for Health Statistics
Todd Whitman, Governor
Mark Fulcomer, Ph.D., Director, Center for Health Statistics
Technical assistance by Rose Marie Martin, M.P.H.
Kenneth O'Dowd, Ph.D.
Prepared by Sandy Deshpande, M.S.
The Centers for Disease Control and Prevention
Grant number: U59/CCU203367
The Office for Prevention of Mental Retardation and
New Jersey Department of Human Services
This is the first publication from the New Jersey traumatic brain injury
(TBI) surveillance system on the incidence of TBI. This report provides
a profile on mortality and morbidity related to such injuries in New Jersey
during 1994. The report was prepared by the Data Analysis and Evaluation
section in the Center for Health Statistics (CHS) of the New Jersey Department of Health (NJDOH).
This project was funded through the Centers for Disease Control and
Prevention (CDC) from a cooperative agreement (grant number: U59/CCU203367)
between the Department of Health and the Disability
Prevention Program of the New Jersey Department of Human Services (NJDHS).
We wish to extend special thanks to Deborah E.Cohen, Ph.D., Director
of the Office for Prevention of Mental Retardation and Developmental Disabilities,
NJDHS through whose office funds were made available for the development
of the TBI system. We acknowledge cooperation from the administrative
staff of CHS and NJDOH.
Inquiries regarding the content and use of this report should be addressed
to the following:
New Jersey Department of Health
Center for Health Statistics
Room 405 - CN 360
Trenton, New Jersey 08625-0360
|Traumatic Brain Injury Summary Highlights,
New Jersey, 1994
|Scope of the Statewide TBI Surveillance
|TBI Surveillance Case Definition and Methodology
|Analysis of TBI Surveillance Data,
New Jersey, 1994
||Distribution and rate of traumatic brain injuries by
sex, age, cause, race and hospitalization status, New Jersey, 1994
||Distribution of traumatic brain injuries by sex, age,
cause, race and severity, New Jersey, 1994
||Percent distribution and rate of traumatic brain injuries
by age and sex, New Jersey, 1994
||Percent distribution and rate of traumatic brain injury
fatalities by age and sex, New Jersey, 1994
||Percent distribution and rate of moderate to severe traumatic
brain injuries by age and sex, New Jersey, 1994
||Percent distribution and rate of mild traumatic brain
injuries by age and sex, New Jersey, 1994
||Percent distribution and rate of traumatic brain injuries
by sex and county of residence, New Jersey, 1994
||Distribution of traumatic brain injuries by county of
residence and severity, New Jersey, 1994
||Distribution of traumatic brain injuries by county of
residence and cause, New Jersey, 1994
||Rate of traumatic brain injuries by county of residence
and cause, New Jersey, 1994
||Distribution of traumatic brain injuries by age, sex,
and cause, New Jersey, 1994
||Rate of traumatic brain injuries by age, sex, and cause,
New Jersey, 1994
||Average age (in years) at the time of traumatic brain
injury by hospitalization status, New Jersey, 1994
||Distribution of traumatic brain injury hospitalizations
by severity, New Jersey, 1994
||Population estimates by age and sex, New Jersey, 1994
||Population estimates by county of residence and sex,
New Jersey, 1994
INJURY SUMMARY HIGHLIGHTS
New Jersey, 1994
- According to the traumatic brain injury (TBI) surveillance system
developed by the New Jersey Department of Health
(NJDOH), there were 10,479 incidents of traumatic brain injury in New
Jersey during the calendar year 1994. These individuals were serious
enough to require hospitalization or died with or without receiving
any form of medical attention. Almost 90% of these occurrences involved
non-fatal hospitalizations, 4.4% hospitalized deaths, and the remaining
5.9% involved non-hospitalized deaths.
- In 1994, there were 132.6 traumatic brain injuries per 100,000 New
Jersey's estimated population. Almost 95% of the TBIs incidents that
occurred in New Jersey occurred to residents of New Jersey, 3.6% involved
out-of-state residents, and the remaining 1.5% were of unknown residence.
- Of the 10,479 TBI incidents, one in every 10 was fatal. Of the remaining
9,400 non-fatal hospitalizations, about one in five (22.5%) was classified
as having a moderate to severe injury, while the majority were mild
(74.0%). The remaining 3.4% were of undetermined level of severity (using
the CDC injury severity scaling system).
- According to the most recent financial data available, the typical
person who was hospitalized for TBI was approximately 40 years old and
was hospitalized for about 6 days costing approximately $14,200 per
- Results indicated that TBI incidence rates were higher among males
than females (a male to female ratio of 2.5 for fatalities; 2.0 for
moderate to severe injuries; and 1.6 for mild injuries) at all levels
- Results indicated that TBI disproportionately affects the young (15-24
year olds), and the elderly (65 years and over). TBI incidence rates
were substantially higher for males overall (174.9 vs. 92.9 for females
per 100,000) and in each age group. The incidence rates ranged from
a low of 52.1 per 100,000 for 5-14 year old females to a high of 719.3
per 100,000 for elderly males 85 and over.
- On an average day in 1994, about three persons (two males and one
female) died and another 27 (17 males and 10 females) were hospitalized
with TBI. The number of persons treated in emergency rooms and out-patient
care settings for TBI are unknown.
- By intent, 85.4% of the traumatic brain injuries were classified as
unintentional, 11.0% involved homicides/assaults; 1.9% involved suicide/self-inflicted
injuries; and 1.8% were of other/undetermined/unknown intent.
- The leading cause of TBI was motor vehicle-related injury (37.7%),
followed closely by falls (36.0%). These two causes account for almost
three out of every four (73.7%) of the TBI incidents that occur in New
- Traumatic brain injuries caused by firearms accounted for about 2.8%
of the total (292 out of 10,479). Over half (156 or 53.4%) of these
were self-inflicted. Firearms also were involved in one in three (32.9%)
- Overall, TBI incidence rates were highest for Atlantic County residents
(207.6 per 100,000) followed by residents of Hudson County (205.8 per
100,000). The lowest incidence of TBI occurred among residents of Hunterdon
County (64.2 per 100,000) followed by residents of Morris County (74.6
per 100,000). The overall resident incidence rate was 125.8 per 100,000
population. These rates varied by age, sex and cause. These rates may
be understated slightly due to unavailability of data on out-of-state
hospitalizations to New Jersey residents.
- Motor vehicle-related TBI incidence rates ranged from a low of 24.4
per 100,000 in Morris County to a high of 85.1 per 100,000 in Camden
County. The overall occurrence rate was 50.0 per 100,000 for New Jersey;
64.1 for males and 36.8 for females. Rates were higher for males than
females for all age groups, particularly for those aged 45 years and
under. Males and females in the age group 15-24 years, and males 85
years and over are at highest risk for motor vehicle-related TBI (137.7
per 100,000 males aged 15-24; 91.2 for males 85 and over; and 83.9 per
100,00 females aged 15-24). Motor vehicle-related injuries accounted
for more than half (55.5%) of the total number (1,974) of traumatic
brain injuries among 15-24 year olds.
- Fall-related TBI incidence rates ranged from a low of 22.6 per 100,000
in Hunterdon County to a high of 81.8 in Atlantic County. The overall
rate for occurrences in New Jersey was 47.7 per 100,000. Both males
and females in the age group 5 years and under and 65 and over had higher
TBI incidence caused by falls. Males had substantially higher rates
than females for all age groups for this category.
- The overall assault-related TBI occurrence rate for New Jersey was
14.6 per 100,000 population. The highest incidence of assault-related
TBI occurred among residents of Hudson County (39.1 per 100,000); the
lowest incidence was for Hunterdon county with no reported assault-related
traumatic brain injuries in 1994.
- The rate of self-inflicted traumatic brain injuries, accounting for
1.9% of the total number of incidents, was 2.5 per 100,000 persons in
1994. This incidence was highest among the residents of Passaic County
(4.8 per 100,000) and lowest among the residents of Gloucester County
(1.2 per 100,000 residents). Self-inflicted rates tend to increase with
advancing age with the highest incidence occurring among elderly males
and females, 65 and over. Rates for males were higher than females in
each age group.
- TBI was listed as the primary diagnosis in nearly three fourths of
the TBI-related hospitalizations. Analysis of hospitalizations by disposition
indicated that approximately 4.6% resulted in death. A vast majority
(87.1%) of those who died had moderate to severe levels of traumatic
brain injury and a majority of them were elderly. Other health conditions
in addition to TBI may have contributed to these deaths. Most of those
who were released to home (78.2% of 8,091) had relatively minor injuries.
- The race distribution indicates that more than three-fourths (76.9%)
of those who died and/or sustained traumatic brain injuries were white.
This was followed by blacks at 15.6%. The remaining 7.5% were mostly
American Indians, Asians, and persons of unknown race.
This is the first annual incidence report from the New Jersey traumatic
brain injury (TBI) surveillance system. Although developmental activities
began as early as 1995, the data have been too incomplete until now to
determine mortality and morbidity associated with traumatic brain injury.
The New Jersey Department of Health (NJDOH) has served
as primary developer of this surveillance system in collaboration with
the Office for Prevention of Mental Retardation and Developmental Disabilities
(OPMRDD) at the New Jersey Department of Human Services (NJDHS). Funds
for these efforts were provided by the Centers for Disease Control and
Prevention's (CDC) cooperative agreement # U59/CCU203367 with NJDHS. The
contents of this report are solely the responsibility of the author and
do not necessarily represent the views of the funding agency. This report,
prepared at the Center for Health Statistics (CHS), is intended to serve
as a guide for defining and understanding the magnitude and scope of TBI
occurrence in New Jersey, and facilitating development of prevention programs.
TBI incidence* for the purpose of this report is defined as an event
leading to either hospitalization or death with an injury to the brain
as a sole or contributory cause. The TBI surveillance case definition
and methodology are included in section I, page 5 of this report. The
current surveillance system consists of data from more than one source
which have been linked using probabilistic matching of records. The hospitalization
(UB-92) and the single and multiple cause-of-death (SCD and MCD) files
maintained by the NJDOH for the calendar year 1994 are the sources of
information from which the TBI statistics are derived. Tables on the incidence
of TBI are based on all three sources of information, while mortality
statistics are based on a linked file of hospitalized deaths from the
UB-92 and deaths attributed to TBI from the death files. Morbidity statistics
are based on hospitalization records (UB-92) submitted to the NJDOH by
all acute care facilities located in New Jersey. Due to extremely limited
resources, validity and reliability of the data in the system have not
been thoroughly studied. Some data problems and resolutions are discussed
in Appendix B. Although some discrepancies exist among the various sources
of data used to create the surveillance system, the impact on overall
TBI incidence rates is expected to be minimal.
This report is divided into two sections. The first section provides
background information on the development of TBI surveillance, case definition
and methodology. Data analysis and detailed tables are presented in Section
II. Population estimates are provided in Appendix A. Data sources, quality,
problems, and resolutions are discussed in Appendix B.
* The term TBI incidence used in this report does not include
TBI cases which were treated and released in hospital emergency departments
or which receive some other form of superficial attention. Also strictly
speaking, incidence rates should reflect the same at-risk population in
the numerator and denominator, which these do not. The numerator is all
incidents which occurred in New Jersey, while the denominator is an estimate
of the resident population.
|TBI incidence rate for a
specified population =
|| Number of TBI incidents * 100,000
| Population at risk specific to the
The estimated population figures (Appendix A) for New Jersey for the
calendar year 1994 developed by the U.S. Bureau of the Census were used
as denominators for computing approximate incidence rates. TBI incidence
rates are expressed per 100,000 estimated population.
New Jersey, with an estimated population of 7.9 million in 1995, is
the most densely populated state in the nation. Almost 80% of the state's
population reside in one-half of the area, with dense urban and suburban
neighborhoods extending across the state from the Delaware River at Philadelphia
to the Hudson River which separates New Jersey from New York City. The
remaining 20% of the population live in the mountains and farmlands of
the northwestern part of the state and in the Pinelands forests, farms
and ocean shore of the southern region.
New Jersey's population is older than the U.S. population as a whole,
but also encompasses large number of residents in the young and young
adult age groups. Approximately one-third of the population is under 25
years of age and another one-third is 25-44 years. One-fifth of the population
is aged 45-64 years, and 13.6% are elderly. The population is 49% male
and 51% female. Population estimates for 1994 suggest that 71.5% of the
population is white non-Hispanic, 13.0% is black non- Hispanic, 4.4% is
other races and non-Hispanic, and the remaining 11.0% is of Hispanic origin,
of any race. Tables P1 and P2 of Appendix A summarize the population by
county of residence, gender and age group.
Physical injury is a leading cause of morbidity and mortality throughout
the United States. In New Jersey, injuries (i.e., intentional and unintentional
injuries combined) are the fourth leading cause of death and a leading
cause of premature death in particular, contributing about 20% of the
total years of potential life lost (YPLL) before age 651. The average
age at death of an individual from injury in New Jersey is only 44.8 years,
twenty-six years younger than the average age of a death from all causes
(71.2 years)12. In addition, it has been estimated that injuries contribute
to about 20% of all disability in New Jersey, with an annual cost of over
one billion dollars in lost output and earnings11.
Injuries are responsible for approximately 3,200 New Jersey resident
deaths and 100,000 hospitalizations annually. The direct yearly costs
of hospitalization in New Jersey are estimated to be between $800 million
and one billion. About one-third of all injury deaths in New Jersey are
classified as intentional (i.e., either homicide or suicide) and of these,
about 40 percent involve firearms. Unintentional injury deaths in New
Jersey most often involve motor vehicles (about 40%), followed by drug
overdoses and other poisonings (about 25%), falls (about 15%), and fires
(about 4%). While most injury-related deaths in general occur among younger
adults, and homicides in particular disproportionately affect young adults,
unintentional injury deaths (particularly those related to falls and motor
vehicle crashes) and suicide deaths occur disproportionately among elderly
Among all types of injury, those to the brain are most likely to have
serious long term consequences, often resulting in death or permanent
disability with a likelihood of developing secondary conditions according
to CDC2 . Both the younger and oldest age groups are particularly vulnerable
to morbidity and mortality from TBI 8. Nationally, about 70,000 head injuries
are classified as moderate to severe; persons with moderate to severe
TBI will live the rest of their lives with a combination of cognitive,
behavioral, and emotional deficits and will require long-term rehabilitation
services. Almost no data are available on so-called mild TBI or on the
impact of mild TBI on a persons's capacity to function normally9. The
costs for severe head injury treatment and rehabilitation are estimated
to be $310,000 per patient10. Preventing such injuries is likely to result
in an enormous savings in terms of both direct costs, including acute
care, long-term care and rehabilitation, and indirect costs, such as lost
The New Jersey Brain Injury Association (NJBIA), a nonprofit organization,
is primarily devoted to providing counseling services to individuals with
head injuries and their families to enable them to return to their premorbid
normal life, or to cope with possibly lifelong residual impairments. NJBIA
contracted, through the Division of Developmental Disabilities of the
Department of Human Services, to conduct a comprehensive study on the
needs of New Jerseyans with severe head injuries. A legislative act (A-2299,
signed in January 1986) required that the study specifically address the
needs for housing, employment, specialized medical care, respite care
and psychological evaluation and training among individuals who have experienced
a TBI. The Needs Assessment study concluded that a statewide registry
for brain injuries for accurate and timely case finding and follow-up
to evaluate the outcomes of traumatic brain injury, efficacy of services,
and the impact on patients and their families was one of the pressing
needs of the population with head injuries3.
Currently, there is no legislation regarding TBI reporting requirements
in New Jersey. Recently, a resolution on programs and policies for persons
with head injuries was introduced in the state Senate. The purpose was
to study and develop recommendations regarding the most effective means
of improving the quality and scope of rehabilitative services provided
or supported by the state government. These efforts were intended to address
the needs of persons who have sustained head injuries, other than those
which are developmental in nature, whether or not permanent disability
results, and to define the role of state government regarding the provision
of policies and programs to assist this population4. The outcome of this
resolution is unknown at this time.
SCOPE OF THE STATEWIDE
TBI SURVEILLANCE SYSTEM
The ability to develop and evaluate prevention programs has been limited
due to inadequate surveillance data specific to TBI. Using the existing
sources of data within the NJDOH, a TBI surveillance system with 1994
as the baseline was developed. Data from 1994 and subsequent years will
provide a source for public health surveillance, prevention and evaluation
of information specific to traumatic brain injuries. Maintaining an ongoing
surveillance system is essential to monitoring progress towards year 2000
objectives, developing prevention activities, and to studying secondary
conditions resulting from brain injuries. The purpose of this report is
to determine the incidence of mortality and morbidity related to traumatic
brain injuries, and to describe differences among populations and geographic
areas for the baseline year, 1994.
CASE DEFINITION AND METHODOLOGY
The TBI surveillance system accounts for all traumatic brain injury
related hospitalizations and deaths which occurred in New Jersey during
1994. Fatal and non-fatal cases were identified through New Jersey's statewide
hospital discharge reporting system (UB-92) and death files. The 1994
UB-92 has patient identifiers (including name) and nine diagnostic fields.
The single cause-of-death (SCD) file has the underlying cause of death
identified by nosologists in the NJDOH, as well as identifiers (including
names) which facilitate linking. The multiple cause-of-death (MCD) file
has 20 fields for contributory causes of death, as well as an underlying
cause, coded independently by the National Center for Health Statistics
(NCHS) using the software Automated Classification of Medical Entities
(ACME). The records were linked using patient name, date of birth and
other key fields, and then merged into one statewide TBI system. The population
on which statistics are derived consists of records classified into one
of three categories:
- NON-FATAL TBI-RELATED HOSPITALIZATIONS: New Jersey residents and nonresidents
admitted to one of the ninety-four acute care facilities located in
New Jersey, and discharged to home, or transferred to another acute
care facility or nursing home (disposition status other than 'deceased').
- FATAL TBI-RELATED HOSPITALIZATIONS: All residents and nonresidents
hospitalized for TBI-related causes, and discharged from New Jersey
acute care facilities with a disposition status of 'deceased' are counted
as TBI-related hospitalized deaths.
- NON-HOSPITALIZED TBI-RELATED DEATHS: This category includes all deaths
from TBI-related causes which occurred at the scene of the injury, while
being transported, in emergency departments, outpatient treatment offices,
and nursing homes.
The specific ICD codes used in identifying TBI cases are:
N800-N801: Fractures of vault of skull or base of skull
N803-N804: Other and unqualified skull fractures and multiple
fractures of the skull
N850-N854: Intracranial injuries including concussion, contusion,
laceration, and hemorrhage without skull fractures
Additional cases of TBI deaths are identified from death certificates
with a diagnosis of N873 (other open wounds of head) accompanied by
an E (External cause-of- injury) code.
The case definition excludes:
hospitalizations with V codes (factors influencing health status)
as the primary diagnosis; newborn admissions; medical injury (N996-N999)
as the primary diagnosis; late effects of skull fractures (N905) or
intracranial injury (N907); and out-of-state hospitalizations to New
Jersey residents due to unavailability of such information.
The New Jersey TBI surveillance system for the baseline year 1994
was created using the following methodology:
- From the 1994 UB-92 data file of about 1.4 million hospital discharges,
an extract was created by selecting the records meeting the TBI
surveillance case definition criteria.
- The software package AUTOMATCH5 was used to identify multiple
hospital admissions using probabilistic matching within the TBI
hospitalization file (about 10,000 records), and also to match hospitalized
deaths (461 records) with death records (about 74,000 records) using
probabilistic record linkage. The matching variables used in the
unduplication and matching process were: Soundex of last name, name,
date of birth, medical record number, residence code, and gender.
All TBI hospitalizations with a deceased status at the time of discharge
were counted as hospitalized deaths; cases who were discharged alive
and died later prior to readmission were counted as non-hospitalized
deaths (see paragraph c). All individuals were counted only once
in the analysis except for individuals with admissions for multiple
episodes of TBI. Only about 1.5% of the TBI surveillance system
consists of such multiple admissions. Multiple admissions with TBI
as primary and /or secondary diagnoses accompanied by other health
conditions were more common among the elderly.
- The SCD and MCD files linked by New Jersey death certificate number
were used to account for non- hospitalized deaths. The SCD has patient
identifiers, underlying cause-of-death and demographic information,
but no nature of injury information. The MCD file has both nature
and external cause of injury information, but no patient identifiers.
These two files were merged using the death certificate number and
then records with a TBI diagnosis were selected according to the
case definition criteria. After eliminating the hospitalized death
records identified (paragraph b) and out-of-state deaths to New
Jersey residents, the remaining records were counted as the TBI-related
non-hospitalized death records.
The hospitalization records identified from the UB-92 file have information
on demographics, nature and cause of injuries, disposition status, source
of admission, source of payment, cost, and length-of-stay. Mortality records
have demographics, geographic and nature and cause of TBI injury. The
TBI system also includes additional computed variables such as age at
the time of injury occurrence, CDC injury severity scores7, and the CDC
proposed assignment of E codes for injury data (not shown). The current
report does not address hospitalization cost analysis and the CDC proposed
assignment of E codes to injury data. However, we intend to add hospitalization
cost analysis in the subsequent reports. Information on functional outcome,
circumstances and other risk factors will also be added when information
becomes available from the New Jersey trauma registry.
ANALYSIS OF TBI SURVEILLANCE DATA
NEW JERSEY, 1994
In 1994, there were 10,479 total incidents (deaths and acute care hospitalizations
combined) of traumatic brain injury in New Jersey-132.6 per 100,000 persons
(Table 1A). Of these, 1,079 persons died, resulting in an annual crude
incidence rate of 13.7 deaths per 100,000 persons (Table 2B). The remaining
9,400 incidents involved persons treated for traumatic brain injuries
in one or more of the 94 acute care facilities located in New Jersey -
resulting in an annual non-fatal hospitalization rate of 118.9 per 100,000
Approximately 1.5% of the hospitalizations were identified either as
subsequent admissions to the same acute care facility for another episode
of injury or transfers to or from one level to another for continued treatment.
About 42.6% of the non- fatal traumatic brain injuries and a majority
(84.1%) of the non-fatal severe traumatic brain injuries were treated
in the eight designated trauma centers12.
Of the 9,400 TBI hospitalized patients who survived through discharge,
2,119 (22.5%) were diagnosed as having a moderate to severe TBI and 6,957
(74.0%) had a mild TBI. For an additional 324 (3.4%) cases, severity of
the TBI could not be determined (Table 1B). Among the survivors, there
were more males with a moderate to severe TBI than females (a ratio of
2 to 1). The modal age group for persons discharged alive with moderate
to severe TBI was 65 through 84 (Table 2C), and the leading cause of these
TBIs was falls (not shown). Motor vehicle-related injury was the leading
cause of non-fatal mild TBI (Table 1B). There were many more whites with
a non-fatal moderate to severe TBI than persons of other racial backgrounds
The highest rate of TBI for fatalities and hospitalized non-fatal cases
combined for any degree of severity was in persons 85 and over (Table 2A).
The second highest rate was in the population aged 15 through 24. In both
of these age groups, male rates were much higher than female rates (719.3
and 453.4 per 100,000 for males and females, respectively, who were 85 and
over, and 277.8 and 120.3 per 100,000 for males and females, respectively,
in the 15 through 24 year age group). The rate of fatalities was also highest
in the 85 and over age group, and male rates in this group outweighed female
rates by a ratio of more than four to one (Table 2B).
The most serious long-term consequences of TBI are experienced by persons
who are diagnosed with moderate to severe brain injuries. The highest
rates were found in the 85 and over age group, with a rate of 132.7 per
100,000, followed by persons 65 through 84 years of age (a rate of 54.9
per 100,000). In each of these age groups, the male rates were considerably
higher than the female rates (Table 2C). Although the rate of mild TBI
in the population 85 and over was also higher than in any other age group
(251.7 per 100,000), this rate was also relatively high in persons 15
through 24 (149.0 per 100,000 persons) (Table 2D).
The leading cause of TBI was motor vehicle-related injury (E810-E825)
(37.7%). This was followed closely by falls (E880- E888) (36.0%). These
two external factors combined accounted for nearly three out of four TBI
incidents (Table 1A). A detailed distribution of external cause of TBI
in 1994 (not shown) indicates that while most of the motor vehicle-related
injuries were of occupants of motor vehicles (73.8%), a substantial number
involved pedestrians (14.2%); the remaining were motorcyclists (4.3%),
pedal cyclists (4.3%), and persons in unspecified circumstances (3.4%).
Another major cause of TBI is persons struck by or against an object.
The majority of these were assault-related (66.1%) and the remainder (33.9%)
were unintentional injuries.
Geographically, the greatest number of TBI incidents occurred to residents
of Hudson County (1,137 or 11.4%), followed by residents of Essex County
(966 or 9.7%) (Table 3A). Essex County residents experienced the highest
combined number of fatal and non-fatal moderate to severe TBIs (369) (Table
3B). TBI incidence rates were highest for Atlantic County (207.6 per 100,000),
followed by Hudson County (205.8 per 100,000). The lowest incidence of
TBI occurred among residents of Hunterdon County (64.2 per 100,000) followed
by residents of Morris County (74.6 per 100,000). The overall resident
incidence rate was 125.8 per 100,000 population (Table 3D). These rates
may be slightly understated due to lack of data on out-of-state hospitalizations
of New Jersey residents.
Camden County residents had the highest number of motor vehicle-related
TBIs (431), followed by residents of Bergen County (308). Hunterdon and
Warren Counties had the lowest number of motor vehicle-related TBIs (32
and 36 respectively). Hudson County residents experienced the greatest
number of TBIs from falls (416) (Table 3C). Hudson County also had the
highest number of assault-related TBIs (216). Motor vehicle-related TBI
incidence rates ranged from a low of 24.4 per 100,000 in Morris County
to a high of 85.1 per 100,000 in Camden County. The overall motor vehicle-related
TBI rate for New Jersey residents was 46.0 per 100,000 for New Jersey
With respect to age, the greatest number of motor vehicle-related TBIs
occurred among persons 25 through 44 years, followed by 15 through 24
years (Table 4A). The highest rates, however, were in the 15 through 24
year olds, with a rate more than twice the rate in 25 though 44 year olds
(111.3 and 51.3, respectively) (Table 4B). The second leading cause of
TBI, falls, occurred at highest numbers among 65 through 84 year olds
(Table 4A). Males 85 and over, however, experienced the highest rate of
fall-related TBIs (503.2 per 100,000). The greatest number of TBIs from
falls in any age-sex subgroup occurred in females 65 through 84. While
the largest number of assault-related TBIs occurred in 25 through 44 year
old males, the highest rate by far occurred in males aged 15 through 24
(59.1 per 100,000)(Tables 4A and 4B).
The mean and median age at the time of TBI occurrence was 40.2 and 34.5
years respectively. On average, males were approximately 10 years younger
(mean age of 36.7 years) than females (mean age of 46.3 years) at the
time of traumatic brain injury (Table 5).
Analysis of TBI-related hospitalizations indicated that an overwhelming
majority (82.1%) were released to home; 11.1% were transferred to/or discharged
under some form of medical care; 4.6% expired; and the remaining 2.2%
left against medical advice (Table 6). A majority (266 or 68.9%) of those
who were released to other institutions (mostly rehabilitation) had moderate
to severe levels of TBI.
The primary goal of New Jersey's TBI surveillance system is to provide
accurate and timely information to facilitate planning and evaluating
prevention programs. Recommended areas for further action and study include:
- Develop quality control measures to ascertain the extent to which
the information provided is accurate and reliable.
- Complete the analysis of the validation study of a sample of hospital
records of TBI patients to provide an estimate of the validity of TBI
diagnoses reported on the UB-92 file.
- Study the reasons for discrepancies in diagnoses and cause of death
between UB-92 and death files.
- Investigate the possibility of obtaining additional funding to be
able to expand the surveillance system and to complete project objectives
in a timely fashion.
- Enhance the current system by adding more data elements, for example,
concerning follow-up of patients affected by traumatic brain injuries.
- Develop strategies to increase the likelihood that the information
provided will be utilized by public and private agencies and public
- New Jersey Department of Health, Center for Health
Statistics. (1996). New Jersey Health Statistics: 1994. Trenton, NJ.
- U.S. Department of Health and Human Services, CDC and National Center
for Injury Prevention and Control. (1995). Guidelines for Surveillance
of Central Nervous System Injury.
- New Jersey Head Injury Association, Inc. (1989). Traumatic Brain Injury
in New Jersey. A Needs Assessment.
- Senate Concurrent Resolution No. 93 State of New Jersey, introduced
March 2, 1995 by Senators DiFrancesco and Sinagra.
- AUTOMATCH Ver 3.0, Record Linkage Technology System. Matchware Technologies,
- New Jersey Department of Health, Center for Health
Statistics. (1997). Evaluation of External Cause-of-Injury Code Compliance
in 1994 Hospital Discharge Data. Trenton,NJ.
- David Thurman, Brigette Finklestein, Steven Leadbetter, and Joseph
Sniezek. National Center for Injury Prevention and Control, Centers
for Disease Control and Prevention. (1996). A Proposed Classification
of Traumatic Brain Injury Severity for Surveillance Systems. Atlanta,GA.
- Kraus, JF. Epidemiology of head injury. (1993). In: Cooper PR, ed.
Head injury. 3rd ed. Baltimore, MD: Williams and Wilkins. Page 1-25.
- Traumatic brain injury, rehabilitation-where we are. Position papers
from The Third National Injury Control Conference "Setting the National
Agenda for Injury Control in the 1990's". (1992). Page 503.
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(1990). Healthy People 2000. The Economics of Prevention. 1990. Washington,
D.C. Page 5.
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Bureau of Economic Research. (1993) Injury and Impairment in New Jersey.
Results from the New Jersey Demographics of Disability Survey.
- New Jersey Department of Health, Center for Health
Statistics, 1997. [1994 injury surveillance file]. Unpublished data.
These notes discuss the sources of data used in creating the TBI surveillance
system, data limitations, and procedures for case ascertainment.
- DATA LIMITATIONS, PROBLEMS AND RESOLUTION:
- It should be noted that the surveillance system is based on multiple
sources of information, and each data file is subject to a certain
unknown degree of error. We believe that the UB-92 may overstate
the incidence of TBI and the death file may understate the incidence
due to differences in administrative and coding practices. Resources
were too limited to conduct a comprehensive investigation of data
quality. However, efforts related to data validation are conducted
whenever possible to minimize errors. Caution should be exercised
in interpreting the results presented in this report.
- All resident death certificates are included on the SCD file regardless
of the state of occurrence. However, the system does not include
out-of-state hospitalizations which occurred to New Jersey residents,
as this information is not available. Efforts are underway to obtain
information on hospitalizations of New Jersey residents in the neighboring
states of New York and Pennsylvania. The effect on overall incidence
rates is expected to be minimal assuming an equal number of out-of-state
hospitalizations to New Jersey residents and hospitalizations of
out-of-state residents in New Jersey (approximately 3.6% of total
occurrences are of out-of-state residents and 1.5% are of unknown
- Non-hospitalized deaths obviously have no in-patient charges.
Information on emergency department and outpatient costs/charges
is currently not available, but acute care hospital charges are
available for both fatal and non-fatal hospitalizations. This report
does not include TBI-related hospitalization cost analysis.
- Another limitation is that both mortality and hospitalization
files lack information on Abbreviated Injury Scores (AIS), Glasgow
coma scores, use of protective devices and alcohol involvement.
TBI cases were classified according to CDC's severity scale7 . Collecting
information on some optional variables (AIS scores, Glasgow coma
scores, etc) may be beyond the scope of the 1994 surveillance system
project. The New Jersey trauma registry, which is expected to be
implemented in the future, may also be used for case verification
and for collecting additional information such as Glasgow coma scores,
protective devices and alcohol involvement. It is planned to add
these data elements from the NJDOH trauma registry, when implemented.
- VALIDATION OF HOSPITAL DEATHS FROM THE DEATH
FILES AND VICE-VERSA:
The software package AUTOMATCH was also used to match records (461)
between the UB-92 data file and the single-cause-of death file for
verification of vital status. Death certificate records were located
for almost all (99%) hospital patients with a discharge status of
'deceased'. The key variables used in the matching process included
last name, soundex of last name, first name, date of birth, date of
death, disposition status, municipality code of residence and place
of death. Minor discrepancies in the vital statistics information,
and major discrepancies regarding diagnoses information (about 38%
of the hospitalized deaths identified through records on the UB-92
file did not have a TBI-related cause of death indicated on their
death certificates) were observed. These certificates are also being
reviewed for verification of TBI diagnoses.
Some of the data problems that remain to be resolved include:
- Five hospital discharge records for deceased patients (out of
461 records) could not be matched with a corresponding death certificate.
These records have been excluded from the TBI surveillance system.
- Of the UB-92 records with a TBI diagnosis as a listed cause of
hospitalization and a discharge disposition of death which were
matched with a death certificate, only 62% (283 records), also had
a TBI diagnosis as a contributory cause of death on the matching
death certificate. The reason the remaining 38% (173 records) did
not have a TBI diagnosis on the death certificate remains to be
investigated. The current analysis includes these 173 hospitalized
deaths with a TBI diagnosis which are counted as TBI- related hospitalized
deaths in the surveillance system. This inclusion may have resulted
in an over-counting of TBI incidence by 1.7% (173) cases out of
10,479 records in the surveillance system.
- Approximately 80 death certificates indicating TBI as a cause
of death did not have a matching TBI-related hospitalization record,
although the death certificate indicated that the death occurred
in a hospital. These deaths may have occurred in an emergency department
or outpatient care setting in a hospital, and the death records
may have been indicated incorrectly as in-hospital occurrences.
These records are counted as non-hospitalized deaths.
- E CODE EVALUATION OF 1994 UB-92 DATA FILE:
The NJDOH mandated that acute care hospital discharge records related
to injury (ICD-9-CM codes N800-N995 with some exclusions) be accompanied
by at least one E (external cause of injury) code and a Z code (place
of occurrence) in the designated fields, beginning January 1, 1994.
A final evaluation report6 for completeness of E coding was prepared
in July 1997. The results indicated a high (over 99%) level of compliance
with E code regulations, specific to TBI.
- VALIDATION OF TBI HOSPITALIZATIONS:
A validation study to assess the 1994 UB-92 data related to TBI
injuries was conducted during February through June 1997. This study
involved reviewing medical charts by selecting a statistically valid
sample of 650 medical charts for case ascertainment. The validation
data are being analyzed at the CHS. Preliminary analysis suggests
that minor discrepancies between hospital charts and UB-92 records
exist with respect to diagnoses and demographic information. One of
the reasons for these discrepancies according to hospital administrators
is that the computer files are often updated, but these updates are
often not reflected in medical charts, especially if records are old.
The computer files are submitted to the NJDOH at the end of each