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

2. 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

3. 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.
Injury chart book: 1 death: 18 hospitalizations: 250 emergency dept visits: ? Self treat/never treated
Emergency Dept
Primary Care/ Self Treat/ Never Treated

4. Resources for Injury Surveillance Guidance
Safe States Alliance (formerly STIPDA)
Center for Disease Control and Prevention (CDC)
Inventory of National Injury Data Systems
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

5. 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

6. 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

7. 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

8. Death Data: Access
Soupfin (Texas/ county)
WISQARS (National/ state)
Data file
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

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

10. 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 and years group
Source: Texas Department of State Health Services, Vital Statistics Unit,

11. 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

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

13. 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.

14. 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

15. 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

16. 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)

17. Hospital Discharge Data: Access
Public Use Data File
State Injury Indicators Report

18. 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,

19. 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 excluding , , and ) 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

20. 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: 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

21. EMS/Trauma Registry: Access
Reports, data requests, PUDF
TRACIT data submission site (txetra.com)
EMS and Hospital reports
Ad hoc data request

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

23. 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

24. 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.

25. Blood Alcohol Level Among Drivers Tested by Year
Blood Alcohol Level (mg/dl)
Year
2003
2004
2005
2006
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,

26. 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,

27. 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

28. 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.

29. YRBSS: Access Query (Texas)
Publications (national, state, major city)
Query has data as recent as 2009
Publications: National data published in Morbidity and Mortality Weekly Report (2007 most recent)

30. 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
Median
27.4 --
Best State
14.8   
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)

31. Other Data Sources National EMS Information System (NEMSIS)
National Trauma Data Bank (NTDB)
National Occupant Protection Use Survey (NOPUS)
Crash Records Information System (CRIS)
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

32. 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.

33. 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

34. Contact Ryan Beal, MPH Epidemiologist
Texas Department of State Health Services
Injury and EMS/Trauma Registry Group
, ext. 2808