Injury Surveillance Data Sources RAC Chairs Meeting August 19, 2010 Ryan Beal, MPH Texas Department of State Health Services

Objectives To identify sites that provide injury research guidance including classification and coding standards To introduce data sources that can be used in injury and trauma research To describe how to access various data sources To show examples

Injury Pyramid Deaths Hospitalizations Emergency Dept According to a CDC report, for every injury death there are 18 injury hospitalizations and 250 ER visits and an unknown number of people who went to their primary care physician, self treated, or were never treated; so to rely on for example a dataset that only looks at death may not fully describe the problem. This is especially true for injuries and causes less likely to result in death. Falls make up about 10% of injury deaths but about 40% of injury hospitalizations. 1996-1997 Injury chart book: 1 death: 18 hospitalizations: 250 emergency dept visits: ? Self treat/never treated http://www.cdc.gov/nchs/data/hus/hus96_97.pdf Emergency Dept Primary Care/ Self Treat/ Never Treated

Resources for Injury Surveillance Guidance Safe States Alliance (formerly STIPDA) http://www.safestates.org/ Center for Disease Control and Prevention (CDC) http://www.cdc.gov/injury/wisqars/index.html Inventory of National Injury Data Systems http://www.cdc.gov/Injury/wisqars/InventoryInjuryDataSys.html The Safe States Alliance is a good source for guidance and recommendations. They have a number of publications with recommendations for using data Consensus Recommendations for Injury Surveillance in State Health Departments – has information about which datasets are most appropriate for a given injury or injury mechanism In addition to the WISQARS query system (link) they also have tools for categorizing data such as the cause by intent matrix and Barell matrix. You can also find the State Injury Indicators definitions there which define mechanisms of injury for hospital discharge and death data. Body regions: Head and neck, spine and back, torso, extremities… Nature: Fracture, dislocations, sprains & strains, internal… Inventory of National Injury Data Systems - List of 47 different injury systems providing nationwide injury-related data Includes public and private datasets spanning a range of data including morbidity, mortality, transportation, violence, and behavior risk factors Some have Texas specific information

Data Sources Death Data (Vital Records) Fatality Analysis Reporting System (FARS) Hospital Discharge Data EMS/Trauma Registry Youth Risk Behavior Surveillance System Contain injury and trauma data elements And Texas specific data

Death Data DSHS, Bureau of Vital Statistics Deaths occurring in Texas and among Texas residents Receive information for Texas residents who die in other states through the interstate exchange program

Death Data: Strengths/Weaknesses Available years easily accessed Population-based Standardized/ Comparable Weaknesses 2007 most recent data Limited number of trauma-related fields Strengths: Accessible – can be accessed via soupfin or wisqars Population-based – Because nearly all deaths are collected in this system it’s generally representative of the population Standardized/ Comparable – Uses nationally standardized data elements, therefore can be compared to national data Weaknesses: Lags behind other data sets – Most recent official year available is 2007

Death Data: Access Soupfin (Texas/ county) http://soupfin.tdh.state.tx.us/deathdoc.htm WISQARS (National/ state) http://www.cdc.gov/injury/wisqars/index.html Data file http://www.dshs.state.tx.us/chs/vstat/ Soupfin: Center for Health Statistics at DSHS WISQARS=Web-based Injury Statistics Query and Reporting System Don’t have a standard PUDF but they’ll create a dataset for you

Intentional Self-Harm Accidents Intentional Self-Harm Assault Arrows drawn to the 3 main external causes of death categories

Suicide Across the Life-Span by Race/Ethnicity per 100,000 White Black Hispanic Suicide rate /100,000 persons This is a good example of differences between races Higher for every age group for whites than for blacks and hispanics With the highest rates occurring in the 45-54 and 75-84 years group Source: Texas Department of State Health Services, Vital Statistics Unit, 2003-2006

Fatality Analysis Reporting System (FARS) National Highway and Traffic Safety Administration (NHTSA) Crash involving a motor vehicle traveling on a traffic-way customarily open to the public, and must result in the death of an occupant of a vehicle or a non-occupant within 30 days of the crash FARS analysts use several data sources to code more than 100 data elements related to the crash, the occupants, and the vehicle Full list of data sources: Police Accident Reports State Vehicle Registration Files State Driver Licensing Files State Highway Department Data Vital Statistics Death Certificates Coroner/Medical Examiner Reports Hospital Medical Reports Emergency Medical Service Reports Other State Records

FARS: Strengths/Weaknesses Accessible Relatively recent Population-based Local data available Weaknesses Deaths only

Publications Data Tables Query Texas Data Here’s a snapshot of the FARS website. As you can see there tabs above the table that you can use to access the data. Where you see the tabs there are options for data tables, queries, and publications. In most cases you can find what you’re looking for in the data tables section. There you’ll find reports by trends, crashes, vehicles, and people. If you click on states you can get comparisons by state, and if you click on any of the states you can find comparisons by county. The tab I indicated as “Texas Data” will allow you to select Texas specific data which will take you to a page containing a large number of tables and maps for Texas.

Vehicle Miles Traveled Fatality Rates: Texas , U.S. and Best State (2008) Fatalities Total VMT (millions) Fatalities per 100 million VMT Total Population Fatalities Per 100,000 Population Texas 3,382 235,382 1.44 24,326,974 13.9 US 37,261 2,973,509 1.25 304,059,724 12.25 Best State   0.67 5.59 Here’s an example I got from the NHTSA website where they have traffic safety facts by state Here we see fatality rate comparisons for Texas, the US and the best state. Rates for both VMT and fatalities per 100,000 persons are higher for Texas than for the US and more than double the rate of the best state. * Vehicle Miles Traveled http://www-nrd.nhtsa.dot.gov/departments/nrd-30/ncsa/STSI/48_TX/2008/48_TX_2008.htm

Hospital Discharge Data DSHS, Texas Health Care Information Collection (THCIC) Includes hospital discharges from all state licensed hospitals except those that are statutorily exempt Housed at the Center for Health Statistics Exempt hospitals include some of the more rural hospitals

Hospital Discharge Data: Strengths/Weaknesses Relatively recent Population-based Standardized, comparable Local data available Hospital charges Weaknesses Restricted use Must be purchased Limited trauma data Incomplete E-code reporting Analytical skills needed Strengths: Quicker turn around time: Usually available one year after closing date Population-based: contains nearly all discharges in the state Standardized/ Comparable: Based on the Uniform billing code Local data available: Can be used to look not only for state but also at the county level Weaknesses: Restricted use: Suppression of demographic data for certain fields in PUDF. Cannot be linked. Must be purchased: Limited trauma data: Set up to monitor billing data (uniform billing code), thus does not include key trauma data elements such as injury severity score and glasgow coma score, as well as risk factors such as protective device use. Incomplete E-code reporting: (83.2% in 2007)

Hospital Discharge Data: Access Public Use Data File http://www.dshs.state.tx.us/thcic/ State Injury Indicators Report

Hospital Charges by the Top 5 Causes of TBI Hospitalization, 2004-2007 Cause of TBI Cases % of cases Avg. Std Dev Total Charges (millions) Percent of Charges Falls 23,085 45.1% $35,737 $51,991 $825 32.6% Motor vehicle traffic 19,971 39.0% $68,601 $95,734 $1,370 54.2% *Struck by/against 4,778 9.3% $32,833 $57,337 $156.9 6.2% **Other transportation 2,299 4.5% $44,779 $69,181 $102.9 4.1% Firearm 1,020 2.0% $71,813 $102,963 $73.3 2.9% Top 5 causes 51,153 100.0% $49,422 $76,131 $2,528 Again, we see that the average hospital charge for MVC and firearms are quite a bit higher than for the other causes We also see that although MVC represent 39% of the cases, it represents 54% of the charges * struck by/against includes: unarmed fight or brawl or using blunt object, legal intervention, struck and injured unintentionally by falling or stationary objects or persons, including TBI originating from sports. **Other transportation includes most instances of railway, bicycle, animal-drawn, watercraft, air/space, and non-traffic related injuries. THCIC Hospital Discharge Data, 2004-2007

EMS/ Trauma Registry DSHS, Injury and EMS/Trauma Registry Group 2 datasets 1: EMS – EMS runs 2: Hospital – Trauma cases (ICD-9-CM diagnosis codes 800-959.9 excluding 905-909, 910-924, and 930-939 ) meeting any of the following: Admitted to a hospital for 48 hours or more Transferred into or out of the hospital Died after receiving any evaluation or treatment Dead on arrival

EMS/Trauma Registry Strengths/Weaknesses Trauma specific data elements Recent data E-code reporting >98% Weaknesses Incomplete participation Limited access to data summaries Limited to trauma requiring admission for 48 hours or more Analytical skills needed Strengths: Trauma specific data elements: ISS, GCS, and risk factors such as protective device use Recent data: 2009 hospital data are available E-code reporting >98% Weaknesses: In 2009, 51% of hospitals submitted data but for trauma designated hospitals it was 98% (19% of undesignated). Participation among EMS was about 46% in 2009 but they’re harder to categorize. We think most of the largest providers are submitting which would enable us to collect the vast majority of runs but we don’t have any definitive numbers. Data are limited to traumas in which length of stay was 48 hours or more, or patient was transferred, or patient died after having received treatment or was DOA

EMS/Trauma Registry: Access Reports, data requests, PUDF http://www.dshs.state.tx.us/injury/ TRACIT data submission site (txetra.com) EMS and Hospital reports Ad hoc data request

Reports Can compare your entity to your RAC and to the State

Outcome by EMS/RAC/State My EMS My RAC State Call Cancelled 9 24 133,577 False Alarm 16 21 48,741 No Treatment, No Transport 205 1,762 255,871 Treatment, No Transport 35 347 57,238 Treatment, Transport Refused 32 68 108,108 Transport and Treatment 1,055 7,537 1,046,398 Transport, No Treatment 15 372 85,190 DNR, Transport DNR, No Transport 1,523 Dead on Scene 12 99 11,622 Unknown 5 396 340,570 Total 1,384 10,630 2,089,043 Transport and treat: My EMS = 76% My RAC = 71% State = 50% In this RAC they have comparatively few unknowns compared to statewide

Cause of Injury by EMS/RAC/State My Hosp My RAC State Assault 988 2,744 10,842 Falls 837 6,696 42,248 Fires/burns 10 437 2,516 Motor vehicle 899 5,183 28,472 Other unintentional injury 402 2,753 15,817 Self-inflicted 98 286 1,510 Undetermined intent injury 44 113 795 Unspecified 5 49 545 Total 3,283 18,261 102,745 With most of the reports you can also compare by age group, gender, and a time period such as month or quarter.

Blood Alcohol Level Among Drivers Tested by Year Blood Alcohol Level (mg/dl) Year 2003 2004 2005 2006 2007 2003-2007 2,757 3,091 2,970 3,248 3,528 15,594 1- 79 686 575 612 619 630 3,122 >= 80 1,831 1,880 1,844 1,931 2,084 9,570 Unknown 322 289 270 310 272 1,463 Missing/Invalid 95 38 458 417 341 1,349 Total 5,691 5,873 6,154 6,525 6,855 31,098 Percent >0 44.2% 41.8% 39.9% 39.1% 39.6% 40.8% Percent >= 80 32.2% 32.0% 30.0% 29.6% 30.4% 30.8% The percent of hospitalized drivers tested was 43.6% from 2003 to 2007 Among drivers tested, for that five year time period 31% had a BAL greater than or equal to 80 mg/dl, and 41% had a BAL greater than 0 mg/dl. EMS/ Trauma Registry, 2003-2007

Traffic Related EMS Runs by Day of Week and Time of Day, 2004-2007 Runs at 1600 hrs by day Sunday 1638 Monday 2137 Tuesday 2172 Wednesday 2086 Thursday 2108 Friday 2757 Saturday 1982 EMS/ Trauma Registry, 2004-2007

Youth Risk Behavior Surveillance System (YRBSS) DSHS, Center for Health Statistics Classroom based paper survey monitoring priority health-risk behaviors that contribute substantially to the leading causes of death, disability, and social problems among youth Full description: Classroom based paper survey conducted biennially on odd years to monitor priority health-risk behaviors that contribute substantially to the leading causes of death, disability, and social problems among youth and young adults in the United States

YRBSS: Strengths/Weaknesses Available years easily accessed Representative sample Standardized/ Comparable Injury focus Weaknesses: Limited local information Done every two years Survey data Self reported Uses a representative sample designed to provide estimates primarily at the state level Because injury is the leading cause of death for kids, questions asked in YRBSS focus on injury including drinking and driving, restraint use, violence, and suicide Self reported: May be subject to bias. Subject to memory and willingness to answer truthfully.

YRBSS: Access Query (Texas) http://www.dshs.state.tx.us/chs/yrbs/ Publications (national, state, major city) http://www.cdc.gov/healthyyouth/yrbs/index.htm Query has data as recent as 2009 Publications: National data published in Morbidity and Mortality Weekly Report (2007 most recent)

Risk Factor: Percentage of students who rode one or more times during the past 30 days in a car or other vehicle driven by someone who had been drinking alcohol (2007) % Confidence Interval Texas 35.6 32.6-38.7 Median 27.4 -- Best State 14.8   12.2-17.9 Of all states in the survey, Texas has the highest percentage of students responding yes to this question There are also surveys for some of the larger cities in the nation and of the 22 cities surveyed Dallas is ranked #1 at 38.4% Houston is ranked #2 at 35.2% San Francisco is best at 18.0% (However, for some cities that have good public transportation their numbers appear to be lower) (SF=18, NY=N/Avail, Boston=23.1) http://www.cdc.gov/mmwr/PDF/ss/ss5704.pdf

Other Data Sources National EMS Information System (NEMSIS) http://www.nemsis.org/ National Trauma Data Bank (NTDB) https://www.ntdbdatacenter.com/Default.aspx National Occupant Protection Use Survey (NOPUS) http://www-nrd.nhtsa.dot.gov/ Crash Records Information System (CRIS) http://www.dot.state.tx.us/drivers_vehicles/crash_records/form.htm NEMSIS: Datasets containing EMS information that can be used to describe EMS systems and events (2008 data available) Have a query-able database (elapsed times, demographics, and cardiac arrest among others) NTDB: contains trauma data from participating hospitals (participation is one requirement of ACS verification process) You can request a research data set at the website listed here – although there is a charge NOPUS: Yearly observed data on seat belt and motorcycle helmet use CRIS: police crash reports; data requests; crash stats on the website

DSHS Injury Website http://www.dshs.state.tx.us/injury/ Non-fatal Trauma Hospitalizations by TSA Compare rates (TSA vs. Texas) EMS/Trauma Registry Hospital Surveillance Reports by TSA Fact Sheets Falls, submersions, traumatic brain injury, suicide The trauma hospitalization tables allow you view the age-adjusted injury hospitalization rates of causes and intents with RAC and state rates side by side.

Summary Identified sites that provide injury research guidance including classification and coding standards Introduced data sources that can be used in injury and trauma research Described how to access Showed examples 33

Contact Ryan Beal, MPH Epidemiologist Texas Department of State Health Services Injury and EMS/Trauma Registry Group 512.458.7111, ext. 2808 ryan.beal@dshs.state.tx.us