# Presentation: 757079

## Injury Data and NCHS

**Lois A. Fingerhut**
**NCIPC Conference, May 2005**

## 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**

## 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**

## Slide 4

## Slide 5

## Slide 6

## Data Source | Mortality-Injury Summary | Injury Death Codes

_**Data Source**_** |**** **_**Mortality-Injury Summary**_** ****|**** **_**Injury Death Codes**_
_**Publications **_**|**_**Presentations**__** **_**|**_**Tabulated Data **_**|**_**Public Use Data**_
** **_**Data Tools**_** | **_**Query Systems**_** | **_**Related Links**_

**                    ****National Databases**

## Slide 8

## Slide 9

## Slide 10

## Slide 11

**Notes:**
E codes here

## 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**

## 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

## Frameworks for presenting data

## Frameworks for presenting data

**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**

## External cause matrix-basic structure

|  | Intent of injury |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- |
| Mechanism | Unintentional | Suicide |  | Homicide | Undeter-mined | Other |
| MV-traffic |  |  |  |  |  |  |
| Cut |  |  |  |  |  |  |
| Firearm |  | ICD-9, ICD-9-CM and ICD-10 External cause codes |  |  |  |  |
| Poisoning |  |  |  |  |  |  |
| Struck by/
against |  |  |  |  |  |  |
| Suffocation
Etc..... |  |  |  |  |  |  |

## External Cause of Injury Mortality Matrix (ICD-10)

## Injury deaths by matrix: 2002

**Injury deaths by matrix: 2002**

## 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

## Barell Matrix-basic structure

**Barell Matrix-basic structure**

## 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

## ICD-10 Injury Mortality Diagnosis Matrix

**ICD-10 Injury Mortality Diagnosis Matrix**

**ICD-10 ‘S’ & ‘T’ codes**

## ICD-10 

**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**

## Additional detail is available, butnot 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**

## 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**

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

## Total and any mentions of injury diagnoses by nature of injury: 2002

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

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

## 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)

- 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**

**Notes:**
Poisoning as a cause of death is also unique because of the myriad of definitional issues that surround it. The “easiest” to explain but by far not the easiest to deal with was the move from ICD-9 to ICD-10. More of that in a bit.
Poisoning, unlike other causes of injury death, has both underlying cause codes that classify intent and whether it was drug-related, related to nonmedicinal substances or to gases and vapors And poisoning has multiple cause of death codes for specific substances.
Mental health and behavioral disorder codes related to abuse of drugs are not in the injury chapter but can certainly be conceptualized as poisoning. Alcohol-related deaths are also in this chapter as well as in the poisoning chapter. 
Lastly, adverse effects codes are also related to drugs- but these are excluded from this presentation.

## ICD ‘definitions’ of drug poisoning

|  |  | ICD-10 |
| --- | --- | --- |
| Nondependent abuse of drugs | 
305.2-.9 | F11-16, 18-19 (not .2) |
| Dependent abuse | 304 | F11-16,18-19(.2) |
| Unintentional | E850-E858 | X40-X44 |
| Suicide | E950(.0-5) | X60-X64 |
| Undetermined | E980(.0-.5) | Y10-Y14 |
| Homicide | E962.0 | X85 |
| [Alcohol intoxication | 305.0 | F10.0] |

- _ICD-9_

**Notes:**
There are various ways one could define drug poisoning deaths. For t he orange block there was unanimous agreement. Note however, in an earlier paper for the US, I included all nondep abuse in the definition of poisoning;, the inclusion of nondependent and dependent abuse codes for drugs have been part of the definition used in England. E&W has excluded codes due to alcohol from the definition of drug-related. The WHO is moving towards including Alcohol intox as a poisoning death

## 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

**Notes:**
On the ICD front, the switch from 9 to 10 made it necessary to either review the literals from the death certificate or code multiple cause data in order to know what the specific substance was,

## ICD mortality coding varies by country

|  | ICD-9-UCOD | ICD-10-UCOD | Substance-specific |
| --- | --- | --- | --- |
| England and Wales | 1990-2000 | 2001-2002 | Literals from text files |
| Canada | 1990-1999 | 2000-2002 | From under-lying cause |
| United States | 1990- 1998 | 1999-2002 | Multiple cause coding |

**Notes:**
Three countries with 3 different approaches and time lines...Important here is how each gleans information about substances. England uses the literal text from the death certificates without detailed coding; Canada does no multiple cause coding at all (but hope to in the future) and in the US our files allow for up to 20 co-morbid conditions to be coded.

## Drug poisoning death rates: US, 2002

**Deaths per 100,0000 pop**

**Notes:**
Excludes alcohol from F10

## 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%

**Notes:**
In the US, where the data come from ICD coding of mult cause data, we identified 8 leading substances and the ones that are underlined are simialar to what was shown for E&W. Cocaine is the leading substance showing up in the US – on% of drug poisoning death certificates; a good example of an improvemtn in specificity of icd-10 is noted by the additional specific code for methadone which in icd-9 was included with other opiates.

## 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

## Injury Severity

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

## 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

## Alphabet Soup

-   INJURY SEVERITY
**Alphabet Soup**

**TRISS**

**AIS**

**GCS**

**ASCOT**

**APACHE**

**IIS**

**CRAMS**

**ICISS**

**APS**

**RTS**

**AP**

**ISS**

**EM**

## Injury Severity Indices:Major Areas of Application

* *Triage
-  Prognostic Evaluation
-  Research and Evaluation
* **Clinical Research *
* **Systems Evaluation *
* **Surveillance and Epidemiology *
* *

**EM**

## 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**

## Scores are subjective assessments assigned by a group of experts and implicitly based on four criteria:

**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**

## 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**

## 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**

## ICD-Based Measures of Injury Severity 

-  ICD to AIS Conversion
-  ICISS Family of Measures**  **

**EM**

## 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**

## 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**

## 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**

## 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**

## 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**

## 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

## 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

## 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?

## 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)

## 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

## 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

## 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/

**Notes:**
Tuesday afternoon session

## Discharge Disposition for injury diagnoses: NHDS, 2002

**Notes:**
2% died
1% not stated disposition

## Survival Risk Ratios (SRR’s): NHDS, 2002

- Based on all 7 dx fields;
- Ordered by # of discharges

**Discharged alive: all discharges**

##  1st listed injury dx by nature of injury grouped by AIS: NHDS, 1999-2002

**% of 1st listed dx AIS 1-9**

**Notes:**
57-67 shorten

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

## NHIS: “severity” variables in addition to nature of injury

- Days out of school
- Days out of work
- Hospitalized
- Any limitations of activity

## Mortality data from NVSS

- ICD-10:  uses all digits; up to 20 listed diagnoses
- For 2001, range (0-15 injuries listed)
- 1 injury listed	65% of deaths
- 2 injuries		22%
- 3 injuries		8%
- 4 -15 injuries		4%
- How can we select the most severe injury?
- Do we need to include underlying cause of death?

## So...

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

## 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

## 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

**Visit us at:**
** ****www.cdc.gov/nchs/injury.htm**

**Email us at:  nchsinjury@cdc.gov**