Pediatric Traumatic Brain Injury in the United States: Rural-Urban Disparities and Considerations

Abstract

Introduction: Traumatic brain injury (TBI) remains a primary cause of pediatric morbidity. The improved characterization of healthcare disparities for pediatric TBI in United States (U.S.) rural communities is needed to advance care. Methods: The PubMed database was queried using keywords ((“brain/head trauma” OR “brain/head injury”) AND “rural/underserved” AND “pediatric/child”). All qualifying articles focusing on rural pediatric TBI, including the subtopics epidemiology (N = 3), intervention/healthcare cost (N = 6), and prevention (N = 1), were reviewed. Results: Rural pediatric TBIs were more likely to have increased trauma and head injury severity, with higher-velocity mechanisms (e.g., motor vehicle collisions). Rural patients were at risk of delays in care due to protracted transport times, inclement weather, and mis-triage to non-trauma centers. They were also more likely than urban patients to be unnecessarily transferred to another hospital, incurring greater costs. In general, rural centers had decreased access to mental health and/or specialist care, while the average healthcare costs were greater. Prevention efforts, such as mandating bicycle helmet use through education by the police department, showed improved compliance in children aged 5–12 years. Conclusions: U.S. rural pediatric patients are at higher risk of dangerous injury mechanisms, trauma severity, and TBI severity compared to urban. The barriers to care include protracted transport times, transfer to less-resourced centers, increased healthcare costs, missing data, and decreased access to mental health and/or specialty care during hospitalization and follow-up. Preventative efforts can be successful and will require an improved multidisciplinary awareness and education.

Differences in State Traumatic Brain Injury–Related Deaths, by Principal Mechanism of Injury, Intent, and Percentage of Population Living in Rural Areas — United States, 2016–2018

“…Level of rurality might play a role in the incidence of TBI-related deaths in states with higher rates. Residents in rural areas experience a higher incidence of TBI ( 2 ) and might face barriers to accessing emergency medical care (including Level I trauma centers) ( 7 ) and specialized TBI care ( 8 ). Disparate TBI-related death rates might also result from risk differences in mechanisms of injury and implementation of state injury prevention policies.…”

Rural Primary Care Providers’ Experience and Usage of Clinical Recommendations in the CDC Pediatric Mild Traumatic Brain Injury Guideline: A Qualitative Study

“…As evidence suggests that rural communities have higher rates of TBI than urban communities, 2,3,17 it is important to ensure that providers who treat patients in these communities have the most up‐to‐date information about TBI best practices. Findings from this qualitative study provide insight into the perception and use of the CDC pediatric mTBI guideline among pediatric rural health care providers.…”

“…Unintentional injuries, including traumatic brain injury (TBI), are the leading cause of death and disability in children in the United States 1 . A recent review found that rural pediatric TBIs were more likely to have increased injury severity and often involved higher velocity injury mechanisms than others 2 . Additionally, a retrospective study of children using data collected as part of the Oregon Trauma Registry found that children living in rural areas had a TBI incidence rate about 50% greater than children living in urban areas 3 .…”

“…Furthermore, total TBI‐related health care costs may be higher for children living in rural areas compared to children living in urban areas, despite children in rural areas having lower rates of utilization of particular services (eg, speech therapy and mental health services) 10 . Lastly, rural TBI patients are at risk of delays in care due to transport, weather, and mis‐triage to nontrauma centers 2 …”

Traumatic Brain Injury in Children

“…Countries with the lowest and highest incidence are Sweden (12 cases per 100,000) and Australia (486 cases per 100,000). Higher incidence, severity, and mortality in pediatric TBI are observed in rural as opposed to urban areas [12]. Bimodal age distribution with peaks at 0-4 years and 14-18 years with male-gender preponderance in the pediatric population is observed [13].…”