Measuring Inflicted Traumatic Brain Injury in Minnesota

1. Measuring Inflicted Traumatic Brain Injury in Minnesota Sara Seifert, M.P.H. & Debra Hagel Injury & Violence Prevention Unit Minnesota Department of Health

2. Nomenclature If we can’t name it, how can we measure it? • Shaken Baby Syndrome • Shaken Impact Syndrome • Abusive Head Trauma • Inflicted Traumatic Brain Injury

3. Overview • Minnesota Trauma Data Bank • Data Sources for iTBI • Strengths & Weaknesses of each Data Source • Epidemiology of Severe iTBI in Minnesota

4. Minnesota Trauma Data Bank Pre-hospital HOSPITAL Post-hospital

5. Hospital Data • Codes assigned by medical records identify diagnoses, procedures, and injury causes. • Minnesota Hospital Association compiles billing data statewide. • gender, age, inpatient / ED, date, zip code, charges • MDH abstracts data from medical records. • relationship to perpetrator, circumstances of injury, alcohol / drug use

6. Partners • Centers for Disease Control & Prevention Funding to: • Identify additional cases • Gather new information • Assess CPS / public health cost differential • Department of Human Services • Midwest Children’s Resource Center • Shaken Baby Syndrome Task Force • Minnesota Department of Health

7. Child Maltreatment in Minnesota Fatalities Central Nervous System Injuries Hospital Treated Cases Outpatient Cases Substantiated Injury Reports to CPS Substantiated Reports to CPS

8. Data Sources • Deaths • Death Certificates • Medical Examiner Reports • Child Fatality Review Panel • Supplemental Homicide Reports • Femicide Report • Newspaper Clippings

9. Strengths Population-based Public data Have ICD 10 Codes Weaknesses Often no perpetrator information Often limited information on circumstances “Abdominal and head injuries” “Multiple injuries of varying ages” “Was injured by another person” Death Certificates

10. Medical Examiner Reports • Don’t know. Anticipate much detail, especially medical.

11. Child Fatality Review Panel • Strengths • Lots of information • Public data • Weaknesses • Only obtain cases that are reported to Child Protective Services North Dakota Case

12. Supplemental Homicide Reports Victim: 1 year old female, Asian, Non-HispanicOffender: 54 year old female, white, Non-HispanicWeapon: [blank]Relationship: Day care providerCircumstance: Victim violently shaken, causing shaken baby syndrome • Strengths • Public data • Often have perpetrator and circumstances • Weaknesses • Voluntary system • Limited detail

13. Femicide Report • Strengths • Public data • Often have perpetrator and circumstances • Weaknesses • Based on voluntary reporting and newspaper clippings

14. Femicide Report continued • 11. Austin Olson, 8 months Otsego November 7 Cynthia Henderson of Rogers, 32, was charged with second- degree murder in connection with the death of Austin Olson of Otsego, 8 months, for whom she was caring. Shortly after noon on November 5, Henderson called 911 to report that Austin had been injured when her own child threw a toy at him. She later told investigators . . . A CAT scan on Austin revealed a skull fracture and other injuries consistent with blunt force trauma and shaking injuries. An autopsy also revealed rib fractures. Cynthia Henderson was sentenced in June of 2002 to 12 ½ years in prison for unintentional second- degree murder.

15. Strengths Public data Often have perpetrator and circumstances Weaknesses Not all cases obtain coverage Cost/time Newspaper Clippings “The boy’s brain injuries were consistent with violent shaking, but medical experts can’t rule out the possibility that the accidents played a role in his death.”

16. Data Sources continued • Inpatient Hospitalizations & ED Treated • Minnesota Hospital Association • TBI/SCI Registry • Abstracted hospital data • Lists from other sources

17. Strengths Identify potential cases Have ICD 9 codes Weaknesses Cannot confirm cases Usually have no circumstance or perpetrator information Private data Cost 801.0 Fracture of base of skull, open with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Minnesota Hospital Association

18. Strengths Identify cases Have ICD 9 codes Usually have perpetrator and circumstances Weaknesses May lack important detail Private data “Alleged fall from jungle gym (suspected child abuse).” TBI/SCI Registry

19. Abstracted Hospital Data • Strengths • Identify cases • Have ICD 9 codes • Have most detail • Weaknesses • Private data • Cost • May vary by facility • May not be conclusive • “Shaken baby syndrome with old tibia fracture. Large subdural hematoma with herniation seizure. Severe disability. Delay in seeking treatment for 16 hours although 1 month was unresponsive. Siblings removed from home. Suspected shaken baby syndrome by dad also old left tibia fracture. Child later became ward of state.”

20. Abstracted Hospital Data continued “There is nothing here except 1) face sheet 2) order for full skeletal series with reason noted as suspected shaken baby syndrome 3) request from County Child Protective Services for all medical records. Lots of unknowns.” “2 subdural hematomas of varying ages. County Social Services unable to prove anything, so child discharged to home.”

21. Child Protective Services • Need to explore this data more. • Identify TBIs, unclear if only due to iTBI and how complete.

22. Clinic, Home or No Treatment • No data at this time.

23. Key Messages About Data Sources • With some effort you can access death data for iTBI cases • The IVPU can provide summary data on inpatient iTBI hospitalizations • The IVPU can provide more limited summary data on ED treated iTBI • No data available on clinic or untreated iTBI at this time

24. Major Limitations of iTBI Data • Requires • Identification, • Documentation, • Coding & • Submission of cases. • Have many unknown/unclear cases • May not obtain cases treated out-of-state

25. Key Findings for Severe iTBI in Minnesota, 1999-2001 • Small number of cases • Majority are boys • Majority are under one year of age • Nearly half have documented previous abuse • Most perpetrators are a parent or parent’s partner • Majority of perpetrators are male

26. Severe iTBI RatesMN, 1999-2001, Ages 0-4 Note: Cases identified from Death Certificates, Abstracting TBI Cases, and TBI Registry. Actual N’s = 32, 35, and 46 respectively.

27. How does Minnesota compare?Ages 0-1 CI=(33.8, 60.0) CI=(22.9, 36.7) CI=(1.78, 40.82) Note: Different case definitions and data collection methods.

28. Deaths and Inpatient Hospitalizations by Gender and Age, MN, 1999-2001 Note: Information available only for TBI Registry and abstracted cases

29. Perpetrator for Inpatient HospitalizationsMN, 1999-2001, Ages 0-4 Note: Information available only for abstracted cases

30. Previous Abuse for Inpatient HospitalizationsMN, 1999-2001, Ages 0-4 Note: Information available only for abstracted cases

31. Hospital Charges, MN,1999-2001 Note: Information available only for abstracted cases

32. Payer Source for Inpatient Hospitalizations, MN,1999-2001 Note: Information available only for abstracted cases

33. Conclusions • We can estimate incidence of severe iTBI in Minnesota and provide descriptive information. • Limited data at local level due to small numbers and lack of access to data sources other than deaths. • The majority of severe iTBI victims in Minnesota are boys under age one. Nearly half have a documented history of previous hospital/ED treated abuse.