Use the prepared TBI PowerPoint slides to include TBI data in your next presentation, or as a resource to understand more about TBI in NC.

These slides give a state-level overview of TBI and can be used to:

• Understand which groups are most impacted by TBI, where TBIs are occurring and how TBI has changed over time in NC.
  • Slides include information on TBI deaths, hospitalizations and ED visits, with specific data on the causes of TBI, like self-inflicted injuries, falls and motor vehicle traffic injuries.
  • The slides were created to provide basic data trends and
    public health surveillance

    public health surveillance

    The systematic, ongoing collection, management, analysis, and interpretation of data.

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    around TBI.
• Incorporate TBI data into your own presentations, grant proposals, reports or any other way they may be useful.
  • Each slide includes detailed notes explaining the information on the slide.
  • Technical notes are included to help with understanding and presenting data.

Use these fall-related TBI maps to compare rates of unintentional fall injuries and deaths that also involved TBI across NC counties.

TBI is a common condition surrounding fall injuries, with many fall injuries resulting in a TBI.

• Know where TBI-related fall injuries are happening in the state.
  • Compare rates of TBI-related fall injuries by county. For more information on comparing injury rates, visit Understanding Counts and Rates.
  • Focus prevention and response activities to areas of the state that are most impacted by fall injuries and TBI.
• Maps include data over the most recent five-year period.
• Maps are available for TBI related fall injury deaths, hospitalizations and ED visits.

Use the TBI Special Emphasis Report for more detailed data about the cause of TBI and the groups most impacted by TBI in NC.

• Describes the impact, magnitude and causes of TBI deaths, hospitalizations and ED visits
• Compares TBI by age and sex, and across race/ethnic groups
• Includes strategies for TBI prevention and activities related to TBI taking place in NC

Use the Mental Health Dashboard to view ZIP, county and state-level ED visit trends for select mental health-related conditions, including TBI.

• Includes data on ED visits with ICD-10-CM codes for mental health-related conditions, including two indicators for TBI.
  • Standard TBI Indicator – Aligns with what IVPB and CDC use to monitor TBI
  • Broad TBI Indicator – Includes an additional ICD-10-CM code for unspecified head injury (S09.90)
    • This indicator offers a broader view of overall TBI risk.
    • There are almost four times as many ED visits for unspecified head injury as there are for TBI.
    • This indicator should be used alongside the Standard TBI indicator.
    • See What Should I Know Before Using TBI Data? for more information on unspecified head injury.
  • Other Mental Health Indicators – Includes indicators for anxiety, depression, self-inflicted injury, suicidal ideation, and trauma and stressors
• Monitors trends in ED visits for mental health-related conditions annually from 2017 through the most recent complete year of data at multiple geographic levels.
  • Includes data by sex, age group, race and ethnicity.
• Summarizes insurance coverage for mental-health ED visits by county.

Use the Catastrophic Sports Injury and Illness Prevention Workgroup Report (PDF) to understand causes and prevention opportunities for catastrophic sports injury and illness and to guide safety planning.

• Catastrophic injury or illness are sports-related injuries and conditions that directly result in death or permanent disability or are life-threatening. Some examples include spinal cord injury, severe TBI, heat stroke and sudden cardiac arrest.
• The Workgroup Report describes the assessment activities of the Catastrophic Sports Injury and Illness Prevention Workgroup related to catastrophic sports injuries and illness among children in NC.
• Visit the National Center for Catastrophic Sports Injury Research to report catastrophic sports injury and to learn more about ongoing efforts in this area.

This dashboard is produced through a collaboration between NCDHHS’ Division of Mental Health, Developmental Disabilities and Substance Use Services and Division of Health Benefits.

Use NC Medicaid TBI Dashboard for data on Medicaid and state-funded program services used by people with a TBI diagnosis.

• Includes data on the number of eligible adults who have received services for TBI.
  • Describes the demographic breakdown of those receiving services, including data by age, race, ethnicity and gender.
  • Data are also summarized by the specific services received and the programs people are enrolled in.
• Data in the dashboard are updated twice a year to provide the most recent data available on services for TBI.

Use NC Behavioral Risk Factor Surveillance System data and NC Youth Risk Behavior Survey data to understand self-reported experiences with TBI.

• NC BRFSS asks adults in NC about their experiences with losing consciousness throughout their lifetime.
  • Questions included in the survey alternate from year-to-year and may change over time.
  • The NC State Center for Health Statistics provides all questionnaires and survey results from the NC BRFSS on the NC BRFSS website.
• YRBS asks middle and high school students in NC about how many times they have experienced a concussion from playing sports or being physically active.
  • The survey is implemented every other year, and questions included in the survey may change over time.
  • Visit NC Healthy Schools Data for YRBS data.
• For more information on considerations when using survey data to understand TBI, visit What Should I Know Before Using TBI Data?
• For more information about NC BRFSS and NC YRBS data, visit Data Sources IVPB Uses for Injury Surveillance.

Who Is Included in TBI Data?

TBI data are limited to NC residents.

Residence describes the area where someone has reported that they live.

• Limiting to residents allows for rate calculations using NC resident population estimates.
  • This ensures that the information used to calculate rates is consistent.
  • Limiting to residents allows for more accurate comparisons across groups and between counties.
• Limiting to residents excludes people that experience a TBI in a given county but are not residents of that county.
  • Someone living in a county, but who has not yet updated their residence status to that county would also be excluded.

Differences in Injury Location and Residence

Where a TBI occurs or where a TBI is treated can be different from where a person lives.

• This is especially true in rural areas where a single hospital or health care facility may serve a large area across multiple counties.
• Someone may experience a fall injury in one county and then be transported to and treated in a hospital in another county.
  • This transfer of care to another county is common for people with serious injuries that require treatment at a designated trauma center.
• This difference is not shown in the IVPB TBI data because these data are normally based on residence rather than injury location.

For more information, visit Understanding Injury Surveillance Case Definitions.

What Is Counted in TBI Data?

IVPB data include TBI that results from any form of injury.

• TBI can be caused by a bump, blow, jolt or penetration to the head that disrupts the normal function of the brain.
  • This is normally caused by another type of injury, like a firearm injury, fall or motor vehicle traffic injury.
• IVPB data include TBIs caused by all mechanisms and intents of injury.
  • For more information on intent, visit Injury Mechanism and Intent.
• The specific causes of TBI are also monitored to understand how TBI happens and help inform TBI prevention.

IVPB data include TBIs that are treated in a hospital setting or that result in death.

Non-fatal fall injury data do not capture:

• TBI treated outside of the ED or hospital
  • This can include TBI treated at urgent care clinics, by primary care providers or by other health care providers.
• TBI where someone does not seek medical care or that are treated at home
  • Symptoms of TBI may not appear right away and may contribute to people not seeking medical care.
  • While data are not available to show exactly how many of these TBIs occur, IVPB does use survey data to understand how many people report being knocked unconscious.
• TBIs that may be missed or misdiagnosed
  • Symptoms of TBI can be similar to other medical conditions that are common among older adults, like dementia, and may not be identified as a TBI.¹
• Severity of TBI
  • IVPB cannot directly measure how severe TBIs are from the datasets we use.
  • Differentiating data by data source (deaths, hospitalizations and ED visits) can provide some insight but is not sufficient alone to fully understand TBI severity.
• Consequences of TBI
  • While some TBI can lead to short-term health problems, others like TBI during childhood can impact brain development or have other long-lasting impacts.¹
• IVPB is not able to monitor the long-term impacts of TBI
  • TBI can put someone at risk of experiencing additional injuries or injury-related death, including falls, self-inflicted injuries, overdose or another TBI.^2-4
• These subsequent injuries would be identified in IVPB data if they were treated in a hospital or resulted in death but may not be documented as being related to a previous TBI.

What Else is Measured to Monitor TBI Risk?

IVPB also monitors hospitalizations and ED visits for unspecified head injury.

• This includes any record with an ICD-10-CM code for unspecified head injury (S09.90) that does not also include a code for a diagnosed TBI.
• TBI indicators that include unspecified head injury should be used along with the standard TBI indicator for a more complete understanding of TBI.
  • Unspecified head injury is not included in the TBI indicator to more accurately identify changes in TBI trends over time.
  • There are almost four times as many ED visits for unspecified head injury as there are for TBI.
  • Using a combined indicator of unspecified head injury and TBI without also considering the TBI indicator alone can inflate TBI numbers and mask changes over time.
• Monitoring unspecified head injury alongside TBI helps provide a broader view of overall TBI risk.

No single data source captures the full scope of TBI in NC. Data sources should be used together to more fully understand the statewide impact of TBI.

For more information on a specific data source, visit Data Sources IVPB Uses for Injury Surveillance.

TBI-Related Death Data

IVPB uses vital statistics death certificate data to monitor TBI-related deaths.

• TBI-related deaths include deaths caused by an injury where TBI was listed as an underlying cause of death.
  • Primary causes of death are the injuries or conditions that directly resulted in the death.
  • An underlying cause of death is an injury or condition that started the chain of events that led to the primary cause of death (directly or indirectly).
• Causes of TBI are identified using the primary cause listed on the death certificate.
• TBI and causes of TBI are identified in the death certificate data using ICD-10 codes.
  • For more information, visit Understanding Injury Surveillance Case Definitions.

TBI-Related Hospital Discharge Data

Hospital discharge data are encounter-based, meaning that the same person may have multiple hospital stays during any given time period.

Identifying unintentional TBI-related hospitalizations.

• ICD-10-CM codes are used to group and classify diagnoses and reasons for health care visits in administrative health care systems, including hospital discharge data.
  • ICD-10-CM codes are intended for administrative and billing purposes, not
    public health surveillance

    public health surveillance

    The systematic, ongoing collection, management, analysis, and interpretation of data.

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    .
    • This purpose can affect which codes are or are not assigned to a record and therefore which events are included or excluded as TBI cases.
  • For more information on ICD-10-CM codes, visit Understanding Injury Surveillance Case Definitions.
• TBI-related hospitalizations include injury hospitalizations that have an ICD-10-CM code for TBI included anywhere in the record.
  • Injury hospitalizations are required to have an ICD-10-CM code for an injury listed as the primary diagnosis.
• IVPB does not exclude hospitalizations that result in death.
  • Including hospitalizations resulting in death helps to understand the full burden of TBIs and other injuries on the NC health care system.
• For more detailed information on how these cases are identified, see Injury Surveillance Technical Notes.

Costs of TBI-related Hospitalizations

Hospital discharge data include information on the total charges from the hospital stay as billed.

• This information can be used to understand the financial costs related to TBI-related hospitalizations.
• The total charges billed is not necessarily the same amount that was paid for the hospital visit.
  • Insurance companies typically negotiate to lower rates for hospital charges.

TBI-Related ED Visit Data 

ED visit data are encounter-based. The same person may have multiple ED visits during any given time period.

Data Quality

• Trends may be impacted by missing data.
• There were changes in the number of people going to the ED for any reason (ED utilization) during the COVID-19 pandemic.
  • See the TBI and COVID-19 section below for more information.

Identifying TBI-related ED Visits

ICD-10-CM codes are also used to identify ED visits for TBI. For more information on ICD-10-CM codes, visit Understanding Injury Surveillance Case Definitions.

• ED visits with an ICD-10-CM code for a TBI anywhere in the record are included.
• IVPB does not exclude ED visits where the patient is admitted to the hospital or visits that result in death.
• Some ED visit case definitions, called syndromes, also search the chief complaint and/or triage notes fields for keywords to head injury-related ED visits.
  • Because these definitions also use keywords, they identify more ED visits than when using ICD-10-CM codes alone.
  • The two main TBI ED visit syndromes look at ICD-10-CM codes alone.
• For more detailed information on how these cases are identified, see Injury Surveillance Technical Notes.

ED Visits with Multiple ICD-10-CM Codes

Some TBI-related ED visits may receive ICD-10-CM codes that identify multiple causes of the TBI, in addition to the TBI code itself. Visits may also include ICD-10-CM codes for other injuries that were not the cause of the TBI.

Multiple Mechanisms of Injury

• For records with a code for TBI, there may be codes to describe multiple types of injuries. For example, an unintentional fall and an unintentional striking injury (being struck by or against an object).

Multiple Injury Intents

• For records with a TBI code, there may be codes to describe multiple types of injury intents, for example an unintentional striking injury and a striking injury from an assault.
  • The ICD-10-CM coding guidance defaults to classifying most injuries as unintentional.
  • Because of this, multiple codes may be used to document different aspects of the ED visit, which can contribute to conflicting or inconsistent coding.

Multiple Mechanisms and Injury Intents

In some instances, records with a TBI code may have multiple injury codes with conflicting intent information, like a code for an unintentional fall injury in addition to a code for a striking injury from an assault.

A visit with multiple ICD-10-CM codes is counted once in each mechanism and intent category that applies to that ED visit, but only as one TBI-related injury ED visit and only once in the total number of injury ED visits.

For example:

• A TBI-related ED visit that had a code for both an unintentional fall and an unintentional striking injury would be counted one time each in:
  • The total number of unintentional injury ED visits
  • The total number of fall injury ED visits
  • The total number of struck by or against ED visits
  • The total number of TBI-related ED visits
  • The total number of injury ED visits
• Similarly, if multiple types of injuries were identified, that had different mechanism and intent categories, such as a code for both an unintentional fall injury and a striking injury from assault, it would be counted once in each category:
  • The total number of unintentional injury ED visits
  • The total number of assault ED visits
  • The total number of fall injury ED visits
  • The total number of struck by or against injury ED visits
  • The total number of TBI-related ED visits
  • The total number of injury ED visits

Survey Data

IVPB uses data from the NC Behavioral Risk Factor Surveillance System (BRFSS) and the NC Youth Risk Behavior Survey (YRBS) to understand the self-reported experiences of TBI.

• Survey data can provide more context on the burden of TBI in NC and can be used to understand connections to other health behaviors, and risk and protective factors. Survey data can provide more context on shared risk and protective factors associated with MVT injury in NC and can be used to understand connections to other health behaviors.

NC BRFSS Data

• The NC BRFSS surveys adults living in NC about behaviors and experiences that impact their health. TBI-related questions have included:
  • If someone has been knocked out or lost consciousness during their lifetime
  • If so, how long they were knocked out or unconscious
  • How old they were the first time they were knocked out or lost consciousness

NC YRBS Data

• NC YRBS surveys middle and high school students in NC to assess youth behaviors that impact their health and includes a question about TBI.
  • The survey asks students how many times they have experienced a concussion from playing sports or being physically active.

Visit Data Sources IVPB Uses for Injury Surveillance for more information on how IVPB uses NC BRFSS and YRBS data.

Considerations For Using Survey Data

Survey data are self-reported and may show different results from what people are actually experiencing. Survey data related to TBI can be affected by:

• Social Desirability Bias – People may report experiencing fewer TBIs than they actually do or may report not experiencing them at all when they have.
  • People may be embarrassed by or not want others to know about these behaviors.
  • People may respond with what they think will make them look good.
• Recall Bias – People may forget how many times they experienced a TBI or not recognize how severe the event was upon reflection.
• Nonresponse Bias – People may not respond to the survey questions about TBI.
  • They may choose to skip the question.
  • Some respondents may have stopped taking the survey before getting to that question.
  • They may choose not to participate in the survey at all.

TBI case definitions have not changed much over the years.

If changes are made, they are also applied to historical data whenever possible.

• Changes are applied retroactively so that data can be counted the same way across multiple years of data.
  • This allows IVPB to accurately monitor trends.
• Because of this, data IVPB shared before a change was implemented can be different from data shared for the same time-period today.
  • Use the data resources posted to the Traumatic Brain Injury Data webpage to be sure you are accessing the most up-to-date information on TBI in NC.
  • If you have questions about data you have received from IVPB previously, email us at InjuryData@dhhs.nc.gov.

Unspecified Head Injury

• Unspecified head injury was removed from the TBI case definition after the ICD-10-CM coding transition.
  • A new TBI indicator including ICD-10-CM code S09.90 for unspecified head injury was created to continue monitoring ED visits and hospitalizations that include unspecified head injury.
  • TBI indicators that include unspecified head injury should be used along with the standard TBI indicator for a more complete understanding of TBI.
• Removing unspecified head injuries caused an artificial drop in the overall number of TBI events identified before and after the ICD-10-CM transition.
  • The current definition that excludes unspecified head injuries more specifically captures events related to TBI.
  • See "What Is Counted in TBI Data?" for more information on unspecified head injury.

There have been many implications from the COVID-19 pandemic that began in 2020, including major changes to the numbers and rates of TBI and related health outcomes.

• TBI deaths have increased since the start of the pandemic.
• There were large impacts to ED visits during the pandemic.
  • There was a large drop in the number of people going to the ED for any reason (ED utilization) starting in March 2020 when the COVID-19 stay-at-home order was implemented.
• All sports were halted and the rules of contact sports were revised during the pandemic. This resulted in a decrease in sports-related TBI injury.
• Changes to TBI in NC align with trends seen across the United States during the pandemic.

Who we count — and how — changes what we know about traumatic brain injury.

The most reliable way to collect information on race and ethnicity is when it is self-reported, where individuals choose the race and ethnicity they use to describe themselves.

Asking someone to report their own race and ethnicity ensures the data are accurate.

• In some cases, race and ethnicity may not be self-reported and may instead be assigned based on someone’s name or their appearance.
• This is most likely to happen if the person was unresponsive when EMS responded or when they arrived at the ED.
• This assumption can result in misclassification of race and ethnicity, when someone is categorized into a racial or ethnic group with which they do not identify.

For more information on how race and ethnicity are collected in the data sources IVPB uses, and how IVPB groups race and ethnicity, visit Using Injury Data by Race and Ethnicity.

Monitoring TBI by Demographic Groups

IVPB uses rates to compare the burden of TBI across groups, including by age group, sex and race/ethnicity.

• This approach allows IVPB to identify groups that are experiencing the greatest burden of TBI.
  • IVPB regularly breaks out data to consider differences in TBI injuries by sex, age group, race/ethnicity and county.
  • Rates account for the size of the population and allow us to compare injuries that happened in small populations to injuries in larger groups.
  • Comparing rates helps us understand differences in MVT injuries between groups.
  • For more information, visit Understanding Counts and Rates.
• When data are broken out for specific groups, results may need to be suppressed if there are very few TBIs within a given group.
  • When the number of injuries or deaths is small, it becomes difficult to separate data further to understand more specifically who was impacted.
  • Visit Data Suppression and Working with Small Numbers.