Injury Data and NCHS

1. 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 Injury Data and NCHS

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.                   National Databases Injury Mortality DataFrom 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

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 Frameworks for presenting data

16. External cause matrix-basic structure

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/icelandexecutifsummary.pdf

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

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, butnot necessarily appropriate for mortality • For example, Level 2- ‘Other lower extremities’ can be disaggregated to Level 3 categories • Thigh L3-31 • Hip & Thigh L3-32 • Upper Leg and thigh L3-33 • Knee L3-34 • Lower leg L3-35 • Foot L3-36 • Ankle L3-37 • Other and multiple ankle and foot L3-38 • Toes L3-39 • Other lower limb L3-40

25. 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 ICD-10 mortality Nature of injury Categories 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. Definitional issues: poisoning mortality • 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 includedhere)

31. ICD ‘definitions’ of drug poisoning ICD-9

32. ICD-9 vs ICD-10Substance 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

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 • Cocaine T40.5: 25% • Other specified opioids T40.2: 21% • Antidepressants T43.0-T43.2: 11% • Alcohol T51: 11% • Carbon Monoxide T58: 8% • Heroin T40.1: 10% • Benzodiazepines T42.4: 9% • 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 4th 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 Alphabet Soup ASCOT APS IIS CRAMS ICISS TRISS ISS APACHE AIS RTS GCS AP 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 Injuriesfor 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. ICDMAPICD-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