1. Research Centre for Injury Studies Flinders University Australia Measuring Non-fatal Road Injury Professor James Harrison Research Centre for Injury Studies and AIHW National Injury Surveillance Unit Flinders University October 2015

2. Research Centre for Injury Studies Flinders University Australia Why measure serious road injury? Deaths are important, but: –Much less numerous than non-fatal cases –Becoming less common (thankfully) –Not a reliable guide to risk factors for disability Non-fatal injuries –Some are near-fatalities –Many leave persistent disability

3. Research Centre for Injury Studies Flinders University Australia Why measure serious road injury? Deaths are important, but: –Much less numerous than non-fatal cases –Becoming less common (thankfully) –Not a reliable guide to risk factors for disability Non-fatal injuries –Some are near-fatalities –Many leave persistent disability Measuring non-fatal road injury: - the case for doing so has become compelling - the questions now are exactly what to measure, and how best to do so.

4. Research Centre for Injury Studies Flinders University Australia Three themes Decide exactly what we need to know about serious road injury (…and are willing to pay for…) Information goals; definitions & specifications Count the cases Relevant attributes: sufficiently accurate, consistent & timely Determine consequences (burden / disability / cost) …in a way that is practicable and consistent with required attributes (These themes are more distinct when measuring serious non-fatal road injury than when measuring road deaths.)

5. Research Centre for Injury Studies Flinders University Australia Three themes Decide exactly what we need to know about serious road injury (…and are willing to pay for…) Information goals; definitions & specifications Count the cases Relevant attributes: sufficiently accurate, consistent & timely Determine consequences (burden / disability / cost) …in a way that is practicable and consistent with required attributes (These themes are more distinct when measuring serious non-fatal road injury than when measuring road deaths.)

6. Research Centre for Injury Studies Flinders University Australia Severity Much more to it than for road deaths Which consequence (or outcome)? –Probability of having died (though did not) –Disability (Which domains? As at when?) –Dollar cost (Of what? To whom? As at when?) Threshold for inclusion? Directly observed cases? Weighted counts?

7. Research Centre for Injury Studies Flinders University Australia Severity Much more to it than for road deaths Which consequence (or outcome)? –Probability of having died (though did not) –Disability (Which domains? As at when?) –Dollar cost (Of what? To whom? As at when?) Threshold for inclusion? Directly observed cases? Weighted counts? ‘Serious’, ‘severe’, etc. don’t have specific and generally accepted meanings.

8. Research Centre for Injury Studies Flinders University Australia Severity Much more to it than for road deaths Which consequence (or outcome)? –Probability of having died (though did not) –Disability (Which domains? As at when?) –Dollar cost (Of what? To whom? As at when?) Threshold for inclusion? Directly observed cases? Weighted counts? ‘Serious’, ‘severe’, etc. don’t have specific and generally accepted meanings. AIS?

9. Research Centre for Injury Studies Flinders University Australia Severity Much more to it than for road deaths Which consequence (or outcome)? –Probability of having died (though did not) –Disability (Which domains? As at when?) –Dollar cost (Of what? To whom? As at when?) Threshold for inclusion? Directly observed cases? Weighted counts? AIS ‘maintains ties’ with these and other dimensions or components of severity: -Threat to life; mortality -Energy dissipated / absorbed -Tissue damage -Hospitalisation; need for intensive care -Treatment: duration / complexity / cost -Disability: temporary; permanent -Impairment -Quality of life

10. Research Centre for Injury Studies Flinders University Australia Severity Much more to it than for road deaths Which consequence (or outcome)? –Probability of having died (though did not) –Disability (Which domains? As at when?) –Dollar cost (Of what? To whom? As at when?) Threshold for inclusion? Directly observed cases? Weighted counts? AIS ‘maintains ties’ with these and other dimensions or components of severity: -Threat to life; mortality -Energy dissipated / absorbed -Tissue damage -Hospitalisation; need for intensive care -Treatment: duration / complexity / cost -Disability: temporary; permanent -Impairment -Quality of life But validation is mainly with respect to mortality and threat to life. Much less evidence concerning disability, impairment, quality of life.

11. Research Centre for Injury Studies Flinders University Australia Severity Much more to it than for road deaths Which consequence (or outcome)? –Probability of having died (though did not) –Disability (Which domains? As at when?) –Dollar cost (Of what? To whom? As at when?) Threshold for inclusion? Directly observed cases? Weighted counts?

12. Research Centre for Injury Studies Flinders University Australia Severity Much more to it than for road deaths Which consequence (or outcome)? –Probability of having died (though did not) –Disability (Which domains? As at when?) –Dollar cost (Of what? To whom? As at when?) Threshold for inclusion? Directly observed cases? Weighted counts? This choice is not self-evident. However, it is feasible to produce estimates for the same cases in terms of more than one outcome.

13. Research Centre for Injury Studies Flinders University Australia Severity Much more to it than for road deaths Which consequence (or outcome)? –Probability of having died (though did not) –Disability (Which domains? As at when?) –Dollar cost (Of what? To whom? As at when?) Threshold for inclusion? Directly observed cases? Weighted counts?

14. Research Centre for Injury Studies Flinders University Australia Severity Much more to it than for road deaths Which consequence (or outcome)? –Probability of having died (though did not) –Disability (Which domains? As at when?) –Dollar cost (Of what? To whom? As at when?) Threshold for inclusion? Directly observed cases? Weighted counts?

15. Research Centre for Injury Studies Flinders University Australia Health state after injury? Rapid progress in knowledge based on –Prospective follow-up of sets of cases; with –Application of health outcome measures How to do this? –Special studies (each a one-off) –Routinely, as part of case documentation A world-leading system in Victoria follows all survivors of serious trauma by CATI to 24 months.

16. Research Centre for Injury Studies Flinders University Australia Current projects Outcomes to 24 months –Gabbe, Simpson, Harrison, et al. (2015) Return to work and functional outcomes after major trauma: who recovers, when and how well? Ann Surg (accepted Sept 2015) –Reports routine follow up to 24 months of all adult major trauma patients in Victoria injured mid-2007 to mid-2012 who survived to initial discharge (n=8,844) –Results presented here expand on those in the paper, to show additional road injury case groups Outcomes & experiences to 5 years –NHMRC project grant; Professor Belinda Gabbe is CI-A –Cases: all in 1 year of Victorian follow-up system, already interviewed at 6, 12, 24 months –This project is following the whole group to 5 years and conducting face-to-face interviews with a sample (incl. qualitative topics)

17. Research Centre for Injury Studies Flinders University Australia Survivors to discharge after serious injury: outcomes to 24 months (Victoria; onset 2007-12)

18. Research Centre for Injury Studies Flinders University Australia Survivors to discharge after serious injury: outcomes to 24 months (Victoria; onset 2007-12) Categories of Glasgow Outcome Scale - Extended

19. Research Centre for Injury Studies Flinders University Australia Survivors to discharge after serious injury: outcomes to 24 months (Victoria; onset 2007-12)

20. Research Centre for Injury Studies Flinders University Australia Survivors to discharge after serious injury: outcomes to 24 months (Victoria; onset 2007-12)

21. Research Centre for Injury Studies Flinders University Australia Survivors to discharge after serious injury: outcomes to 24 months (Victoria; onset 2007-12)

22. Research Centre for Injury Studies Flinders University Australia Summary We should measure and monitor non-fatal road injury Think carefully about exactly what information is needed … and design information systems accordingly Technical basis Follow-up registers for outcome measurement Population data linkage, to: Combine data on crashes with health service data to get benefits of both. Refine indicators (e.g. to minimise under- and over-counting). Improve understanding of the extent to which post-injury disability reflects pre- injury state rather than effects of injury. Monitoring p(survival)|diagnosis. Can be suitable for comparisons (national, international). No available method is perfect. TMPM? p(disability)|diagnosis. Apply periodically-updated weights to latest set of case-data to estimate future disability.