1. AIHW National Injury Surveillance Unit Research Centre for Injury Studies Flinders University - Adelaide - South Australia Injury indicators: purposes, progress, prognosis James Harrison

2. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Overview Injury indicators –Purposes: Why have indicators? –Principles: Concepts, definitions & standards –Progress: Where are we up to? –Problems: Constraints –Prognosis: Next steps…

3. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Purposes: Why have indicators? Information to support injury prevention & control Support planning and policy-making Guide targeting and priority-setting by Measuring and monitoring injury, its consequences, injury risk-factors and exposure to them (Contributing to) evaluation of interventions

4. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Pressure- time indicator Operator Control valves Steam- engine Purposes: Origin of indicators

5. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Injury indicator Injury prevention practitioners Start or alter prevention program Injury prevention program Purposes: Origin of indicators

6. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University What to indicate? Steam-engine –Risk of explosion –Efficiency –Effect of altered settings Injury prevention –Burden of injury –Risk exposure –Effect of intervention Things worth knowing …especially if not directly observable

7. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University How to indicate it? Steam-engine –Pressure-time relationship Injury prevention –Injury incidence –Prevalence of risk exposure –Reach of an intervention A. Identify and specify another thing, which: 1.Can be measured 2.Varies with the ‘thing worth knowing’ B. Make a device / information system able to provide measured values of A. Steam-engine indicatorInjury indicator

8. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University What is a good indicator? Steam-engine indicator –Varies predictably with time- pressure –Not much influenced by other things –Sensitive enough to show important changes –Timely enough to allow good control of engine Injury prevention indicator –Varies predictably with injury occurrence –Not much influenced by other things –Sensitive enough to show important changes –Timely enough to allow effective response to findings –Well-defined –Comparable (esp. over time) One with attributes suitable for its purpose

9. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University What is a good indicator? I Information objectiveAssessment as topic for indicator Trends in total burden of injury Broad scope is appealing Lack information for reliable measurement, especially over time Trends in incidence of fatal and severe injury Narrower scope: may not be a reliable guide to (eg) trends in burden of total Measurement is feasible

10. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Principles: concepts, definitions, standards Indicators require data Necessary but not sufficient Must be COMPARABLE Foundations for comparability Clear meaning for key concepts: eg. ‘injury’, ‘severity’, ‘outcome’ Classifications –eg. ICD-10, ICD-10-AM, ICECI Operational definitions –eg. STIPDA Consensus Recommendations for using hospital discharge data for Injury Surveillance Reporting standards –eg. Recommended Framework for reporting injury mortality data Derived measures –eg. ICISS severity, remoteness, Socio-Economic Status Institutional arrangements –eg. WHO-FIC, Injury ICE, STIPDA

11. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Injury outcome indicators Consensus criteria (ICE on Injury Statistics) –Define in terms of anatomical/physiological damage –Serious injury –Case ascertainment independent of extraneous factors –Representative of target population –Available data –Well-documented (definitions, methods, etc) (Cryer, Langley, et al 2005)

12. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Progress: Where are we up to? Australia as an example Focus on trends in severe & fatal injury c. 10 years at national level Deaths and hospitalised injury Onion metaphor: layers of work (iterative) –Getting, understanding, ‘cleaning’ & documenting data –Scope: defining and operationalising definition of ‘injury’ –Methods to avoid multiple counting –Methods to assess & control changing sample fraction

13. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Full specification can be complex Fatal cases Deaths occurring in Australia during the year from 1 July 2002 and registered within six months of the end of that year where any Multiple Cause of Death code is in the range S00-T75 or T79 and Underlying Cause of Death is in the range V01-V98. If Underlying Cause is not an External Cause, then include if (any) (first-mentioned external cause) Multiple Cause of Death code is in the range V01-V98 and the person was a resident of Australia. Non-fatal high- threat to life cases Episodes of admitted patient (acute) care in any acute-care hospital that (commenced) (ended) during the year from 1 July 2002 where (principal) (any) diagnosis code is in the range S00-T75 or T79 and (any) (the corresponding) external cause code is in the range V01-V75 or V79 and the person was not admitted following transfer from an acute care hospital and the (all injuries multiplicative) (worst injury) ICISS severity score is < 0.941 and the person is recorded as residing in Australia and the episode ended with the patient alive. Population Estimated resident population at 31 December 2000. Rates Numerator values are sums of fatal cases and the non-fatal instances of types of injury that pose high threat to life. Rates are adjusted for age by the direct method using the Australian population in 2001 as the reference (and stratified or adjusted for remoteness of place of residence and Indigenous status). Incident fatal and severe injury due to Transport

14. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University …but different methods can give very different values ‘Underlying cause of death’ coded to Accidental Falls (W00-W79)629 ‘Underlying cause of death’ coded to Unspecified cause (X59) with a fracture as an ‘additional cause’ Mostly falls by people aged 75 and older at death Cause unspecified mainly because ABS does not seek one at this age 888 ‘Underlying cause of death’ coded to Natural cause (i.e. not injury) with additional cause codes for injury condition(s) and for fall as external cause of injury ‘Underlying cause’ is coded to circulatory disease in 49% Small differences in wording on death certificates affect whether coded as injury deaths. 1,518 How many deaths following injury due to a fall are recognised as such? Of deaths registered in Australia in 2002:

15. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University …even if differences are subtle Age-adjusted rates

16. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Has the age-adjusted rate risen? Age-adjusted rates

17. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Aspects of burden of hospitalised injury Hospitalisation due to Accidental Falls ages 65 and older, Australia 1995-6 to 2002-3

18. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Aspects of burden of hospitalised injury Hospitalisation due to Accidental Falls ages 65 and older, Australia 1995-6 to 2002-3

19. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Problems: Constraints Data quality (incl timeliness) –Variation in % of cases incident in population admitted to hospital? (Especially for low severity injuries?) Difficulty and costliness of validation studies –special studies; WA linked data Data (mostly) not person-linked –>episode (ie record) / incident case of admitted injury: tricky to allow for this source of multiple counting of cases –hospital data and deaths data: do in-hospital ‘injury deaths’ appear as ‘injury deaths’ in national deaths data collection? Access (administrative issues, privacy) Complexity (esp for ‘clever data cleaning’) Classification –Australian clinical modification of ICD-10 (ICD-10-AM) –revisions (each 2y) allow useful enhancement of Injury & External Cause codes –… but (so far) the revised codes are not used for routine mortality data

20. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Signal & noise: example 1 Age-adjusted rates

21. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Signal & noise: example 2 Age-adjusted rates

22. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Prognosis: Next steps… What? –Broader scope: of burden (eg rehab, late care) –Broader scope: of severity (eg ED) –Broader scope: exposures as well as outcomes –Prediction of non-fatal outcomes –Better denominators –Shorter lag (+/- model-based prediction) How? –Standards (more, better, more widely used) –Linkage –Incremental system improvements

23. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Summary –Purposes: Why have indicators? To estimate trends (and differences) in important phenomena, which are not directly observable –Principles: concepts, definitions & standards The technical foundation; essential for comparability –Progress: Coming together… quite good trends data for serious injury –Problems: Constraints are real, tricky but generally manageable –Prognosis: Exciting times (nb linkage) Grail: ICISS-like measure(s) for important non-fatal outcomes

24. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University

25. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University After dinner…?

26. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University

27. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Understanding the issue Demographics of injured people Types of injury Severity and outcomes Risk factors and exposure Effectiveness and use of interventions

28. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Targeting and priority-setting (potential) topics for indicators –Frequency –Risk –Burden –Potential for improvement

29. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Approaches Opportunistic Using existing data and other resources Making the most of them for injury surveillance –Understanding, creative use, incremental enhancements Purposive / strategic Data sources and other components of injury surveillance developed specially to serve this purpose

30. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Approaches OpportunisticPurposive Case data sources ABS mortality NHMD VEMD NCIS QISU-ED Trauma registers ASCIR Classifications ICD (‘vanilla’)ICD-10-AM ICECI Concepts, definitions ICD, NHDDICE on Injury Statistics

31. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Status Fatal and serious injury Hospital separations and deaths Cross-sectional and trends Better understanding of data -> better use Good useable system –Will benefit from further validation, etc Basis for –Reporting of indicators –Numerous analyses of specific topics –Use with cost-models for good injury costings –Use in GBD models –…

32. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Status Occurrence –Incident fatal & severe injury –Characterised in terms of ICD-10-AM, LoS, threat to life, demographic characteristics etc. –Period: deaths - many years, hospitalised – c. 10 years –1-2 year lag (2-3 y latency for system changes) Risks and burden –Population-based rates Age/sex/remoteness/SEIFA/CoB/etc (+/- indigenous status) –Other denominators Potentially diverse; patchy availability –Other units Cost, DALYs

33. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Status Change in occurrence (trends) Challenges: –Hospital data (largely) not person-linked: multiple counting differences in admission/recording: variable sample variations in data quality –Deaths ‘Injury death’ vs UCoD External Cause changes in coding some types of death Manageable with care …

34. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Future? Technical developments Maintenance Operational links

35. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Future? Technical developments 1. Standards For comparable & meaningful data… 2. Outcomes Measure & describe outcomes of injury (in addition to death) 3. Linkage Illness service utilisation data, case data/event data, case data/population data 4. Denominators / exposure data Better population data (nb Indigenous); other denominators 5. Knowledge, attitudes, behaviour …of Australians concerning injury, injury prevention, interventions

36. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University 1. Standards Needed for comparable & meaningful data –Including: Operational definition(s) of ‘injury’ –For deaths, hospital data, other sources –Australia: Technical Review & Revision of injury indicators –International: ICE on Injury Statistics; ICECI Classifications –ICD-10, ICD-10-AM, ICECI Data standards / minimum data sets –NDS-IS, NCIS data set Survey questions –Opportunities: Consideration/contribution to/adoption of international standards Further development & updating of Australian standards

37. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University 2. Outcomes Measure & describe outcomes of injury –Overview: Fairly good methods to measure threat to life of injury –AIS & derivatives, GCS etc, ICISS Much of burden of injury is due to consequences other than death Methods to measure ‘threat to health’ of injury are immature Progress is likely to require large and expensive prospective studies –Opportunities: Collaborative project(s), national or international

38. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University 3. Linkage Potential for more information from existing data –May include: Person-based linkage of illness service utilisation data, etc Linking case data to event data (eg hospital / crash) Linking case data to population data (eg enhanced census) Linking special injury register data to any of these –Opportunities: Collaborative projects using WA Linked Health Data Advocacy for similar capabilities elsewhere National developments

39. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University 4. Denominators/exposure data Potential for more information from existing case data –Types of denominators: Better population data –nb reliable estimates of Indigenous population Injury risk factor / exposure data –Eg. more specific sports-participation data, alcohol use data, travel/vehicle use data Injury protective factor / intervention –Eg participation by older persons in specified exercise activities –Opportunities: Diverse

40. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University 5. Knowledge, attitudes, behaviour Knowledge, attitudes, behaviour …of Australians concerning injury, injury prevention, interventions –Themes: Knowledge –What is the extent, distribution and reliability of knowledge about injury occurrence, consequences and potential for prevention. Attitudes –What is the direction (positive or negative) and strength of attitudes towards injury prevention generally and to specific interventions. Behaviour –What are the population patterns of certain behaviours that increase or decrease injury risk –Opportunities: CATI surveys

41. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Future? Maintenance –Maintain current data sources & quality eg loss of items from ABS mortality data eg signs of possible deterioration of injury coding in some hospital records –Ensure good understanding of data Validation studies (eg ARC project) –Continue to tap value from existing sources Novel analytic methods (eg ICISS) More efficient analysis & access (cf US WISQARS) Minor changes (eg ICD-10-AM biennial revisions)

42. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Future? Operational links –Better understanding of uses and users Governments, researchers, industry, community –Consult, discuss, seek feedback Look for lessons in related activities –Other public health surveillance ane information activities –Injury surveillance elsewhere –Close liaison with policy-makers Individually and though national forums Health and other sectors –Seek two-way connection with policy … in which surveillance information –helps shape policy –supports its implementation and monitoring

43. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Review Injury surveillance systems & information Purposes Information to support injury prevention & control Approaches Opportunistic and purposive Status Good system for severe and fatal injury Future –Standards; Outcomes; Linkage; Denominators/exposure data; Knowledge, attitudes, behaviour –Maintenance –Operational links and relationships

44. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University

45. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Why better now? Ten year series of data Quality fairly good and has generally improved Completeness Similarity between jurisdictions Better understanding Of data strengths and limitations Development of concepts and methods Eg severity measures, injury definitions

46. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Trends in injury incidence: issues Records are for inpatient episodes, not persons injured Proportion of incident injury cases resulting in admission might change over time. Identifiability of separation records as relating to an “injury” might change over time

47. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Burden of hospitalised injury Hospitalisation due to Accidental Falls ages 65 and older, Australia 1995-6 to 2002-3

48. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University SCI: trends and priorities Persisting Spinal Cord Injury due to motor vehicle accidents, ages 15y and older, Australia 1995-6 to 2003-4

49. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Improvements Understanding the data Estimating incident cases Comparability over time & between places Coding validation (ARC project) Completeness (external cause codes, activity, etc) New uses of the data ICD-based severity measures Classification ICD-10-AM 3 rd ICD-10-AM 5 th

50. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University Classification ICECI Development was prompted by dissatisfaction with ICD External Causes classification: –Lagged behind theory (eg energy transfer concept) –Technical defects (eg not multi-axial) Developed by international collaborative group Challenges: –Enable refinement –Keep current –Translation (concepts as well as language) –Minimise burden of maintenance

51. AIHW National Injury Surveillance Unit Research Centre for Injury Studies, Flinders University