1. Injury Data and NCHS U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics Lois A. Fingerhut NCIPC Conference, May 2005

2. Focus for this morning NCHS injury-related web pages ICD-9 to ICD-10 comparability file Frameworks for presenting data Poisoning- a recent example of a question of definition Injury severity- new collaborative work

3. Our new injury website pages One stop shopping for questions/presentations/publications regarding NCHS surveys and data sets that have an injury component Links to non-NCHS sources (eg WISQARS) Up-to-date information on the International Collaborative Effort (ICE) on Injury Statistics

7. Injury Mortality Data From the National Vital Statistics System Data Source | Mortality-Injury Summary | Injury Death Codes Publications | Presentations | Tabulated Data | Public Use Data Data Tools | Query Systems | Related Links National Databases

12. ICD-9 to ICD-10 Comparability A Guide to State implementation of ICD-10 for mortality ( 2000) Comparability reports going back to ICD-4 to ICD-5 ICD-9 t o ICD-10 detail Downloadable file on ICD-9 to ICD-10 comparability study Full file documentation SAS statements http://www.cdc.gov/nchs/datawh/statab/unpubd/comp.htm #A%20guide%20to%20state%20implementation%20of%20ICD-10

13. ICD-10 on the WHO Website WHO Family of International Classifications http://www.who.int/classifications/en/ There is a complete online version of ICD-10

14. Frameworks for presenting data

15. External causes ICD-9 and ICD-9 CM external cause code matrices ICD-10 external cause code matrix Injury Diagnoses ICD-9 CM Diagnosis codes: Barell Matrix ICD-10 injury diagnosis code matrix

16. External cause matrix-basic structure Intent of injury Mechanism UnintentionalSuicideHomicideUndeter -mined Oth er MV-traffic Cut Firearm ICD-9, ICD-9-CM and ICD-10 External cause codes Poisoning Struck by/ against Suffocation Etc…..

17. External Cause of Injury Mortality Matrix (ICD-10)

18. Injury deaths by matrix: 2002

19. New International Recognition! The Mortality Reference Group (MRG), the group charged with refining and recommending changes to the ICD formally recommended “Publish External Cause of Injury Mortality Matrix data in addition to standard WHO tabulations to facilitate statistical analysis” Source: www.who.int/classifications/network/en/icelandexe cutifsummary.pdf

20. Barell Matrix-basic structure ICD-9 CM codes

21. Barell matrix: a standard for presenting injury morbidity data See ICE webpage for full description of the matrix www.cdc.gov/nchs/about/otheract/ice/barellmatrix.htm Barell V, Aharonson-Daniel L, Fingerhut LA, MacKenzie EJ, et al. An introduction to the Barell body region by nature of injury diagnosis matrix. Injury Prevention 2002;8:91-6. National Hospital Discharge Survey: 2002 Annual Summary With Detailed Diagnosis and Procedure Data (table 24) www.cdc.gov/nchs/data/series/sr_13/sr13_158.pdf

22. ICD-10 Injury Mortality Diagnosis Matrix ICD-10 ‘S’ & ‘T’ codes

23. Head and neck all Traumatic brain injury Other head Neck Head and Neck Spine and upper back Spinal cord Vertebral column Torso Thorax Abdomen Pelvis and lower back Abdomen, lower back & pelvis Trunk, other Extremities Upper extremities Hip Other lower extremities Not classifiable by site Multiple body regions System wide Unspecified ICD-10 Body region of injury categories for mortality Level 1 Level 2

24. Additional detail is available, but not necessarily appropriate for mortality For example, Level 2- ‘Other lower extremities’ can be disaggregated to Level 3 categories ThighL3-31 Hip & ThighL3-32 Upper Leg and thighL3-33 KneeL3-34 Lower legL3-35 FootL3-36 AnkleL3-37 Other and multiple ankle and footL3-38 ToesL3-39 Other lower limb L3-40

25. ICD-10 mortality Nature of injury Categories Fractures Dislocation Internal organ injuries Open wounds Amputations Blood vessels Superficial & contusion Crushing Burns Effects of foreign body Other effects of external causes Poisoning Toxic effects Multiple injuries Other specified Sprain or strain Muscle and tendon injuries Nerve injuries Unspecified Level 1 Level 2

26. Total and any mentions of injury diagnoses by body region: 2002

27. Total and any mentions of injury diagnoses by nature of injury: 2002

28. Injuries mentioned in MVT deaths (44,065 deaths and 70,684 injuries) by body region and nature of injury: US, 2002

29. Under discussion.. How should we define poisoning?

30. ICD-9 vs ICD-10 Underlying cause: external cause codes (ICD-10 X & Y codes) ICD-10 Multiple cause: T codes for substances Mental health “F” codes Nondependent abuse Dependent abuse Alcohol intoxication (not included here) Adverse effects codes (not included here) Definitional issues: poisoning mortality

31. ICD ‘definitions’ of drug poisoning ICD-10 Nondependent abuse of drugs305.2-.9F11-16, 18-19 (not.2) Dependent abuse304F11-16,18-19(.2) UnintentionalE850-E858X40-X44 SuicideE950(.0-5)X60-X64 UndeterminedE980(.0-.5)Y10-Y14 HomicideE962.0X85 [Alcohol intoxication305.0F10.0] ICD-9

32. ICD-9 vs ICD-10 Substance selection ICD-9 underlying cause codes for poisoning more specific than ICD-10 codes ICD-10, to get specific substances Literals from the death certificate Code the multiple cause data

33. ICD mortality coding varies by country ICD-9- UCOD ICD-10-UCODSubstance- specific England and Wales 1990-20002001-2002Literals from text files Canada1990-19992000-2002From under- lying cause United States 1990- 1998 1999-2002Multiple cause coding

34. Drug poisoning death rates: US, 2002 Deaths per 100,0000 pop

35. Leading specified substances mentioned in drug deaths for 35-54 year olds: US, 2002 1. Cocaine T40.5: 25% 2. Other specified opioids T40.2: 21% 3. Antidepressants T43.0-T43.2: 11% 4. Alcohol T51: 11% 5. Carbon Monoxide T58: 8% 6. Heroin T40.1: 10% 7. Benzodiazepines T42.4: 9% 8. Methadone T40.3 10%

36. Next Steps In 2003, the MRG recommended to the URC of the WHO that new rules will apply in January 2006 to the underlying cause coding of certain ICD codes from Mental and Behavioral Disorders (F10-F19) If there is any mention of an external cause on the certificate, the code will be to the external cause rather than MBD code Codes in the F10-F19 range with a 4 th digit of.0 (acute intoxication) will be coded to poisoning codes in the external cause of poisoning section

37. Injury Severity Some new considerations for national data Acknowledging many of these next slides from Dr. Ellen MacKenzie, Johns Hopkins University

38. September 2004 Meeting Meeting convened at NCHS bringing together national and international experts in the area of injury severity scoring Why? Because the current standards “AIS” and “ICDMAP” are proprietary and many believe that There are nonproprietary alternatives They should not be proprietary any longer

39. INJURY SEVERITY INJURY SEVERITY Alphabet Soup EM

40. Injury Severity Indices: Major Areas of Application  Triage  Prognostic Evaluation  Research and Evaluation  Clinical Research  Systems Evaluation  Surveillance and Epidemiology EM

41. The Abbreviated Injury Scale (AIS)  A classification of injuries based on anatomic descriptors  A severity score ranging from 1 (minor) to 6 (maximum injury, virtually unservivavle) assigned to each injury EM

42. Scores are subjective assessments assigned by a group of experts and implicitly based on four criteria:  Threat to life  Permanent Impairment  Treatment Period  Energy Dissipation EM

43. AIS  Currently, most widely used severity score based on anatomic descriptors  Official injury data collection tool of NHTSA crash investigation teams  Developed in 1971; 5th revision to be published in 2005 EM

44. Using AIS for Multiple Injuries for predicting survival  Injury Severity Score (ISS)  The New Injury Severity Score (NISS)  The Anatomic Profile (AP) and the Anatomic Profile Scale (APS) EM

45. ICD-Based Measures of Injury Severity  ICD to AIS Conversion  ICISS Family of Measures EM

46. ICDMAP ICD-CM to AIS Conversion  Converts ICD-9CM coded discharge diagnoses into AIS injury descriptors, AIS scores and computes ISS, NISS, APS  Conservative measure of injury severity - refer to as ICD/AIS scores  Limitations identified; revision needed EM

47. ICISS  Based strictly on ICD rubrics  The ICISS score for a given patient is the product of the survival risk ratios (SRRs) associated with each ICD diagnosis  SRRs are calculated by dividing the number of survivors among patients with a specific ICD by the total number of patients with that ICD code EM

48. Refining the ICISS  Computation of SRRs: based on multiple trauma patients or patients with single injuries?  Database used for calculation of SRRs:  Trauma centers only vs. population based ?  Include ALL deaths, only deaths in ED or hospital or only in-hospital deaths ?  Registry data vs. administrative data ?  Regional/local vs. national data?  Computation of ICISS: use product of SRRs or lowest SRR? EM

49. To think about….  Need to keep in mind the application; severity (case mix?) adjustment for use with hospital discharge data (HDD) – also mortality data, ambulatory care encounter data ?  By necessity – must be based on ICD (but what do we lose – how good can we get without physiology ?)  Age, gender, co-morbidities and mechanism are important in case mix adjustment – and all are measurable using HDD EM

50. and...  Are we just interested in measures that predict mortality ?  Need to carefully consider the overall advantages (current and future) of the AIS classification in any recommendations  What are implications of the 2005 revision of the AIS and the ICD-10 (CM??) EM

51. What we know National trends in injury-related hospital discharges and emergency dept. visits reflects utilization, but not differences in injury severity ICD codes alone cannot distinguish severity among injuries ICD-10 has provided no real guidance on how to select a main injury among multiple cause of injury mortality data

52. The “practical problems” ICD-9 CM is still being used for coding morbidity data; annual updates to CM continue Most recent version of ICDMAP doesn’t recognize new codes ICD-10 CM doesn’t yet have an implementation date and there is no new ICDMAP based on ICD-10 ICD codes used for mortality data often lack specificity

53. What was discussed Strengths and weaknesses of different severity scales Solutions for administrative data acknowledging the limitations of the source data (e.g., non-specific coding, changes in admission practices) Can we measure threat to function as well as threat to life?

54. What “we” would have liked to accomplish Agree upon a measure of injury severity to add to NCHS survey data Incorporate a method to identify the “main injury” in mortality and add it to the mortality file Recommend a standard measure to users of administrative databases (e.g., Statewide hospital discharge data sets)

55. Where might these measures be used? Tracking Department’s Healthy People Objectives CDC Futures Initiative- Health Protection Goals NCHS reports: Health, United States Injury Chart book(s) Statewide trauma and general injury databases

56. NCHS Data Sources for Injury Severity National Hospital Discharge Survey National Hospital Ambulatory Medical Care Survey-ED component National Health Interview Survey ?? Mortality data from vital statistics

57. Other Federal Sources Agency for Health Care Research and Quality Medical Expenditure Panel Survey (MEPS) Healthcare Cost & Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) State inpatient databases (SID) State emergency dept databases (SEDD) http://www.ahrq.gov/data/hcup/

58. Discharge Disposition for injury diagnoses: NHDS, 2002

59. Survival Risk Ratios (SRR’s): NHDS, 2002 Based on all 7 dx fields; Ordered by # of discharges Discharged alive: all discharges

60. 1 st listed injury dx by nature of injury grouped by AIS: NHDS, 1999-2002 1 st listed injury dx by nature of injury grouped by AIS: NHDS, 1999-2002 % of 1st listed dx AIS 1-9

61. NHAMCS- ED: Percent hospitalized by nature and body region of injury, 1999-2002

62. NHIS: “severity” variables in addition to nature of injury Days out of school Days out of work Hospitalized Any limitations of activity

63. Mortality data from NVSS ICD-10: uses all digits; up to 20 listed diagnoses For 2001, range (0-15 injuries listed) 1 injury listed65% of deaths 2 injuries22% 3 injuries8% 4 -15 injuries4% How can we select the most severe injury? Do we need to include underlying cause of death?

64. So… Most hospitalized injuries are not fatal Most ED visits don’t result in hospitalization Too many mortality records lack detailed diagnosis codes

65. Optimism…. SRR’s and ICISS can be readily calculated from hospital discharge data – we are creating a file with them that will be on the web AIS could theoretically be added also to hospital discharge data file once it is in public domain and ICDMAP is updated Main injury (method yet to be determined) will be added to mortality file

66. Consensus (well almost….) AIS and ICDMAP should be maintained and updated BOTH should be non-proprietary ICISS is a useful alternative to the current non-updated ICDMAP Statistical methods need continued evaluation and improvement Lowest SRR may be better than ICISS

67. Visit us at: www.cdc.gov/nchs/injury.htm Email us at: nchsinjury@cdc.gov