediatric Oncology Group of Ontario
(4)
Dalla Lana School of Public Health, University of Toronto
(5)
Holland Bloorview Kids Rehabilitation Hospital
(6)
Centre for Addiction and Mental Health

References

  1. CARF International. CARF-CCAC Standards Manual 2015. Tucson, Arizona, USAGoogle Scholar
  2. Giustini A, Pistarini C, Pisoni C. Traumatic and nontraumatic brain injury. Handb Clin Neurol. 2013;110:401–9.View ArticlePubMedGoogle Scholar
  3. Chan V et al. Older adults with acquired brain injury: a population based study. BMC Geriatr. 2013;13:97.View ArticlePubMedPubMed CentralGoogle Scholar
  4. Chan V et al. Older adults with acquired brain injury: outcomes after inpatient rehabilitation. Can J Aging. 2013;32(3):278–86.View ArticlePubMedGoogle Scholar
  5. Chen A, Zagorski B, Chan V, Parsons D, Vander Laan R, Colantonio A. Acute care alternate level of care days due to delayed discharge for traumatic and non-traumatic brain injuries. Healthcare Policy. 2013;7(4):41–55.Google Scholar
  6. Chen A et al. Direct cost associated with acquired brain injury in Ontario. BMC Neurol. 2012;12:76.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Chen A et al. Factors associated with living setting at discharge from inpatient rehabilitation after acquired brain injury in Ontario, Canada. J Rehabil Med. 2014;46(2):144–52.View ArticlePubMedGoogle Scholar
  8. Chen AY et al. Factors associated with discharge destination from acute care after acquired brain injury in Ontario, Canada. BMC Neurol. 2012;12:16.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Colantonio A, Chan V, Zagorski B, Parsons D. Ontario acquired brain injury (ABI) dataset project phase III: Highlights, numbers of episodes of care and causes of brain injury. Toronto: Acquired Brain Injury Research Lab; 2012.Google Scholar
  10. Colantonio A, Chan V, Zagorski B, Parsons D. Ontario Acquired Brain Injury (ABI) Dataset Project Phase III: Highlights: Alternate level of care (ALC) days, length of stay, and discharge disposition of ABI patients. Toronto, Ontario, Canada: Acquired Brain Injury Research Lab; 2012.Google Scholar
  11. Cullen NK, Crescini C, Bayley MT. Rehabilitation outcomes after anoxic brain injury: a case-controlled comparison with traumatic brain injury. PMR. 2009;1(12):1069–76.View ArticleGoogle Scholar
  12. Cullen NK, Park YG, Bayley MT. Functional recovery following traumatic vs non-traumatic brain injury: a case-controlled study. Brain Inj. 2008;22(13-14):1013–20.View ArticlePubMedGoogle Scholar
  13. Brain Injury Rehabiltiation Program. 2015. Available from: http://rusk.med.nyu.edu/brain-injury-rehabilitation-program. Accessed 7 July 2015.
  14. Brain Injury Rehab including Concussions. 2015. Available from: http://hollandbloorview.ca/programsandservices/ProgramsServicesAZ/Braininjuryrehab. Accessed 7 July 2015.
  15. Forsyth R, Kirkham F. Predicting outcome after childhood brain injury. CMAJ. 2012;184(11):1257–64.View ArticlePubMedPubMed CentralGoogle Scholar
  16. Canadian Institute for Health Information. The burden of neurological diseases, disorders, and injuries in Canada. Ottawa: CIHI; 2007.Google Scholar
  17. Canadian Brain Tumour Registry 2015. Available from: http://www.braintumour.ca/4475/brain-tumour-registry. Accessed 7 July 2015.
  18. Greenberg ML, Barnett H. Atlas of Childhood Cancer in Ontario, 1985-2004. Toronto: Pediatric Oncology Group of Ontario; 2015.Google Scholar
  19. Donoghue AJ et al. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med. 2005;46(6):512–22.View ArticlePubMedGoogle Scholar
  20. Johnson AR, DeMatt E, Salorio CF. Predictors of outcome following acquired brain injury in children. Dev Disabil Res Rev. 2009;15(2):124–32.View ArticlePubMedGoogle Scholar
  21. Holmquist L, Russo CA, Elixhauser A. Meningitis-Related Hospitalizations in the United States, 2006: Statistical Brief #57, in Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality; 2006.Google Scholar
  22. Hviid A, Melbye M. The epidemiology of viral meningitis hospitalization in childhood. Epidemiology. 2007;18(6):695–701.View ArticlePubMedGoogle Scholar
  23. Kneen R et al. Management of suspected viral encephalitis in children - Association of British Neurologists and British Paediatric Allergy, Immunology and Infection Group national guidelines. J Infect. 2012;64(5):449–77.View ArticlePubMedGoogle Scholar
  24. Weingarten L, Enarson P, Klassen T. Encephalitis. Pediatr Emerg Care. 2013;29(2):235–41. quiz 242-4.View ArticlePubMedGoogle Scholar
  25. Emergency and Ambulatory Care. 2015. Available from: https://www.cihi.ca/en/types-of-care/hospital-care/emergency-and-ambulatory-care. Accessed 7 July 2015.
  26. Acute Care. 2015. Available from: https://www.cihi.ca/en/types-of-care/hospital-care/acute-care. Accessed 7 July 2015.
  27. Juurlink D, Preyra C, Croxford R, Chong A, Austin P, Tu J, Laupacis A. Canadian Institute for Health Information Discharge Abstract Database: A Validation Study. Toronto, Ontario, Canada: Institute for Clinical Evaluative Sciences; 2006.Google Scholar
  28. Colantonio A, Parsons D, Vander Laan R, Zagorski B. ABI Dataset Pilot Project Phase 1 Report. Toronto: Ontario Neurotrauma Foundation; 2009.Google Scholar
  29. Centers for Medicare & Medicaid Serices. The Inpatient Rehabiltiation Facility Patient Assessment Instrument (IRF-PAI) Training Manual. UB Foundation Activities, Inc; 2012.Google Scholar
  30. Background on the National Rehabilitation Reporting System. Available from: http://www.cihi.ca/CIHI-ext-portal/internet/en/document/types+of+care/hospital+care/rehabilitation/services_nrs_intro. Accessed 7 July 2015.
  31. About our programs. Available from: http://www.uhn.ca/TorontoRehab. Accessed 18 May 2016.
  32. Departments and programs. Available from: http://rusk.med.nyu.edu/patients-families/departments-programs. Accessed 18 May 2016.
  33. Evidence based review of rehabilitation of moderate to severe acquired brain injuries. Defining acquired brain injury. . 2011. Available from: http://www.abiebr.com/module/1-introduction-and-methodology. Accessed 18 May 2016.
  34. Chan V, Thurairajah P, Colantonio A. Defining pediatric traumatic brain injury using International Classification of Diseases Version 10 Codes: a systematic review. BMC Neurol. 2015;15:7.View ArticlePubMedPubMed CentralGoogle Scholar
  35. Population by sex and age group 2015. Available from: http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo10a-eng.htm. Accessed 10 July 2015.
  36. Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CL, Lozano R, Inoue M. Age standardization of rates: A new WHO standard. World Health Organization; 2001. http://www.who.int/healthinfo/paper31.pdf.
  37. Charlson ME et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.View ArticlePubMedGoogle Scholar
  38. Sundararajan V et al. New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. J Clin Epidemiol. 2004;57(12):1288–94.View ArticlePubMedGoogle Scholar
  39. Charlson M et al. The Charlson comorbidity index can be used prospectively to identify patients who will incur high future costs. PLoS One. 2014;9(12):e112479.View ArticlePubMedPubMed CentralGoogle Scholar
  40. Colantonio A, Saverino C, Zagorski B, Swaine B, Lewko J, Jaglal S, Vernich L. Hospitalizations and emergency department visits for TBI in Ontario Canadian. J Neurol Sci. 2010;37:783–90.Google Scholar
  41. DeMatteo CA et al. Exploring postinjury living environments for children and youth with acquired brain injury. Arch Phys Med Rehabil. 2008;89(9):1803–10.View ArticlePubMedGoogle Scholar
  42. Faul M, Xu L, Wald MM, Coronado VG. Trauamtic brian injury in the United States: Emergency department visits, hospitalziations, and deaths 2002 - 2006. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control Atlanta; 2010.Google Scholar
  43. Feigin VL et al. Incidence of traumatic brain injury in New Zealand: a population-based study. Lancet Neurol. 2013;12(1):53–64.View ArticlePubMedGoogle Scholar
  44. Canadian Institute for Health Information. Head injuries in Canada: A decade of change (1994-1995 to 2003-2004). Ottawa: CIHI; 2006.Google Scholar
  45. Barbadoro P et al. Trend of hospital utilization for encephalitis. Epidemiol Infect. 2012;140(4):753–64.View ArticlePubMedGoogle Scholar
  46. Britton PN et al. Acute encephalitis in children: Progress and priorities from an Australasian perspective. J Paediatr Child Health. 2015;51(2):147–58.View ArticlePubMedGoogle Scholar
  47. Koskiniemi M et al. Infections of the central nervous system of suspected viral origin: a collaborative study from Finland. J Neurovirol. 2001;7(5):400–8.View ArticlePubMedGoogle Scholar
  48. Olsen SJ et al. Infectious causes of encephalitis and meningoencephalitis in Thailand, 2003-2005. Emerg Infect Dis. 2015;21(2):280–9.View ArticlePubMedPubMed CentralGoogle Scholar
  49. Wong CP et al. Incidence, aetiology, and outcome of non-traumatic coma: a population based study. Arch Dis Child. 2001;84(3):193–9.View ArticlePubMedPubMed CentralGoogle Scholar
  50. Parsons D, Colantonio A, Mohan M. The utility of administrative data for neurotrauma surveillance and prevention in Ontario, Canada. BMC Res Notes. 2012;5:584.View ArticlePubMedPubMed CentralGoogle Scholar
  51. Ontario Cancer Registry 2015. Available from: https://www.cancercare.on.ca/ocs/csurv/ocr/. Accessed 8 July 2015.
  52. Saverino C, et al. Re-hospitalization after Traumatic Brain Injury: A Population Based Study. Arch Phys Med Rehabil. 2016;97(Suppl 2):S19–S25.Google Scholar
  53. The Johns Hopkins ACG System. Baltimore, MD, USA: Johns Hopkins Bloomberg School of Public Health; 2009.Google Scholar

Copyright

© The Author(s). 2016

Advertisement