1. Injury and External Causes Professor James Harrison Chair, WHO Topic Advisory Group for Injury and External Causes Director, AIHW National Injury Surveillance Unit

2. Acknowledgements Kirsten McKenzie and Lois Fingerhut Managing editors: –Adam Harrison (to April 2011) –David van der Zwaag (current) The many other contributors to the work of the TAG Research Centre for Injury Studies Flinders University Adelaide

3. Injury & External causes –What are injury and external causes? –How are ICD-coded injury data are used? Injury & External causes in the ICD –Background and history –What is distinctive about this subject for ICD? –Injury in ICD-10, clinical modifications & other classifications Work of the TAG –TAG and other contributors –Processes What’s likely to change? –Injury –External causes of injury Opportunities to participate Research Centre for Injury Studies Flinders University Adelaide

4. A. Injury & External Causes Research Centre for Injury Studies Flinders University Adelaide

5. Definition Injury: An injury is the physical damage that results when a human body is suddenly or briefly subjected to intolerable levels of energy. It can be a bodily lesion resulting from acute exposure to energy in amounts that exceed the threshold of physiological tolerance, or it can be an impairment of function resulting from a lack of one or more vital elements (i.e. air, water, warmth), as in drowning, strangulation or freezing. WHO Injury Surveillance Guidelines, 2001.

6. Major injury issues Injury conditions –Traumatic brain injury –Hip fractures –Burns –Toxic effects of poisons External Causes –Transport crashes –Suicide and other intentional self-harm –Falls Modifiable risk factors –Alcohol Research Centre for Injury Studies Flinders University Adelaide

7. Using ICD-coded data to ‘see’ injury Research Centre for Injury Studies Flinders University Adelaide

8. Injury in Australia Deathsc. 10,000 / year Hospitalisedc. 500,000 episodes –representing about 400,000 people Injury in past 4wc. 12% of population Research Centre for Injury Studies Flinders University Adelaide

9. Road deaths Research Centre for Injury Studies Flinders University Adelaide Road deaths in Australia

10. Road deaths Research Centre for Injury Studies Flinders University Adelaide Road deaths in Australia

11. Motorcyclists Pedal cyclists Road injuries with a high threat to life, Australia

12. Injury burden, Australia 2003

13. Implications for priority-setting National estimates based on the GBD method, published in the 2010 edition of Australia’s Health, the leading national report on health statistics. Research Centre for Injury Studies Flinders University Adelaide

14. Implications for priority-setting National estimates based on the GBD method, published in the 2010 edition of Australia’s Health, the leading national report on health statistics. Research Centre for Injury Studies Flinders University Adelaide

15. Injury globally

16. Injury compared with other conditions Global Burden of Disease 2004 Update: Selected figures and tables. WHO, Geneva Distribution of global DALYs 2004, by sex

17. Injury compared by income Global Burden of Disease 2004 Update: Selected figures and tables. WHO, Geneva Burden of injury by Gross National Income per capita, 2004

18. Injury compared by income Global Burden of Disease 2004 Update: Selected figures and tables. WHO, Geneva Burden of injury by Gross National Income per capita, 2004

19. Projections of global burden Global Burden of Disease 2004 Update: Selected figures and tables. WHO, Geneva

20. B. Injury in the ICD Research Centre for Injury Studies Flinders University Adelaide

21. Public Health Surveillance of Mortality Universal death registration plus Systematic cause coding, combined with Population censuses –to allow rates to be calculated William Farr

22. Public Health Surveillance of Injury Not only deaths –Hospital data and other sources as well ‘Cause’ coding –The injury (e.g. fractured femur; burn) –Factors that led to the injury (e.g. car crash; fall)

23. External cause data inform injury prevention Four critical factors for injury epidemiology 1 : –the host (i.e. the person injured) –the agent (i.e. the force or energy) –the vector (i.e. the person or thing that applies the force) –the environment (i.e. the conditions under which the injury happens) 1 Runyan, Epidemiol Rev, 2003. 25(1): p. 60-64.

24. Overview of injury in the ICD Farr (1840s and later)External causes (several dimensions) International List (1890s-1930s) Mingled injury and external causes of injury ICD-6 (1948)Separate chapters for Injury and the External causes of injury. Several “dimensions of interest”: - Nature of injury and body part injured - Intent, mechanism, place of occurrence ICD-7, 8, 9Some elaborations of ICD-6 schema ICD-10Injury: reversed concept hierarchy; refinements Ext Causes: Activity dimension; refinements Clinical modificationsnb -AM, -CA, -CM Injury: more specificity (e.g. part of…, extent of…) External Causes: Structure: Place & Activity as separate dimensions Content: developed place, activity (nb sport), perpetrator of assault, types of object/substance Related classificationInternational Classification of External Causes of Injury (ICECI) – more multi-dimensional & detailed

25. Main concepts InjuryExternal Causes Nature Superficial Location Intra-cranial* ContusionEye(s) Open woundFace AmputationHead - other FractureNeck DislocationHand(s) CrushingUpper limb(s) - other Organ damageThorax - internal Foreign bodyThorax - other Blood vessel damageAbdomen - internal Nerve damageAbdomen - other BurnPelvis/lower back Multiple injuriesFemur PoisoningLower limb(s) - other Toxic effectsSpinal cord Complications of care Vertebral column Multiple *Major/minor TBI Intent Unintentional Interpersonal: assault/homicide Interpersonal: collective violence Self-harm: suicidal Self-harm: other Undetermined Not (yet) determined Not specified Not applicable (e.g. 'interpersonal - therapeutic') Mechanism Transport crash Fell Stabbed Shot etc. Place Home Road Farm Hospital etc. Activity Working for income Working - other Engaged in sport etc. Main dimensions implicit in Injury and External Cause chapters populated with illustrative categories

26. External cause matrix-basic structure Intent of injury Mechanism UnintentionalSuicideHomicideUndeter- mined Other MV-traffic Cut Firearm Poisoning Struck by/ against Suffocation etc…

27. C. Work of the TAG Research Centre for Injury Studies Flinders University Adelaide

28. Chair: James Harrison Managing Editor: David van der Zwaag (Flinders University) Work groups –notably the External cause workgroup –led by Kirsten McKenzie (QUT) & Ms Lois Fingerhut (Chair, ICE on Injury Statistics) Injury and External Cause TAG

29. Engaging collaborators Two types of contributor –WHO accredited TAG-IEC members –Plus: Expert Consultants Greater spread of expertise Indicative of wide scope of Injury and External Causes chapters More contributors welcome! TAG-IEC Members as of June 2011 Mr Jerry Abraham Mr Lars Age Johansson Dr Limor Aharonson-Daniel Dr Lee Annest Ms Kidist Bartolomeus Dr Kavi Bhalla Professor Louisa Degenhardt Associate Professor Tim Driscoll Professor Caroline Finch Ms Lois Fingerhut Dr Belinda Gabbe Professor James Harrison (Chair) Mrs Yvette Holder Ms Kerry Innes Emeritus Professor John Langley Professor Ronan Lyons Mr Richard Matzopoulos Dr Kirsten McKenzie Dr Michael Peck Professor Jurgen Rehm Associate Professor Mohsen Rezaeian Professor Hamid Soori Professor Tjerk van der Schaaf Mr David van der Zwaag (ME) Dr Martti Virtanen Dr Margaret Warner Dr Tetsuo Yukioka Associate Professor Maria Segui- Gomez Professor Gordon Smith

30. Global representation

31. Sources and inputs Literature Consultation within TAG Consultation via TAG Consultation with WHO-FIC committees –Meetings with MbRG, MRG/MB-TAG, Q&S TAG, etc. ICD –ICD-9 to 10; clinical modifications; related classifications (nb ICECI) Data –ICD-coded data –Data from special studies

32. Kirsten McKenzie

33. Current process TAG-IEC Revision guide → –Consolidates instructions to encourage contributors to work within iCAT –Work groups encouraged to reach consensus first then populate content –WHO Content Model Reference Guide ultimate reference source iCAT to help facilitate collaboration and discussion in Working Groups

37. D. What is likely to change? (or stay the same) Research Centre for Injury Studies Flinders University Adelaide

38. Injury: overview 1.Scope About the same as ICD-10 2.Structure Default: largely the same as ICD-10 i.e. Body part subdivided by nature of injury (cf ICD-9: Nature of injury by body part). Discussion: Recent proposal for a ‘topography’ attribute harmonised across the ICD. Should extensions in ICD-10-CM be adopted? (e.g. laterality) 3.Topics Spinal cord injury: proposal from ISCoS (trauma level; functional level; degree) Burns: work group revising ‘depth’ aspect. TBI: In consultation with Neurology TAG. Potential to harmonise with AIS (via ICD-10- CM) Duration of loss of consciousness could become part of a suite of neurology manifestations. Poisoning: need to update substances (e.g. new synthetic opioids) and allow for changes. Not supportive of ICD-10-approach of bringing External Causes in to this part of the Injury chapter. Organ damage: extend and regularise specification of degree/extent. Long bone fractures: some changes to characterisation in clinical modifications. Clinical modifications of ICD-10 take different approaches. 4.Relationships ICD-10. Default to compatibility. (Exceptions? E.g. Proposals by Q&S TAG) ICD-10 clinical modifications. Which to follow in ICD-11 clinical mod? ICD-10 based methods (e.g. ICISS). Issue: preserve valued performance in ICD-11. External Causes chapter: (e.g. Q&S TAG proposals require careful coordination) Research Centre for Injury Studies Flinders University Adelaide

39. External causes: overview 1.Scope About the same as ICD-10 2.Structure Thoroughly reviewed. Revised to be more regular and fill gaps. Concept order in linearizations: Intent-Mechanism-Object Continue use of “code also” grammar (e.g. as for Place and Activity in -AM -CA -CM) 3.Topics Intent: Allow for Intent not yet determined. Allow suicidal/non-suicidal self-harm. Mechanism: Refinements. Object/substance: Default to ICD-10 & ICECI. Work in progress. Place: refinement of ICD-10, drawing on clinical modifications (e.g. health care) Activity: ditto. Additional aspects: draw on ICD-10 clinical modifications (e.g. Perpetrator from –AM). Quality & Safety: ICD-10 Y40-Y84 is main focus of next meeting of Q&S TAG 4.Relationships ICD-10 external causes: high degree of compatibility Injury chapter: careful coordination needed for some topics (e.g. Q&S) ICECI: version 1.2 is embedded in iCAT as reference classification Use-case versions: intend to provide external causes classification variants for Mortality, Hospital morbidity, Lower resource settings and Research/Special use. Research Centre for Injury Studies Flinders University Adelaide

40. E. Getting Involved There are still opportunities to contribute –Current example: finalising object/substance lists for particular mechanisms of injury Please get in touch james.harrison@flinders.edu.au david.vanderzwaag@flinders.edu.au Research Centre for Injury Studies Flinders University Adelaide

41. Questions welcome Research Centre for Injury Studies Flinders University Adelaide james.harrison@flinders.edu.au