Ohio Brain Injury Program and the Brain Injury Advisory Committee. Biennial Report on the Incidence of Traumatic Brain Injury in Ohio: 2012

Transcription

1 Ohio Brain Injury Program and the Brain Injury Advisory Committee Biennial Report on the Incidence of Traumatic Brain Injury in Ohio: 212 Presented to the Brain Injury Advisory Committee Report Date: January 21, 216

2 This Report is prepared in accordance with the requirement set forth in ORC that the Brain Injury Program of Ohio will prepare a biennial report on the incidence of brain injury in the state. This report has been developed by the staff of the Ohio Brain Injury Program and the Data Workgroup of the Brain Injury Advisory Committee. The staff of the Ohio Brain Injury Program and the Ohio Valley Center at the Wexner Medical Center, Ohio State University is proud to accept leadership for administration of the Brain Injury Program for Ohio. We appreciate the work and commitment of the Brain Injury Advisory Committee for charting a direction and providing an energy to develop a robust brain injury program for the people of Ohio and look forward with anticipation to the work ahead. We wish to acknowledge a past author and editor for his contribution in the development and preparation of previous reports, which were the basis for formatting and development of this current production. Dr. F. Barry Knotts, M.D., Ph.D., Brain Injury Advisory Committee Data Workgroup Chair We also wish to acknowledge the contribution of the Ohio Departments of Public Safety, Division of Emergency Medical Services and the Ohio Department of Health for their selfless offers of time toward the completion of this reporting requirement. Schuyler Schmidt, Brain Injury Advisory Committee Data Workgroup, Ohio Department of Public Safety Ryan G. Frick, MPH, Epidemiologist, Brain Injury Advisory Committee Data Workgroup, Ohio Department of Public Safety Jolene Defiore Hyrmer, M.P.H. Brain Injury Advisory Committee Data Workgroup, Ohio Department of Health Mbabazi Kariisa, MPH, PhD, Epidemiologist, Ohio Department of Health We wish to acknowledge the contribution of the Brain Injury Association of Ohio for their continued commitment to the cause of traumatic brain injury prevention, treatment and long term support. Stephanie Ramsey, B.S.N., M.P.H., Brain Injury Advisory Committee Data Workgroup, Brain Injury Association of Ohio With deepest respect to the Brain Injury Advisory Committee, this Report is presented. Dr. John Corrigan, Director of Ohio Brain Injury Program and the Ohio Valley Center at the Ohio State University Wexner Medical Center Monica Lichi, MS Ed., PC, MBA, Program Director Ohio Brain Injury Program and the Ohio Valley Center at the Ohio State University Wexner Medical Center 2

3 Table of Contents Acknowledgements 2 Table of Contents.3 Overview.4 Definition of Traumatic Brain Injury 4 Inclusion Criteria Ohio Trauma Registry and Ohio Department of Health..5 Selection Criteria for this Report Section 1: Data from the Ohio Trauma Registry.8 Section 2: Ohio Hospital Discharges & Ohio Death Certificate Data...13 Summary and Conclusions..17 3

4 OVERVIEW This report is in fulfillment of the requirement of the Ohio Revised Code for the production by the Brain Injury Program of a statewide biennial report on the incidence of traumatic brain injury (TBI) in Ohio. It is the sixth report so prepared using data from the Ohio Trauma Registry (OTR). It is the first such report to include data on inpatient hospital discharges, emergency room visitations (discharges), and deaths. These different data sources are included in an effort to provide a more comprehensive overview of the incidence of TBI across the spectrum of severity and an indicator of impact on the population through such measures as cost and resource consumption. It should be noted that the OTR collects data only on the most severe injuries, and therefore, does not reflect the true burden of injury in the state. Thus, in an effort to provide additional information, the data set from the ODH has been included on inpatient hospital discharges, emergency room visitations (discharges), and deaths. The quantity and quality of the data being reported to the OTR continues to improve as the system matures. A greater number of hospitals are reporting data to the OTR and those that have been reporting since the inception of the OTR have not only become better at identifying cases that meet the inclusion criteria, but have improved in their ability to interpret, abstract, and submit complete and accurate data to the OTR. As of this writing, no data are available for 213 because the data collection methodology has changed. Therefore, only 212 data are included. The data from ODH are drawn from hospital discharge records and death certificates to study patterns and trends in injuries among Ohio residents. Specific data collection methodology is described in this report. Because the data collection criteria and methodology of each data set differ, direct comparison of the data is not possible, nor is it intended. Rather, both sets are presented in order to provide a more comprehensive picture of the incidence and impact of TBI on citizens of Ohio over time along a variety of dimensions. Data may, at times, show parallel trends or suggest similar conclusions. However, in order to maintain clarity, the data sets are reported in two separate Sections in this report. Copies of this report will be distributed by the Ohio Brain Injury Program staff to members of the Ohio Brain Injury Advisory Committee as required by ORC for information and review. Additional copies of the report as well as previous reports may be obtained by contacting Monica Lichi at (614) or monica.lichi@osumc.edu Definition of Traumatic Brain Injury Traumatic Brain Injury (TBI) is defined by the Centers for Disease Control and Prevention as an injury caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. (1) The Traumatic Brain Injury Model Systems National Data Center provides a more detailed definition: TBI is defined as damage to brain tissue caused by an external mechanical force as evidenced by medically documented loss of consciousness or post traumatic amnesia (PTA) due to brain trauma or by objective neurological findings that can be reasonably attributed to TBI on physical examination or mental status examination. (2) 4

5 How big is the problem in Ohio? In Ohio, injury is the leading cause of death and disability for Ohioans age 1 44 years of age, and is the 3 rd leading cause of death in Ohio behind only heart disease and cancer. TBI is involved in over 3% of injury cases in Ohio and increasing. For those individuals with TBI the mortality rate is 7 to 9%. In addition to this, TBI is the signature injury of the Afghanistan and Iraq conflicts and is responsible for bringing thousands of new cases of TBI home to Ohio. According to the CDC report to Congress in 215, Military service members and veterans from recent conflicts and combat are a population of special concern. However, of all new cases of TBI among military personnel, approximately 8% occur in non deployed settings. a.pdf In short, TBI remains a major public health problem which exacts a high personal and financial cost for the citizens of Ohio. The findings presented in this report indicate a troubling trend of increased incidence and cost, both human and economic, among all strata of the population and emphasize the critical need for prevention among all age and gender groups. Furthermore, while prevention is a hallmark objective, the obvious corollary is the need for a system of services available to meet the care, treatment and rehabilitation needs of individuals and their families who have experienced brain injury and are currently facing the challenges of residual disabilities or impairments that can limit or threaten resumption of a full and productive future course. Ohio Trauma Registry Data: A. Inclusion Criteria: The following are the inclusion criteria used by each hospital to determine which injury cases shall be submitted to the Ohio Trauma Registry. (3) 1. Patient s first or initial admission for at least 48 hours, and who meet one of the following inclusion criteria: OR 2. Patients who transfer into or out of any hospital, regardless of their length of stay, and who meet one of the following inclusion criteria; OR 3. Patients who arrive dead on arrival (DOA) and who meet one of the following inclusion criteria; OR 4. Patients who die after receiving any evaluation or treatment while on hospital premises, and who meet one of the following inclusion criteria: ICD 9 CM Diagnosis Codes on discharge from acute care hospital ICD 9 CM Diagnosis Codes ICD 9 CM Diagnosis Descriptions Fractures Fractures, dislocations/sprains, intracranial injury, internal injury of thorax, abdomen and pelvis, open wounds, injury to blood vessels 911.,911.1,912.,912.1 Abrasions/friction burns to trunk, shoulder and upper arm 916.,916.1,919.,919.1 Abrasions/friction burns hip, thigh, leg, ankle, other or multiple sites Contusions and crush injuries Burns, injury to nerves and spinal cord, traumatic complications and unspecified injury Smoke inhalation Frostbite, hypothermia, and external effects of cold 994.,994.1,994.7,994.8 Asphyxiation, strangulation, drowning, and electrocution Child maltreatment and abuse 5

6 Exclusion Criteria: Excluded Diagnoses and ICD 9 CM codes Isolated hip fracture Late effects of injury Superficial abrasions, blisters, insect bites Foreign bodies B. SELECTION CRITERIA This report is based on OTR data on patients with traumatic brain injury who were discharged from any acute care hospital in Ohio from January 1, 212 December 31, 212. Appropriate cases for this report were selected based on the Ohio Trauma Registry Patient Inclusion criteria defined on the previous pages as well as the following criteria: ICD 9 CM Codes: Fracture of vault or base of skull Other and unqualified and multiple fractures of skull Intracranial injury including concussion, contusion, laceration and hemorrhage(s) subarachnoid, subdural, extradural, other Head injury, unspecified Ohio Emergency Department (ED) Discharge Data A. Inclusion Criteria: 1. Discharge dataset includes nonfederal, acute care, or inpatient facilities. The dataset does not include Veterans Affairs and other federal hospitals, rehabilitation centers, or psychiatric hospitals. 2. Injury ED visits were defined as an ED visit with an injury listed in the primary discharge diagnosis field or a valid external cause of injury code in any of the discharge diagnosis fields. Principle Diagnosis of Injury (a principle diagnosis of , 99.4, 99.9, or OR a valid external cause of injury) and any of the following TBI ICD 9 CM codes in any diagnosis field: , , , , 959.1, or ED visits included in this report were restricted to Ohio residents. 4. Persons who are treated at an ED and later admitted to a hospital are removed from the ED dataset, and therefore are not included in any analysis of ED data. 5. The external cause of injury code used in the analysis was the first listed cause of the discharge diagnosis fields. If the codes E E3, E849, E967, E869.4, E87E879, or E93 E949 were the first listed codes then the next valid external cause code was used. 6. Rates were calculated by dividing the number of injuries by the number of Ohio residents. Population estimates were based on estimates from the National Center for Health Statistics. Rates were age adjusted to the 2 U.S. standard population. 7. The source of the data set is the Ohio Hospital Association. Ohio Death Certificate Data: 8. Injury deaths were defined as a death with the underlying cause of death listed as an injury. Traumatic brain injury deaths were defined as deaths with an injury as underlying cause of death and a traumatic brain injury listed in one of the multiple cause of death fields. Injury underlying cause of death ICD 1 Codes: V1 Y36, Y85 Y87, Y89,*U1 *U3 and ICD 1codes in any field of the multiple cause of death file: S1. S1.9, S2., S2.1, S2.3, S2.7 S2.9, S4., S6. S6.9, S7., S7.1, S7.8, S7.9, S9.7 S9.9, T1., T2., T4., T6., T9.1, T9.2, T9.4, T9.5, T9.8, T9.9 6

7 9. Deaths included in this report were restricted to Ohio residents. 1. Rates were calculated by dividing the number of injuries by the number of Ohio residents. Population estimates were based on estimates from the National Center for Health Statistics. Rates were age adjusted to the 2 U.S. standard population. 11. Data source is Ohio Vital Statistics, Ohio Department of Health. Hospitalizations: 12. Discharge dataset includes nonfederal, acute care, or inpatient facilities. The dataset does not include Veterans Affairs and other federal hospitals, rehabilitation centers, or psychiatric hospitals. 13. Injury hospitalizations were defined as an inpatient visit with an injury listed in the primary discharge diagnosis field. Traumatic Brain Injury deaths were defined as deaths with an injury as underlying cause of death and a traumatic brain injury listed in one of the multiple cause of death fields. 14. Datasets include readmissions, transfers, and deaths occurring in the hospital. 15. Hospitalizations included in this report were restricted to Ohio residents. 16. The external cause of injury code used in the analysis was the first listed cause of the discharge diagnosis fields. If the codes E E3, E849, E967, E869.4, E87E879, or E93 E949 were the first listed codes then the next valid external cause code was used. 17. Rates were calculated by dividing the number of injuries by the number of Ohio residents. Population estimates were based on estimates from the National Center for Health Statistics. Rates were age adjusted to the 2 U.S. standard population. 7

8 SECTION I: Data from the OHIO TRAUMA REGISTRY Figure 1. Traumatic brain injury patients by CFR, Ohio, Year Survivors Deaths Total Case Fatality Rate 23 6, , % 24 6, , % 25 7, , % 26 7, ,98 7.6% 27 8, , % 28 8, , % 29 9, , % 21 8, ,43 8.% 211 8, , % 212 9, , % Total 82,488 7,342 89,83 8.2% Discussion: Incidence of TBI has showing a gradual increase over the years reported above. Whether this is due to actual occurrence or better reporting is difficult to ascertain. However, it is clear that TBI continues to remain a significant public health issue in Ohio with little evidence that prevention strategies are being effective. Mortality rates, however, have been trending downward from over 9% in 1999 to slightly below 8% in 212, which may be due to a variety of factors including severity of injury, age of the injured party, or the impact of improved trauma care measures among the possibilities. It should be noted that incidence between the years 211 and 212 increased by 11.5% which is three times the numerical increase in the two prior years. (The population of Ohio increased only.1% from 21 to 213 so population change is not a factor.) Whether this jump in incidence is the result of improved reporting or a true increase cannot be explained at this point but does suggest concern that TBI incidence is increasing. Figure 2. Traumatic brain injury patients by sex, Sex Total Male 4,694 4,873 5,463 5,69 5,889 6,149 6,136 5,72 5,721 6,416 56,13 Female 2,594 2,623 3,7 2,836 3,336 3,645 3,646 3,683 3,94 4,168 33,478 NK/ND Total 7,291 7,498 8,475 7,98 9,229 9,799 9,785 9,43 9,664 1,778 89,83 The gender distribution among patients suffering a TBI has remained consistent over time, with approximately two thirds male. Again, incidence in 212 remains a concern. # and % of Ohio TBI Patients by Gender, , 1.78% 4,214, 38.66% \ 6,491, 59.56% Male Female Unknown 8

9 Figure 4: Number of TBI by age group Age Group Number of Patients , , , , , , ,44 Total 1,778 The age years shows the highest number of TBI s with 158 cases. The next highest group is that of age 85 years and above. These findings continue the trend Identified in the data from in which the number of individuals in each of these age groups led respectively all other age groups. 9

10 Figure 6. Traumatic brain injury patients by MOI, Ohio, 212 Mechanism of Injury Number of Patients % of Total Assault % Cut/Pierce 5.5% Drowning/Submersion 6.6% Fall 5, % Fire/Burn 2.2% Firearm 17.99% Machinery 31.29% Motorcycle Collision % Motor vehicle Collision 2, % Pedal Cyclist % Pedestrian % Stuck by/against % Transport, other % Other % Total 1,778 1.% Falls continue to lead all mechanisms of injury as cause of TBI in Ohio. This finding is consistent with those of prior years reported of 27 through 211. Motor vehicle collisions continue within the range of 25% 3% for the same period. Together, they account for more than three fourths of all TBI s in the year 212. Figure 7. Traumatic brain injury patients by injury type, Ohio, 212 Injury Type Alive Deaths Total CFR Blunt 9, , % Penetrating % Burn 7 7.% Asphyxia % Total 9, , % 97.8% of individuals sustaining a TBI in Ohio during the calendar year 212 were injured as a result of blunt force trauma. This finding is absolutely consistent with and, in fact, practically duplicates prior reporting periods January 27 through December 211 when blunt force trauma accounted for 97.6% and 98% respectively. However, as Figure 8 below illustrates, while penetrating injuries are relatively rare among TBI patients, they represent the highest mortality rate (58.6%) of all injury types. 1

11 Figure 9. Traumatic brain injury patients by injury location, Ohio, 212 Location Number of Patients % of Total Home 4, % Farm 55.51% Mine/Quarry.% Industrial Place % Recreation/Sports Place % Street/Highway 3, % Public Building % Residential Institution % Other Specified Place % Not Documented/Unknown % Total 1,778 1.% The majority of the TBI s occurred in the home with a frequency of 39.71% of all the injuries. This may be considered a logical connection to the most frequent cause of injury being falls. The second most common site of injury is streets and highways which is consistent with the second most common mechanism of injury, i.e. motor vehicle accidents. Figure 1: Patients with TBI in Ohio by Hospital Discharge Disposition Ohio TBI Patients by Discharge Disposition 212 Hospital Discharge Disposition N % of Total Home 5, % Home with Professional Care or Assistance % Morgue/Coroner/Funeral Home % Extended Care Facility/Nursing Home or Facility % Rehabilitation Facility % Transfer % Jail 32.29% Against Medical Advice (AMA) 88.8% Other % Total 1,899 As in prior reporting periods of and , more than half the TBI patients were discharged home from the hospital, with or without assistance. There were 28.4% discharges to extended care facilities, nursing homes or rehabilitation facilities, which, once again is consistent with the prior reporting periods. All other discharge destinations remained consistent with prior findings as well. 11

12 Limitations of the Data As with any large data set, Ohio Trauma Registry data has inherent limitation and weaknesses. Those identified limitations and weaknesses include the following: All hospitals that provide initial treatment to persons with traumatic injury are required by law to submit data to the Ohio trauma Registry. However, as no enforcement authority was provided in this law, not all hospitals contribute. To date, approximately 85% of hospitals required to report data to OTR did so during the time period covered in this report. For various administrative reasons, hospitals that routinely submit the required data to the OTR are unable to identify or submit all cases meeting inclusion criteria. Due to the inclusion criteria, patients with TBI who have a hospital length of stay less than 48 hours are not included in the data set. The exception to this is patients who die in the emergency department or who die in the hospital prior to the 48 hour cutoff. Evaluation of injury severity scoring (ISS) data in relation to traumatic brain injury would add considerable value to the study topic, but because there is not statewide consistency in the application of ISS (due largely to the lack of formal and standardized training) the information was excluded from this report. Prevalence data is not available to be presented in this report. The current registry data can only give an indication of the incidence of new traumatic brain injury cases. There is no information about the ultimate postdischarge outcome for patients who have sustained a TBI. There is no information about eventual cognitive nor functional capability nor quality of life for the people with TBI in Ohio Financial data is excluded from this report because it is not reliably reported to the Ohio Trauma Registry. Charges billed are not consistently reported throughout the state and the data are considered flawed. Payor data, while reported more reliably than charges billed, is still considered suspect. This is largely because payor data is collected based on how the patient expects to pay for the treatment at the time of registration. Final determination of the true primary payor frequently remains undetermined for periods of time that may reach six months to a year following discharge. Individuals who die of TBI before transport to a hospital are not included in this data set. It would be necessary to include statewide coroners data to complete the picture of all deaths due to TBI. 12

13 Section 2: Data from the Ohio Department of Health Figure 11: Overview of TBI in Ohio in 211: Number and age adjusted death rate for traumatic brain injuries by year, Ohio 211 Deaths 2,259 Inpatient Hospitalizations 7,3 Emergency Room Visits 99,135 Unknown (Primary Care, unreported, ect.) Figure 12: Number and age adjusted death rate for traumatic brain injuries by year, Ohio Figure 1. Number and age adjusted death rate for traumatic brain injuries by year, Ohio, Number of deaths 2,5 2, 1,5 1, 5 Number Rate ,818 1,921 1,999 1,825 2,9 2,6 1,986 2,136 2,156 2,22 2,13 2,259 2, Rate per 1, Source: Ohio Department of Health, Vital Statistics TBI death rates did not follow a consistent linear trend over most of the study period until the years 211 and 212 which while remaining consistent, showed an increase over prior years. From the period of 2 to 212, the mortality rate for TBI increased by nearly 16 percent from 15.9 per 1, to 18.4 per 1,. During the same time period, the numbers of deaths increased by 25 per cent. 13

14 Figure 13: Number and Age Adjusted Death Rate for Traumatic Brain Injury by Year, 212 Traumatic brain injury fatality rates by age and sex, Ohio, 212 Rate per 1, < 1 yr* 1 4 * 5 14 * Males Females or older Source: Ohio Department of Health, Office of Vital Statistics *Rate suppressed if <2 deaths; may be unreliable Over 2,268 Ohioans died from a traumatic brain injury in 212. The death rate was 18.4 per 1,. Rates were 3 times higher among males than females while the highest rates of deaths occurred among adults ages 75 or older. The most common mechanisms associated with TBI deaths were falls, suicides, motor vehicle traffic crashes and homicides. Figure 14: Number of Traumatic Brain Injury Deaths by Mechanism and Year, Ohio 212 Traumatic Brain Injury Deaths by Mechanism, % 29% Unintentional Falls Homicide 27% MV Traffic Suicide 1% Other 23% Data show that unintentional falls comprise the foremost mechanism of injury for TBI cases in 211. Suicides/Self harm was identified as the 2 nd most common mechanism of injury followed by motor vehicle crashes which was shown to be the 2 nd most common in the data of the Ohio Trauma Registry. 14

15 Figure 15: Cost estimates for Injury Related Deaths, Ohio 212 Cost Estimates for Injury Related Deaths, Ohio 212* Medical Related Cost to Fatal Injury $25,311, Work Lost $1,399,999, Combined $1,425,39, *Source: CDC WISQARS Cost of Fatal Injury Reports This information developed from CDC data illustrates the high cost of Injury related deaths in Ohio in 212. Among unintentional injuries, mechanisms associated with highest costs were falls, motor vehicle traffic crashes and poisoning. Since these mechanisms are highly correlated with the incidence of TBI, it suggests the cost impact of TBI within this estimate. Figure 16: Number and Age Adjusted Rate for Traumatic Brain Injury Related Hospitalizations by Year, Ohio Number of hospitalizations Figure 5. Number and age adjusted rate for traumatic brain injury related hospitalizations by year, Ohio, , 8, 6, 4, 2, Number ,541 6,983 7,297 7,54 7,612 7,935 7,855 7,641 7,413 7, Source: Ohio Hospital Association Rate Rate per 1, Figure 17: Number and Age Adjusted Rate for Traumatic Brain Injury Related ED Visits by Year, Ohio 211 Rate per 1, Hospitalization rates for traumatic brain injuries by sex and age, Ohio, 211 Males Females < 1 yr or older Source: Ohio Hospital Association The above tables show that while the hospitalization rates have fallen consistently since a high of 67.9 in 27, the rate for ED visits has consistently increased over time. 15

16 Figure 18: ED Visit Rates for Traumatic Brain Injuries by Age and Sex, Ohio, 211 Number and age adjusted rate for traumatic brain injury related ED visits by year, Ohio, Number Rate Number of ED Visits 12, 1, 8, 6, 4, 2, ,953 52,878 57,329 59,416 66,25 71,562 75,4 91,576 92,698 99, , Rate per 1, Source: Ohio Hospital Association ED visits for TBI are highest at either end of the age spectrum with visits by patients over 85 years of age being the highest. In 211, females of 85 years of age or higher led the number of ED visits with approximately 2,5 visits per 1, population. This data is consistent with the identification of the age high risk groups for TBI being those members of the population 4 years of age and over 75 years of age. Figure 19: Number of ED visits for Sports Related TBIs, 18 years of age and younger by cause of injury, Ohio Pedal cycle Recreation, no wheels Sports Wheeled recreation Source: Ohio Hospital Association Over time, the number of ED visits due to TBI has remained fairly stable over the years of except for those related to injuries due to sports activities. Whether this is due to an actual increase of occurrence or a greater recognition for the need for medical care, or improved reporting is not clear. 16

17 SUMMARY Data from the Ohio Trauma Registry and the Ohio Department of Health continue to provide a grim picture of the reality of traumatic brain injury on the population of Ohio. Over the past 16 years, the incidence of TBI has continued to trend higher affecting both sexes and all age groups. TBI is seen more frequently in males than females ( 6.64% to 39.36%) while individuals over the age of 75 years are affected more than any other age group (27% of the entire TBI population). TBI occurs in all 88 of Ohio s counties, regardless of county size, population, or topography. As expected, counties with large metropolitan areas have a higher number of patients with traumatic brain injuries. TBI also occurs in any setting, but most frequently in the home or on streets or highways. In fact, these two settings account for 72% of all traumatic brain injuries in Ohio (consistent with two prior reporting periods.) Although virtually all causes of injury have the potential to result in traumatic brain injury, falls and motor vehicle crashes account for 72.9% of TBIs reported in the OTR. This is almost 5% higher than the previous period reported. Data from the Ohio Department of Health indicate that suicide/self harm also ranks very high as a mechanism of injury. The counterpoint to these facts is that while incidence is rising, mortality rates continue to decline. So in the words of the health care economist, Alain Enthoven, are we doing better and feeling worse? The risk population, leading causes of injury, hazardous locations and related prevention measures are well defined in the field of health promotion and injury prevention. The number of individuals and families who must cope with the long term care needs is growing. This increase underscores the importance of the Brain Injury Program and Brain Injury Advisory Committee s Strategic Plan which focuses on individuals whose lives are impacted by the chronic residuals of this injury. Facts supported by both data sets: Males are more likely to experience fatal and non fatal TBI than females The highest rates of fatal and non fatal TBIs were found among ages 85 and older Falls are the most common cause of fatal and non fatal TBIs Development of additional data sets that illustrate the wider view of the human and financial costs of TBI is the next level of challenge to the Ohio Brain Injury Program and the Brain Injury Advisory Committee. The goal of more precisely describing the personal, familial and societal losses that this major public health enemy exacts will provide a roadmap for the State of Ohio to develop robust programs and services to address the human and economic costs of traumatic brain injury. 17