Findings from current measuring system
Practical Aspects of Conducting a Prospective Statewide Incidence Study: The Incidence of Serious Inflicted Traumatic Brain Injury in North Carolina

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Abstract

The article describes practical problems encountered in setting up and maintaining an active statewide surveillance system for a low-frequency but high-impact injury, inflicted traumatic brain injury (inflicted TBI). A system was designed to identify prospectively all children aged <2 years with a traumatic brain injury (TBI) admitted to any of the nine pediatric intensive care units (ICUs) in North Carolina in 2000 and 2001. Children who died prior to admission to hospital were identified from the records of the Office of the Chief Medical Examiner. The study design had strengths and weaknesses for ongoing surveillance. Strengths included a clear definition of a case, mechanisms to jury undecided cases, and a high level of quality control. Difficulties included appropriately addressing investigators’ ethical and legal obligations in the study of child abuse, differing requirements of multiple institutional review boards (IRBs), and the time-intensive nature of the system. The described surveillance system produced high-quality data, but may not be practical for ongoing multi-year injury surveillance. Incorporation of inflicted TBI into an existing surveillance system, such as a trauma database, may be a feasible solution to many of the problems encountered.

Section snippets

Study Findings

The study found a total of 152 children with TBI who met entrance criteria. Of the 152 children, 80 (53%) incurred an inflicted TBI. The rate of inflicted TBI for children aged <2 years was 17.0 (95% CI=13.3–20.7) per 100,000 person-years. Rates of inflicted TBI were higher in children in the first year of life compared to the second year of life, higher in boys than in girls, and higher in minority populations (Table 1). Factors that appeared to increase the risk of injury when compared to the

Discussion

These studies were all performed in the southeastern U.S., which is homogenous compared to the country as a whole. It is possible that incident cases of inflicted TBI could vary by geographic region, state levels of poverty, or different cultural attitudes toward child rearing in different regions of the country. Therefore, the results of these studies may not be generalizable to the U.S. as a whole. This study could be replicated in a different region over a longer time period to capture

Funding

A project of this scope requires external funding. Funding agencies had multiple concerns about the feasibility of the project including case ascertainment, credible case definitions, the likelihood of hospitals cooperating in a study of abusive injury, and the ability of gaining parental or caregiver participation for follow-up.

Case Definition

For study purposes, a case definition was required that could be applied consistently across hospitals and would allow for complete case capture. The case definition

Conclusion

The exact protocol used in the North Carolina study may not be advisable as an ongoing surveillance system. The main strengths of the system were a clear definition of a case, multiple sources of information, and ongoing quality checks in the form of investigator review of each case and review of all radiographs. The major weaknesses in the system for ongoing injury surveillance included fatigue of volunteers for the maintenance of such a time-intensive method of surveillance and that the

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