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What is already known?
Traumatic brain injury is the leading cause of disability worldwide.
Falls are the most common cause of traumatic brain injuries in children.
What this study adds?
Transportation-related and suspected non-accidental injuries increase the average acute costs of mild traumatic brain injuries in children.
Falls and sports-related injuries lower the average acute costs of moderate and severe traumatic brain injuries in children.
INTRODUCTION
Traumatic brain injury (TBI) in children is the leading cause of disability and is associated with a significant burden of disease globally.1 Population-based studies reporting the incidence of TBI in Australia have focused on hospitalised patients.2 Most paediatric head trauma results in mild TBIs that do not require hospitalisation.1 In Australia, a 13% increase in emergency department (ED) presentations for paediatric head injuries were reported between 2014 and 2018.3
The most common mechanisms of head injuries are falls for children less than 11 years and transportation-related injuries for children 11 to 16 years.2 While falls are the most common mechanism of head injury in children and can be associated with the most long-term costs, transportation-related TBIs incur high acute care costs, with pedestrian injuries having the highest mean per-patient cost.2 3 This research estimates the effect of mechanisms of injury and severity on the acute care costs of TBI in children.
Methods
A planned subanalysis of children <18 years enrolled in the prospective multicentre Australasian Paediatric Head Injury Study (APHIRST) between 2011 and 2014. The study was designed to validate clinical decision rules for the diagnosis of TBI in children.4 The eight participating sites were all government-funded large tertiary hospitals.
The standard definition of acute care was used, including emergency presentations with discharge and acute admissions until hospital discharge. Common mechanisms of head injuries were identified a priori and were recorded at the time of patient enrolment in the APHIRST study. Transportation-related injuries included occupants in motor-vehicle collisions, high speed (>60 km/h), and pedestrians or bicycle riders struck by motor vehicles.3
TBI is commonly classified as mild, moderate and severe, with variations in definitions across studies. TBI severity was dichotomised as mild and moderate/severe due to the relatively small numbers in the severe TBI category. Mild TBI was defined as Glasgow Coma Scale (GCS) scores 13–15 on ED presentation, no neurological deficits, with negative cranial CT or MRI if performed. Moderate and severe TBI included all the other patients, with either GCS scores <13, or GCS 13–15 with neurological deficits, or evidence of TBI on cranial CT or MRI.
Hospital costs
The costing analysis was conducted from a publicly funded healthcare perspective, applying hospital costs for paediatric head injuries to patient-level data of the Australian cohort. Using the International Classification of Diseases 10th revision–Australian Modification (ICD-10-AM) codes of the patients enrolled in the APHIRST study, we retrospectively obtained direct and indirect hospital costs of ED visits and acute admissions for calendar years 2011 to 2014. The details of the costing methodology and data inputs have been published.3
All costs were inflated to 2018 Australian dollars using the Reserve Bank of Australia general consumer price index rates from 13 September 2019 and presented as pounds sterling with the average exchange rate of UK £0.60 from 30 June 2018.
Statistical analysis
We estimated the effects of individual injury mechanisms and TBI severity on the mean per-patient costs using generalised linear models with log link and gamma family specifications adjusting for age and sex. Results were reported as the adjusted mean per-patient acute care costs and cost ratios with 95% CIs; p<0.05 was considered statistically significant. Cost ratios compare the adjusted mean per-patient costs of individual injury mechanisms with all other mechanisms combined. Data analysis was performed with Stata (V.15; StataCorp, College Station, TX).
Results
Of the 20 137 children in the APHIRST study, 17 841 (89%) were enrolled across eight EDs in Australia. The mean age was 5.7 years (SD 4.7 years), the median age of 4.1 years (IQR 1.9–9 years), and 64% were male. The total acute care costs were £10.7 million, with a mean per-patient cost of £599 (95% CI £535 to £662). Mild TBIs occurred in 96.3% of children and accounted for 57% of acute care costs (£6.1 million), with a mean per-patient cost of £357 (95% CI £344 to £370). Moderate and severe TBIs were associated with a mean per-patient cost of £6927 (95% CI £5312 to £8544). Severe TBI (GCS scores ≤8) occurred in 0.61% of the cohort and accounted for 26% of acute care costs (£2.7 million), with a mean per-patient cost of £25 136 (95% CI £18 656 to £31 617).
TBI severity and mechanisms of injury
Mild TBIs from falls occurred in 70% of the cohort and were associated with 36% of the total acute care costs (table 1). Moderate/severe TBIs from transportation-related injuries occurred in less than 1% of the cohort and accounted for 27% of the total acute care costs. The impact of individual injury mechanisms on the adjusted mean per-patient costs by TBI severity is reported in table 2. Cost ratios >1.0 indicate higher cost, and <1.0 indicate lower cost relative to all other injury mechanisms. For mild TBIs, the cost ratios were significant for falls (0.80, 95% CI 0.75 to 0.86), suspected non-accidental (4.3, 95% CI 2.5 to 7.4) and transportation-related injuries (4.5, 95% CI 3.9 to 5.1). For moderate/severe TBIs, the cost ratios were significant for falls (0.24, 95% CI 0.17 to 0.33), sports activities (0.31, 95% CI 0.21 to 0.45) and transportation-related injuries (7.4, 95% CI 5.4 to 10.2).
Adjusted mean per-patient acute care costs* for injury mechanisms by TBI severity†
Cost ratios of injury mechanisms by TBI severity*
Discussion
Cost-of-illness studies provide estimates of the economic burden of disease. Mild TBIs from falls were associated with the highest total acute care costs from the far greater numbers of children with falls. This may be related to the increased public awareness of concussions and thus increased ED presentations for minor falls and sports-related injuries. Since most of these patients are discharged from the ED, our results capture a broader spectrum of TBI when compared with population-based datasets of hospitalised children.2 3
Head injury mechanisms and TBI severity affect the acute care costs of paediatric head trauma. For mild TBIs, the adjusted mean per-patient acute cost of transportation-related injuries was four times higher than the cost of all other injury mechanisms combined and seven times higher for moderate/severe TBIs, especially with high speed and pedestrians struck by motor vehicles. Lower socioeconomic status and children’s inability to assess danger are associated with higher pedestrian injuries.5 The introduction of autonomous emergency breaking in new vehicles, speed cameras to enforce lower speed limits, improving traffic light density, and strategies to restrict mobile phone use during driving are some initiatives to reduce traffic casualties.3
This study has several limitations. We focused on the acute care hospital costs and did not take a societal perspective, including the indirect costs for families of children with TBIs. Further, we did not consider the costs associated with lifetime or long-term rehabilitation. There are limited data on the productivity loss for families and long-term care costs in children with TBIs. In Australia, approximately 50% of the total hospital costs for TBIs in children are associated with severe TBIs.2 We report a significant variation in the mean per-patient costs of mild TBIs, and further research is required to capture their long-term and societal costs.
Conclusion
This study highlights the differences in acute care costs of injury mechanisms by TBI severity. Transportation-related mild and moderate/severe TBIs are associated with significantly higher mean per-patient acute hospital costs. Injury prevention strategies should focus on road safety to reduce the burden of TBIs in children.
Data availability statement
All data relevant to the study are included in the article. Not applicable.
Ethics statements
Patient consent for publication
Ethics approval
The Human Research Ethics Committee of the Royal Children’s Hospital, Melbourne, Australia (31 008A) and the participating sites' institutional ethics committees approved this study.
Acknowledgments
We thank the participating families and emergency department staff at participating sites. We thank Meredith L Borland (Perth Children's Hospital, Perth, WA); Stuart R Dalziel (Starship Children's Health, Auckland, New Zealand and Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand); Ed Oakley (Royal Children's Hospital, Melbourne, VIC); Amit Kochar (Women's & Children's Hospital, Adelaide, SA); Natalie Phillips and Yuri Gilhotra (Queensland Children's Hospital, Brisbane, QLD); Sarah Dalton and Mary McCaskill (The Children's Hospital at Westmead, Sydney, NSW); Jeremy Furyk (The Townsville Hospital, Townsville, QLD); Jocelyn Neutze (Kidzfirst Middlemore Hospital, Auckland, New Zealand); Mark Lyttle (Bristol Royal Hospital for Children, Bristol, UK and Academic Department of Emergency Care, University of the West of England, Bristol, UK); Silvia Bressan (Department of Women's and Children's Health, University of Padova, Padova, Italy); and Louise Crowe (Murdoch Children's Research Institute, Melbourne, VIC) for their involvement with obtaining the data and prior data analysis.
Footnotes
Twitter @SoniaSinghPEM, @KimCreatif
Contributors SS conceptualised and designed the study, acquired the cost data, conducted the analysis, wrote the first draft of the manuscript, and reviewed and revised the manuscript. FEB conceptualised and designed the APHIRST study, coordinated and supervised data collection, contributed to data interpretation, and critically reviewed and revised the manuscript. SJCH had full access to the APHIRST data, analysed the data, contributed to data interpretation, and critically reviewed and revised the manuscript. LH, JSH, JAC, VA and KD contributed to the interpretation of the data, and reviewed and revised the article critically. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Funding The work was supported by grants from the National Health and Medical Research Council (project grant GNT1046727, Centre of Research Excellence for Paediatric Emergency Medicine GNT1058560), Canberra, Australia; the Murdoch Children's Research Institute, Melbourne, Australia (no award/grant number); the Emergency Medicine Foundation (EMPJ-11162), Brisbane, Australia; Perpetual Philanthropic Services (2012/1140), Australia; Auckland Medical Research Foundation (No. 3112011) and the A+ Trust (Auckland District Health Board), Auckland, New Zealand (no award/grant number); WA Health Targeted Research Funds 2013, Perth, Australia (no award/grant number); the Townsville Hospital and Health Service Private Practice Research and Education Trust Fund, Townsville, Australia (no award/grant number); and supported by the Victorian Government's Infrastructure Support Program, Melbourne, Australia (no award/grant number). SS was supported by an Australian Government Research Training Program Scholarship and a PREDICT CRE Research Higher Degree scholarship. FEB's time was partly funded by a grant from the Royal Children's Hospital Foundation and the Melbourne Campus Clinician Scientist Fellowship, Melbourne, Australia, and an NHMRC Practitioner Fellowship, Canberra, Australia.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.