Trends in Outcomes and Hospitalization Costs for Traumatic Brain Injury in Adult Patients in the United States

Abstract

Several new therapeutic strategies have been introduced for the management of adult traumatic brain injury (TBI) over the last decade, such as the development of management pathways and specialized TBI units and improved treatment of cerebral perfusion. The purpose of this study is to compare TBI-related hospitalization outcomes in the United States between two time periods, 1993–1994 and 2006–2007. We determined the rates of occurrence, in-hospital outcomes, and mean hospital charges for patients hospitalized with adult TBI in 1993–1994 using the nationally representative all-payer Nationwide Inpatient Survey (NIS) database, and compared these outcomes with homologous data from 2006–2007. The incidence of TBI admissions was reduced by 35% in 2006–2007 compared with 1993–1994; (22/100,000 versus 34/100,000 population; p<0.0001). The mean length of hospitalization (mean±SD, in days) was significantly lower in 2006–2007 than in 1993–1994 (2.5±2.4 days versus 2.7±2.6 days; p<0.0001). In-hospital mortality increased significantly in 2006–2007 compared with 1993–1994 (0.8% versus 0.4%, p<0.0001). Average hospitalization charges were significantly higher in 2006–2007 compared with 19993–1994 ($21,460±$21,212 versus $5,142±$4,625; p<0.0001), even after adjusting for inflation. In both time periods, most hospitalized adult TBI patients were graded as mild (98.2% in 1993–1994 versus 98.0% in 2006–2007; p=0.20). There was a significant increase in average hospitalization charges and death rates in all TBI severity subgroups in 2006–2007 compared with 1993–1994. The decline in rate of hospitalization between the two time periods was predominantly related to the decline in the number of admissions of patients with mild TBI. Although the number of TBI admissions was reduced, a significant increase in average hospitalization charges and in-hospital mortality rate was observed in 2006–2007 compared with 1993–1994.

Introduction

T raumatic brain injury (TBI) continues to be a leading cause of death and disability in the United States, especially among young adults.^1,2 TBI occurred in ∼1,700,000 United States civilians annually from 2002 to 2006 and was responsible for an average of 53,014 deaths per year during 1997–2007.¹ A sharp decline in the rate of TBI hospitalization was reported between 1980 and 1995,³ a change that was presumably related to changes in hospitalization practices for mild TBI.³ Subsequent studies confirmed the trend of reduction of TBI admissions in inpatient settings as well.^2,4 Despite the continuous reduction in hospitalization, TBI remains a serious social and financial burden to families and society.^5,6 According to the Center for Disease Control and Prevention (CDC), the estimated direct and indirect cost of TBI in 1995 was $56.3 billion, exceeding the cost of spinal cord injury and AIDS.⁵

Although changes in the pattern of TBI hospitalization in the past three decades have been reported, trends in hospitalization outcomes and charges have not been studied.^3,4 In addition, the impact of new therapeutic strategies developed in the past decade on cost and outcome of adult TBI have not been evaluated.⁷ These strategies include the development of trauma units and major trauma centers and management pathways in intensive treatment units, as well as improved treatment of cerebral perfusion pressure. In addition, better understanding of the uses of hyperventilation, osmotherapy, tracheostomy, and leakage of cerebrospinal fluid (CSF) have accumulated during the last decade and have modified management of patients with TBI.⁷

The purpose of this study is to compare TBI-related hospitalization outcomes in the United States between two time periods, 1993–1994 and 2006–2007.

Methods

We used data from the Nationwide Inpatient Sample (NIS) sponsored by the Agency for Healthcare Research and Quality to determine the demographic and clinical characteristics of TBI patients for the two study periods (1993–1994 and 2006–2007).^8,9 The NIS is the largest inpatient all-payer database in the United States that is designed to identify, track, and analyze national trends in health care utilization, access, charges, quality, and outcome. The NIS contains data from ∼5,000,000–8,000,000 hospital stays, and includes all discharge data from ∼1,000 hospitals located in 40 states. The sample constitutes an ∼20% stratified sample of United Stats community hospitals. Detailed information on the design of the NIS is available at (http://www.hcupus.ahrq.gov). Briefly, the NIS database includes data on >100 clinical and nonclinical variables associated with hospital stays, including primary and secondary diagnoses, primary and secondary procedures, patients' admission and discharge status, patient demographic information (i.e., sex, age, race, median income, or ZIP code), expected payment source, total charges, and length of stay. We identified adult patients, ≥18 years of age, with a primary diagnosis of TBI using the International Classification of Disease, 9th Revision (ICD-9-CM) codes in the ranges 800.0–801.9, 803.0–804.9, or 850.0–854. We used ICD codes 96.7, 96.70, 96.71, and 96.72 to identify patients with TBI who were mechanically ventilated. We reviewed hospitalization characteristics of adult patients with TBI in two time periods, 1993–1994 and 2006–2007. We compared the demographic characteristics, number of admissions, hospitalization outcome, and charges, as well as hospitalization outcome and total charges according to TBI severity, in the two time periods. To facilitate the production of national estimates, the NIS provides both hospitalization and discharge weights. The sampling weight is the inverse of patient selection probability, which signifies the number of individuals in the target population that the sampled individual represents. Sample weights are needed to obtain unbiased estimates of population parameters when the sample members are chosen with unequal probabilities. To assess the severity of TBIs among hospitalized patients, we used the ICDMAP-90 software (John Hopkins University and Tri-Analytics, Baltimore, MD) to calculate an abbreviated brain injury scale score (AIS).^3,5,10 The latter score is widely accepted as a valid measure of brain injury severity.^4,10,11 ICDMAP-90 software is a computer algorithm that maps ICD-9-CM diagnostic codes to a six level score approximating the abbreviated injury scale (ICD/AIS).^3,4 We then reclassified the ICD/AIS scores into a three level scale as previously described by Bowman and colleagues, and Thurman and Guerrero:^3,4 ICD/AIS scores of 1 or 2 were defined as mild, scores of 3 were defined as moderate, and scores of 4–6 were defined as severe. We used the United States Census estimates for the national civilian population to determine the TBI incidence rates during the studied time periods. We used the SPSS 17 software program to convert raw counts generated from the NIS database into weighted counts that were used to generate national estimates. SPSS 17 procedures were used to analyze the data. We used two sample independent proportion tests for categorical data and two sample independent t-tests for continuous data, to detect statistically significant differences. We considered α=0.05 as the level of significance. The effect of inflation on hospital charges was adjusted using the Bureau of Labor Statistic's Consumer Price Index ( www.bls.gov/cpi ).

Results

Demographics, clinical characteristics, and in-hospital outcomes of all adult TBI patients

The mean age was higher among patients hospitalized in 2006–2007 compared with 1993–1994 (47.7±22.2 years versus 44.4±21.8; p<0.0001). The proportion of men with TBI was significantly higher than that of women in both time periods, p<0.0001 (Table 1). There was a 23.5% reduction in the number of TBI patients hospitalized in 2006–2007 compared with 1993–1994 (64,964 patients in 1993–1994 versus 49,680 patients in 2006–2007). The incidence of TBI was reduced by 35% in 2006–2007 compared with 1993–1994 (22/100,000 people versus 34/100,000 people; p<0.0001). The average length of hospitalization was significantly lower in 2006–2007 than in1993–1994 (2.5±2.4 days versus 2.7±2.6 days; p<0.0001). Routine discharges occurred in 78.5% and 86.5% of patients admitted in 2006–2007 and 1993–1994, respectively (p<0.0001). Transfers to short-term hospitalization centers were significantly lower in 2006–2007 compared with 1993–1994, whereas transfers to other facilities such as skilled nursing centers and home health care were significantly higher in 2006–2007 (Table 1). In-hospital death rate was significantly higher in 2006–2007 than in 1993–1994 (0.8% versus 0.4%; p<0.0001).

Table 1.

Demographic Profile of Adult TBI Patients. 1993–1994 and 2006–2007

	1993–1994	2006–2007
Total number of adult TBI patients	64,954	49,680
Age±Standard deviation (year)^*	44.4±21.8	47.7±22.2
Sex
Male	38,806 (59.7%)	29,942 (60.3%)
Female	26,148 (40.3%)	19,634 (39.5%)
Unknown	0	104 (0.2%)
Race
White^*	36,552 (56.3%)	23,780 (47.9%)
African-American^*	7,091 (10.9%)	3,943 (7.9%)
Other (Asian, Hispanic, …)^*	6,606 (10.3%)	7,019 (14.1%)
Not stated/Missing^*	14,705 (22.5%)	14,938 (30.1%)
Length of stay (days)
Length of stay±Standard deviation^*	2.7±2.6	2.5±2.4
Discharge status
Routine^*	56,193 (86.5%)	39,005 (78.5%)
Transfer to short term hospital^*	1,032 (1.6%)	622 (1.3%)
Other transfer skilled nursing facility, intermediate care^*	4,367 (6.7%)	6,010 (12.1%)
Home health care^*	1,757 (2.7%)	2,310 (4.6%)
Against medical advice^*	1,280 (2%)	1,301 (2.6%)
Died in hospital^*	282 (0.4%)	400 (0.8%)
Not stated/Missing	43 (0.1%)	32 (0.1%)
Severity (based on AIS scores)
AIS=1 and 2 (Mild)	63,749 (98.2%)	48,708 (98%)
AIS=3 (Moderate)^*	873 (1.3%)	429 (0.9%)
AIS=4 and 5 (Severe)^*	317 (0.5%)	288 (0.6%)
AIS=9^*	15	255 (0.5%)
Cost
Cost (average) USD±SD^*	$5,142±$4,625	$21,460±$21,212
Average Cost (corrected for inflation)	$7,200

p<0.05.

TBI, traumatic brain injury; AIS, abbreviated brain injury scale score.

Mean hospitalization charges were significantly higher in 2006–2007 than in 1993–1994 ($21,460±$21,212 versus $5,142±$4,625; p<0.0001), even after adjustment for inflation ($21,460 versus $ 7,200). In both time periods, most admitted patients had mild TBI (98.2% in 1993–1994 versus 98% in 2006–2007).

Demographics and in-hospital outcomes of adult TBI: Mechanically ventilated subgroup

There was a significant increase in number of mechanically ventilated patients in 2006–2007 compared with 1993–1994 (5% versus 1%; p<0.0001).

The average age of mechanically ventilated patients was significantly higher in 2006–2007 compared with 1993–1994 (38±16.8 years versus 35.3±16.8 years; p<0.0001), and the average length of stay was significantly shorter in 2006–2007 compared with 1993–1994 (2.6±2.5 days versus 5.03±4.9 days; p<0.0001). The number of in-hospital deaths was significantly higher in 2006–2007 than in 1993–1994 (4.3% versus 2.1%; p=0.024). The average cost of hospitalization was significantly higher for mechanically ventilated patients in 2006–2007 than in 1993–1994 ($33,294±$27,932 versus $16,573±$12,883; p<0.0001), even after adjusting for inflation ($32,294 versus $23,202) (Table 2).

Table 2.

TBI Patients on Mechanical Ventilation

	1993–1994	2006–2007
Total number of mechanically ventilated adult TBI patients	515	2,377
Age±Standard deviation (year)^*	35.3±16.8	38±16.8
Sex
Male	373 (72.3%)	1,878 (79%)
Female^*	143 (27.7%)	490 (20.6%)
Unknown	0	9 (0.4%)
Race
White	297 (57.6%)	856 (36%)
African-American	51 (9.8%)	218 (9.2%)
Other (Asian, Hispanic, …)	73 (14.3%)	361 (15.2%)
Not stated/Missing	94 (18.3%)	942 (39.6%)
Length of stay (days)
Length of stay±Standard deviation^*	5.03±4.9	2.6±2.5
Discharge status
Routine	415 (80.6%)	1,921 (80.8%)
Transfer to short term hospital^*	24 (4.7%)	14 (0.6%)
Other transfer skilled nursing facility, intermediate care	39 (7.5%)	176 (7.4%)
Home health care	15 (3%)	50 (2.1%)
Against medical advice^*	11 (2.1%)	114 (4.8%)
Died in hospital^*	11 (2.1%)	101 (4.3%)
Not stated/Missing	0	0
Severity (based on AIS scores)
AIS=1 and 2 (Mild)^*	444 (86.3%)	2,203 (92.7%)
AIS=3 (Moderate)^*	43 (8.3%)	101 (4.2%)
AIS=4 and 5 (Severe)^*	28 (5.4%)	73 (3.1%)
AIS=9	0	0
Cost
Cost (average) USD±SD^*	$16,573±$12,883	$33,294±$27,932
Average cost (corrected for inflation)	$23,202

p<0.05.

TBI, traumatic brain injury; AIS, abbreviated brain injury scale score.

Demographics and in-hospital outcomes of adult TBI: Mild TBI subgroup

In both time periods, most hospitalized adult patients had mild TBI (98.2% in 1993–1994 versus 98% in 2006–2007; p=0.20). In patients with mild TBI, the average age was significantly higher in 2006–2007 than in 1993–1994 (47.7±22.2 years versus 44.4±21.8 years; p<0.0001), and the average hospitalization length of stay was significantly shorter in 2006–2007 (2.5±2.4 days versus 2.7±2.6 days; p<0.0001). Most patients were routinely discharged in both time periods. In-hospital death was significantly higher in 2006–2007 than in 1993–1994 (0.6% versus 0.4%; p<0.0001). The average hospitalization charge was significantly higher in 2006–2007 than in 1993–1994 time period ($21,160±$20,500 versus $5,142±$4,591; p<0.0001), even after adjusting for inflation (Table 3).

Table 3.

Demographic of Mild TBI Patients (AIS: 1 & 2)

	1993–1994	2006–2007
Total number of mild adult TBI	63,748	48,697
Age±Standard deviation (year)^*	44.4±21.8	47.7±22.2
Sex
Male	38,065 (59.7%)	29,339 (60.2%)
Female	25,683 (40.3%)	19,265 (39.6%)
Unknown	0	103 (0.2%)
Race
White^*	35,864 (56.3%)	23,220 (47.7%)
African-American^*	6,932 (10.9%)	3,882 (8%)
Other (Asian, Hispanic, …)^*	6,516 (11.3%)	6,948 (14.2%)
Not stated/Missing	14,436 (22.5%)	14,657 (30.1%)
Length of stay (days)
Length of stay±Standard deviation^*	2.7±2.6	2.54±2.5
Discharge status
Routine^*	55,280 (86.7%)	38,397 (78.8%)
Transfer to short term hospital^*	951 (1.5%)	574 (1.2%)
Other transfer skilled nursing facility, intermediate care^*	4,252 (6.6%)	5,909 (12.1%)
Home health care^*	1,720 (2.7%)	2,266 (4.7%)
Against medical advice^*	1,269 (2%)	1,290 (2.6%)
Died in hospital^*	231 (0.4%)	240 (0.6%)
Not stated/Missing	45 (0.1%)	31
Cost
Cost (average) USD±SD^*	$5,142±$4,591	$21,160±$20,500
Average cost (corrected for inflation)	$7,200	……

p<0.05.

TBI, traumatic brain injury; AIS, abbreviated brain injury scale score.

Demographics and in-hospital outcomes of adult TBI: Moderate TBI subgroup

The rate of moderate TBI was significantly lower in 2006–2007 than in 1993–1994 (0.9% versus 1.3%; p<0001). The average length of stay and in-hospital death did not significantly differ between the two time periods. However, average hospitalization charges were significantly higher in 2006–2007 than in 1993–1994 ($25,271±$15,917 versus $ 7,605±$6,300; p<0.0001), even after accounting for inflation (Table 4).

Table 4.

Moderate TBI Patients (AIS=3)

	1993–1994	2006–2007
Total number of moderate adult TBI patients	873	429
Age±Standard deviation (year)^*	39.4±19.6	43.4±21
Sex
Male	510 (58.5%)	288 (67.2%)
Female	363 (41.5%)	141 (32.8%)
Unknown	0	0
Race
White^*	462 (52.9%)	259 (60.3%)
African-American^*	122 (14%)	25 (5.8%)
Other (Asian, Hispanic, …)	86 (9.9%)	49 (11.3%)
Not stated/Missing	203 (23.2%)	96 (22.6%)
Length of stay (days)
Length of stay±Standard deviation	3.7±3.3	3.6±3.4
Discharge status
Routine^*	750 (85.9%)	350 (81.6%)
Transfer to short term hospital^*	28 (3.2%)	5 (1.1%)
Other transfer skilled nursing facility, intermediate care	58 (6.6%)	30 (7%)
Home health care^*	21 (2.4%)	29 (6.7%)
Against medical advice	11 (1.3%)	10 (2.4%)
Died in hospital	5 (0.6%)	5 (1.2%)
Not stated/Missing	0	0
Cost
Cost (average) USD±SD^*	$7,605±$6,300	$25,271±$15,917
Average cost (corrected for inflation)	$10,640	…………

p<0.05.

TBI, traumatic brain injury; AIS, abbreviated brain injury scale score.

Demographics and in-hospital outcomes of adult TBI: Severe TBI subgroup

Among the total number of TBI admissions, only 0.6% in 2006–2007 and 0.5% in 1993–1994 were rated as severe. Although rate of severe TBI (number of severe TBI divided by the total number of TBI in each time period) is significantly higher in 2006–2007 than in 1993–1994 (p<0.05), the incidence of severe TBI was significantly lower in 2006–2007 than in 1993–1994 (0.14/100.000 versus 0.17/100.000 p<0.0001). The average age of hospitalization in years was not significantly different between the two time periods. The mean length of hospitalization in days was significantly lower in 2006–2007 than in 1993–1994 (2.3±2 versus 10.2±10; p<0.0001). In-hospital death rate was significantly higher in the 2006–2007 time period (50.1% versus 14.3%; p<0.0001) as were the average in-patient hospitalization charges ($57,637±$54,000 versus $19,000±$18,900; p<00001), even after adjusting for inflation (Table 5).

Table 5.

Severe TBI Patients (AIS of 4 and 5)

	1993–1994	2006–2007
Total number of severe TBI patients	317	288
Age±Standard deviation (year)	48±24	49.2±23.3
Sex
Male	232 (73%)	225 (78%)
Female	86 (27%)	63 (22%)
Unknown	0	0
Race
White^*	221 (69.6%)	149 (51.5%)
African-American	37 (11.7%)	36 (12.6%)
Other (Asian, Hispanic, …)^*	4 (1.3%)	16 (5.6%)
Not stated/Missing	55 (17.4%)	87 (30.3%)
Length of stay (Days)
Length of stay±Standard deviation^*	10.2±10	2.3±2
Discharge status
Routine^*	147 (46.4%)	43 (14.9%)
Transfer to short term hospital^*	53 (16.7%)	19 (6.7%)
Other transfer skilled nursing facility, intermediate care	56 (17.7%)	67 (23.3%)
Home health care	16 (4.9%)	14 (5%)
Against medical advice	0	0
Died in hospital^*	45 (14.3%)	145 (50.1%)
Not stated/Missing	0	0
Cost
Cost (average) USD±SD^*	$19,000±$18,900	$57,637±$54,000
Average cost (corrected for inflation)	$26,600

p<0.05.

TBI, traumatic brain injury; AIS, abbreviated brain injury scale score.

Discussion

With better understanding of the mechanisms and pathogenesis of TBI, the development and wide use of new brain imaging modalities and new therapeutic modalities have been incorporated in the management of adult TBI. Most of the new supportive care modalities for TBI were not available in 1993–1994, whereas in 2006–2007, several strategies, including specialized intensive care units and Bilevel Positive Airway Pressure were widely available.^12,13 These modalities contributed to the implementation of organizational changes that promoted the development of trauma units where TBI patients could be managed more appropriately. Improvement of cerebral perfusion pressure and better management of hyperventilation, osmotherapy, tracheostomy, and noninvasive ventilation have occurred during the last decade and have become the standard of care in the management of TBI patients.⁷

Our study demonstrated a significant decline in the hospitalization rate of adult TBI patients between 1993–1994 and 2006–2007. The decline was most conspicuous in mild TBI admissions. Similar findings were reported by other authors during the 1980–2005 time period.⁴ An improvement in injury-prevention policies such as mandating the wearing of crash helmets or seat belts may explain the reduction of TBI admissions between 1993–1994 and 2006–2007.^3,14

–17 Several findings suggest that injury prevention is not the only factor that contributed to the observed decline in the number of TBI admissions, as this decline was not seen in cases of severe TBI. Not only did we not observe a decline in severe TBI proportional to that seen with mild TBI, but our data revealed a significant increase in the rate of severe TBI in 2006–2007 compared with 1993–1994. Similar findings were observed when the rate of in-hospital death was evaluated, with a significant increase in death rates in 2006–2007 patients with TBI of any severity. Other factors may account for the decline in mild and moderate TBI admission rates: 1) a change in hospital practice admissions shifting mild TBI medical care to outpatient settings secondary to changes in first-aid guidelines and the growing influence of managed care and prospective payment system reimbursement excluding hospitalization of a large number of mild TBI patients,^3,10,18 2) the improvement in the delivery of pre-hospital care and medical emergencies services, as well as the development of trauma systems offering more accurate screening and effective care of TBI patients,^19
–21 which would limit hospitalization to more severe TBI patients, and 3) the availability of more advanced diagnostic tools, including imaging technology that allows rapid identification of mild TBI patients who otherwise would need hospitalization for observation before being properly diagnosed.^3,10

The significant increase in the rate of patients with severe TBI as well as the number of mechanically ventilated patients is suggestive that more severe TBI patients were hospitalized in 2006–2007 than in 1993–1994. This is supported by the significant increase in the rate of inpatient death in 2006–2007 in all TBI patients, particularly in the severe TBI category. This, however, should be interpreted with caution, as the data may be influenced by improvement in ICD-9-CM coding practices with more accurate distribution of ICD codes to TBI severity. The improvement of pre-hospital care of trauma patients may rescue critically injured TBI patients and reduce rate of death before hospital admission, which would increase the number of severe TBI admissions.^3,10 This may explain the dramatic increase of mortality in adults with severe TBI, as well as the significant increase in the number of severe TBI patients in 2006–2007. Despite the significant reduction in length of hospitalization, a significant increase in inpatient hospitalization charges was reported without reduction in inpatient mortality in 2006–2007 when compared with 1993–1994. The highest increase in charges was observed in the severe TBI group, with the most dramatic increase in in-hospital death rate and the sharpest reduction in length of hospitalization. This may raise concerns about cost effectiveness of the new therapeutic strategies to manage TBI.

In the past decade, evidence has accumulated for new treatment modalities for the management of acute TBI, to improve outcome. This resulted in the publication of the National Institute for Health and Clinical Excellence (NICE) guideline on brain injury (2007) that incorporated the new therapeutic strategies and focused on early management of TBI. The NICE guidelines reflected the tendency to use more resources to diagnosis and manage TBI. In addition, new intensive care unit (ICU) strategies have been implemented to manage TBI complications such as diffuse axonal injury and cerebral perfusion dysfunction.

The shift toward hospitalization of more severe TBI patients in the past decade and the availability of new therapeutic resources, as well as guidelines to help use these resources, may explain the dramatic increase in average TBI charges despite the reduction of average hospitalization length of stay.^3,10 The improvement of pre-hospitalization interventions may have inflated the number of patients with severe TBI who survived the initial trauma. It may also have inflated the number of mild or moderate TBI patients with other coexisting traumatic injuries. The charges reported in our study are total charges of hospitalization, and as such, include inpatient treatment related to other complication not directly related to TBI. Coexisting injuries aggravated by the severity of trauma may have inflated TBI charges in 2006–2007.

The global cost of TBI is not limited to the cost of acute treatment during hospitalization, but extends to the cost of rehabilitation and loss of productivity associated with TBI-related disability and death. The cost effectiveness of the new therapeutic strategies used during 2006–2007 cannot be evaluated based on hospitalization charges, death rates, and length of hospitalization during the acute treatment period only, but should include the long-term effect of these strategies on the cost of disability, rehabilitation, and premature death. The NIS Database cannot shed the light on patient's long-term outcome and does not include longitudinal follow-up of studied patients. The increase in hospitalization charges and death rates in 2006–2007 compared with those in 1993–1994 should be interpreted with caution.

Limitations

Our analysis has several limitations. First, our study is a retrospective analysis of NIS data that did not include comorbid conditions, pre-hospital care, and pre-injury functional status. Only the primary diagnosis was reported in the NIS database during the 1993–1994 time period, and no other complications or secondary diagnoses were reported. Second, the study subjects were identified on the basis of ICD-9-CM coding for the diagnosis on patient discharge. Limitation in the accuracy and consistency of coding among different institutions participating in the NIS database may occur during the studied periods.^3,22,23 Third, to determine TBI severity, we relied on ICDMAP-90 software, which may have inaccurate, inconsistent, or incomplete coding of TBI severity.^4,24 However, these limitations do not appear sufficient to explain the dramatic increase in average hospitalization charges in all TBI categories and the sharp decline in the rate of mild TBI hospitalizations.

Conclusion

In conclusion, our study provided in-hospital outcomes and hospitalization charges of adult patients with TBI according to severity. Our study suggested a significant increase in average hospitalization charges and in-hospital death rates, with reduction in average length of stay in 2006–2007 compared with 1993–1994. Further longitudinal and prospective studies are needed to fully assess the cost effectiveness of the current management of TBI, and should include the impact of new TBI therapeutic strategies on disability and long-term care, in addition to the cost and outcomes of acute TBI care.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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