ICE on Injury StatisticsICE on Injury Statisticsand its Success in and its Success in

Problem Identification & Problem Identification & DescriptionDescription

99thth World Conference on Injury Prevention & World Conference on Injury Prevention & Safety PromotionSafety Promotion

Merida, 15-18 March, 2008Merida, 15-18 March, 2008

Yvette Holder, MPH Yvette Holder, MPH International Biostatistics & Information ServicesInternational Biostatistics & Information Services

Public Health ApproachPublic Health Approach & Injury Control (CDC) & Injury Control (CDC)

Information Needs & PHAInformation Needs & PHA Define the problemDefine the problem

• Surveillance data from various sourcesSurveillance data from various sources

• Identification of at-risk populationsIdentification of at-risk populations

• Description of potential risk factorsDescription of potential risk factors

Information Needs & PHA ct’d Information Needs & PHA ct’d

Identify risk/protective factorsIdentify risk/protective factors

• Comparison of data across environments Comparison of data across environments (sites, sub-populations, countries etc.)(sites, sub-populations, countries etc.)

• Characterization of injury patternsCharacterization of injury patterns

• Case-mix comparisonsCase-mix comparisons

• In-depth research studies In-depth research studies

Information Needs & PHA ct’d Information Needs & PHA ct’d Develop and test intervention Develop and test intervention

strategiesstrategies

• Evaluation for effectivenessEvaluation for effectiveness

• Indicators for monitoring Indicators for monitoring

Information Needs & PHAInformation Needs & PHA Define the problemDefine the problem

• Surveillance data from various sourcesSurveillance data from various sources

• Identification of at-risk populationsIdentification of at-risk populations

• Description of potential risk factorsDescription of potential risk factors

Challenge IChallenge I To establish data collection systemsTo establish data collection systems

• Absence of an information cultureAbsence of an information culture Resistance to dataResistance to data Knee-jerk and short-sighted reaction to Knee-jerk and short-sighted reaction to

problems vis-a-vis designed and evaluated problems vis-a-vis designed and evaluated interventionsinterventions

• Lack of resourcesLack of resources Human – staff shortages, mobility Human – staff shortages, mobility Skills and knowledge re IS implementationSkills and knowledge re IS implementation MaterialsMaterials

Injury ICE ResponseInjury ICE Response In collaboration with WHO and CDC, In collaboration with WHO and CDC,

developed a “How To” manual, developed a “How To” manual, adaptable to any environmentadaptable to any environment

Injury Surveillance Guidelines Injury Surveillance Guidelines provide a basis for continuity in a provide a basis for continuity in a situation of high staff mobilitysituation of high staff mobility

Injury Surveillance GuidelinesInjury Surveillance GuidelinesManualManual Identifies potential data sourcesIdentifies potential data sources

Describes minimum data that should be Describes minimum data that should be collected for major types of injuriescollected for major types of injuries

Provides options for increased data Provides options for increased data collection if resources are availablecollection if resources are available

Recommends data analyses and outputs Recommends data analyses and outputs

Injury Surveillance Guidelines ct’dInjury Surveillance Guidelines ct’d Outlines the steps to establishing an Outlines the steps to establishing an

ISSISS• Identifying and engaging stakeholdersIdentifying and engaging stakeholders• Seeking resourcesSeeking resources• Identifying and overcoming potential Identifying and overcoming potential

obstaclesobstacles• Monitoring and evaluating the system Monitoring and evaluating the system

and its ouputsand its ouputs

Information Needs & PHA ct’d Information Needs & PHA ct’d

Identify risk/protective factorsIdentify risk/protective factors

• Comparison of data across environments Comparison of data across environments (sites, sub-populations, countries etc.)(sites, sub-populations, countries etc.)

• Characterization of injury patternsCharacterization of injury patterns

• Case-mix comparisonsCase-mix comparisons

• In-depth research studies In-depth research studies

Challenge IIChallenge II To operate and maintain injury data To operate and maintain injury data

collection systemscollection systems

• What data to collect?What data to collect?

• Quality of dataQuality of data

• Comparability and compatibility of injury Comparability and compatibility of injury datadata

Injury ICE ResponseInjury ICE Response An injury data classification system, An injury data classification system,

the International Classification of the International Classification of External Cause of Injury (ICECI) that External Cause of Injury (ICECI) that • standardises injury data and standardises injury data and • facilitates comparabilityfacilitates comparability

Initiative to standardise questions for Initiative to standardise questions for household surveys (work in progress)household surveys (work in progress)

ICECIICECI The ICECI isThe ICECI is

• Comprehensive (encompasses all types of Comprehensive (encompasses all types of injuries), with definitions for all termsinjuries), with definitions for all terms

• Multi-axial (covering all factors that Multi-axial (covering all factors that describe the circumstances of the event)describe the circumstances of the event)

• Flexible (modular with optional levels of Flexible (modular with optional levels of detail, appropriate to capacity) detail, appropriate to capacity)

• Compatible with the ICD-10 Compatible with the ICD-10

International Classification of International Classification of External Cause of Injury (ICECI)External Cause of Injury (ICECI)

ALL INJURIESALL INJURIES DemographicsDemographics IntentIntent MechanismMechanism ObjectObject PlacePlace ActivityActivity Alcohol UseAlcohol Use Other Psychoactive Other Psychoactive

Drug UseDrug Use Nature of InjuryNature of Injury SeveritySeverity Disposition/OutcomeDisposition/Outcome

MOTOR VEHICLE INJURIESMOTOR VEHICLE INJURIES Mode of TransportMode of Transport Type Type CounterpartCounterpart

ASSAULTS/HOMICIDESASSAULTS/HOMICIDES Perpetrator/Victim Perpetrator/Victim

RelationshipRelationship Circumstances of AssaultCircumstances of Assault

SUICIDESSUICIDES Proximal Risk FactorProximal Risk FactorOTHER e.g. SPORTS, OTHER e.g. SPORTS,

OCCUPATIONALOCCUPATIONAL

Place of Occurrence Category of place where the injury event occurred Codes

1 Home, includes garden, garage and other building attachments 2 Street/ highway 3 School, includes playground; excludes sports field 8(98) Other This may be further separated into

4 Institution , includes prison, shelters, old people’s home 5 Sports and athletics area

6 Other Transport area 7 Industrial/ construction 8 Commercial 9 Farm, excludes farmhouse 10 Countryside, water, sea 9(9) Unknown

Place Of Occurrence (First Two Levels of Detail

5 Sports and athletics area 51 Sportsground (outside) 52 Sportshall (inside) 53 Public swimming centre 54 Racetrack, racecourse 55 Riding school 56 Skating rink, ice palace 57 Ski area 58 Other specified sports and athletics area

59 Unspecified sports and athletics area

Place of Occurrence (Third Level of Detail)

Information Needs & PHA ct’d Information Needs & PHA ct’d Develop and test intervention Develop and test intervention

strategiesstrategies

• Evaluation for effectivenessEvaluation for effectiveness

• Indicators for monitoring Indicators for monitoring

Challenge IIIChallenge III

To transform data into information such To transform data into information such thatthat• Data are easily understood and interpretedData are easily understood and interpreted• Data are comparable across countries, in Data are comparable across countries, in

different environmentsdifferent environments

Specifically to group 1200 codes into Specifically to group 1200 codes into meaningful but standard groups for meaningful but standard groups for reporting.reporting.

Injury ICE Response – Injury ICE Response – Data Reporting Frameworks - IData Reporting Frameworks - I

External Cause of Injury MatrixExternal Cause of Injury Matrix• Based on the axes of intent and mechanism Based on the axes of intent and mechanism

(from the external cause code)(from the external cause code)• 4 x 12 matrix, expandable to 5 x 264 x 12 matrix, expandable to 5 x 26• < 50 groups, suitable for mortality data< 50 groups, suitable for mortality data• Updated from ICD-9 to ICD-10Updated from ICD-9 to ICD-10• Provision for a third variable Provision for a third variable

External Cause of Injury Matrix External Cause of Injury Matrix (ICD-9)(ICD-9)

MechanismMechanism IntentIntentUnintentionalUnintentional SuicideSuicide HomicidHomicid

eeUndeter-Undeter-minedmined

DrowningDrowningPoisoningPoisoningFallFallFire/burnFire/burnCut/pierceCut/pierce E920E920 E956E956 E966E966 E986E986

Etc.Etc.

Injury Ice Response – Injury Ice Response – Data Reporting Frameworks IIData Reporting Frameworks II

Barell MatrixBarell Matrix

• Framework presenting ICD9-CM codes Framework presenting ICD9-CM codes (morbidity) using body region and nature (morbidity) using body region and nature of injuryof injury

• Basic 5 x 12 expandable to 10 x 12 and Basic 5 x 12 expandable to 10 x 12 and to 36 X 12 cellsto 36 X 12 cells

Barell MatrixBarell Matrix

The Matrix structureNature of injury

Body

Reg

ion

Injury ICE Response – Injury ICE Response – Data Reporting Frameworks – IIIData Reporting Frameworks – III

Injury Mortality Diagnosis Matrix:Injury Mortality Diagnosis Matrix:ICD-10ICD-10• Framework that combines the two main Framework that combines the two main

axes of injury description, axes of injury description, vizviz the body the body region and the nature of injuryregion and the nature of injury

• Reduction from 1169 ICD-10 codes to a Reduction from 1169 ICD-10 codes to a minimal 17X16 matrix that captures all of minimal 17X16 matrix that captures all of all injury deaths all injury deaths

• Option of a more detailed 43 x 20 matrixOption of a more detailed 43 x 20 matrix• Potential for use with morbidity dataPotential for use with morbidity data

Injury Mortality Diagnosis MatrixInjury Mortality Diagnosis MatrixNature of injuryFractures Dislocations Internal Open Amputation

wound

Body region Head and NeckTraumatic Brain Injury

specific sites

Spine and upper backspecific sites

Torsospecific sites

Extremitiesspecific sites

UnclassifiableMultiple body regions

System wide

Unspecified

ICD-10 ‘S’ or ‘T’ code

Challenge IVChallenge IV To monitor changes in injury To monitor changes in injury

situations and evaluate interventionssituations and evaluate interventions• Valid stable indicators that reflect real Valid stable indicators that reflect real

changes and not artifactschanges and not artifacts• More accurate identification of risk and More accurate identification of risk and

protective factorsprotective factors

Injury ICE Response –Injury ICE Response – Indicators Working Group Indicators Working Group

Finalizing a set of valid, robust Finalizing a set of valid, robust indicatorsindicators

Determining a set of severity scores.Determining a set of severity scores.

ICE – A Mechanism for Global ICE – A Mechanism for Global Injury DataInjury Data

Tools for data collectionTools for data collection

Methodologies for analysisMethodologies for analysis

Frameworks for information Frameworks for information disseminationdissemination

ConclusionConclusion

All ICE efforts serve multiple objectives All ICE efforts serve multiple objectives toward the goal of information for toward the goal of information for global injury prevention – truly a global injury prevention – truly a mechanism of globalization for injury mechanism of globalization for injury prevention and controlprevention and control