FEATURE
Increasing Trauma Deaths in the United States Peter Rhee, MD, MPH, Bellal Joseph, MD, Viraj Pandit, MD, Hassan Aziz, MD, Gary Vercruysse, MD, Narong Kulvatunyou, MD, and Randall S. Friese, MD
Objective: To determine the impact of the increasing aging population on trauma mortality relative to mortality from cancer and heart disease in the United States. Background: The population in the United States continues to increase as medical advancements allow people to live longer. The resulting changes in the leading causes of death have not yet been recognized. Methods: Data were obtained (2000–2010) from the Web-based Injury Statistics Query and Reporting System database of the Centers for Disease Control and Prevention. We defined trauma deaths as unintentional injuries, suicides, and homicides. Results: From 2000 to 2010, the US population increased by 9.7% and the number of trauma deaths increased by 22.8%. Trauma deaths and death rates deceased in individuals younger than 25 years but increased for those 25 years and older. During this period, death rates for cancer and heart disease decreased. The largest increases in trauma deaths were in individuals in their fifth and sixth decades of life. Since 2000, the largest proportional increase (118%) in crude trauma deaths occurred in 54-year-olds. Overall, in 2010, trauma was the leading cause of death in individuals 46 years and younger. Trauma remains the leading cause of years of life lost. Results: Trauma is now the leading cause of death for individuals 46 years and younger. The largest increase in the number of trauma deaths and the highest crude number of trauma deaths occurred in baby boomers. Policy makers allocating resources should be made aware of the larger impact of trauma on our aging and burgeoning US population. Keywords: death, epidemiology of trauma, injury, leading cause of death, trauma (Ann Surg 2014;260:13–21)
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n 2011, the first of the US baby boomer population (born from 1946 to 1964) turned 65. For the next 19 years, about 10,000 Americans a day are expected to turn 65, amounting to more than 75 million individuals reaching traditional retirement age by 2029.1 As this demographic transition continues, the baby boomer population will continue to have a profound influence on the composition and configuration of our population. The social and demographic impact of this large and aging population remains an interesting phenomenon to which our society in general and our health care system in particular must adapt. As the baby boomer population ages, the cohort representing the largest proportion of the US population will shift to the right from young adults to middle-aged and older individuals. As this shift of the
From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona Health Sciences Center, Tucson. Disclosure: This study has not been supported by anyone. The authors of the study have no financial or proprietary interests in the subject matter or material discussed in the manuscript. Reprints: Peter Rhee, MD, MPH, Division of Trauma, Burns, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N Campbell Ave, Room 5411, PO Box 245063, Tucson, AZ 85724. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26001-0013 DOI: 10.1097/SLA.0000000000000600
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population curve to the right progresses, the demographics of patients requiring trauma care and associated resources will likely change.2 An increase in middle-aged and geriatric admissions to trauma centers is anticipated,3,4 and multiple studies have shown that advanced age is associated with poor outcome after injury.5,6 Specifically, injured patients aged 40 to 45 years reportedly have higher complication and mortality rates than younger patients.4,5 In fact, a linear relationship between advancing age and increasing mortality after injury has been described, with the oldest patients experiencing the highest mortality rates.6,7 Significant advancements have been made in the therapy of cancer and heart disease. In particular, emphasis on these 2 leading killers has long resulted in a disproportionate allocation of research funding.8 Medical advancements brought about by such research have enabled us to live longer and stay more active, with obvious benefits to individuals and society. However, as a result, trauma may now have a more significant epidemiological impact, increasingly burdening society. In our study, we examined changes in the epidemiology of trauma deaths relative to the other 2 leading causes of death (cancer and heart disease) in the United States. We hypothesized that as the population changes and the baby boomer generation ages, trauma deaths will become a more predominant cause of death than cancer and heart disease.
METHODS We analyzed mortality data, over an 11-year period (2000– 2010), in the Web-based Injury Statistics Query and Reporting System (WISQARS) database of the Centers for Disease Control and Prevention (CDC).9 An interactive online database, WISQARS is the leading source of mortality statistics in the United States. It classifies mortality data by the cause of death. We collected mortality data for each year (from 2000 to 2010) and for each age group (from 1 year to 85 years and older). The database categorizes individuals 85 years and older into one category, so we grouped them similarly. For each year and each age group, we noted the number of deaths due to trauma, cancer, and heart disease. We defined trauma deaths as unintentional injuries (CD-10V01-X59, Y85–Y86), suicides (U03, X60–X84, Y87.0), and homicides (U01–U02, X85-Y09, Y87.1). Mechanisms included motor vehicle accident, drowning, fall, suffocation, fire burn, other transport-related accident, firearms, environmental exposure, machinery accident, pedal cycling accident, cutting/piercing wounds, overexertion, and nonspecified modes of injury.3 Deaths from poisoning were also included as trauma death, as per the definition of the World Health Organization (WHO). We identified deaths due to heart disease (I00–I09, I11, I13, I20–I51) and cancer (C00–C97) by using WHO’s International Classification of Diseases, Tenth Revision, codes. We obtained, from the US Census Bureau, population data for 2000 to 2010. Data are reported as proportions for categorical variables. χ 2 test was used to explore for differences between categorical variables. A P value of 0.05 or less was considered statistically significant. Data management and analysis were performed using STATA Data Analysis and Statistical Software (version 11.0). www.annalsofsurgery.com | 13
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TABLE 1. Trauma in Baby Boomers Population per Census, n
Year 2000 (age 36–54) 2010 (age 46–64) ∗
Crude Trauma Trauma Death Deaths, n Rate per 100,000
82,826,479 81,489,445
42,422 49,115
51.2∗ 60.3∗
P ≤ 0.05 for pairwise comparison of 2000 and 2010.
RESULTS Trauma deaths increased by 22.8% (32,189 deaths) from 2000 (140,951 deaths) to 2010 (173,140 deaths). During that same decade, the US population increased by only 9.7%: from 281,421,906 in 2000 to 308,745,538 in 2010, according to US Census Bureau data. The trauma death rate increased from 50.1 per 100,000 in 2000 to 56.1 per 100,000 in 2010 (P < 0.05) (Fig. 1). Table 1 demonstrates the baby boomer population death rate per 100,000 for 2 years: 2000 and 2010. Despite the slight decrease in the population of baby boomers from 2000 to 2010, their trauma death rate per 100,000 significantly increased by 17.8%, from 51.2 to 60.3 per 100,000 (P < 0.05). The total crude number of trauma deaths by age for the period 2000 to 2010 is shown in Figure 2. There was a trimodal distribution of death: the first peak was at age 21; the second peak, age 46; and the third peak, 84 years and older. From 2000 to 2010, the peaks in the crude number of trauma deaths shifted to the right (Fig. 3). The first peak shifted about 2 years, from age 19 in 2000 to age 21 in 2010. The second peak shifted 9 years, from age 40 in 2000 to age 49 in 2010. The third peak shifted 6 years, from age 79 in 2000 to age 84 in 2010. The 3 peaks not only shifted to the right but also increased in height. In 2010, the second peak was higher than the first peak: 3284 deaths occurred in 49-year-olds as compared with 2860 deaths in 21-year-olds. Over the study period, 21-year-olds had the highest crude death rate, with 33,285 trauma deaths. The number of deaths in 21-yearolds over the study period was relatively stable, as it reached its peak in 2006 (Fig. 4) but then declined. The second peak in trauma deaths occurred in middle-aged individuals (Fig. 5). The highest crude number of trauma deaths occurred in 46-year-olds, with 32,408 deaths over the study period. The most significant increase in the number of trauma deaths was in baby boomers (aged 45–64 years in 2010). The highest percent change was in 54-year-olds. In 2000, there were 1303
crude trauma deaths compared with 2836 deaths in 2010: a 118% increase. The third peak in trauma deaths occurred in individuals 85 years and older: a 56% increase. Figure 6 shows the population change from 2000 to 2010, demonstrating a trimodal growth pattern. The population increased for those aged 15 to 29 years, 45 to 74 years, and older than 80 years. There was a decrease in those aged 30 to 45 years. Trauma death rate adjusted for the population showed a decrease in the number of people younger than 25 years and an increase in the number of people 25 years and older. Death rates from cancer decreased over all age groups. Heart disease death rate decreased for all age groups except for those aged 25 to 34 years. The increase in trauma deaths by mechanism is shown in Table 2. There was a decrease in homicide rates over the study period but an increase in suicide and death rates from unintentional trauma. Unintentional trauma death rate accounted for 62.3% of the total trauma death rate and suicide 35.0%. The cumulative death rates due to trauma, cancer, and heart disease are shown in Figure 7. The crossover point at which the crude number of cancer and heart disease deaths surpassed the crude number of trauma deaths in 2010 was age 59 for heart disease and age 62 for cancer. The change in the crude number of deaths due to trauma, cancer, and heart disease over the study period is represented in Table 3. In the year 2000, crude trauma deaths were higher than crude cancer deaths for those 43 years and younger. However, the crude number of trauma deaths in 46-year-olds increased over the study period in contrast to the crude number of cancer and heart disease deaths, which declined. Thus, in 2010, trauma was the leading cause of death in people 46 years and younger as at age 47 deaths from cancer was more than trauma. Compared with heart disease, deaths from heart disease were more than those for trauma in 49-year-olds. In 2010, trauma was the leading cause of years of life lost when calculated with a life expectancy of 75 years as shown in Table 4. Compared with cancer and heart disease, trauma also had the largest increase in years of life lost from 2000 to 2010.
DISCUSSION Trauma deaths have continued to increase since 2000.10 In the past decade alone, trauma deaths increased by 22.8%, from 140,951 deaths in 2000 to 173,140 in 2010. This increase cannot be explained by the growth in the US population, which increased only by 9.7%
FIGURE 1. All trauma deaths (crude number) per year, 2000–2010. 14 | www.annalsofsurgery.com
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Trauma Deaths in the United States
FIGURE 2. 2000–2010 cumulative trauma deaths (crude number) by age.
FIGURE 3. Cumulative trauma deaths by age in 2000 and 2010. A higher peak and a right shift in trauma deaths were identified over time.
according to US Census Bureau data. After adjusting for population growth, we found that trauma death rate increased significantly, from 50.1 per 100,000 in 2000 to 56.1 per 100,000 in 2010. Moreover, older individuals are being disproportionately affected by trauma. Trauma is not just an affliction of the young, as has been traditionally thought. Death from trauma is now the leading cause of death in individuals 46 years and younger, whereas in 2000, it was the leading cause of death in those 43 years and younger. The CDC WISQARS database is the largest database that reports the total number of deaths in the United States based on the C 2014 Lippincott Williams & Wilkins
cause of death (heart disease, cancer, and injury). The mortality data in the WISQARS database are obtained from the National Center for Health Statistics and the CDC annual mortality data files.11 The cause of mortality in the CDC has been coded using the International Classification of Diseases, Tenth Revision, which is the standard coding system used worldwide.12,13 The US Census Bureau is responsible for recording the US population every 10 years.14 The population is recorded on census day (April 1 for the 2010 census) on the basis of the permanent place of residence of an individual. The place of residence is identified on the basis of report of census workers visiting www.annalsofsurgery.com | 15
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FIGURE 4. All trauma deaths in 21-year-olds per year, 2000–2010.
FIGURE 5. Focusing in of the second peak in trauma deaths (crude number) for ages 40 to 65 per year, 2000–2010. All trauma deaths per year for each age group are shown.
each neighborhood across the country and also by the census forms returned to the census bureau. As census is conducted every 10 years, we restricted our mortality data from the CDC WISQARS database to the same 10 years (2000–2010) to compare the homogenous population sample. The scientific literature frequently states that trauma is the leading cause both of death and of years of life lost in individuals 44 years and younger.15 Yet, we could not trace the original source of this conclusion. The most likely explanation is that the CDC generally reports its data in age groups of 10 years. Therefore, in the past, according to CDC reports, cancer and heart disease deaths have been higher than trauma deaths in the age group of 45 to 55 years. Thus, categorizing trauma as the leading cause of death in individuals 44 years and younger was technically correct. However, when we analyzed deaths by each year of age, we found that for the year 2010 alone, trauma is the leading cause of death in individuals 46 years and younger. Cancer overcomes trauma as the leading cause of death in 16 | www.annalsofsurgery.com
47-year-olds, whereas heart disease does not surpass trauma-related deaths until the age 49. In our cumulative analysis (2000–2010), we found that trauma was the leading cause of death until age 59 when heart disease deaths were higher (Fig. 7). In 2010, the crossover point at which the crude number of cancer deaths surpassed the crude number of trauma death was age 62. With regard to years of life lost, trauma still remains the number 1 reason for years of life lost in the United States if the life expectancy is 75 years. The crude number of trauma deaths had a trimodal pattern, with peaks in the early 20s, 40s, and 80s, when we combined all deaths over our year study period. On closer examination, the pattern persisted but shifted to the right, meaning that individuals dying from trauma were older than before. This shift occurred in all 3 peaks. Understanding that shift is important in terms of our prior assumptions, and our new knowledge, regarding who is susceptible to trauma. We do not know why the first peak shifted to the right only a few years whereas the second peak shifted 9 years and the third peak 6 years. C 2014 Lippincott Williams & Wilkins
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Trauma Deaths in the United States
FIGURE 6. Percent change in the US population by 5-year age group increments for years 2000–2010 (A). Percent change in US death rates by 5-year age group increments for years 2000–2010, (B) trauma death rate, (C) heart disease death rate, and (D) cancer death rate.
Trauma is typically thought to predominantly affect the young, as evidenced by the first peak in the early 20s. But the first peak decreased in height, meaning that the number of trauma deaths in individuals in their early 20s decreased over time. The census data showed that the population of individuals aged 20 to 25 years actually grew by 13.8%, from 18,964,001 in 2000 to 21,585,999 in 2010. We could only speculate as to why the number of trauma deaths in this young age group decreased whereas the population increased; reasons could include better trauma systems, better trauma care, more trauma centers, improved injury prevention, decreased risky C 2014 Lippincott Williams & Wilkins
behaviors, and/or safer vehicles. However, if these were the causes for lower deaths in younger trauma victims, this effect should have been seen across all ages, which was not the case. The shift in the second peak in the trimodal pattern was the most prominent: it not only shifted about 9 years but also increased in height over the study period. Middle age, at least in the past, has been when death from cancer and heart disease become major factors. Our detailed examination of the second peak (age 40–64) revealed a significant trend toward an increased number of trauma deaths over time. In fact, in 54-year-olds, the number of trauma deaths increased www.annalsofsurgery.com | 17
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TABLE 2. Trauma Deaths by Mechanism US population, n
Homicide, n
Crude trauma death rates Age 45–64 2000 61,952,636 2,493 2010 81,489,445 3,062 Difference 19,536,809 569 Trauma death rates (adjusted for population per 100,000) Age 45–64 2000 619.5 4.0 2010 814.9 3.8 % Change 31.5 − 6.6∗ ∗
Suicide, n
Unintentional, n
Total Trauma Deaths, n
7,734 15,183 7,449
20,432 33,690 13,258
30,659 51,935 21,276
12.5 18.6 49.2∗
33.0 41.3 25.4∗
49.5 63.7 28.8∗
P ≤ 0.05 for pairwise comparison of 2000 and 2010.
FIGURE 7. Death rates from trauma, heart disease, and cancer by cumulative age (0–84) for all years, 2000–2010. Trauma is the leading cause of death from ages 0 to 59.
by 118% from 2000 to 2010, a possible consequence, in part, of the shift in population as the baby boomer population aged. Yet, that increase in trauma deaths may not be solely explained by aging baby boomers. In fact, the baby boomer generation decreased slightly in total number between 2000 and 2010. Trauma deaths and trauma death rates outpaced the growth in population in individuals 25 years and older. Nonetheless, the effect of baby boomers on society and health care is huge. In individuals aged 45 to 64 years—the age group in which trauma has previously thought to have less of an impact— the trauma death rate per 100,000 increased more than the general population, from 51.2 per 100,000 in 2000 to 60.3 per 100,000 in 2010. In 2000, baby boomers were aged 36 to 55 years. Ten years later, the population of baby boomers aged 46 to 65 years decreased slightly according to US census data. The change over time in this cohort is likely affected by individuals entering and leaving the country. Despite the decrease in the baby boomers’ population, both their crude trauma death rate and their cumulative trauma death rate increased. This is counterintuitive, given the long-standing idea that trauma predominantly affects the young and that aging individuals outgrow the risks from trauma. The question then remains as to why the increase in trauma is predominantly in middle-aged individuals. Possible reasons are 18 | www.annalsofsurgery.com
outside the scope and capabilities of this study. However, this study should increase awareness of this trend and investigations should look for the reasons behind these changes in trauma deaths. When examining the mechanisms of trauma deaths, we found as shown in Table 2, that suicides increased at an alarming rate for those aged 45 to 64 years, accounting for 35% of the increase in total crude trauma deaths in 2010. The suicide rate increased to 18.6 per 100,000. Although the population of people aged 45 to 64 years increased by 31.5%, even after adjusting for this change in population, the trauma death rate increased by 28.8%. Attention has been focused on the increasing number of suicides in the military personnel returning from deployment. However, there seems to be an equally alarming increase in the civilian population as well. The reasons for the increase in trauma deaths and death rates need immediate attention, but the reasons for the increase in suicides in the US population demand special attention. Several studies have highlighted the improvement in mortality rates among patients managed in trauma centers.16–19 Kahl et al17 in an 11-year (2000–2011) retrospective review demonstrated decreasing mortality rate over the years independent of the injury severity score, which remained constant throughout the study period. However, they highlighted a significant increase in the mean age of the population and incidence of blunt traumatic injury over the years. C 2014 Lippincott Williams & Wilkins
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TABLE 3. Change in Crude Deaths Age 43 yr
44 yr
45 yr
46 yr
47 yr
Year
Trauma
Cancer
Trauma
Cancer
Trauma
Cancer
Trauma
Cancer
Trauma
Cancer
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
2557 2723 2858 3027 2945 2968 3058 3052 2841 2693 2429
2556 2557 2484 2340 2448 2301 2245 2141 2013 1802 1777
2474 2758 2785 2878 2865 3107 3117 3123 3090 2852 2712
2718 2836 2841 2801 2662 2694 2539 2518 2300 2287 1999
2425 2641 2727 2866 3013 3158 3185 3221 3141 2925 2820
3144 3185 3166 3225 2989 3053 2913 2783 2799 2649 2473
2175 2538 2724 2832 2985 2984 3278 3267 3306 3263 3056
3386 3382 3466 3544 3553 3423 3226 3238 3152 3116 2989
2256 2437 2604 2676 2971 3049 3146 3273 3289 3203 3054
3654 3900 3803 3876 3819 3820 3825 3739 3748 3646 3478
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Trauma 2425 2641 2727 2866 3013 3158 3185 3221 3141 2925 2820
Heart 2454 2365 2537 2496 2495 2508 2493 2332 2302 2269 2112
Trauma 2175 2538 2724 2832 2985 2984 3278 3267 3306 3263 3056
Heart 2610 2665 2761 2863 2777 2818 2707 2755 2659 2594 2537
Trauma 2256 2437 2604 2676 2971 3049 3146 3273 3289 3203 3054
Heart 2831 2864 3041 3072 3192 2969 3034 2975 2973 2808 2848
Trauma 2070 2342 2488 2645 2782 2941 3149 3135 3197 3201 3170
Heart 3039 3132 3390 3413 3311 3323 3435 3185 3218 3120 3123
Trauma 1990 2234 2306 2550 2600 2874 3136 3106 3275 3119 3284
44 yr
46 yr
47 yr
48 yr
49 yr Heart 3379 3364 3450 3676 3615 3677 3698 3618 3595 3427 3494
TABLE 4. Years of Life Lost Life Expectancy 70 yr
2000 2010 % Change
75 yr
80 yr
Trauma
Cancer
Heart
Trauma
Cancer
Heart
Trauma
Cancer
Heart
3,756,290 4,027,833 7.2
2,860,630 2,941,436 2.8
2,102,400 2,072,014 −1.4
4,329,971 4,716,360 8.9
4,241,028 4,404,361 3.9
3,141,877 3,018,497 −3.9
4,936,030 5,437,945 10.2
6,068,694 6,250,321 3.0
4,633,538 4,246,667 −8.3
Similarly, Glance et al18 in a 10-year (2000–2009) retrospective review of the Pennsylvania State database demonstrated a decrease in the mortality rate, with a stable injury severity score over the years. In another study by Dutton et al,19 the authors demonstrated that improved survival rates increased in patients with severe trauma despite increasing age and severity of injury over a 12-year study period. This decreasing in-hospital mortality rates can be postulated to be an effect of multiple variables including a change in the denominator due to the evolution of a maturing trauma system with increasing trauma centers, especially those that are not level I trauma centers, and improved safety of vehicles and improved trauma care. Although in our study, we were not able to assess for injury severity, we were able to demonstrate an overall increase in trauma mortality and age-related increase in trauma mortality. This increasing and changing trauma deaths are also probably multifactorial and could include the changing population, economic factor with decreasing crime and violence in the young trauma population, increased activity level of the middle-aged and baby boomers exposing them to more risk from trauma, improvement in the care of the severely injured, increasing number of persons in the geriatric trauma population who have more comorbid factors than those in the younger population, and possibly even the increas C 2014 Lippincott Williams & Wilkins
ing number of the elderly on anticoagulants. However, the data used for the analysis in our study unfortunately cannot identify the exact causes for the changes in the epidemiology of trauma. Although the data presented do not directly answer the reason as to why there is an increase in mortality among trauma patients, several studies have addressed proposed changing patterns of injury among trauma patients. Potenza et al20 in an 11-year retrospective review of the San Diego County highlighted a significant change in the pattern of injury over the years. They reported a decline in the rate of motor vehicle collision; however, they found an increasing incidence in fall- and poisoning-related injuries over the study period. In another study assessing the changing patterns of injury among trauma patients, Dutton et al19 demonstrated a significant increase in the number of patients with fall-related injury presenting to their level I trauma center. Contrastingly, there was no difference in the rate of motor vehicle accidents over the 12-year study period. We believe that the changing demographic pattern of the trauma patient is primarily responsible for these changing injury patterns among trauma patients. The CDC data showed that cancer and heart disease deaths decreased or remained stable in individuals aged 48 to 66 years. www.annalsofsurgery.com | 19
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FIGURE 8. Research funding, in millions of dollars, for cancer, heart disease, HIV/AIDS, and trauma by the National Institutes of Health (NIH) in 2012.
However, as shown in Figure 6, the death rates for cancer and heart disease changed in almost all age groups from 2000 to 2010. The reasons for the decrease in cancer and heart disease death rates may include medical and surgical advancements and improved overall general health. Trauma, however, had an increase rate for those 25 years and older. The number of trauma deaths grew at an unprecedented and alarming rate. Perhaps, as general health improves, individuals remain more active and thus are more exposed to traumatic events. The number of verified trauma centers in the United States continues to increase to meet the increasing demand, and it has resulted in a corresponding decrease in overall trauma death rates in the trauma centers. So why are trauma deaths increasing over time, especially among the baby boomer population? The change in the third peak is also of interest as there was a 56% increase in the elderly. Starting at age 83, the number of cancer deaths also increased, but the number of heart disease deaths decreased or remained relatively stable. In individuals aged 40 to 65 years, the number of cancer and heart disease deaths continues to decline but the trauma death rate has alarmingly increased. The WHO projects that by 2020, injury will surpass infectious disease as the leading cause of death worldwide as third-world countries become more developed and mechanized. Unfortunately, despite this startling increase in trauma deaths, federal funding from the National Institutes of Health (NIH) for trauma research has been much less than that for cancer, heart disease, and HIV/AIDS (Fig. 8). This study demonstrated that there has been progress made in the area of cancer and heart disease as research efforts may have realized benefit. Federal funding may need to be reappropriated to determine the reasons for the increasing burden of trauma in the United States and to afford the development of preventive and ameliorative strategies. The increase in trauma deaths we described should be relayed to the public and to policy makers alike. Funds for research from both federal and philanthropic sources need to be increased to identify causes for increased trauma deaths, improve trauma systems, and improve trauma care. It is also vitally important to improve our long-term rehabilitative care and most of all trauma prevention. We made progress in several areas of health care when attention and funding were appropriately focused upon those 20 | www.annalsofsurgery.com
areas. It is now time to pay more attention and reallocate funding to trauma care and prevention. Our study comes with the inherent limitation of the WISQARS database that we were not able identify the cause of death in all the patients. Second, we did not access the changing injury patterns among the study population over the study period. Third, we were not able to collect the data for trauma-related hospital admission and mortality. Despite these limitations, our study highlights the increasing burden on trauma and the changing epidemiology of trauma mortality.
CONCLUSIONS The trauma death rate has alarmingly increased since 2000, whereas the cancer and heart disease death rates have decreased. As of 2010, trauma is now the leading cause of death in individuals 46 years and younger. It remains the single, largest cause for years of life lost. The number of trauma deaths is now higher than the number of cancer deaths until age 47—and higher than the number of heart disease deaths until age 49. The changing epidemiology of trauma mortality must be a focus of robust future investigations to make strides in preventing and treating trauma, the greatest increasing killer in our era.
ACKNOWLEDGMENTS Authors acknowledge the support of Mary Knatterud PHD, for her help in editing the manuscript. Author contributions: P.R, B.J, N.K, and R.S.F designed this study; P.R, B.J, V.P, and H.A, searched the literature; P.R, B.J, V.P, H.A, G.V collected data, which were analyzed by P.R, B.J, N.K, G.V, and R.S.F All authors participated in data interpretation and manuscript preparation.
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Trauma Deaths in the United States
12. World Health Organization. International Classification of Diseases, Injuries, and Causes of Death. Vols I and II. 9th rev.. Geneva, Switzerland: World Health Organization; 1977. 13. Anderson RN, Minino AM, Hoyert DL, et al. Comparability of cause of death between ICD-9 and ICD-10: preliminary estimates. Natl Vital Stat Rep. May 18, 2001;49. 14. US Census Bureau, US Department of Commerce. Available at http://www .census.gov. Accessed November 10, 2013. 15. Baker SP, O’Neill B, Ginsburg MJ. The Injury Fact Book. New York: Oxford University Press; 1992. 16. Branas CC, MacKenzie EJ, Williams JC, et al. Access to trauma centers in the United States. JAMA. 2005;293:2626–2633. 17. Kahl JE, Calvo RY, Sise MJ, et al. The changing nature of death on the trauma service. J Trauma Acute Care Surg. 2013;75:195–201. 18. Glance LG, Osler TM, Mukamel DB, et al. Outcomes of adult trauma patients admitted to trauma centers in Pennsylvania, 2000–2009 adult patients in Pennsylvania trauma centers. Arch Surg. 2012;147:732– 737. 19. Dutton RP, Stansbury LG, Leone S, et al. Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997– 2008. J Trauma Acute Care Surg. 2010;69:620–626. 20. Potenza BM, Hoyt DB, Coimbra R, et al. The epidemiology of serious and fatal injury in San Diego County over an 11-year period. J Trauma Acute Care Surg. 2004;56:68–75.
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Increasing Trauma Deaths in the United States Peter Rhee, MD, MPH, Bellal Joseph, MD, Viraj Pandit, MD, Hassan Aziz, MD, Gary Vercruysse, MD, Narong Kulvatunyou, MD, and Randall S. Friese, MD
Objective: To determine the impact of the increasing aging population on trauma mortality relative to mortality from cancer and heart disease in the United States. Background: The population in the United States continues to increase as medical advancements allow people to live longer. The resulting changes in the leading causes of death have not yet been recognized. Methods: Data were obtained (2000–2010) from the Web-based Injury Statistics Query and Reporting System database of the Centers for Disease Control and Prevention. We defined trauma deaths as unintentional injuries, suicides, and homicides. Results: From 2000 to 2010, the US population increased by 9.7% and the number of trauma deaths increased by 22.8%. Trauma deaths and death rates deceased in individuals younger than 25 years but increased for those 25 years and older. During this period, death rates for cancer and heart disease decreased. The largest increases in trauma deaths were in individuals in their fifth and sixth decades of life. Since 2000, the largest proportional increase (118%) in crude trauma deaths occurred in 54-year-olds. Overall, in 2010, trauma was the leading cause of death in individuals 46 years and younger. Trauma remains the leading cause of years of life lost. Results: Trauma is now the leading cause of death for individuals 46 years and younger. The largest increase in the number of trauma deaths and the highest crude number of trauma deaths occurred in baby boomers. Policy makers allocating resources should be made aware of the larger impact of trauma on our aging and burgeoning US population. Keywords: death, epidemiology of trauma, injury, leading cause of death, trauma (Ann Surg 2014;260:13–21)
I
n 2011, the first of the US baby boomer population (born from 1946 to 1964) turned 65. For the next 19 years, about 10,000 Americans a day are expected to turn 65, amounting to more than 75 million individuals reaching traditional retirement age by 2029.1 As this demographic transition continues, the baby boomer population will continue to have a profound influence on the composition and configuration of our population. The social and demographic impact of this large and aging population remains an interesting phenomenon to which our society in general and our health care system in particular must adapt. As the baby boomer population ages, the cohort representing the largest proportion of the US population will shift to the right from young adults to middle-aged and older individuals. As this shift of the
From the Division of Trauma, Burns, Critical Care, and Emergency Surgery, University of Arizona Health Sciences Center, Tucson. Disclosure: This study has not been supported by anyone. The authors of the study have no financial or proprietary interests in the subject matter or material discussed in the manuscript. Reprints: Peter Rhee, MD, MPH, Division of Trauma, Burns, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N Campbell Ave, Room 5411, PO Box 245063, Tucson, AZ 85724. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26001-0013 DOI: 10.1097/SLA.0000000000000600
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population curve to the right progresses, the demographics of patients requiring trauma care and associated resources will likely change.2 An increase in middle-aged and geriatric admissions to trauma centers is anticipated,3,4 and multiple studies have shown that advanced age is associated with poor outcome after injury.5,6 Specifically, injured patients aged 40 to 45 years reportedly have higher complication and mortality rates than younger patients.4,5 In fact, a linear relationship between advancing age and increasing mortality after injury has been described, with the oldest patients experiencing the highest mortality rates.6,7 Significant advancements have been made in the therapy of cancer and heart disease. In particular, emphasis on these 2 leading killers has long resulted in a disproportionate allocation of research funding.8 Medical advancements brought about by such research have enabled us to live longer and stay more active, with obvious benefits to individuals and society. However, as a result, trauma may now have a more significant epidemiological impact, increasingly burdening society. In our study, we examined changes in the epidemiology of trauma deaths relative to the other 2 leading causes of death (cancer and heart disease) in the United States. We hypothesized that as the population changes and the baby boomer generation ages, trauma deaths will become a more predominant cause of death than cancer and heart disease.
METHODS We analyzed mortality data, over an 11-year period (2000– 2010), in the Web-based Injury Statistics Query and Reporting System (WISQARS) database of the Centers for Disease Control and Prevention (CDC).9 An interactive online database, WISQARS is the leading source of mortality statistics in the United States. It classifies mortality data by the cause of death. We collected mortality data for each year (from 2000 to 2010) and for each age group (from 1 year to 85 years and older). The database categorizes individuals 85 years and older into one category, so we grouped them similarly. For each year and each age group, we noted the number of deaths due to trauma, cancer, and heart disease. We defined trauma deaths as unintentional injuries (CD-10V01-X59, Y85–Y86), suicides (U03, X60–X84, Y87.0), and homicides (U01–U02, X85-Y09, Y87.1). Mechanisms included motor vehicle accident, drowning, fall, suffocation, fire burn, other transport-related accident, firearms, environmental exposure, machinery accident, pedal cycling accident, cutting/piercing wounds, overexertion, and nonspecified modes of injury.3 Deaths from poisoning were also included as trauma death, as per the definition of the World Health Organization (WHO). We identified deaths due to heart disease (I00–I09, I11, I13, I20–I51) and cancer (C00–C97) by using WHO’s International Classification of Diseases, Tenth Revision, codes. We obtained, from the US Census Bureau, population data for 2000 to 2010. Data are reported as proportions for categorical variables. χ 2 test was used to explore for differences between categorical variables. A P value of 0.05 or less was considered statistically significant. Data management and analysis were performed using STATA Data Analysis and Statistical Software (version 11.0). www.annalsofsurgery.com | 13
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TABLE 1. Trauma in Baby Boomers Population per Census, n
Year 2000 (age 36–54) 2010 (age 46–64) ∗
Crude Trauma Trauma Death Deaths, n Rate per 100,000
82,826,479 81,489,445
42,422 49,115
51.2∗ 60.3∗
P ≤ 0.05 for pairwise comparison of 2000 and 2010.
RESULTS Trauma deaths increased by 22.8% (32,189 deaths) from 2000 (140,951 deaths) to 2010 (173,140 deaths). During that same decade, the US population increased by only 9.7%: from 281,421,906 in 2000 to 308,745,538 in 2010, according to US Census Bureau data. The trauma death rate increased from 50.1 per 100,000 in 2000 to 56.1 per 100,000 in 2010 (P < 0.05) (Fig. 1). Table 1 demonstrates the baby boomer population death rate per 100,000 for 2 years: 2000 and 2010. Despite the slight decrease in the population of baby boomers from 2000 to 2010, their trauma death rate per 100,000 significantly increased by 17.8%, from 51.2 to 60.3 per 100,000 (P < 0.05). The total crude number of trauma deaths by age for the period 2000 to 2010 is shown in Figure 2. There was a trimodal distribution of death: the first peak was at age 21; the second peak, age 46; and the third peak, 84 years and older. From 2000 to 2010, the peaks in the crude number of trauma deaths shifted to the right (Fig. 3). The first peak shifted about 2 years, from age 19 in 2000 to age 21 in 2010. The second peak shifted 9 years, from age 40 in 2000 to age 49 in 2010. The third peak shifted 6 years, from age 79 in 2000 to age 84 in 2010. The 3 peaks not only shifted to the right but also increased in height. In 2010, the second peak was higher than the first peak: 3284 deaths occurred in 49-year-olds as compared with 2860 deaths in 21-year-olds. Over the study period, 21-year-olds had the highest crude death rate, with 33,285 trauma deaths. The number of deaths in 21-yearolds over the study period was relatively stable, as it reached its peak in 2006 (Fig. 4) but then declined. The second peak in trauma deaths occurred in middle-aged individuals (Fig. 5). The highest crude number of trauma deaths occurred in 46-year-olds, with 32,408 deaths over the study period. The most significant increase in the number of trauma deaths was in baby boomers (aged 45–64 years in 2010). The highest percent change was in 54-year-olds. In 2000, there were 1303
crude trauma deaths compared with 2836 deaths in 2010: a 118% increase. The third peak in trauma deaths occurred in individuals 85 years and older: a 56% increase. Figure 6 shows the population change from 2000 to 2010, demonstrating a trimodal growth pattern. The population increased for those aged 15 to 29 years, 45 to 74 years, and older than 80 years. There was a decrease in those aged 30 to 45 years. Trauma death rate adjusted for the population showed a decrease in the number of people younger than 25 years and an increase in the number of people 25 years and older. Death rates from cancer decreased over all age groups. Heart disease death rate decreased for all age groups except for those aged 25 to 34 years. The increase in trauma deaths by mechanism is shown in Table 2. There was a decrease in homicide rates over the study period but an increase in suicide and death rates from unintentional trauma. Unintentional trauma death rate accounted for 62.3% of the total trauma death rate and suicide 35.0%. The cumulative death rates due to trauma, cancer, and heart disease are shown in Figure 7. The crossover point at which the crude number of cancer and heart disease deaths surpassed the crude number of trauma deaths in 2010 was age 59 for heart disease and age 62 for cancer. The change in the crude number of deaths due to trauma, cancer, and heart disease over the study period is represented in Table 3. In the year 2000, crude trauma deaths were higher than crude cancer deaths for those 43 years and younger. However, the crude number of trauma deaths in 46-year-olds increased over the study period in contrast to the crude number of cancer and heart disease deaths, which declined. Thus, in 2010, trauma was the leading cause of death in people 46 years and younger as at age 47 deaths from cancer was more than trauma. Compared with heart disease, deaths from heart disease were more than those for trauma in 49-year-olds. In 2010, trauma was the leading cause of years of life lost when calculated with a life expectancy of 75 years as shown in Table 4. Compared with cancer and heart disease, trauma also had the largest increase in years of life lost from 2000 to 2010.
DISCUSSION Trauma deaths have continued to increase since 2000.10 In the past decade alone, trauma deaths increased by 22.8%, from 140,951 deaths in 2000 to 173,140 in 2010. This increase cannot be explained by the growth in the US population, which increased only by 9.7%
FIGURE 1. All trauma deaths (crude number) per year, 2000–2010. 14 | www.annalsofsurgery.com
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Trauma Deaths in the United States
FIGURE 2. 2000–2010 cumulative trauma deaths (crude number) by age.
FIGURE 3. Cumulative trauma deaths by age in 2000 and 2010. A higher peak and a right shift in trauma deaths were identified over time.
according to US Census Bureau data. After adjusting for population growth, we found that trauma death rate increased significantly, from 50.1 per 100,000 in 2000 to 56.1 per 100,000 in 2010. Moreover, older individuals are being disproportionately affected by trauma. Trauma is not just an affliction of the young, as has been traditionally thought. Death from trauma is now the leading cause of death in individuals 46 years and younger, whereas in 2000, it was the leading cause of death in those 43 years and younger. The CDC WISQARS database is the largest database that reports the total number of deaths in the United States based on the C 2014 Lippincott Williams & Wilkins
cause of death (heart disease, cancer, and injury). The mortality data in the WISQARS database are obtained from the National Center for Health Statistics and the CDC annual mortality data files.11 The cause of mortality in the CDC has been coded using the International Classification of Diseases, Tenth Revision, which is the standard coding system used worldwide.12,13 The US Census Bureau is responsible for recording the US population every 10 years.14 The population is recorded on census day (April 1 for the 2010 census) on the basis of the permanent place of residence of an individual. The place of residence is identified on the basis of report of census workers visiting www.annalsofsurgery.com | 15
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FIGURE 4. All trauma deaths in 21-year-olds per year, 2000–2010.
FIGURE 5. Focusing in of the second peak in trauma deaths (crude number) for ages 40 to 65 per year, 2000–2010. All trauma deaths per year for each age group are shown.
each neighborhood across the country and also by the census forms returned to the census bureau. As census is conducted every 10 years, we restricted our mortality data from the CDC WISQARS database to the same 10 years (2000–2010) to compare the homogenous population sample. The scientific literature frequently states that trauma is the leading cause both of death and of years of life lost in individuals 44 years and younger.15 Yet, we could not trace the original source of this conclusion. The most likely explanation is that the CDC generally reports its data in age groups of 10 years. Therefore, in the past, according to CDC reports, cancer and heart disease deaths have been higher than trauma deaths in the age group of 45 to 55 years. Thus, categorizing trauma as the leading cause of death in individuals 44 years and younger was technically correct. However, when we analyzed deaths by each year of age, we found that for the year 2010 alone, trauma is the leading cause of death in individuals 46 years and younger. Cancer overcomes trauma as the leading cause of death in 16 | www.annalsofsurgery.com
47-year-olds, whereas heart disease does not surpass trauma-related deaths until the age 49. In our cumulative analysis (2000–2010), we found that trauma was the leading cause of death until age 59 when heart disease deaths were higher (Fig. 7). In 2010, the crossover point at which the crude number of cancer deaths surpassed the crude number of trauma death was age 62. With regard to years of life lost, trauma still remains the number 1 reason for years of life lost in the United States if the life expectancy is 75 years. The crude number of trauma deaths had a trimodal pattern, with peaks in the early 20s, 40s, and 80s, when we combined all deaths over our year study period. On closer examination, the pattern persisted but shifted to the right, meaning that individuals dying from trauma were older than before. This shift occurred in all 3 peaks. Understanding that shift is important in terms of our prior assumptions, and our new knowledge, regarding who is susceptible to trauma. We do not know why the first peak shifted to the right only a few years whereas the second peak shifted 9 years and the third peak 6 years. C 2014 Lippincott Williams & Wilkins
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FIGURE 6. Percent change in the US population by 5-year age group increments for years 2000–2010 (A). Percent change in US death rates by 5-year age group increments for years 2000–2010, (B) trauma death rate, (C) heart disease death rate, and (D) cancer death rate.
Trauma is typically thought to predominantly affect the young, as evidenced by the first peak in the early 20s. But the first peak decreased in height, meaning that the number of trauma deaths in individuals in their early 20s decreased over time. The census data showed that the population of individuals aged 20 to 25 years actually grew by 13.8%, from 18,964,001 in 2000 to 21,585,999 in 2010. We could only speculate as to why the number of trauma deaths in this young age group decreased whereas the population increased; reasons could include better trauma systems, better trauma care, more trauma centers, improved injury prevention, decreased risky C 2014 Lippincott Williams & Wilkins
behaviors, and/or safer vehicles. However, if these were the causes for lower deaths in younger trauma victims, this effect should have been seen across all ages, which was not the case. The shift in the second peak in the trimodal pattern was the most prominent: it not only shifted about 9 years but also increased in height over the study period. Middle age, at least in the past, has been when death from cancer and heart disease become major factors. Our detailed examination of the second peak (age 40–64) revealed a significant trend toward an increased number of trauma deaths over time. In fact, in 54-year-olds, the number of trauma deaths increased www.annalsofsurgery.com | 17
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TABLE 2. Trauma Deaths by Mechanism US population, n
Homicide, n
Crude trauma death rates Age 45–64 2000 61,952,636 2,493 2010 81,489,445 3,062 Difference 19,536,809 569 Trauma death rates (adjusted for population per 100,000) Age 45–64 2000 619.5 4.0 2010 814.9 3.8 % Change 31.5 − 6.6∗ ∗
Suicide, n
Unintentional, n
Total Trauma Deaths, n
7,734 15,183 7,449
20,432 33,690 13,258
30,659 51,935 21,276
12.5 18.6 49.2∗
33.0 41.3 25.4∗
49.5 63.7 28.8∗
P ≤ 0.05 for pairwise comparison of 2000 and 2010.
FIGURE 7. Death rates from trauma, heart disease, and cancer by cumulative age (0–84) for all years, 2000–2010. Trauma is the leading cause of death from ages 0 to 59.
by 118% from 2000 to 2010, a possible consequence, in part, of the shift in population as the baby boomer population aged. Yet, that increase in trauma deaths may not be solely explained by aging baby boomers. In fact, the baby boomer generation decreased slightly in total number between 2000 and 2010. Trauma deaths and trauma death rates outpaced the growth in population in individuals 25 years and older. Nonetheless, the effect of baby boomers on society and health care is huge. In individuals aged 45 to 64 years—the age group in which trauma has previously thought to have less of an impact— the trauma death rate per 100,000 increased more than the general population, from 51.2 per 100,000 in 2000 to 60.3 per 100,000 in 2010. In 2000, baby boomers were aged 36 to 55 years. Ten years later, the population of baby boomers aged 46 to 65 years decreased slightly according to US census data. The change over time in this cohort is likely affected by individuals entering and leaving the country. Despite the decrease in the baby boomers’ population, both their crude trauma death rate and their cumulative trauma death rate increased. This is counterintuitive, given the long-standing idea that trauma predominantly affects the young and that aging individuals outgrow the risks from trauma. The question then remains as to why the increase in trauma is predominantly in middle-aged individuals. Possible reasons are 18 | www.annalsofsurgery.com
outside the scope and capabilities of this study. However, this study should increase awareness of this trend and investigations should look for the reasons behind these changes in trauma deaths. When examining the mechanisms of trauma deaths, we found as shown in Table 2, that suicides increased at an alarming rate for those aged 45 to 64 years, accounting for 35% of the increase in total crude trauma deaths in 2010. The suicide rate increased to 18.6 per 100,000. Although the population of people aged 45 to 64 years increased by 31.5%, even after adjusting for this change in population, the trauma death rate increased by 28.8%. Attention has been focused on the increasing number of suicides in the military personnel returning from deployment. However, there seems to be an equally alarming increase in the civilian population as well. The reasons for the increase in trauma deaths and death rates need immediate attention, but the reasons for the increase in suicides in the US population demand special attention. Several studies have highlighted the improvement in mortality rates among patients managed in trauma centers.16–19 Kahl et al17 in an 11-year (2000–2011) retrospective review demonstrated decreasing mortality rate over the years independent of the injury severity score, which remained constant throughout the study period. However, they highlighted a significant increase in the mean age of the population and incidence of blunt traumatic injury over the years. C 2014 Lippincott Williams & Wilkins
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TABLE 3. Change in Crude Deaths Age 43 yr
44 yr
45 yr
46 yr
47 yr
Year
Trauma
Cancer
Trauma
Cancer
Trauma
Cancer
Trauma
Cancer
Trauma
Cancer
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
2557 2723 2858 3027 2945 2968 3058 3052 2841 2693 2429
2556 2557 2484 2340 2448 2301 2245 2141 2013 1802 1777
2474 2758 2785 2878 2865 3107 3117 3123 3090 2852 2712
2718 2836 2841 2801 2662 2694 2539 2518 2300 2287 1999
2425 2641 2727 2866 3013 3158 3185 3221 3141 2925 2820
3144 3185 3166 3225 2989 3053 2913 2783 2799 2649 2473
2175 2538 2724 2832 2985 2984 3278 3267 3306 3263 3056
3386 3382 3466 3544 3553 3423 3226 3238 3152 3116 2989
2256 2437 2604 2676 2971 3049 3146 3273 3289 3203 3054
3654 3900 3803 3876 3819 3820 3825 3739 3748 3646 3478
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Trauma 2425 2641 2727 2866 3013 3158 3185 3221 3141 2925 2820
Heart 2454 2365 2537 2496 2495 2508 2493 2332 2302 2269 2112
Trauma 2175 2538 2724 2832 2985 2984 3278 3267 3306 3263 3056
Heart 2610 2665 2761 2863 2777 2818 2707 2755 2659 2594 2537
Trauma 2256 2437 2604 2676 2971 3049 3146 3273 3289 3203 3054
Heart 2831 2864 3041 3072 3192 2969 3034 2975 2973 2808 2848
Trauma 2070 2342 2488 2645 2782 2941 3149 3135 3197 3201 3170
Heart 3039 3132 3390 3413 3311 3323 3435 3185 3218 3120 3123
Trauma 1990 2234 2306 2550 2600 2874 3136 3106 3275 3119 3284
44 yr
46 yr
47 yr
48 yr
49 yr Heart 3379 3364 3450 3676 3615 3677 3698 3618 3595 3427 3494
TABLE 4. Years of Life Lost Life Expectancy 70 yr
2000 2010 % Change
75 yr
80 yr
Trauma
Cancer
Heart
Trauma
Cancer
Heart
Trauma
Cancer
Heart
3,756,290 4,027,833 7.2
2,860,630 2,941,436 2.8
2,102,400 2,072,014 −1.4
4,329,971 4,716,360 8.9
4,241,028 4,404,361 3.9
3,141,877 3,018,497 −3.9
4,936,030 5,437,945 10.2
6,068,694 6,250,321 3.0
4,633,538 4,246,667 −8.3
Similarly, Glance et al18 in a 10-year (2000–2009) retrospective review of the Pennsylvania State database demonstrated a decrease in the mortality rate, with a stable injury severity score over the years. In another study by Dutton et al,19 the authors demonstrated that improved survival rates increased in patients with severe trauma despite increasing age and severity of injury over a 12-year study period. This decreasing in-hospital mortality rates can be postulated to be an effect of multiple variables including a change in the denominator due to the evolution of a maturing trauma system with increasing trauma centers, especially those that are not level I trauma centers, and improved safety of vehicles and improved trauma care. Although in our study, we were not able to assess for injury severity, we were able to demonstrate an overall increase in trauma mortality and age-related increase in trauma mortality. This increasing and changing trauma deaths are also probably multifactorial and could include the changing population, economic factor with decreasing crime and violence in the young trauma population, increased activity level of the middle-aged and baby boomers exposing them to more risk from trauma, improvement in the care of the severely injured, increasing number of persons in the geriatric trauma population who have more comorbid factors than those in the younger population, and possibly even the increas C 2014 Lippincott Williams & Wilkins
ing number of the elderly on anticoagulants. However, the data used for the analysis in our study unfortunately cannot identify the exact causes for the changes in the epidemiology of trauma. Although the data presented do not directly answer the reason as to why there is an increase in mortality among trauma patients, several studies have addressed proposed changing patterns of injury among trauma patients. Potenza et al20 in an 11-year retrospective review of the San Diego County highlighted a significant change in the pattern of injury over the years. They reported a decline in the rate of motor vehicle collision; however, they found an increasing incidence in fall- and poisoning-related injuries over the study period. In another study assessing the changing patterns of injury among trauma patients, Dutton et al19 demonstrated a significant increase in the number of patients with fall-related injury presenting to their level I trauma center. Contrastingly, there was no difference in the rate of motor vehicle accidents over the 12-year study period. We believe that the changing demographic pattern of the trauma patient is primarily responsible for these changing injury patterns among trauma patients. The CDC data showed that cancer and heart disease deaths decreased or remained stable in individuals aged 48 to 66 years. www.annalsofsurgery.com | 19
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FIGURE 8. Research funding, in millions of dollars, for cancer, heart disease, HIV/AIDS, and trauma by the National Institutes of Health (NIH) in 2012.
However, as shown in Figure 6, the death rates for cancer and heart disease changed in almost all age groups from 2000 to 2010. The reasons for the decrease in cancer and heart disease death rates may include medical and surgical advancements and improved overall general health. Trauma, however, had an increase rate for those 25 years and older. The number of trauma deaths grew at an unprecedented and alarming rate. Perhaps, as general health improves, individuals remain more active and thus are more exposed to traumatic events. The number of verified trauma centers in the United States continues to increase to meet the increasing demand, and it has resulted in a corresponding decrease in overall trauma death rates in the trauma centers. So why are trauma deaths increasing over time, especially among the baby boomer population? The change in the third peak is also of interest as there was a 56% increase in the elderly. Starting at age 83, the number of cancer deaths also increased, but the number of heart disease deaths decreased or remained relatively stable. In individuals aged 40 to 65 years, the number of cancer and heart disease deaths continues to decline but the trauma death rate has alarmingly increased. The WHO projects that by 2020, injury will surpass infectious disease as the leading cause of death worldwide as third-world countries become more developed and mechanized. Unfortunately, despite this startling increase in trauma deaths, federal funding from the National Institutes of Health (NIH) for trauma research has been much less than that for cancer, heart disease, and HIV/AIDS (Fig. 8). This study demonstrated that there has been progress made in the area of cancer and heart disease as research efforts may have realized benefit. Federal funding may need to be reappropriated to determine the reasons for the increasing burden of trauma in the United States and to afford the development of preventive and ameliorative strategies. The increase in trauma deaths we described should be relayed to the public and to policy makers alike. Funds for research from both federal and philanthropic sources need to be increased to identify causes for increased trauma deaths, improve trauma systems, and improve trauma care. It is also vitally important to improve our long-term rehabilitative care and most of all trauma prevention. We made progress in several areas of health care when attention and funding were appropriately focused upon those 20 | www.annalsofsurgery.com
areas. It is now time to pay more attention and reallocate funding to trauma care and prevention. Our study comes with the inherent limitation of the WISQARS database that we were not able identify the cause of death in all the patients. Second, we did not access the changing injury patterns among the study population over the study period. Third, we were not able to collect the data for trauma-related hospital admission and mortality. Despite these limitations, our study highlights the increasing burden on trauma and the changing epidemiology of trauma mortality.
CONCLUSIONS The trauma death rate has alarmingly increased since 2000, whereas the cancer and heart disease death rates have decreased. As of 2010, trauma is now the leading cause of death in individuals 46 years and younger. It remains the single, largest cause for years of life lost. The number of trauma deaths is now higher than the number of cancer deaths until age 47—and higher than the number of heart disease deaths until age 49. The changing epidemiology of trauma mortality must be a focus of robust future investigations to make strides in preventing and treating trauma, the greatest increasing killer in our era.
ACKNOWLEDGMENTS Authors acknowledge the support of Mary Knatterud PHD, for her help in editing the manuscript. Author contributions: P.R, B.J, N.K, and R.S.F designed this study; P.R, B.J, V.P, and H.A, searched the literature; P.R, B.J, V.P, H.A, G.V collected data, which were analyzed by P.R, B.J, N.K, G.V, and R.S.F All authors participated in data interpretation and manuscript preparation.
REFERENCES 1. Congressional Budget Office. Congress of the United States: a CBO StudyBaby Boomers Retirement Prospects: An Overview. Washington, DC: Congressional Budget Office; 2003. 2. Knickman JR, Snell EK. The 2030 problem: caring for aging baby boomers. Health Serv Res. 2002;37:849–884.
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Annals of Surgery r Volume 260, Number 1, July 2014
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Trauma Deaths in the United States
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