Skip to main content Accessibility help
×
Home

Early Identification and Incidence of Mild TBI in Ontario

  • Won Hyung A. Ryu (a1) (a2) (a3), Anthony Feinstein (a4) (a5), Angela Colantonio (a2) (a6) (a3), David L. Streiner (a1) (a2) (a4) and Deirdre R. Dawson (a1) (a2) (a6) (a3)...

Abstract

Objectives:

(1) To examine the variability in diagnosis of mild traumatic brain injury (mTBI) in primary care relative to that of an expert reviewer; and (2) to determine the incidence rate of mTBI in Ontario, Canada.

Method:

Potential mTBI cases were identified through reviewing three months of Emergency Department (ED) and Family Physician (FP) health records. Potential cases were selected from ED records using the International Classification of Disease, 9th revision, Clinical Modification and External Cause codes and from all FPs records for the time period. Documented diagnoses of mTBI were compared to expert reviewer diagnosis. Incidence of mTBI was determined using the documented diagnoses and data from hospital catchment areas and population census.

Results:

876 potential mTBI cases were identified, 25 from FP records. Key indicators of mTBI were missing on many records (e.g., 308/876 records had Glasgow Coma Scale (GCS) scores). The expert reviewer disagreed with the documented diagnosis in 380/876 cases (kappa=0.19). The expert reviewer was more likely to give a diagnosis if the GCS was 13-14, if there was documented loss of consciousness and/or post-traumatic amnesia, and/or if there was pathology found on an acute brain scan. Calculated incidence rates of hospital-treated mTBI were 426 or 535/100,000 (expert review - hospital diagnosis). Including family physician cases increased the rate to 493 or 653/100,000.

Conclusion:

Health record documentation of key indicators for mTBI is often lacking. Notwithstanding, some patients with mTBI appear to be missed or misdiagnosed by primary care physicians. A more comprehensive case definition resulted in estimated incidence rates higher than previous reports.

RÉSUMÉ: Objectifs :

(1) Examiner la variabilité dans le diagnostic du traumatisme cérébral léger (TCL) en première ligne par rapport au diagnostic d’un réviseur expert et (2) déterminer le taux d’incidence du TCL en Ontario, Canada.

Méthode :

Nous avons identifié les cas potentiels de TCL par révision des dossiers du service des urgences et des médecins de famille sur une période de trois mois. Les cas potentiels identifiés à partir des dossiers du service des urgences au moyen de la Classification internationale des maladies, 9e révision, modification clinique et codes des causes externes, et de tous les dossiers des médecins de famille pour ces trois mois. Les diagnostics de TCL certains selon les dossiers ont été comparés aux diagnostics de l’expert réviseur pour ces mêmes cas. L’incidence de TCL a été déterminée d’une part au moyen des diagnostics certains et des données hospitalières des secteurs sanitaires et d’autre part du recensement de population.

Résultats :

Huit cent soixante-seize cas potentiels de TCL ont été identifiés dont 25 à partir des dossiers des médecins de famille. Des indicateurs clés d’un TCL étaient absents de plusieurs dossiers (par exemple 308/876 dossiers contenaient un score du Glasgow Coma Scale (GCS)). Le réviseur expert était en désaccord avec le diagnostic établi chez 380/876 cas (kappa = 0,19). Le réviseur expert était plus enclin à poser ce diagnostic si le score GCS était de 13 ou 14, si le patient avait perdu conscience et/ou avait présenté une amnésie post-traumatique et/ou si le scan cérébral effectué en phase aiguë était pathologique. Les taux d’incidence calculés pour les cas de TCL traités à l’hôpital étaient de 426 ou 535/100,000 (révision par l’expert - diagnostics hospitaliers). Si on inclut les cas des médecins de famille, le taux passait à 493 ou 653/100,000.

Conclusion :

Les indicateurs clés de TCL sont souvent absents des dossiers médicaux. Néanmoins, il semble que le diagnostic de TCL soit manqué ou qu’un diagnostic erroné soit posé par le médecin de première ligne. Une définition de cas plus complète a fourni des taux d’incidence estimés plus élevés que ceux rapports antérieurement.

    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Early Identification and Incidence of Mild TBI in Ontario
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Early Identification and Incidence of Mild TBI in Ontario
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Early Identification and Incidence of Mild TBI in Ontario
      Available formats
      ×

Copyright

Corresponding author

Kunin-Lunenfeld Applied Research Unit, Baycrest, 3560 Bathurst St., Toronto, Ontario, M6A 2E1, Canada

References

Hide All
1. Cassidy, JD, Carroll, LJ, Peloso, PM, Borg, J, von Holst, H, Holm, L, et al. Incidence, risk factors and prevention of mild traumatic brain injury: results of the WHO collaborating centre task force on mild traumatic brain injury. J Rehabil Med. 2004 Feb; 43 Suppl:2860.
2. Kurtzke, JF, Kurland, LT. The epidemiology of neurologic disease. In: Joynt, RJ, editor. Clinc Neurol. Philadelphia: J.B. Lippincott; 1993.
3. Alexander, MP. Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology. 1995 Jul; 45(7):125360.
4. Rutherford, WH, Merrett, JD, McDonald, JR. Symptoms at one year following concussion from minor head injuries. Injury. 1979 Feb;10(3):22530.
5. Vanderploeg, RD, Curtiss, G, Luis, CA, Salazar, AM. Long-term morbidities following self-reported mild traumatic brain injury. J Clin Exp Neuropsychol. 2007 Aug;29(6):58598.
6. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed. Text Revision. ED. American Psychiatric Association. and American Psychiatric Association, editors. Washington, DC: American Psychiatric Association; 2000.
7. Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine. Definition of mild traumatic brain injury. J Head Trauma Rehabil. 1993; 8(3):867.
8. Mild Traumatic Brain Injury Work Group. The report to Congress on mild traumatic brain injury in the United States: Steps to prevent a serious public health problem. National Center for Injury Prevention and Control; 2003. Report No.: 1.
9. Quality Standards Subcommittee of the American Academy of Neurology. Practice Parameter: The management of Concussion in Sports. [Cited January 2009] Available from: http://www.aan.com/professionals/practice/guidelines/pda/Concussion_sports.pdf
10. Blostein, P, Jones, SJ. Identification and evaluation of patients with mild traumatic brain injury: Results of a national survey of level I trauma centers. J Trauma. 2003 Sep;55(3):4503.
11. De Kruijk, JR, Twijnstra, A, Meerhoff, S, Leffers, P. Management of mild traumatic brain injury: lack of consensus in Europe. Brain Inj. 2001 Feb;15(2):11723.
12. von Wild, K, Terwey, S. Diagnostic confusion in mild traumatic brain injury (MTBI). Lessons from clinical practice and EFNS- inquiry. European Federation of Neurological Societies. Brain Inj. 2001 Mar;15(3):2737.
13. Borg, J, Holm, L, Cassidy, JD, Peloso, PM, Carroll, LJ, von Holst, H, et al. Diagnostic procedures in mild traumatic brain injury: results of the WHO collaborating centre task force on mild traumatic brain injury. J Rehabil Med. 2004 Feb;(43 Suppl): 6175.
14. Kennedy, JE, Lumpkin, RJ, Grissom, JR. A survey of mild traumatic brain injury treatment in the emergency room and primary care medical clinics. Mil Med. 2006 Jun;171(6):51621.
15. Borg, J, Holm, L, Peloso, PM, Cassidy, JD, Carroll, LJ, von Holst, H, et al. Non-surgical intervention and cost for mild traumatic brain injury: results of the WHO collaborating centre task force on mild traumatic brain injury. J Rehabil Med Suppl. 2004 Feb;36(43):7683.
16. Comper, P, Bisschop, SM, Carnide, N, Tricco, A. A systematic review of treatments for mild traumatic brain injury. Brain Inj. 2005 Oct;19(11):86380.
17. Carroll, LJ, Cassidy, JD, Holm, L, Kraus, J, Coronado, VG, WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Methodological issues and research recommendations for mild traumatic brain injury: The WHO collaborating centre task force on mild traumatic brain injury. [see comment]. J Rehabil Med. 2004 Feb; 43 Suppl:11325.
18. Kraus, JF, McArthur, DL, Silberman, TA. Epidemiology of mild brain injury. Semin Neurol. 1994 Mar;14(1):17.
19. Pickett, W, Ardern, C, Brison, RJ. A population-based study of potential brain injuries requiring emergency care. Can Med Assoc J. 2001;165:28892.
20. Schootman, M, Fuortes, LJ. Ambulatory care for traumatic brain injuries in the US, 1995-1997. Brain Inj. 2000 Apr;14(4):37381.
21. Sosin, DM, Sniezek, JE, Thurman, DJ. Incidence of mild and moderate brain injury in the United States, 1991. Brain Inj. 1996 Jan;10(1):4754.
22. Jaakkimainen, L, Upshur, R, Klein-Geltink, J, Leong, A, Maaten, S, Schultz, S, et al. Primary care in Ontario: ICES atlas. Toronto: Institute for Clinical Evaluative Sciences; 2006.
23.2006 census [homepage on the Internet]. Available from: http://www12.statcan.ca/
24. ICD-9-CM: International Classification of Diseases, 9th revision, Clinical Modification. 5th Ed Salt Lake City, Utah: Medicode; 1997.
25. Norman, GR. Biostatistics: the bare essentials. 2nd ed. Streiner, DL, editor. Hamilton: B.C. Decker; 2000.
26. Landis, JR, Koch, GG. The measurement of observer agreement for categorical data. Biometrics. 1977 Mar;33(1):15974.
27. Ontario Physician Human Resources Data Centre [homepage on the Internet]. [cited December 2007]. Available from: https://www.ophrdc.org/Home.aspx
28. Ghaffar, O, McCullagh, S, Ouchterlony, D, Feinstein, A. Randomized treatment trial in mild traumatic brain injury. J Psychosom Res. 2006; 61(2);15360.
29. Ponsford, J. Rehabilitation interventions after mild head injury. Curr Opin Neuro. 2005; 18:6927.
30. Russell, WR. Cerebral involvement in head injury. Brain. 1932; 55: 549603.
31. Hustey, FM, Meldon, SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002; Mar 39:24853.
32. Servadei, F, Teasdale, G, Merry, G. Neurotraumatology Committee of the World Federation of Neurosurgical Societies. Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. J Neurotrauma. 2001 Jul;18 (7):65764.
33. McCrory, P, Johnston, K, Meeuwisse, W, Aubry, M, Cantu, R, Dvorak, J, et al. Summary and agreement Statement of the Second International Symposium on Concussion in Sport. Br J Sports Med. 2005; 39(4):196204.
34. Klauber, MR, Barrett-Conner, E, Marshall, LF, Bowers, SA. The epidemiology of head injury: a prospective study of an entire community-San Deigo, California, 1978. Am J Epidemiol. 1981; 113:5009.
35. Tate, RL, McDonald, S, Lulham, JM. Incidence of hospital-treated traumatic brain injury in an Australian community. Aust N Z J Public Health. 1998 Jun;22(4):41923.
36. Anderson, DW, Kalsbeek, WD, Hartwell, TD. The national head and spinal cord injury survey: design and methodology. J Neurosurg. 1980 Nov;Suppl:S118.
37. Bazarian, JJ, Veazie, P, Mookerjee, S, Lerner, EB. Accuracy of mild traumatic brain injury case ascertainment using ICD-9 codes. Acad Emerg Med. 2006 Jan;13(1):318.

Early Identification and Incidence of Mild TBI in Ontario

  • Won Hyung A. Ryu (a1) (a2) (a3), Anthony Feinstein (a4) (a5), Angela Colantonio (a2) (a6) (a3), David L. Streiner (a1) (a2) (a4) and Deirdre R. Dawson (a1) (a2) (a6) (a3)...

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed