Incidence of Dog Bite-Associated Emergency Department Visits in Maryland, 2008-2012

Incidence of Dog Bite-Associated Emergency Department Visits in Maryland, 2008-2012 Financial and Policy Implications Emily Pieracci, DVM, MPH Candidate

Project Introduction & Overview 4.7 million dog bites occur every year 1 million of which are in children under 18 years of age IR in children is 129.3 per 100,000 persons Highest injury rates are observed in children 5-9 years of age Males are disproportionately represented among dog bite victims Over 53% of males accounting for all injuries Dog bites can be psychologically traumatizing, disfiguring, incapacitating, and even fatal

Project Introduction & Overview Incidence of dog bites has been associated with the age of the patient Younger children bitten due to unintentionally provocative behavior Children are shorter in stature Parents or dog owners may have limited supervision of children while they are interacting with dogs

Financial Costs An estimated annual medical cost of over $100 million for dog biterelated emergency services in the U.S Estimated mean medical cost >$630 for ED visits per individual between 2008-2010

Methods- Health Service Cost Review Commission (HSCRC) The non-confidential outpatient HSCRC dataset for the years 2008-2012 was searched for emergency room visits for dog biteassociated injuries. The HSCRC diagnoses are recorded using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.

Methods- ICD-9-CM Official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States. Categorized primary diagnostic codes with additional external cause of injury codes (E codes) being assigned as needed. The code E906.0 is specifically used to denote dog bite-related injuries

Methods-Patients Cross-sectional study All patients that were seen in an emergency room in a Maryland healthcare facility during 2008-2012 All records with E906.0 and Emergency room charges greater than $0 Maryland census data from 2010 and population estimates from the U.S. Census Bureau were used for analyzing data.

Annual Trends Linear regression analyses 2008 was the baseline year for analysis Incidence Rate 98.00 96.00 94.00 92.00 90.00 88.00 Incidence Rate of ER Visit due to Dog Bite Injuries by Year 86.00 84.00 2008 2009 2010 2011 2012 Year

Incidence Rates of Dog Bite Injuries in Maryland by Year Year Frequency Maryland Incidence per 100,000 Population 2008 5,470 5,684,965 96.2 2009 5,388 5,730,388 94.0 2010 5,087 5,773,552 88.1 2011 5,500 5,839,572 94.1 2012 5,240 5,884,563 89.0 Total 26,685 5 year average 92.4

Incidence rates of Dog Bite Injuries; Descriptive Analysis ED Visits 2008-2012 Maryland Population 2010 Average Annual Incidence Rate per 100,000 Sex Male 13,775 2,791,762 98.7 Female 12,910 2,981,790 86.6 Age Category 0-4 2,759 364,488 151.4 5 to 9 3,116 366,686 170.0 10 to 14 2,588 379,029 136.6 15-19 2,068 406,241 101.8 20-24 2,269 393,698 115.3 25-29 2,031 393,548 103.2 30-34 1,610 368,494 87.4 35-44 3,107 795,572 78.1 45-54 3,281 902,204 72.7 55-64 2,024 695,768 58.2 65-84 1,644 609,516 53.9 85+ 188 98,126 38.3

Incidence rates of Dog Bite Injuries; Descriptive Analysis ED Visits 2008-2012 Maryland Population 2010 Average Annual Incidence Rate per 100,000 Race White 17,583 3,359,284 104.7 Black /African 6,930 1,700,298 81.5 American Asian/Pacific Islander 483 322,010 30.0 Am. Indian, Eskimo 75 20,420 73.5 Other 1,336 206,832 129.2 Biracial 205 164,708 24.9 Unknown 73 Ethnicity Hispanic 1,044 470,632 44.4 Not Hispanic 22,216 5,302,920 83.8 Unknown 3,425 Total 26,685 5,773,552 92.4

Sex of Dog Bite Victims in Maryland, 2008-2012 Male 48% 52% Female

Incidence Rates of Dog Bites by Age Category 170.0 151.4 136.6 Incidence Rates 101.8 115.3 103.2 87.4 78.1 72.7 58.2 53.9 38.3 Under 5 5-9 10-14 15-19 20-24 25-29 30-34 35-44 45-54 55-64 65-84 85+ Age Group

5 Year Frequency and Average Annual Incidence Rates by County: County Average County Population 2008-2012 Number of ED Visits 2008-2012 Average Annual ED Visit IR Number of Aggregate Reports 2008-2012 Average Annual Aggregate IR Allegany County 74,665 536 143.57 730 195.58 Anne Arundel County 538,132 2024 75.22 4318 160.35 Baltimore City 620,642 4046 130.38 4238 136.57 Baltimore County 807,069 3306 81.93 4639 115.14 Calvert County 88,732 586 132.08 1028 231.51 Caroline County 32,947 178 108.05 335 203.36 Carroll County 167,225 731 87.43 1261 150.81 Cecil County 101,096 804 159.06 1019 201.56 Charles County 146,994 608 82.72 1118 152.14 Dorchester County 32,562 429 263.50 598 234.65 Frederick County 234,101 1042 89.02 1301 110.69 Garrett County 30,083 205 136.29 301 200.01

5 Year Frequency and Average Annual Incidence Rates by County County Average County Population 2008-2012 Number of ED Visits 2008-2012 Average Annual ED Visit IR Number of Aggregate Reports 2008-2012 Average Annual Aggregate IR Harford County 245,313 1057 86.18 1961 159.87 Howard County 288,372 948 65.75 1297 89.73 Kent County 20,187 170 168.43 154 152.53 Montgomery County 973,978 2695 55.34 2717 55.75 Prince George's County Queen Anne's County 864,986 2687 62.13 2738 63.28 47,878 231 96.50 555 231.60 St. Mary's County 105,403 673 127.70 894 169.28 Somerset County 26,398 118 89.40 189 143.12 Talbot County 37,731 191 101.24 254 134.67 Washington County 147,811 750 101.48 1067 144.28 Wicomico County 98,905 611 123.55 1195 241.76 Worcester County 51379.00 369 143.64 668 259.92

Aggregate Bite Reports vs. Emergency Room Visits Statewide more aggregate bite reports than ER visits 33% more aggregate bite reports than ER visit reports Maryland aggregate bite report system is working effectively at county level

Total Charges Associated with Dog Bite Injuries by Year Year Minimum Charge Maximum Charge Median Charge Total Annual Charges 2008 $22.00 $10,210.38 $265.14 $2,150,000.00 2009 $28.39 $11,278.01 $283.76 $2,430,000.00 2010 $26.02 $13,849.05 $294.53 $2,650,000.00 2011 $7.00 $18,226.87 $297.62 $3,250,000.00 2012 $25.50 $47,880.86 $325.16 $3,740,000.00

Limitations and Challenges Medical record review not performed to verify E-coding, chief complaints, or triage notes. Includes only patients seen in MD Don t capture MD residents bitten and treated in other jurisdictions No reference group No control group, everyone in dataset was a dog bite victim Is the population being treated for dog bites in the ER different from the rest of the population seen in the ER? Coding error with county variables Slowed data analysis Had to recode and re-run analysis

Lessons Learned Be flexible Sometimes you have to go back to drawing board Collaboration is the key Get to know people who work in areas that you are less knowledgeable in Ask your colleagues for help Recognize your limitations There s always another analysis you can run know when to stop

Policy Implications Breed Specific Legislation are laws that regulate dog ownership based on the breed of the dog Advocates claim it reduces the number of attacks resulting in severe injuries to people Opponents state that there is little evidence that such laws actually reduce the number of dog bites Source: www.animallaw.info/topics/tabbed

Policy Implications Annual trends for 2008-2012 don t support change in incidence of dog bite injuries May need to follow for longer time Focus on targeting interventions toward high risk groups Children Dog Owners

Practice Implications Interventions should be aimed at high risk groups Children in pre-school Children 5-9 years old in elementary school Consideration for spring/summer programs when interactions with dogs may be higher

References Overall, K. L., & Love, M. (2001). Dog bites to humans- demography, epidemiology, injury and risk. Journal of the American Veterinary Medical Association, 1923-1934. Maryland Health Services Cost Review Commission. (2013, November 15). Retrieved from Maryland Health Services Cost Review Commission Website: www.hscrc.state.md.us/ ICD-9-CM. (2013, November 15). Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/icd/icd9cm.htm V-Codes and E-Codes FAQ. (2013, November 15). Retrieved from American College of Emergency Physicians: http://www.acep.org/clinical---practice-management/v-and-e-codes-faq/ REFERENCE DROPPPING $0 ER CHARGES- EMAIL FROM ANDREA, HSCRC ADDENDUM 2010 Census Interactive Population Search. (2014, March 28). http://www.census.gov/2010census/popmap/ipmtext.php?fl=24 Maryland Statistical Handbook.. (4 April, 2014). Retrieved from Department of Planning, Maryland State Data Center Website: http://planning.maryland.gov/msdc/md_statistical_handbook11.pdf, page 4. By County Order (2012). (4, April 2014). Retrieved from Department of Planning, Maryland State Data Center Website: http://planning.maryland.gov/msdc/pop_estimate/estimate_12/municipal/popest_muni12.shtml Age Profile 1: Age by Sex for Persons in Households and Persons in Group Quarters (2010). (15, April 2014). Retrieved from Department of Planning, Maryland State data Center Website: http://planning.maryland.gov/msdc/census/cen2010/sf1/ageprof/age_mdst.pdf, page 1 & 2. American Veterinary Medical Association: Task Force n Canine Aggression and Human-Canine Interactions (2001). A Community Approach to Dog Bite Prevention. Journal of the American Veterinary Medical Association, 218; 11; 1732-1749. Protect Maryland Dogs, Accessed November 20,2013. www.humanesociety.org/animals/dogs/protect_maryland_dogs.html

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Acknowledgements Dr. Katherine Feldman, DHMH Ms. Kimberly Mitchell, DHMH Ms. Brenna Hogan, DHMH Ms. Mary Armolt, DHMH Dr. Meghan Davis, JHU