Traumatic Brain Injuries Among
Arizona Residents, 2009

Resources for the development of this report were provided through funding to the
Arizona Department of Health Services from the Centers for Disease and Control and
Prevention, Cooperative Agreement 5U17CE924770-04, Integrated Core Injury
Prevention and Control Program.
Permission to quote from or reproduce materials from this publication is granted when
acknowledgment is made.

Prepared by: Alana Shacter, MPH
150 North 18th Avenue, Suite 320
Phoenix, AZ 85007
Injury Prevention Program
Bureau of Women’s and Children’s Health
Arizona Department of Health Services
July 2010

Table of Contents
Executive Summary ...................................................................................................... 2
Trends in Traumatic Brain Injuries among Arizona Residents, 2005-2009 .............. 5
Mortality ....................................................................................................................... 5
Non-Fatal Inpatient Hospitalizations ............................................................................ 7
Non-Fatal Emergency Department Visits................................................................... 10
Deaths among Arizona Residents During 2009 ........................................................ 12
Firearm-Related TBI Mortality .................................................................................... 15
Fall-Related TBI Mortality .......................................................................................... 16
Non-Fatal Inpatient Hospitalizations among Arizona Residents During 2009 ....... 17
Non-Fatal Fall-Related TBI Inpatient Hospitalizations ............................................... 21
Non-Fatal Motor Vehicle Traffic Crash-Related TBI Inpatient Hospitalizations .......... 22
Non-Fatal Emergency Department Visits among Arizona Residents During 2009 24
Non-Fatal Fall-Related Emergency Department Visits .............................................. 28
Non-Fatal Struck By/Against-Related TBI Emergency Department Visits ................. 29
Data Notes ................................................................................................................... 31
Appendix A. Definitions of Mechanisms of Injury ................................................... 32

1

Executive Summary
Traumatic brain injuries (TBI) were the cause of death for 1,288 Arizona residents in 2009.
Males ages 85 years and older had the highest rate of TBI deaths with 211.4 deaths per
100,000 residents. TBI death rates were highest among American Indians (30.3 per
100,000 residents) and Non-Hispanic Whites (19.1 per 100,000 residents). Forty-four
percent of TBI deaths in 2009 were due to unintentional injuries (n=578); 41 percent were
due to suicides (n=523); and 10 percent were due to homicides (n=127). The most common
causes of TBI deaths of any intent were firearms (47 percent, n=610), falls (24 percent,
n=310), and motor vehicle traffic crashes (16 percent, n=206).
In 2009, there were 6,943 non-fatal inpatient hospitalizations due to TBI. Adults 85 years
and older had the highest rates of TBI inpatient hospitalizations. Males 85 years and older
had a rate of 564.5 hospitalizations per 100,000 residents. The rate for females 85 years
and older was 477.7 hospitalizations per 100,000 residents. Age-adjusted TBI inpatient
hospitalization rates were highest among American Indians (175.9 per 100,000 residents)
and Non-Hispanic Whites (106.2 per 100,000 residents). Unintentional injuries accounted
for 85 percent of TBI hospitalizations (n=4,945) and assaults comprised an additional 13
percent (n=898). Falls were the most common cause of TBI hospitalizations (42 percent,
n=2,896), followed by motor vehicle traffic crashes (30 percent, n=2,053). Total hospital
charges for non-fatal inpatient hospitalizations due to TBIs were $433 million.
In 2009, there were 43,369 non-fatal TBI emergency department visits among Arizona
residents. Almost half of TBI emergency department visits were among children ages 19
years and younger (46 percent, n=20,120), as a result of physical and mental factors that
make children and young adults more susceptible to TBIs and more likely to engage in
activities that have a high risk for TBIs. TBI emergency department visit rates were highest
among children younger than one year of age. Females younger than one year of age had a
rate of 2,233.8 visits per 100,000 residents, and males younger than one year of age had a
rate of 2,620.7 visits per 100,000 residents. The majority of TBI emergency department
visits were due to unintentional injuries (89 percent, n=38,424), and 11 percent were due to
assaults (n=4,733). The leading causes of TBI emergency department visits were falls (50
percent, n=21,755), struck by/against injuries (25 percent, n=10,849), and motor vehicle
traffic crashes (12 percent, n=5,273). Total hospital charges for non-fatal emergency
department visits due to TBIs were $178 million.
The data presented in this report show that TBI is a public health problem that
impacts the lives of thousands of Arizona residents each year. The effects of TBI can
include chronic pain, disability, large medical bills, changes in quality of life, and premature
death. TBI can occur throughout the life span, and the repercussions of these injuries may
be experienced for many years. The consequences of TBI can extend beyond the injured
individuals to their families and communities. With non-fatal TBI, family members are often
required to provide care, which can result in time away from work, loss of income, and
increases in stress. Within a community, the financial costs of TBI include medical
expenses, rehabilitation, lost wages, and lost productivity. Most TBI injuries are
predictable and preventable. Understanding the causes of TBI is an important step
towards educating and empowering communities and implementing effective prevention
strategies.

2

Introduction
Traumatic brain injury (TBI) is defined as damage to the brain following a sudden blow
or impact to the head or by shaking the head violently. TBI can also be caused by a
penetrating head injury that disrupts brain function. An estimated 1.4 million Americans
sustain these injuries each year, and of these, 50,000 die as a result of the trauma.1 An
additional 80,000 to 90,000 people experience permanent disability, and it is estimated
that 5.3 million Americans are currently living with a TBI-related disability.2,3 TBI can
cause cognitive function deficits, which can lead to depression and other secondary
outcomes including problems working and performing daily activities such completing
school work, managing personal finances, or driving a vehicle.
Figure 1. Traumatic Brain Injury Pyramid, 2009

Deaths
1,288
Inpatient
Hospitalizations
6,943

Emergency Department Visits
43,369

Injuries treated in physician offices,
other outpatient facilities, at home, or
not treated
???

Figure 1 shows a TBI pyramid for Arizona in 2009. This pyramid shows that deaths
represent the smallest proportion of injuries. The proportions increase towards the
foundation of the pyramid, which is comprised of hospital discharges, emergency

1

Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: Emergency Department
Visits, Hospitalizations and Deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for
Injury Prevention and Control; 2006
2
Ibid
3
Thurman D, Alverson C, Dunn K, Guerrero J, Sniezek J. Traumatic brain injury in the United States: a public health
perspective. Journal of Head Trauma Rehabilitation 1999;14(6):602–15.

3

department visits, and self-care. Although TBIs that do not require medical treatment
may be the most numerous, no existing datasets capture these types of injuries.

4

Trends in Traumatic Brain Injuries among Arizona Residents, 2005-2009
Mortality
Between 2005 and 2009, the age-adjusted mortality rate of traumatic brain injury
decreased 17 percent, from 23.1 deaths per 100,000 Arizona residents in 2005 to 19.2
deaths per 100,000 residents in 2009. Age-adjusted mortality rates among males were
more than double the rates among females. Rates for males decreased 17 percent from
2005 through 2009, and rates for females decreased 15 percent. Figure 2 shows ageadjusted TBI mortality rates by sex from 2005 through 2009.
Figure 2. Age-Adjusted TBI Mortality Rates by Sex, Arizona, 2005-2009
45.0

35.0

Males

39.5

40.0

Females

35.0

33.6
31.3

29.1

30.0
25.0
20.0
15.0

13.3
11.8

9.9

10.0

9.9

10.1

5.0
0.0

2005

2006

2007

2008

2009

While total age-adjusted TBI mortality rates declined from 2005 through 2009, changes
in rates varied by manner and mechanism of injury. Figures 3 and 4 show age-adjusted
TBI mortality rates by manner and selected cause of injury.

5

Figure 3. Age-Adjusted TBI Mortality Rates per 100,000 Residents by Manner of
Death, Arizona, 2005-2009
16.0
Unintentional (28% decrease)
14.0
12.0

Suicide (7% increase)

13.4

Homicide (34% decrease)

11.8
10.8

10.1

10.0

8.5

8.0
6.0
4.0

7.3

7.8

7.5

7.1

3.0

2.8

2.5

2.4

7.9

2.0

2.0
0.0

2005

2006

2007

2008

2009

Figure 4. Age-Adjusted TBI Mortality Rates per 100,000 Residents by Selected
Cause of Death, Arizona, 2005-2009
12.0

10.0

9.9

10.1
9.4

9.0

9.2

8.0
7.0
6.1
6.0
4.6
4.0

4.2

2.0

4.7
4.1

4.5

4.4

4.2
3.2

Firearms (7% decrease)
Falls (5% increase)
Motor Vehicle Crashes (48% decrease)

0.0

2005

2006

2007

2008

2009

6

Non-Fatal Inpatient Hospitalizations
Between 2005 and 2009, the age-adjusted rate of TBI-related inpatient hospitalizations
increased five percent, from 99.5 hospitalizations per 100,000 Arizona residents in 2005
to 104.1 hospitalizations per 100,000 residents in 2009. Age-adjusted hospitalization
rates among males were almost double the rates among females. Rates for males
increased five percent from 2005 through 2009, and rates for females increased four
percent. Figure 5 shows age-adjusted non-fatal TBI-related inpatient hospitalization
rates by sex from 2005 through 2009. Please refer to the Data Notes Section of this
report for additional information regarding increased inpatient hospitalization rates in
2009.
Figure 5. Age-Adjusted Non-Fatal TBI-Related Inpatient Hospitalization Rates by
Sex, Arizona, 2005-2009
160.0
140.0

133.1

137.1

130.4

120.0

112.0
99.8

100.0
80.0

67.6

70.3

62.9

55.3

60.0

49.8

40.0
20.0
0.0

2005

2006

2007
Males

2008

2009

Females

While total age-adjusted TBI-related inpatient hospitalization rates increased from 2005
through 2009, changes in rates varied by manner and mechanism of injury. Figure 6
shows age-adjusted TBI hospitalization rates by manner of injury.

7

Figure 6. Age-Adjusted Non-Fatal TBI-Related Inpatient Hospitalization Rates per
100,000 Residents by Manner of Injury, Arizona, 2005-2009
100.0
90.0

88.6

88.7
84.2

80.0

73.5

70.0
64.8

Unintentional (No change)

60.0

Self‐Inflicted (46% increase)

50.0

Assault (42% increase)

40.0
30.0
20.0
10.0

9.7
0.6

0.0

2005

9.9
0.6

2006

9.9
0.4

2007

9.4
0.5

2008

13.8
0.8

2009

From 2005 through 2009, the rate of non-fatal inpatient hospitalizations due to fallrelated traumatic brain injuries increased 48 percent, from 28.8 hospitalizations per
100,000 residents in 2005 to 42.4 hospitalizations per 100,000 residents in 2009. Males
had a higher rate of fall-related TBI hospitalizations than females in each of the five
years examined.
While the rate of fall-related TBI hospitalizations increased since 2005, the rate of motor
vehicle crash-related TBI hospitalizations decreased 31 percent. There was an overall
decrease in the rate from 2005 through 2008, followed by a slight increase in the rate
from 2008 through 2009. The rate of non-fatal inpatient hospitalizations for TBIs due to
motor vehicle crashes decreased from 45.2 hospitalizations per 100,000 residents in
2005 to 31.2 hospitalizations per 100,000 residents in 2009. As with falls, males had a
higher rate of motor vehicle crash-related TBI hospitalizations than females in each of
the years examined.
From 2005 through 2008, the rate of fall-related TBI hospitalizations remained lower
than the rate for TBI hospitalizations due to motor vehicle crashes. In 2009, however,
the rate of motor vehicle crash-related TBI hospitalizations was lower than the rate of
fall-related cases (42.4 fall-related hospitalizations in 2009, 31.2 motor vehicle crashrelated hospitalizations in 2009). Figure 7 shows the trend of fall-related TBI
hospitalizations by sex from 2005 through 2009, and Figure 8 shows the trend of motor
vehicle crash-related TBI hospitalizations by sex from 2005 through 2009.

8

Figure 7. Age-Adjusted Non-Fatal Fall-Related TBI Inpatient Hospitalization Rates
per 100,000 Residents by Manner of Injury, Arizona, 2005-2009
60.0

50.0

40.0

Male
Female

34.7

48.9

36.0

34.0
29.0

30.0

23.1

22.7

25.5
19.6

17.8

20.0

10.0

0.0

2005

2006

2007

2008

2009

Figure 8. Age-Adjusted Non-Fatal Motor Vehicle Crash-Related TBI Inpatient
Hospitalization Rates per 100,000 Residents by Manner of Injury,
Arizona, 2005-2009
70.0
60.0

Male
Female

59.4
56.0
50.7

50.0

40.3

38.4

40.0

33.9
29.6

30.0

28.6
21.6

22.0

20.0
10.0
0.0

2005

2006

2007

2008

2009

9

Non-Fatal Emergency Department Visits
From 2005 through 2009, the age-adjusted rate of non-fatal TBI-related emergency
department visits increased 44 percent, from 450.9 visits per 100,000 Arizona residents
in 2005 to 647.3 visits per 100,000 residents in 2009. Age-adjusted emergency
department visit rates among males were higher than rates among females. Rates for
males increased 35 percent from 2005 through 2009, and rates for females increased
56 percent. Figure 9 shows age-adjusted TBI-related emergency department visit rates
by sex from 2005 to 2009. Please refer to the Data Notes Section of this report for
additional information regarding increased emergency department visit rates in 2009.
Figure 9. Age-Adjusted Non-Fatal TBI-Related Emergency Department Visit Rates
by Sex, Arizona, 2005-2009
800.0

Males
700.0

695.8

Females
603.2

580.4

567.1

600.0

517.1

465.4

500.0
400.0

590.6

378.7

423.3

441.5

300.0
200.0
100.0
0.0

2005

2006

2007

2008

2009

While total age-adjusted TBI-related emergency department visit rates increased from
2005 through 2009, changes in rates varied by manner and mechanism of injury.
Unintentional injuries, injuries related to self-harm, and injuries related to assaults
increased at varying levels from 2005 through 2009. Figure 10 shows age-adjusted TBI
emergency department visit rates by manner of injury, and Figure 11 shows ageadjusted rates for non-fatal TBI-related emergency department visits for selected
causes of injury. Though not shown in Figure 10, the rate of emergency department
visits related to self-harm increased 28 percent, from 0.78 visits per 100,000 residents
in 2005 to 1.0 visits per 100,000 residents in 2009.

10

Figure 10. Age-Adjusted Non-Fatal TBI-Related Emergency Department Visit
Rates per 100,000 Residents by Manner of Injury, Arizona, 2005-2009
700.0
Unintentional (44% increase)
Assault (41% increase)

600.0

571.5

500.0
396.8

420.8

448.1

467.5

400.0
300.0
200.0
100.0

68.1
51.4

57.1

72.6

64.2

0.0

2005

2006

2007

2008

2009

Figure 11. Age-Adjusted Non-Fatal TBI-Related Emergency Department Visit
Rates per 100,000 Residents by Selected Cause of Injury, Arizona, 2005-2009
350.0

319.1

Falls (63% increase)
Struck By/Against (53% increase)

300.0

Motor Vehicle Crashes (2% decrease)
250.0
200.0

195.5

211.1

253.9
228.0

164.2
150.0
107.2

116.0

127.5

131.9

100.0
50.0

82.1

86.2

85.6

76.6

80.2

0.0

2005

2006

2007

2008

2009

11

Deaths among Arizona Residents During 2009
In 2009, 1,288 Arizona residents died as a result of TBI. The majority of deaths were
among males (72 percent, n=929), while females accounted for 28 percent of TBI
deaths (n=359). The largest percentage of deaths was among individuals ages 65 years
and older (37 percent, n=468). Children ages 19 years and younger accounted for eight
percent of TBI deaths in 2009 (n=110). Age distributions are shown in Figure 12.
Figure 12. TBI Deaths by Age Group, Arizona, 2009
(n=1,288)
0‐4 Years
2% (n=28)
5‐14 Years
1% (n=19)

65+ Years
37% (n=468)

15‐19 Years
5% (n=63)
20‐24 Years
8% (n=100)
45‐64 Years
26% (n=337)

25‐44 Years
21% (n=272)

Males 85 years and older accounted for 88 deaths and had the highest rate of TBI
deaths in 2009 (211.4 per 100,000 residents). For all adults 85 years and older, 71
percent of TBI deaths were due to unintentional falls (n=120). Figure 13 shows the 2009
TBI death rates by age group and sex for Arizona residents.

250.0

200.0

Figure 13. TBI Mortality Rates per 100,000 by Age Group and
Sex, Arizona, 2009 (n=1,288)
Females (n=359)
Males (n=929)

211.4

150.0
116.5
87.1

100.0
48.9

50.0

0.0

19.1

8.8 6.4

6.1 4.3

1.7 1.7

<1

1‐4

5‐9

2.2 2.5 8.2

10‐14

33.7
8.8

21.8
6.8

15‐19 20‐24 25‐44
Age in Years

35.3
9.7

45‐64

30.2
11.7

65‐74

75‐84

85+

12

Age-adjusted TBI death rates were highest among American Indians (30.3 deaths per
100,000 residents) and Non-Hispanic Whites (19.1 deaths per 100,000 residents).
Figure 14 shows the 2009 age-adjusted TBI death rates by race/ethnicity in Arizona.
Figure 14. Age-Adjusted TBI Mortality Rates per 100,000 by
Race/Ethnicity, Arizona, 2009 (n=1,288)
35.0

30.3

30.0
25.0
19.1

20.0

19.2
17.6

17.1

15.0

13.2

10.0
5.0
0.0
American
Indian
(n=94)

White, Non‐
Hispanic
(n=902)

African
American
(n=42)

Hispanic
(n=229)

Asian
(n=15)

All
race/ethnicities
(n=1,288)

Age-adjusted TBI mortality rates were highest among residents of rural counties, with
the highest rates in La Paz, Apache, and Gila Counties. Figure 15 shows age-adjusted
mortality rates by county of residence. Rates may be unstable for counties with fewer
than 20 TBI-related deaths.

13

Figure 15.

14

Forty-four percent of the TBI deaths in 2009 were due to unintentional injuries (n=578);
41 percent were due to suicides (n=523); and 10 percent were due to homicides
(n=127). Figure 16 shows TBI deaths by manner of injury during 2009 in Arizona.
Figure 16. TBI Deaths by Manner of Injury, Arizona, 2009
(n=1,288)
Homicide
10% (n=127)
Suicide
41% (n=523)

Other/unknown
5% (n=60)

Unintentional
44% (n=578)

The most common causes of deaths were firearms (47 percent, n=610), falls (24
percent, n=310), and motor vehicle traffic crashes (16 percent, n=206). Causes of TBI
deaths during 2009 in Arizona are shown in Table 1. Descriptions of these causes are
given in Appendix A.
Table 1. TBI Deaths by Cause, Arizona 2009
Cause
Number
Percentage
Firearm
610
47%
Fall
310
24%
Motor vehicle traffic
206
16%
Other/unspecified
113
9%
Other land transport
19
1%
Unknown cause
30
2%
Total
1,288
100%

Firearm-Related TBI Mortality
Among the 610 Arizona residents who died as a result of firearm-related TBI, the
majority were male (81 percent, n=496) and 19 percent were female (n=114). Six
percent of TBI deaths due to firearms were among children 19 years and younger
(n=34). Ten percent of the deaths were among individuals ages 20 through 24 years
(n=62); 60 percent were among individuals ages 25 through 64 years (n=364); and 25
percent were among individuals 65 years and older (n=150).
The highest age-adjusted rate of firearm-related TBI deaths was among White NonHispanics (n=465). This population had a rate of 10.4 deaths per 100,000 residents.
The second highest rate was among African Americans, who accounted for 22 deaths,
or 8.0 deaths per 100,000 residents.
15

The majority of firearm-related TBI deaths were suicides (85 percent, n=516). Fourteen
percent of the deaths were due to homicides (n=84); one percent were of undetermined
intent (n=7); and less than one percent were due to unintentional injuries (n=2). There
was one firearm-related TBI resulting from legal intervention. Figure 17 shows TBI
deaths due to firearms by manner of injury.
Figure 17. TBI Deaths due to Firearms by Manner of Injury,
Arizona, 2009 (n=610)
Legal
Intervention
0% (n=1)
Suicide
85% (n=516)

Homicide
14% (n=84)
Undetermined
1% (n=7)
Unintentional
0% (n=2)

Fall-Related TBI Mortality
Of the 310 TBI deaths due to falls, 53 percent were among males (n=165) and 47
percent were among females (n=145). All but four of the falls were unintentional. Two
percent of TBI deaths due to falls were among children and young adults ages 24 years
and younger (n=6). Eighteen percent of the deaths were among adults ages 25 through
64 years (n=56); and 80 percent were among adults 65 years and older (n=248).
The highest age-adjusted rate of fall-related TBI deaths was among Asians, who
accounted for six deaths, or 6.8 deaths per 100,000 residents. The second highest rate
was among American Indians (6.2 deaths per 100,000 residents, n=13). The ageadjusted mortality rate for fall-related TBI deaths among all races/ethnicities was 4.4
deaths per 100,000 residents.

16

Non-Fatal Inpatient Hospitalizations among Arizona Residents During 2009
In 2009, 6,943 Arizona residents were hospitalized due to non-fatal TBIs. Males
comprised 64 percent of total TBI hospitalizations (n=4,474) and females accounted for
36 percent (n=2,465). Four hospitalizations were among individuals of unknown sex.
Twenty-three percent of TBI inpatient hospitalizations were among children ages 19
years and younger (n=1,476). The age distribution is shown in Figure 18.
Figure 18. TBI Inpatient Hospitalizations by Age Group,
Arizona, 2009 (n=6,943)
65+ Years
28% (n=1,870)

0‐4 Years
8% (n=498)
5‐14 Years
7% (n=454)
15‐19 Years
8% (n=524)

45‐64 Years
22% (n=1,465)

20‐24 Years
9% (n=582)
25‐44 Years
18% (n=1,150)

Adults 85 years and older had the highest rates of TBI inpatient hospitalizations in 2008.
Males 85 years and older had a rate of 564.5 hospitalizations per 100,000 residents
(n=235), and the rate for females 85 years and older was 477.7 hospitalizations per
100,000 residents (n=332). For adults 85 years and older, 90 percent of hospitalizations
were due to unintentional falls (n=508). Figure 19 shows the 2009 TBI inpatient
hospitalization rates by age group and sex for Arizona residents.

17

Figure 19. TBI Inpatient Hospitalization Rates per 100,000 by Age
Group and Sex, Arizona, 2009 (n=6,943)
600.0

564.5

Females (n=2,465)
Males (n=4,474)

500.0

477.7

400.0
303.9

300.0
200.0

230.3

196.8

248.9

190.8
160.1

132.3

121.3
75.0

100.0
55.0

75.6
32.4

48.6

36.0

66.2

56.9

41.8

152.5
108.8

62.1

0.0

<1

1‐4

5‐9

10‐14

15‐19 20‐24
Age in Years

25‐44

45‐64

65‐74

75‐84

85+

Does not include four individuals of unknown sex

Age-adjusted TBI inpatient hospitalization rates were highest among American Indians
(175.9 hospitalizations per 100,000 residents) and Non-Hispanic Whites (106.2
hospitalizations per 100,000 residents). Figure 20 shows the 2009 age-adjusted TBI
inpatient hospitalization rates by race/ethnicity in Arizona.
Figure 20. Age-Adjusted TBI Inpatient Hospitalizations
Rates per 100,000 by Race/Ethnicity, Arizona, 2009
(n=6,943)
200.0
180.0
160.0
140.0
120.0
100.0
80.0
60.0
40.0
20.0
0.0

175.9

106.2

87.8

104.1

87.2
79.7

American
White, Non‐
Indian (n=573)
Hispanic
(n=4,575)

Asian
(n=128)

African
American
(n=220)

Hispanic
(n=1,269)

All
race/ethnicities
(n=6,943)

178 hospitalizations were among individuals of other or unknown race/ethnicity

For TBI inpatient hospitalizations, the average length of stay was five days, with the
majority of stays less than five days (68 percent, n=4,717). Length of stay in hospitals

18

due to TBI ranged from less than one full day to 111 days. Figure 21 shows TBI
inpatient hospitalizations by length of stay.
Figure 21. TBI Inpatient Hospitalizations by Length of Stay,
Arizona, 2009 (n=6,943)
5‐9 Days
19% (n=1,331)
0‐4 Days
68% (n=4,717)

10‐14 Days
6% (n=440)

15 Days or More
7% (n=455)

TBI inpatient hospitalization charges in 2009 totaled more than $433 million, with 51
percent paid by the Arizona Health Care Cost Containment System
(AHCCCS)/Medicaid and Medicare (n=3,537). This total does not include costs related
to physician care, rehabilitation, lost wages, or long-term costs of disability.
Age-adjusted TBI hospitalization rates were highest among residents of rural counties,
with the highest rates in La Paz, Apache, and Gila Counties. While Mohave County had
an extremely low rate of hospitalizations for non-fatal TBIs, this may be due to the fact
that severely injured patients are transported for treatment at trauma centers in Nevada.
Because these patients are not treated at Arizona facilities, data on these patients is not
available. Figure 22 shows age-adjusted hospitalization rates by county of residence.
Rates may be unstable for counties with fewer than 20 TBI-related hospitalizations.

19

Figure 22.

20

Unintentional injuries accounted for 85 percent of TBI hospitalizations (n=4,945). There
were 54 self-inflicted TBI hospitalizations (one percent) and 898 assaults (13 percent).
Figure 23 shows the TBI inpatient hospitalizations by manner of injury for Arizona in
2009.
Figure 23. TBI Inpatient Hospitalizations by Manner of
Injury, Arizona, 2009 (n=6,943)
Self‐Inflicted
1% (n=54)
Assault
13% (n=898)
Unintentional
85% (n=4,945)

Other/unknown
1% (n=46)

Fall-related injuries were the most common cause of TBI hospitalizations (42 percent,
n=2,896), followed by motor vehicle traffic injuries (30 percent, n=2,053). Table 2 shows
causes of TBI inpatient hospitalizations in Arizona during 2009. Descriptions of these
causes are given in Appendix A.
Table 2. TBI Inpatient Hospitalizations by Cause,
Arizona 2009
Cause
Number
Percentage
Fall
2,896
42%
Motor vehicle traffic
2,053
30%
Struck by/against
829
12%
Other/unspecified
474
7%
Transport
416
6%
Other pedal cycle
167
2%
Firearm
65
1%
Cut/pierce
43
1%
Total
6,943
100%

Non-Fatal Fall-Related TBI Inpatient Hospitalizations
There were 2,896 inpatient hospitalizations due to fall-related TBI. Fifty-four percent
were among males (n=1,557) and 46 percent were among females (n=1,337). There
were two cases among individuals of unknown sex. Nineteen percent of the
hospitalizations were among children 19 years and younger (n=536), and 52 percent of
the hospitalizations were among adults 65 years and older (n=1,514). Almost all of
these falls were unintentional (n=2,881), but 15 were self-inflicted or from assaults or
undetermined intents.
21

American Indians had the highest age-adjusted rate of fall-related TBI hospitalizations
with 52.3 hospitalizations per 100,000 residents (n=137). The second highest rate was
among Non-Hispanic Whites (44.8 hospitalizations per 100,000 residents; n=2,168).
The age-adjusted rate for non-fatal fall-related inpatient hospitalizations among all
Arizonans was 42.4 hospitalizations per 100,000 residents.
In more than one quarter of fall-related hospitalizations, the hospital discharge database
did not contain any specific information about the events contributing to these falls (27
percent, n=783). The most frequently specified contributing events were slipping,
tripping, or stumbling (40 percent of specified events, n=826) and falls from wheelchairs,
beds, or other furniture (15 percent of specified events, n=318). Figure 24 shows TBI
inpatient hospitalizations due to falls by specified contributing event.
Figure 24. TBI Inpatient Hospitalizations due to Falls by
Specified Contributing Event (All Manners), Arizona, 2009
(n=2,113)
From or out of
building 4% (n=89)

Slipping, tripping, or
stumbling
40% (n=826)

Suicide attempt,
assault, or
undetermined intent
1% (n=15)
Other fall from one
level to another
10% (n=220)

Fall resulting in
striking an object
6% (n=127)
From recreational
equipment or in sports
5% (n=107)
From stairs/ladders
13% (n=285)

Other
6% (n=126)
From
wheelchair/furniture
15% (n=318)

Non-Fatal Motor Vehicle Traffic Crash-Related TBI Inpatient Hospitalizations
Of the 2,053 TBI hospitalizations due to motor vehicle traffic crashes, 65 percent were
among males (n=1,332) and 35 percent were among females (n=719). There were two
non-fatal motor vehicle traffic-related inpatient hospitalizations among individuals of
unknown sex. Almost all of the crashes were unintentional (n=2,045). Twenty-one
percent of TBI hospitalizations due to motor vehicle traffic crashes were among children
19 years and younger (n=424); 14 percent were among individuals ages 20 through 24
years (n=280); 56 percent were among individuals 25 through 64 years (n=1,147); and
10 percent were among adults 65 years and older (n=202).

22

American Indians had the highest rate of TBI hospitalizations for motor vehicle traffic
crashes (49.4 hospitalizations per 100,000 residents; n=173). With 31.3 hospitalizations
per 100,000 residents, Non-Hispanic Whites had the second highest rate (n=1,252).
The age-adjusted rate for non-fatal motor vehicle traffic-related inpatient hospitalizations
among all Arizonans was 31.2 hospitalizations per 100,000 residents.
The majority of TBI inpatient hospitalizations due to motor vehicle traffic collisions were
among occupants of motor vehicles (64 percent, n=1,258). Nineteen percent were
motorcyclists (n=362); 11 percent were pedestrians (n=209); and four percent were
pedal cyclists (n=82). Two percent were other/unspecified (n=45). Figure 25 shows TBI
inpatient hospitalizations due to motor vehicle traffic crashes by injured person.
Figure 25. TBI Inpatient Hospitalizations due to
Motor Vehicle Traffic Crashes by Injured Person
(All Manners), Arizona, 2009 (n=2,053)
Motor Vehicle
Occupant
64% (n=1,307)

Other/unspecified
3% (n=62)
Pedestrian
11% (n=230)

Motorcyclist
17% (n=355)
Pedalcyclist
5% (n=99)

23

Non-Fatal Emergency Department Visits among Arizona Residents During 2009
In 2009, there were 43,369 TBI emergency department visits among Arizona residents.
Males accounted for more than half of TBI emergency department visits (54 percent,
n=23,408), while females accounted for 46 percent of visits (n=19,960). There was one
case among an individual of unknown sex. Forty-six percent of TBI emergency
department visits were among children ages 19 years and younger (n=20,120).
Emergency department visits by age group are shown in Figure 26.
Figure 26. TBI Emergency Department Visits by
Age Group, Arizona, 2009 (n=43,369)
65+ Years
14% (n=6,189)

0‐4 Years
20% (n=8,854)

45‐64 Years
13% (n=5,569)
5‐14 Years
16% (n=6,882)
25‐44 Years
19% (n=8,074)
20‐24 Years
8% (n=3,417)

15‐19 Years
10% (n=4,384)

TBI emergency department visit rates were highest among children younger than one
year of age. There were 1,010 emergency department visits among females younger
than one year of age (a rate of 2,233.8 visits per 100,000 residents), and 1,233 visits
among males younger than one year of age (a rate of 2,620.7 visits per 100,000
residents). For all children younger than one year of age, 86 percent of TBI emergency
department visits were due to unintentional falls (n=1,927). Figure 27 shows the 2009
TBI emergency department visit rates per 100,000 Arizona residents.

24

Figure 27. TBI Emergency Department Visit Rates per 100,000 by
Age Group and Sex, Arizona, 2009 (n=43,369)
3,000

Females (n=19,960)
Males (n=23,408)

2,620.7
2,500

2,233.8

2,000

1,844.4

1,847.8
1,396.0

1,500

1,419.6
1,131.9
950.2

951.5

1,000

899.5
778.5

537.4

838.0
647.9
415.7445.6 382.1
351.0

477.8

500

508.8

612.6

364.5

0

<1

1‐4

5‐9

10‐14

15‐19 20‐24 25‐44
Age in Years

45‐64

65‐74

75‐84

85+

Age-adjusted TBI emergency department visit rates were highest among Non-Hispanic
Whites (738.1 visits per 100,000 residents) and African Americans (727.6 visits per
100,000 residents). Figure 28 shows the 2009 age-adjusted TBI emergency department
visit rates by race/ethnicity in Arizona.
Figure 28. Age-Adjusted TBI Emergency Department Visit
Rates per 100,000 by Race/Ethnicity, Arizona, 2009
(n=43,369)
800.0
700.0
600.0
500.0
400.0
300.0
200.0
100.0
0.0

738.1

727.6

647.3
521.1

476.2
393.6

White, Non‐
Hispanic
(n=27,806)

African
American
(n=2,039)

Hispanic
(n=10,490)

American
Indian
(n=1,689)

Asian
(n=663)

All
race/ethnicities
(n=43,369)

682 emergency department visits were among individuals of other or unknown race/ethnicity

TBI emergency department charges in 2009 totaled more than $178 million, with 42
percent paid by the Arizona Health Care Cost Containment System

25

(AHCCCS)/Medicaid and Medicare. This total does not include costs related to
physician care, rehabilitation, lost wages, or long-term costs of disability.
Unlike with mortality and hospitalization rate, age-adjusted TBI emergency department
visit rates were highest among residents of Pima County, with the next highest rates in
the central counties: Yavapai, Pinal, and Gila Counties. Apache and Navajo Counties
have lower rates of TBI-related non-fatal emergency department rates than expected,
but this is likely an artifact of the data rather than a truly low rate in these counties. A
large area of the Navajo Nation is situated within the borders of Apache and Navajo
Counties, and tribal residents tend to seek medical care for less severe injuries at local
health facilities operated by the tribe or Indian Health Services (IHS). Since the Arizona
Hospital Discharge Database only collects data from private, non-federal facilities,
injuries seen exclusively at tribal or IHS facilities are not included in the data shown
here, accounting for a potential undercount among tribal residents. Figure 29 shows
age-adjusted emergency department visit rates by county of residence.

26

Figure 29.

27

The majority of TBI emergency department visits were due to unintentional injuries (89
percent, n=38,424), and 11 percent were assaults (n=4,733). Figure 30 shows TBI
emergency department visits by intent during 2009 in Arizona.
Figure 30. TBI Emergency Department Visits by Manner of
Injury, Arizona, 2009 (n=43,369)
Unintentional
89% (n=38,424)

Self‐Inflicted
0% (n=66)
Other/unknown
0% (n=146)

Assault
11% (n=4,733)

The leading causes of TBI emergency department visits were falls (50 percent,
n=21,755), struck by/against injuries (25 percent, n=10,849), and motor vehicle trafficrelated injuries (12 percent, n=5,273). Table 3 shows TBI emergency department visits
by cause for Arizona in 2009. Descriptions of these causes are given in Appendix A.

Table 3. TBI Emergency Department Visits by Cause,
Arizona 2009
Cause
Number
Percentage
Fall
21,755
50%
Struck by/against
10,849
25%
Motor vehicle traffic
5,273
12%
Other/unspecified
2,850
7%
Transport
1,330
3%
Other pedal cycle
1,126
3%
Cut/pierce
216
< 1%
Total
43,369
100%

Non-Fatal Fall-Related Emergency Department Visits
There were 21,755 emergency department visits due to fall-related TBI. Forty-eight
percent were among males (n=10,471) and 52 percent were among females
(n=11,284). Nearly all of these falls were unintentional (n=21,747). Fifty percent of TBI
emergency department visits due to falls were among individuals 19 years and younger
(n=10,948).

28

Ten percent of the falls did not have contributing event information specified in the
hospital discharge database (n=2,252). The most frequently specified contributing
events to fall-related TBI were slipping, tripping, or stumbling (35 percent of specified
events, n=7,063) and falls from furniture or wheelchairs (21 percent of specified events,
n=4,001). Figure 31 shows TBI emergency department visits due to falls by specified
contributing event.
Figure 31. TBI Emergency Department Visits due to Falls by
Specified Contributing Event (All Manners), Arizona, 2009
(n=19,503)
From or out of
building 1% (n=107)
Suicide attempt,
assault, or
undetermined intent
0% (n=8)
Fall resulting in
striking an object
13% (n=2,487)
From recreational
equipment or in sports
5% (n=1,052)
From stairs/ladders
7% (n=1,301)

Slipping, tripping, or
stumbling
35% (n=7,063)
Other fall from one
level to another
11% (n=2,172)
Other
7% (n=1,312)

From
wheelchair/furniture
21% (n=4,001)

Non-Fatal Struck By/Against-Related TBI Emergency Department Visits
Struck by/against injuries include being struck by an object (such as falling furniture),
striking against an object (such as the edge of a bathtub), or being struck by other
people (such as when playing sports). Of the 10,849 TBI emergency department visits
due to struck by/against injuries, 63 percent were among males (n=6,834) and 37
percent were among females (n=4,014). There was one case among an individual of
unknown sex. Seventy-four percent of these injuries were unintentional (n=7,990), and
26 percent were assaults (n=2,767). Fifty-two percent of TBI emergency department
visits from struck by/against injuries were among individuals 19 years and younger
(n=5,689).
The emergency department discharge database did not include information regarding
contributing event for 32 percent of the struck by/against injuries (n=3,428). The most
frequently specified contributing events were unintentional blows while playing sports
(26 percent of specified events, n=1,918) and assaults in unarmed fights (26 percent of
specified events, n=1,899). Figure 32 shows TBI emergency department visits due to
struck by/against injuries by specified contributing event.

29

Figure 32. TBI Emergency Department Visits due to Struck
By/Against Injuries by Specified Contributing Event
(All Manners), Arizona, 2009 (n=7,421)
Assault with blunt
object
12% (n=868)

Struck unintentionally
by falling object
11% (n=834)
Legal intervention
1% (n=92)

Assaulted in unarmed
fight
26% (n=1,899)

In sports
26% (n=1,918)

Other
0% (n=22)
Against other
stationary objects
17% (n=1,265)

By furniture
7% (n=523)

30

Data Notes
All rates were calculated using the 2009 Arizona resident population estimates
published by the Arizona Department of Health Services in Arizona Health Status and
Vital Statistics 2009. Age-adjusted rates were standardized to the 2000 U.S. standard
population using the direct standardization method. Age-adjusted rates have been
presented when possible, as age-adjusting controls for the effects of age differences in
populations (e.g., a large proportion of older adults or young children) and allows for
more accurate rate comparisons.
Mortality data were tabulated from death certificates for Arizona residents who died in
2009. Inpatient hospitalization data were compiled from the 2009 Arizona Hospital
Discharge Database. Emergency department visit data were compiled from the 2009
Arizona Emergency Department Discharge Database.
The discharge databases contain information from private, acute-care facilities in the
state of Arizona, and do not include visits to federal facilities, such as Veterans’ Affairs
Hospitals or Indian Health Services facilities. The discharge databases do not contain
data from urgent care facilities, private physician practices, or medical clinics.
Additionally, discharge data include hospital transfers and readmissions. Therefore, a
single injured individual may be counted more than once. These data should be
interpreted as episodes of medical treatment, not individual injuries.
Hospital discharge data collected since January 1, 2008 are maintained in a different
data layout from earlier hospital discharge data, and comparisons between data from
each time period should be treated with caution. Enhanced understanding of the new
data layout may have contributed to more thorough reporting of ICD-9-CM E-Codes in
2009 and a subsequent increase in the rate of inpatient hospitalizations and emergency
department visits for traumatic brain injuries.
Codes from the International Classification of Diseases, Version 9, clinical modification
(ICD-9-CM) were used for determining TBI cases among hospital and emergency
department data. ICD-10 codes were used for mortality data. The specific codes used
are described in Traumatic Brain Injury in the United States: Emergency Department
Visits, Hospitalizations and Deaths, published in 2006 by the U.S. Centers for Disease
Control and Prevention (CDC). Traumatic brain injury-related inpatient hospitalizations
and emergency department visits resulting from medical misadventures have been
excluded from this report.

31

Appendix A. Definitions of Mechanisms of Injury
Cause
Fall
Firearm
Unknown cause
Motor vehicle traffic

Other land transport

Other pedal cycle
Other/unspecified
Struck by/against

Transport

Definition
Includes falls from furniture, stairs, playground
equipment, and those that occur while playing sports.
Includes injuries from handguns, shotguns, BB guns,
etc.
Cause not listed.
Includes collisions that occur on public highways and
streets. These collisions may include pedestrians,
pedal cyclists, motorcyclists, and occupants of motor
vehicles.
Includes collisions involving railway transport or allterrain vehicles operating off-road. This cause only
applies to deaths and is not used in hospitalization or
emergency department databases.
Includes injured pedal cyclists struck by pedestrians,
pedal cycles, or non-motorized vehicles.
Unspecified events or other rare events.
Includes being struck by furniture, struck by other
people while playing sports, or hit by objects while
playing sports.
Other non-motorized, off-road vehicle, or rail transport.
This cause only applies to hospitalization and
emergency department databases and is not used on
death certificates.

32