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. Death Certificates “Abdominal and head injuries”
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”

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
Strengths
Public data
Often have perpetrator and circumstances
Weaknesses
Voluntary system
Limited detail
Victim: 1 year old female, Asian, Non-Hispanic Offender: 54 year old female, white, Non-Hispanic Weapon: [blank] Relationship: Day care provider Circumstance: Victim violently shaken, causing shaken baby syndrome

13. Femicide Report Strengths Weaknesses 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. Newspaper Clippings Strengths
Public data
Often have perpetrator and circumstances
Weaknesses
Not all cases obtain coverage
Cost/time
“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. Minnesota Hospital Association
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

18. TBI/SCI Registry Strengths Weaknesses
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).”

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 Rates MN, 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
66% boys
82% under 1
Note: Information available only for TBI Registry and abstracted cases

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

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

31. Hospital Charges, MN,1999-2001 iTBI, Inpatient Hospitalizations (n=66)
CM, Inpatient Hospitalizations (n=58)
CM, ED Treated (n=110)
Mean
$36,219
$9,361
$776
Median
$20,234
$5,461
$310
Sum
$2,390,476
$541,912
$85,573
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.