West virginia death certificate

SYNOPSIS

Objective. The objective of this study was to describe fatal cases of traumatic brain injury (TBI) among West Virginia residents.

Methods. The authors analyzed data from the National Center for Health Statistics Multiple Cause of Death tapes for the period 1989-1998. They compared West Virginia's annualized average TBI death rate with the rates of other states and with the rate among U.S. residents for the same period. U.S. Bureau of Census population estimates were used as denominators.

Results. A total of 4,416 TBI deaths occurred in West Virginia in 1989-1998, for an annual average death rate of 23.6 per 100,000 population. From 1989 to 1998, TBI death rates declined 5% (p=0.4042). Seventy-five percent (n=3,315) of fatalities occurred among men. Adults [greater than or equal to] 65 years of age accounted for the highest percentage of fatal injuries (n=1,135). The leading external causes of fatal TBI were: firearm-related (39% of reported fatalities), motor vehicles-related (34%), and fall-related (10%). Firearm-related TBI became the leading cause of TBI fatalities in 1991, surpassing motor vehicle-related TBI. Seventy-five percent of firearm-related TBI deaths were suicides (n=1,302). West Virginia's TBI death rate (23.6 per 100,000) was higher than the national rate (20.6 per 100,000). In 23 states, the average TBI death rates over the 10-year period were higher than West Virginia's. Whereas modest declines in TBI death rates occurred for motor vehicle-related and firearm-related causes in West Virginia, a concomitant 38% increase occurred in the fall-related TBI death rate during the decade.

Conclusion. Data presented in this report can be used to develop targeted prevention programs in West Virginia.

Traumatic brain injury (TBI) is a major cause of mortality and morbidity in the United States. Published data indicate that 52,000 U.S. residents die from TBI-related causes every year (1) and that an estimated 80,000 to 90,000 U.S. residents are disabled annually as a result of TBI. (2) An estimated 5.3 million individuals live with permanent TBI-related disabilities. (3) Unintentional injury rates are very high in West Virginia; (4,5) however, studies have not examined the epidemiology of TBI in that state. Surveillance of serious injuries such as TBI could assist in the development of specific injury prevention measures. This study describes the epidemiologic characteristics of fatal TBI among West Virginia residents for the period 1989 through 1998.

METHODS

The National Center for Health Statistics (NCHS) Multiple Cause of Death data files were analyzed to identify residents of West Virginia who died of TBI from January 1, 1989, through December 31, 1998. The NCHS mortality data were compiled from death certificates flied directly from the vital statistics offices in the 50 states and the District of Columbia.

NCHS data were coded according to the International Classification of Diseases, Ninth Revision (ICD-9) codes (6) for cause of death, including underlying external cause of death. For the present study, a TBI-related death was defined as a death for which at least one TBI-associated diagnosis code was listed on the death certificate in the sequence of conditions contributing to death. TBI-associated diagnosis codes included the nature of death codes 800 (fracture of vault of skull); 801 (fracture of base of skull); 803 (other and unqualified skull fractures); 804 (multiple fractures involving skull or face with other bones); 850 (concussion); 851 (cerebral laceration and contusion); 852 (subarachnoid, subdural, and extradural hemorrhage following injury); 853 (other and unspecified intracranial hemorrhage following injury); 854 (intracranial injury of other and unspecified nature); 905.0 (late effects of fracture of skull and face); 907.0 (late effects of intracranial injury without skull fracture); and 873 (other open wound of head). The causes of TBI deaths were divided on the basis of the external cause of death (E-codes) into motor vehicle-related (E810-E825); fall-related (E880-E886, E888); firearm-related (E922, E955.0-E955.4, E965.0-E965.4, E970, E985.0-E985.4); or "other/unspecified" codes for cases with infrequent occurrence or of nonspecific nature.

Denominators for the calculation of rates were derived from the mid-year population estimates maintained by the Census Bureau for individual years of study. (7) Age-adjusted rates were standardized to U.S. Census population estimates for 2000 by the direct method. Appropriate 95% confidence intervals (CIs) were calculated for the rates based on the standard error that accounts for random variation in the number of deaths each year, as recommended by NCHS. (8) Poisson regression was used to determine the significance of the decline or increase in rates over the interval. (9) Using the same Multiple Cause of Death tapes, comparable age-adjusted fatal TBI data were determined for residents of the U.S., the 50 states, and the District of Columbia.

The Census Bureau has published data on land area, population, and population density for all states and the District of Columbia. (10) In 2000, Alaska had the lowest population density per square mile at 1.0, and the District of Columbia had the highest population density per square mile at 9,882.6. (10) The population density per square mile for West Virginia was 74.5. The Census data identified 25 states with lower population densities than West Virginia's, and the average TBI death rates of each of these states was compared with that of West Virginia.

Multiple Cause of Death tapes for 1999 and 2000 were not used in this analysis because the new ICD-10 coding scheme was used to code these data. Cause of death categories in the ICD-9 are different from those in the ICD-10, and a crosswalk between the coding schemes has not yet been developed. In addition, NCHS recommends that data from 1999 and beyond not be combined with previous years for trend analysis. (11)

RESULTS

A total of 4,416 TBI-associated fatalities occurred in West Virginia from January 1, 1989, through December 31, 1998, for an average annual death rate of 23.6 per 100,000 population (Table 1). This rate is almost 15% higher than the national average of 20.6 per 100,000. Nationally, TBI death rates declined 11.4%, from 21.9 per 100,000 to 19.4 per 100,000 (p=0.0001) during this interval. For West Virginia, however, TBI-related death rates declined 5%, from 24.0 per 100,000 to 22.8 per 100,000 (p=0.4042). A subgroup analysis of TBI death rates indicated that West Virginia rates were much higher than national rates in almost every gender, race, and age subgroup (Table 1).

TBI deaths by race, gender, and age group

Ninety-seven percent of West Virginia's TBI-associated deaths were among individuals identified as white (Table 1); 96% of West Virginia's population is white. (7) Unlike national rates, TBI death rates in West Virginia did not differ by race. In West Virginia and the United States, males were approximately four times as likely as females to die of a TBI (38.4 per 100,000 for males vs. 10.8 per 100,000 for females). The death rate among adults ages [greater than or equal to]65 years (41.5 per 100,000) was higher than the rate among other age groups. One out of every four fatal TBIs in West Virginia occurred among adults ages [greater than or equal to]65 years (Table 1).

Gender and major external causes of TBI death

The three leading causes of TBI-associated fatalities were: firearm-related (39%), motor vehicle-related (34%), and fall-related (10%) (Table 1). Firearms became the leading cause of TBI-associated deaths in 1991 (Figure). Eighty-six percent (n=1,485) of firearm-related TBI deaths were among males (16.9 per 100,000). Seventy-five percent (n=1,302) of firearm-related TBI deaths were suicides (6.9 per 100,000); 90% (n=1,176) of those firearm-related suicide deaths were among males. Overall, from 1989 to 1998, a nonsignificant decline occurred in the suicide-related TBI death rate (p=0.3901).

An average of 152 residents died of motor vehicle-related TBI annually, with 70% of these fatalities occurring among males. The rate of motor vehicle-related TBI declined 13% from 1989 through 1998 (p=0.0018) (Figure). In contrast, fall-related TBI death rates increased 38%, from 2.1 per 100,000 in 1989 to 2.9 per 100,000 in 1998 (p=0.0531).

Age group and major external causes of TBI death

Marked differences are noted in the external causes of TBI death by age group (Table 2). For residents ages <35 years, the leading cause of fatal TBI was motor vehicle-related. Firearm-related incidents were the leading cause of TBI fatalities among people ages [greater than or equal to]35 years.

Trends in external cause of TBI-associated deaths