Utah geriatric head injury and in-hospital death

1. Utah Geriatric Head Injury
and In-Hospital Death
From Utah Statewide Trauma Registry 2008-2015
June 12, 2017 - Trauma System Advisory Committee Meeting
Yukiko Yoneoka, BEMSP, Utah Department of Health

2. Geriatric head injury and In-Hospital Death:
Why analyze Utah Statewide Trauma Registry (UTR) data?
To find out
 Prevalence of geriatric head injury in Utah
 Characteristics of head injury patients
 Who is at risk of dying in hospital after head injury

3. Geriatric head injury: Definition
• Primary cause Ecode 880-888 (Accidental fall)
• In ICD9_1 to ICD9_10 fields: 800 -800.99, 801-801.99, 802.6-802.7, 803-
803.99, 804-804.99, 850-850.9, 851-851.99, 852-853.19, 854-854.19, 873-
873.9, 950-950.9, 951-951.9, 959.01
• Age 65+

4. Prevalence of Geriatric head injury in Utah
• Census estimate for 2015 Utah population is 2,995,919.
• Of those, estimated proportion for geriatric population (age 65+) is 10.3%.
• Fall data was included in UTR in 2008.
• There are 93,826 patients in UTR between 2008 and 2015.
• 35.7% (33,522) of them are geriatric patients.
• 86.8% (29,110) of geriatric patients in UTR had a fall.
• 96.8% (28,187) of geriatric falls in UTR are accidental falls.
• 23.7% (6,685) of UTR geriatric patients who had accidental falls had head injury.
• Of those, 7% (469) died in hospital.

5. Head injury Patients: Head injury incidents
and in-hospital deaths by age
0
50
100
150
200
250
300
350
65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100101102104
Number of geriatric head injury patients and in-hospital death by age
Head Injury Death
There are two peaks
for head injury deaths -
Around age 80 and age
87.
Head injury incidents
increase after age 75,
peak around age 83–85,
then taper down there
after.

6. Head injury Patients: Outcome by sex
More males
seem to die
after head
injury94.5%
91.0%
5.5%
9.0%
85%
90%
95%
100%
Female Male
Head injury outcome by sex
Alive Dead

7. Head injury Patients: All and deceased
Mean Age, ISS, and TRISS
Deceased head injury PatientsAll head injury Patients
Male Female
Mean Age 79.2 81.0
Mean ISS 13.5 11.9
Mean TRISS 89.9% 92.5%
Male Female
Mean age 80.5 82.6
Mean ISS 19.7 19.0
Mean TRISS 69.5% 72.2%
Males are younger than females
with higher ISS and lower TRISS score.
Males are younger than females with lower TRISS
score. ISS for both deceased males and females are
significantly higher than that of all patients.
Deceased
patients
are older than
all patients.

8. Head injury Patients: All and deceased - ISS by sex
Males have higher ISS than females

9. Head injury Patients: All and deceased - Comorbidity by sex
There are some variabilities in comorbidities
between all and deceased patients and two sexes
All patients
Male - Diabetes, bleeding disorder,
heart disease, obesity, smoker,
cancer, kidney disease, alcohol
abuse.
Female - Hypertension, dementia,
need_assist, psychiatric disease.
Deceased patients
Male – Bleeding disorder, diabetes, heart disease,
obesity, kidney disease, alcohol abuse.
Female – Hypertension, DNR, cerebrovascular,
dementia, psychiatric, cancer, sensorium, need_assist,
smoker, liver disease.

10. 89.3%
91.4%
97.5% 97.0% 96.7%
98.1% 98.2%
10.7%
8.6%
2.5% 3.0% 3.3%
1.9% 1.8%
85%
90%
95%
100%
Level 1 Level 2 Level 3 Level 4 Level 5 CAH Resource
Outcome by Trauma center Level
Alive Dead
Total #
Hospitals 2 4 5 12 3
Total #
patients 2,122 2,115 870 714 30 53 622
Head injury Patients: Outcome by trauma center level
Head injury patients go to Level 1 or Level 2, therefore
more deaths at those trauma centers

11. Head injury Patients: All and deceased
- Percentage of transferred-in patients
Level 1 and level 2 are the destinations for head injury transfer patients
49.7%
25%
0.9% 1% 0% 0% 0.3%
39.5%
29.3%
0%
4.5%
0% 0% 0%
8.5% 9.7%
0%
14.2%
0% 0% 0%
0%
10%
20%
30%
40%
50%
60%
Level 1 Level 2 Level 3 Level 4 Level 5 CHA Resource
Percentage of transferred-in patients in all and deceased head injury patients
per trauma center level
plus percentage of deaths within transferred-in patients
%Transferred-in among all HI patients %Transferred-in among deceased HI patients
Transferred-in patients consisted 39.5% of all deaths after head injury
for level 1, and 29.3% for level 2. However, within the transferred

12. Head injury and In-Hospital Death: Who is at risk?
Variables used for logistic regression
Dependent variable
• Outcome: Alive or Dead
Independent variables
• Age (old 65-74, older 75-84, oldest 85+ )
• Sex (female, male)
• ISS (not severe 1-15, sever 16-75)
• TRISS score ( <=50%, >50% )
• Transfer (transferred, not-transferred)
• Trauma center level (level 1 to level 5, CAH, resource, obsolete)

13. head injury and In-Hospital Death: Who is at risk?
Variables used for logistic regression (cont.)
Independent variables (cont.)
• Comorbidity from risk_type1 to risk_type3 fields
ADD_ADHD ALCOHOL NEED_ASSIST BLEEDING
BLOOD_CIRC HYPERTENSION CONGENITAL DEMENTIA
DNR DRUG_ABUSE ESOPHVAR FLUID_ACCU
HEART_DISEASE
(included CHF, MI, Angina)
CANCER
(included Chemo therapy)
KIDNEY_DISEASE
(included dialysis)
LIVER_DISEASE
OBESE OTHER_RISK PSYCHIATRIC RESPIRATORY
SENSORIUM SMOKER STEROIDS STROKE

14. head injury and In-Hospital Death: Who is at risk?
Final model – 13 risk factors affect death (P < 0.05)

15. Head injury and In-Hospital Death: Who is at risk?
Final model – Odds ratio and 95 confidence limits for 12 risk factors
• Odds ratio (Estimate) 1 = No difference
• More than 1 = Increased risk
• Less than one = Protective against death
• 95% confidence intervals should not contain
1 in between to be statistically significant
*Lower 95%CI for Respiratory disease is considered as 1.
Since level 1 and level 2 have most of head injury
patients and deaths, we disregard the protective effects of
other trauma center levels.
Thus we now have 12 risk factors.
*

16. *
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17. Head injury and In-Hospital Death: Who is at risk?
Findings 1-4 of 12
• Females are 28% less likely to die after head injury compared to males. (Note: Males tend to have higher ISS.)
• Older age group (75-84) is about 35% more likely to die compared to old age group (65-74) after head injury. Oldest
age group (85+) is 2 times more likely to die after head injury compared to age group (65-74).
• Head injury patients with ISS 16-75 are about 4.6 times more likely to die than those who with ISS 1-15.
• Transferred-in patients are about 40% less likely to die after head injury compared to not-transferred patients.

18. Head injury and In-Hospital Death: Who is at Risk?
Findings 5-8 of 12
• Those who had TRISS score greater than 50% are about 81% less likely to die after
head injury compared to those who had TRISS score less than 50%.
• Those who had cancer are about 80% more likely to die after head injury
compared to those who did not have cancer.
• Those who had dementia are about 42% less likely to die after head injury
compared to those who did not have dementia (Note: This may be because more
females have dementia than males?)
• Those who had DNR are about 2.6 times more likely to die after head injury
compared to those who did not have DNR. (Note: This makes sense. The older,
the more DNR they had.)

19. Head injury and In-Hospital Death: Who is at risk?
Findings 9-12 of 12
• Those who had heart disease are about 70% more likely to die compared to
those who did not have heart disease.
• Those who had kidney disease are about 50% more likely to die after head
injury compared to those who did not have kidney disease.
• Those who had respiratory disease are about 40% more likely to die after
head injury compared to those who did not have respiratory disease.
• Those who smoked are about 60% less likely to after head injury compared to
those who are not smokers. (Note: Have no explanations for this.)

20. Head injury and In-Hospital Death: Who is at risk?
Summary
Patient risk factors
• Severe injury (ISS >15)
• TRISS score <= 50%
• Age 75 -84, 85 and older
• Male
• Have heart disease, cancer,
kidney disease, respiratory
disease
Other risk factors
• DNR
Protective factors
• Transferred to level 1 or level 2
Other protective factors (conundrum!)
• Smoker
• Dementia

21. Questions?
• Yukiko Yoneoka
• Data Analyst
• Bureau of Emergency Medical Services and Preparedness (BEMSP)
• Utah Department of Health
• yyoneoka@utah.gov