Childhood TBI Prevalence Dependent on Insurance Coverage

Juliet Haarbauer-Krupa, PhD

With approximately half a million children aged 0—14 years admitted to emergency departments (EDs) for traumatic brain injuries (TBIs) annually in the US—and up to 90% of cases being mild TBIs—efforts like the new guidelines for mild TBIs from the US Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention only further address the large issue at hand.

However, a recent study led by Juliet Haarbauer-Krupa, PhD, now shows another area the 19 recommendations in the new CDC guidelines missed: insurance.

Aside from finding that healthcare professionals should be more aware of the increased risk of associated health conditions, the team also found a higher TBI prevalence in states with greater levels of private insurance and insurance adequacy, suggesting children with less access to care may have overlooked TBIs.

“The purpose of this study was to estimate lifetime prevalence of TBI in children (specifically TBIs diagnosed by healthcare providers), based on a nationally representative sample of US parents/adults,” lead investigator Juliet Haarbauer-Krupa, PhD, of CDC Injury Center, told MD Magazine^Ò. “In addition, the study sought to describe the association between TBI and other childhood health conditions.”

In order to determine lifetime TBI history, the team analyzed data from the 2011-2012 National Survey of Children’s Health, a cross-sectional telephone survey of US households on children’s health, from February 1, 2016, to November 1, 2017.

Main outcomes and measures included associate childhood health conditions, life time estimate of TBI in children, and parent report of health insurance type and adequacy.

Sociodemographic characteristics were used to stratify TBI prevalence estimates, and the probability of recording specific health conditions was compared between children with and without TBI. Each state had age-adjusted prevalence estimates computed for it. In addition, relevance between TBI prevalence, insurance type, and parent rating of insurance adequacy were assessed.

Representing over 1.8 million children nationally, the reported lifetime estimate of parent-reported TBI among children was 2.5% (95% CI; 2.3 - 2.7).

A variety of health conditions was also likely to be had by children with a lifetime history of TBI compared to those without. Learning disorders (21.4%; 95% CI; 18.1 - 25.2); attention-deficit/hyperactivity disorder (20.5%; 95% CI; 17.4 - 24.0); speech/language problems (18.6%; 95% CI; 15.8 - 21.7); developmental delay (15.3%; 95% CI; 12.9 - 18.1); bone, joint, or muscle problems (14.2%; 95% CI; 11.6 - 17.2); and anxiety problems (13.2%; 95% CI; 11.0 - 16.0) included those with the highest prevalence.

Haarbauer-Krupa noted that the states with a higher number of childhood TBIs were more likely to have a higher proportion of children with private health insurance and higher parent report of adequate insurance.

“This suggests that access to adequate health insurance may affect the likelihood of seeking healthcare after TBI and this, in turn, may lead to higher estimates of diagnosed TBIs,” Haarbauer-Krupa said. “In other words, a lack of adequate health insurance may result in some childhood TBIs going untreated.”

A higher proportion of children with private health insurance and higher parent report of adequate insurance were also found to be in states with a higher prevalence of childhood TBI. Maine, Vermont, Pennsylvania, Washington, Montana, Wyoming North Dakota, South Dakota, and Colorado included states with higher prevalence of TBI and higher proportion of private insurance.

In 2011 and 2012, uninsured populations were reported to be the highest in states in the South (18.6%) and West (17%) compared to the Northeast (10.8%) and Midwest (11.9%).

Some limitations were noted by the study authors, such as exclusion of conferring medical records due to NSCH’s reliance on parent-reported information. In addition, pediatric patients who experienced a TBI who did not seek a medical assessment were not included in the study.

Despite the study’s limitations, the team concluded that an association between insurance type and health care quality for children with TBI since children with TBI and private health insurance had lower mortality rate and better quality of care following TBI compared to those with public insurance or those who were uninsured.

“Based on a review of 25 years of research, the CDC Pediatric mild TBI (mTBI) Guideline, was designed to help healthcare provider improve the care of their young patients with this injury,” Haarbauer-Krupa added. “This guideline is not inclusive of TBIs classified as ‘moderate’ or ‘severe.’ CDC created educational tools in support of the CDC Pediatric mTBI Guideline that can be downloaded and used at no cost by healthcare providers, parents, and schools.”

Looking forward, the team decided further investigation is needed to address additional factors related to TBI in children, such as parents’ views on the need for medical assessment of TBI.

“To produce more comprehensive estimates of TBI in children, nonmedical data sources will need to be expanded to capture children who do not or cannot seek treatment,” the investigators wrote. “A proposed system, the National Concussion Surveillance System, holds the potential for obtaining more comprehensive prevalence estimates of TBI in children.”

The study, "Prevalence of Parent-Reported Traumatic Brain Injury in Children and Associated Health Conditions," was published online in JAMA.