Transcript Creating an Injury Surveillance System for Indian Country

Designing and Implementing
Surveillance Systems in Indian
Country
Introduction
1
Introductions
•
•
•
•
Who are you?
Where are you from?
What do you do?
Do you have any experience in injury
surveillance?
Introduction
2
Course Learning Objectives
• Review the concepts and framework of injury
prevention
• Learn to assess injury data sources and use
data to describe the injury problem
• Learn how to build partnerships or a coalition
to support the injury surveillance system
Introduction
3
Course Learning Objectives
• Learn how to determine the appropriate methodology for the
surveillance system
• Learn how to define and develop an analysis plan for the
surveillance data
• Learn to use injury surveillance data to inform injury
prevention
• Learn how to define an evaluation plan for the surveillance
system and monitor prevention activities
Introduction
4
About the Course Manual
• Pre-test on Page 3
• Post-test Page 107
• Larger versions of charts in Appendix 6
Introduction
5
Introduction
6
What is an Injury Surveillance System?
• Ongoing systematic collection, analysis and
interpretation of injury data for use in
planning, implementing and evaluating
prevention activities
• Injury prevention programs use the data to
assess the need for new policies or programs
and to evaluate the effectiveness of those that
already exist
Introduction
7
Questions for Class
• Why do you want to develop an injury
surveillance system?
• What do you plan to do with the data you
collect?
Introduction
8
About the Course Exercise
• Create a surveillance system
• Goal to show how each step or concept could
be applied
• Choose a scenario
• Work in groups
• Complete worksheet after each section or at
the end of the course
• Share with group
Introduction
9
Step 1: Understand the Concepts
and Framework of Injury Prevention
Section 1
10
Objectives for Section 1
• Review the concepts, definitions and classification of
injuries
• Review the burden and the cost of injury
• Understand the conceptual models for
understanding and preventing injuries
• Introduce the steps to developing an injury
surveillance system
• Understand the ethical considerations associated
with injury surveillance
Section 1
11
Injury Problem in the United States
• Unintentional & Intentional Injuries in 2010
– 3rd leading cause of death – all ages
– Leading cause of death in ages 15-34
– Cost an estimated $403 billion annually in medical
expenses and lost productivity
Section 1
12
Injury Problem in Indian Country
• Unintentional & Intentional Injuries in 2010
– 3rd Leading Cause of Death – all ages
– Leading cause of death in ages 15-34
Section 1
13
Injury Definition
Damage to the body caused by:
• Exposure to an outside force or
• Lack of something essential or
• Uncontrolled release of mechanical energy
Section 1
14
Injury Definition
Injuries
Are Not the Same As
Disease
Section 1
15
Injury Definition
Injury vs. Disease
Injury: Broken toe caused by a
jackhammer
Disease: Tendonitis of the elbow
caused by years of exposure to the
vibration of a jackhammer
Section 1
16
Injury Definition
Injury vs. Disease
Injury
Disease
A child is bitten by a dog
and requires ten stitches
to his leg
A child contracts rabies
after a dog bite
A firefighter suffers
smoke inhalation while
fighting a wildfire
A former uranium miner
contracts lung cancer
from years of exposure to
uranium dust
Section 1
17
Injury Definition
Injuries
Are Not
Accidents
Section 1
18
Injury Classification
•
•
•
•
•
Unintentional
Fall
Car Crash
Dog Bites
Burns
Drowning
Section 1
Intentional
• Suicide
• Stabbing
• Gun Shot
19
Injury Classification
Unintentional Injury
• Occur without the intent of anyone involved
• 5th leading cause of death in US -- all ages
• In Indian Country
– 3rd leading cause of death all ages
– Leading cause of death under age 44
Section 1
20
Injury Classification
Unintentional Injury
• Physical damage to the body
• Caused by
– Excessive force or
– Exposure to external agents, such as poison or
– Deprivation of an essential elements, such as air
or warmth
• Damage is not done deliberately
Section 1
21
Injury Classification
Unintentional Injury
• Can be inflicted by a number of mechanisms,
including:
– Mechanical
– Radiant
– Thermal
– Electrical
– Chemical
Section 1
22
Injury Classification
Intentional Injury
• Deliberate harm to oneself or another
• Includes
– Domestic violence
– Child or elder abuse
– Suicide attempts
Section 1
23
Injury Classification
Intentional Injury
• In US (2010)
– 10th Leading Cause of Death – all ages
– Leading Cause of Death – ages 15-34
• In Indian Country (2010)
– 6th leading cause of death – all ages
– Leading cause of death – ages 15-34
– Account for 28% of all injury deaths
Section 1
24
Injury Classification
Intentional Injury
• World Health Organization divides intentional
injuries in three categories
– Self-directed
– Interpersonal
– Collective
Section 1
25
Injury Classification
Intentional Injury
• Nature of Intentional Injuries
– Physical violence
– Sexual violence
– Psychological violence
– Deprivation or neglect
Section 1
26
Burden of Injury
Injury Severity Pyramid
US 2010
Death
180,811
Hospitalization*
2.4 million
Ambulatory Care*
Visits to physicians offices, outpatient care
and emergency department
80.2 million
Section 1
27
The Burden of Injury in Indian Country
• 2,523 deaths in 2010
• 66,612 years of potential life lost in 2010
• Cost an Estimated $2.1 billion
– Medical care
– Rehabilitation cost
– Lost wages and productivity
Section 1
28
Burden of Injury
Lifetime Cost of AI/AN Injuries
Medical Productivity Administrative
Costs
Loss
Costs
($ Millions)
All Injuries $489
$1,477
Motor
Vehicle
Suicide
Total
Costs
$211
$2,176
285
610
83
978
19
156
20
194
Falls
30
89
16
135
Homicides
16
94
19
129
Fires
19
30
7
56
Section 1
29
Financial Benefits of Injury Prevention
Interventions that Save
Money in Indian Country
•
•
•
•
•
•
•
DUI Laws
Personal Flotation Devices
Smoke Detectors
Bike Helmets
Primary Seat Belt Laws
Livestock Control
Child Car Seat Program
Section 1
30
Financial Benefits of Injury Prevention
Cost Outcome Analysis
Intervention
Section 1
Cost per
Cost
Unit
Savings
Sobriety Checkpoints
$12,000 per
checkpoint
$82,000 per
checkpoint
Battery-Operated Smoke Alarms
$44 per alarm
$770 per
alarm
Bicycle Helmets for ages 3-14
$12 per
helmet
$580 per
helmet
Child Safety Seat Distribution, Ages 0-4
$52 per seat
$2,200 per
seat
31
Conceptual Models for Understanding and Preventing Injury
Public Health Approach
Section 1
32
Conceptual Models for Understanding and Preventing Injury
EPI Triad
Host
Agent
Section 1
Environment
33
Conceptual Models for Understanding and Preventing Injury
EPI Triad
• Offers three opportunities for intervention
– Host: Injured Person
– Agent: Mechanism that inflicted the injury
– Environment: Physical and social environment in
which the injury occurred
Section 1
34
Conceptual Models for Understanding and Preventing Injury
Haddon Matrix
Host
Agent
Physical & Social
Environment
Factors in a motor vehicle crash
Phase
Pre Event
Alcohol consumption,
fatigue, experience
Brakes, tires,
steering
DUI laws (social), road
conditions (physical),
speed limit (social)
Event
Seat belt use, age, sex
Speed at impact,
automatic
restraints
Median barriers,
roadside
embankments (both
physical)
Post Event
Physical condition,
disabilities
Integrity of fuel
system
Emergency
communications (social),
transport systems
(social), distance to
medical service
35
(physical)
Section 1
Conceptual Models for Understanding and Preventing Injury
Ecological Model for Understanding Violence
Societal
Section 1
Community
Relationship
Individual
36
Conceptual Models for Understanding and Preventing Injury
Ecological Model for Understanding Violence
• Interaction of biology, behavior and
environment
• Changes over the course of life
• Violence prevention a continuum of activities
Section 1
37
Conceptual Models for Understanding and Preventing Injury
Ecological Model for Understanding Violence
• Looks at factors on four levels
– Individual
– Relationship
– Community
– Societal
Section 1
38
Conceptual Models for Understanding and Preventing Injury
Ecological Model for Understanding Violence
• Individual Level
– Biological and personal factors, such as age,
education, income, substance abuse, history of
abuse
– Prevention strategies would promote attitudes,
behaviors or beliefs to prevent violence
Section 1
39
Conceptual Models for Understanding and Preventing Injury
Ecological Model for Understanding Violence
• Relationship Level
– Includes peers, partners and family members
– Prevention strategies would promote healthy
relationships
Section 1
40
Conceptual Models for Understanding and Preventing Injury
Ecological Model for Understanding Violence
• Community Level
– Includes settings, such as schools, workplace and
neighborhood
– Prevention strategies designed to impact system
could include marketing campaigns to promote
healthy relationships
Section 1
41
Conceptual Models for Understanding and Preventing Injury
Ecological Model for Understanding Violence
• Societal Level
– Include societal or cultural norms, policies that
maintain economic or social inequalities
– Prevention strategies aimed at policy
Section 1
42
Conceptual Models for Understanding and Preventing Injury
For More Information
• Energy damage and the 10 countermeasures
strategies by Dr. William Haddon, Jr.
• The Social Ecological Model: A Framework for
Prevention Centers for Disease Control and
Prevention
• The Ecological Model and Risk Protection
Factors Centers for Disease Control and
Prevention
Section 1
43
1. Review the
concepts and
framework of injury
prevention
2. Assess injury
data sources and
define the injury
problem
7. Define an
evaluation plan for the
surveillance system and
monitor prevention
activities
Steps to
Developing an
Injury Surveillance
System
6. Use injury
surveillance data to
inform injury prevention
5. Define and develop
an analysis plan for the
surveillance data
Section 1
3. Build a
partnership or
coalition to support
the injury surveillance
system and
prevention activities
4. Determine the
appropriate methodology
for the surveillance system
44
Steps to Developing a Surveillance System
Important Things to Remember
•
•
•
•
•
These steps are a guide
Not every step will be achievable or feasible
Implement as much as you can
Modify steps as need be
Seek the help of experts
Section 1
45
Steps to Developing a Surveillance System
Ethical and Cultural Considerations
•
•
•
•
Privacy
Confidentiality
Privacy Act of 1974
HIPAA
Section 1
46
Steps to Developing a Surveillance System
Ethical and Cultural Considerations
• Institutional Review Boards
• Cultural Concerns
Section 1
47
Summary of Section 1
• Questions?
• What did you already know?
• What did you learn that was new?
• Complete Question 1 on Final Exercise
Section 1
48
Step 2: Assess Injury Data Sources
and Describe Injury Problem
Section 2
49
Objectives for Section 2
• Identify injury data sources and the strengths
and weaknesses of each
• Identify available data sources that can
provide information to your surveillance
system
• Use data to describe the size of the injury
problem
Section 2
50
Overview of Common Data Sources
Death Certificates
• Pros
– Inexpensive
– Readily accessible
• Cons
– May not contain enough information
– Not all tribal or IHS facilities report to state
– Not a good guide to determining overall problem or
medical consequences
Section 2
51
Overview of Common Data Sources
Hospitalization Records
• Pros
– Combined with mortality data, can provide a better
picture of injury problem
• Cons
–
–
–
–
Access more difficult
Coding inconsistent
Difficult to determine ethnicity of victim
May require manual review of records
Section 2
52
Overview of Common Data Sources
Outpatient Visits Records
• Pros
– Good source of supplementary information on specific
injuries
• Cons
– Injuries that require hospitalization may be treated at
non-IHS/non-tribal facilities
– May need to combine with contract health care
records for a better picture
– Access may be difficult
Section 2
53
Overview of Common Data Sources
CDC WISQARS™
• Interactive
• Online database
• Fatal and nonfatal injuries
• Information from
variety of trusted sources
Section 2
54
Overview of Common Data Sources
WISQARS™
• Pros
– Search, sort, and view injury data
– Create reports, charts and maps based on
mechanism, body region, nature of injury,
geographic location, sex, race/ethnicity, age
• Con
– Morbidity data not available for AI/AN population
Section 2
55
Other Common Data Sources
•
•
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•
•
•
Police Reports
Records of Occupational Injuries
State Data Sources
National Data Sources
Local Newspaper Accounts
See Appendix 2 for Matrix of Data Sources
Section 2
56
Forensic
Medicine/Coroner
may conduct
autopsy,but
autopsies are not
always done
Transportation
Office collects
information
related to victims,
vehicles and
circumstances
State Data Sources
Common Data
Sources for
Investigating an
Injury in Indian
Country
District Attorney
attends all cases of
injury deaths and
collects
information on
victims, suspects
and circumstances
Law Enforcement:
BIA Police, Tribal
Police, Country or
State Police
Local EMS
Section 2
57
Determining the Strength and
Weaknesses of Each Data Source
 Its usefulness for injury surveillance, research
and practices.
 Estimates of its accuracy, completeness and
representativeness
 Timeliness of the data
 Resource requirements. (How long will it take
you to collect the data? How much will it
cost?)
 Simplicity
Section 2
58
Determining the Strengths and
Weaknesses of Each Data Source
Jurisdiction
Who collected the data and why?
Section 2
59
Determining the Strengths and
Weaknesses of Each Data Source
Method and Flow
How was the data
collected?
Where does it go?
Database
Preliminary
Reports,
Certificates,
Information Etc.
Taken at the
Scene
Section 2
60
Data Assessment Exercise
• Time: 30-45 minutes
• Purpose: What specific things would you want to see
in a database.
• You have been offered access to a locally run
database on youth activity
• What specific questions would you ask to determine
the strengths and weaknesses of this data source?
– Keep previously discussed considerations in mind
Section 2
61
Identify Data Sources to Include in the
System
•
•
•
•
Consider the injury you’re tracking
Consider the goal of your surveillance system
Quality of the data
Existing sources
Section 2
62
Identify Data Sources to Include in the System
Preliminary Data Analysis
• Develop a strategy to ensure cases are not
counted more than once
• Start with the analysis of a broad category,
such as interpersonal violence
• Then go more in depth if possible
Section 2
63
Identify Data Sources to Include in the System
Compare Frequency with Data from
Different Sources
• You may find discrepancies
• Identify the mission/goal of the institution
collecting the data
• Compare it with the goal of the surveillance
system
Section 2
64
Identify Data Sources to Include in the System
Linkage with Other Data Sources
Advantages
• Supplemental data
• More comprehensive
descriptions
• Highlights the completeness
• Improved data quality
Section 2
Disadvantages
• Personal identifiers
• Interagency politics
• Different storage media
• Worse data quality
• Duplications
65
Using Data to Define the Injury
Problem
•
•
•
•
Who is being injured
How they are being injured
Cause of injury
Severity of injury
Section 2
66
Using Data to Define the Injury
Problem
• Determining the frequency of the leading
causes of death
• Determine the frequency of injury deaths
Section 2
67
10 Leading Causes of Death - 2010
General US Population
Rank
Cause of Death
American Indian/Alaska Native
Number Rank
Cause of Death
Number
1
Heart Disease
597,689 1
Malignant Neoplasms
2,962
2
574,743 2
Heart Disease
2,793
3
Malignant Neoplasms
Chronic Low. Respiratory
Disease
138,080 3
Unintentional Injury
1,701
4
Cerebrovascular
129,476 4
Diabetes Mellitus
857
5
Unintentional Injury
120,859 5
787
6
Alzheimer's Disease
83,494
6
Liver Disease
Chronic Low. Respiratory
Disease
7
Diabetes Mellitus
69,071
7
Cerebrovascular
559
8
Nephritis
50,476
8
Suicide
469
9
10
Influenza & Pneumonia
Suicide
50,097
38,364
9
10
Nephritis
Influenza & Pneumonia
339
326
Section 2
702
68
10 Leading Causes of AI/AN Injury Deaths 2010
Rank
Number
1
Unintentional MV Traffic
610
2
Unintentional Poisoning
521
3
Suicide Suffocation
206
4
Suicide Firearm
178
5
Unintentional Fall
161
6
Homicide Firearm
113
7
Unintentional Suffocation
69
8
Unintentional Drowning
68
9
Suicide Poisoning
64
Unintentional Natural/ Environment
62
10
Section 2
Cause of Death
69
Why Determine the Leading Cause of
Injury Deaths
•
•
•
•
Monitor trends
Identify high risk groups or communities
Make comparison among groups.
Motivate stakeholders to support injury
prevention
• Help in building a coalition
Section 2
70
Summary of Section 2
• Questions?
• What did you already know?
• What did you learn that was new?
• Questions 2 and 3 of course exercise.
Section 2
71
Step 3: Build Partnerships or
Coalition to Support the Injury
Surveillance System, Data Collection
and Prevention Activities
Section 3
72
Section 3 Objectives
• Identify partners to include in the system
• Identify local, regional and national
organizations working on injury prevention in
your area
• Define the existing social, legal and political
framework in which an injury surveillance
system and prevention activities may be
established.
Section 3
73
Considerations for
Coalition/Partnerships
• Commitment of lead agency
• Effective core planning group
• Planned recruitment of coalition
members/partners
• Structure of coalition or partnership
• Roles
• Mission and goals
• Leadership
Section 3
74
Identify Partners/Coalition Members
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Who would contribute to success of system?
Who has access to data sources you need?
What is the quality of their data?
What other support do you need?
Whose objectives overlap with yours?
Can you share or link data?
What expertise do you need?
Section 3
75
Identify State and Local Organizations
Working in Injury Prevention
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Health care providers
Police departments
Fire departments
Schools
Social service agencies
Government agencies
Local IP coalition
State death review
team
Section 3
76
Determine the Existing Social, Legal,
and Political Framework
Section 3
77
Summary of Section 3
•
•
•
•
Questions?
What did you already know?
What did you learn that was new?
Questions 3, 4 and 5 of course exercise.
Section 3
78
Step 4: Determine the Appropriate
Methodology for Your Surveillance
System
Section 4
79
Section 4 Objectives
• Define the injury events and data elements to
include in the system
• Develop the data collection instrument and
determine data collection frequency
• Plan for systemization, maintenance and data
security
• Define the functions and skill sets for key
positions in your surveillance system
Section 4
80
Considerations When Developing
Methodology
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Potential for intervention
What do you want the system to do?
The size and type of the injury problem
Available data sources
Access to information
Political priorities
Sustainability
Section 4
81
Considerations When Developing
Methodology
Keep the data collection plan in mind
– Identify your topic
– Narrow your focus
– Identify a specific question
– Anticipate data needs
– Develop and pre-test your data collection
instrument
Section 4
82
Defining Injury Events
What are Your Objectives
• Identifying emerging hazards
• Describing injury patterns to justify the need
for intervention
• Assessing the impact of a prevention program
• Determining the health care costs associated
with injury
• Describe the magnitude of the injury problem
Section 4
83
Defining Injury Events
Case Definition
• Needs to be clearly stated and easily understood
• Use comparable definitions as those used elsewhere
• Contain a clear statement of the following
–
–
–
–
–
–
–
Person
Place
Time
Intentionality: intentional/unintentional
Age grouping
Severity
Optional: Injury Code
Section 4
84
Defining an Injury Event
A Closer Look at Injury Severity
• Important to determine severity for case
definition
• Severity is based on the level of medical
intervention required
–
–
–
–
Deaths
Hospitalization
Emergency Department (ED) visits
Outpatient visits
• Advantages and disadvantages for each
Section 4
85
Defining Injury Events
Injury Severity - Death
Advantages
•
•
•
Data is readily accessible
Cause of death is consistently
reported
Race or ethnicity information is
usually available
Disadvantages
•
•
•
•
Rare event
Not a good guide to ascertaining
overall injury problem or medical
consequences
Influenced by small numbers
Potential for racial misclassification
Section 4
Death
180,811
Hospitalization
2.4 million
Ambulatory Care
Visits to physicians offices, outpatient care and emergency
department
80.2 million
86
Defining Injury Events
Injury Severity - Hospitalization
Advantages
•
•
•
•
Combined with mortality data, offers a
better picture of overall problem
Disability and healthcare costs can be
better described
Staff can collect data
Patients and family can be interviewed
Disadvantages
•
•
•
•
•
•
Access to data is more difficult
Privacy is more of a consideration
Records may be manual
Inconsistent, incomplete or incorrect
coding
Race or ethnicity information is
sometimes not available
May not be representative of problem
Section 4
Death
180,811
Hospitalization
2.4 million
Ambulatory Care
Visits to physicians offices, outpatient care and emergency
department
80.2 million
87
Defining Injury Events
Injury Severity – ED Visits
Advantages
•
•
•
•
•
Combined with other data, helps provide the big
picture
Casts the net wider
Useful for specialized studies
Staff can collect data
Patients and family can be interviewed
Disadvantages
•
•
•
•
•
Large number of cases may be difficult to
handle
Access to data may be difficult
Records may be manual
Inconsistent, incomplete or incorrect
coding
Race or ethnicity information not readily
available from non-local sources
Section 4
Death
180,811
Hospitalization
2.4 million
Ambulatory Care
Visits to physicians offices, outpatient care and emergency
department
80.2 million
88
Defining Injury Events
Injury Severity – Out-patient Visits
Advantages
•
•
•
•
May be a primary source of injury
data if there is no hospital
May be good for specialized injuries,
such as sports related injuries or eye
injuries
Might be good supplemental
information
Might be the only source of data for
some
Disadvantages
•
•
•
Difficult access
Privacy issues
Race or ethnicity information is not
readily available
Section 4
Death
180,811
Hospitalization
2.4 million
Ambulatory Care
Visits to physicians offices, outpatient care and emergency
department
80.2 million
89
Defining Injury Events
A Closer Look at Injury Codes
• What is an injury code?
– Part of standardized codes used by the health sector
to classify diseases and health conditions
– Used worldwide, including IHS and tribal health care
– ICD-9 CM = International Classification of Disease ,
Version 9, Clinical Modification
• Supplemental Classification of External Causes of Injury and
Poisoning (E-Codes)
– ICD-10/CM = International Classification of Disease,
version 10, Clinical Modification
Section 4
90
Defining Injury Events
More about ICD Codes
• Used for health data management and to
improve healthcare
• Updated periodically for new conditions and
system changes
• Sometimes easier to query data system using
specific codes
Section 4
91
ICD-9 CM
• Used to code non-fatal events (doctor’s visits and
hospitalizations)
– Diagnosis codes (injury or illness - fractures, diabetes,
etc.)
– External cause codes = E-codes (used for what caused
injury - fall, car crash, etc.)
• Used US-wide from 1999-2014
• Primary user = those who assign codes
– Training required
• Secondary user = those who utilize coded data
Section 4
92
Anatomy of an E-Code
E XXX.Y
E = External cause
Injury Category
Section 4
Specificity
93
ICD-9 Code Example
E 813.1
E = External cause
• Example:
Motor vehicle traffic accident
involving collision with other
vehicle
Passenger
– 804.12 (injury)
– E813.1 (cause of injury)
Section 4
94
ICD-10 CM
• October 1, 2014, the ICD-9 code sets will be
replaced by ICD-10 code sets
• More codes for more specificity
• Used in the US for coding fatal illness and injury
• Primary user = those who assign codes
– Training required
• Secondary user=those who utilize coded data
• ICD-9 codes valid through 10/2014
Section 4
95
Anatomy of an ICD-10 Code
X X X . XXX X
Injury Category
Section 4
Specificity: Cause,
Anatomic Site,
Severity
Encounter
96
ICD-10 Code Example
S02.91X A
Skull Fracture
Initial Encounter
S06.332 A
Laceration, Loss of Consciousness
Initial Encounter
V54
Occupant of a pick-up truck or van injured in
collision with a heavy transport vehicle or bus
Section 4
97
Defining an Injury Event
Using ICD-Codes
Advantages
Disadvantages
• Ability to identify trends
• Ability to describe the specific
causes and contributing
factors
• Standardization of descriptions
that can aid in sharing data or
linking databases
• As of October 1, 2014 all
Indian Health
Service/Tribal/Urban programs
must use ICD-10 codes on all
HIPAA electronic record
transactions.
• Not all records may be coded
• Records can be miscoded or
inconsistently coded
• Poor chart information results
in non-specific code
• Don’t always provide the
desired specificity
• You must stay apprised of
updates
• Previously not required for
billing, so seen by some coders
as unnecessary
Section 4
98
Defining an Injury Event
Determining if Injury Codes Should be Included
in Case Definition
• Does your data source (clinic, hospital, trauma
registry, etc.) use ICD codes?
• Are you looking for specific types of injuries?
• Does your data source assign a code to most
injuries?
• Are you confident in the completeness, accuracy,
and specificity of the coded data?
• Yes? Consider including codes in the case
definition.
Section 4
99
For More Information on ICD-9
or ICD-10 Codes
• Contact your Area Office for training options.
• Check these references:
– American Academy of Professional Coders
http://www.aapc.com/
– World Health Organization
http://www.who.int/classifications/icd/en/
– CDC National Center for Health Statistics
http://www.cdc.gov/nchs/icd.htm
– CDC article on improving E-coding
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5701a1
.htm
Section 4
100
Case Definition Exercise
• Purpose: Practice developing a case definition
• Time for exercise: 30 minutes
– Develop case definition to include the following:
• Person, injury type(s), place, time, intent, severity
– Report back to the group. Include how/why decisions
were made for each.
• Example:
All confirmed fractures (outpatient and inpatient)
resulting from a fall from a horse during a rodeo,
including all genders and ages, from 2010-2013, with
treatment paid for by tribal health.
Section 4
101
Defining Injury Events
Important Things to Remember
• It’s not necessary to be all encompassing
• Start small; track the most severe injuries
• Expand or phase in other levels when you can
You can initiate prevention without knowing
everything about every injury in your
community
Section 4
102
Determine the Variables in Your System
• Variables = Data for each injury event
• Determines the data collected
• Determines data collection form
Keep injury prevention goal in mind
Section 4
103
Determine the Variables in Your System
•
•
•
•
Name or other identifier
Age and sex
Marital Status
Education Level
Section 4
104
Determine the Variables in Your System
• Employment Level
• BAC - Nice to have, but rarely available
• Occupant Protection for Transportation
Section 4
105
Determine the Variables in Your System
• Time
• Place
• Circumstances surrounding the injury event
Section 4
106
Data Collection Instrument and Data Collection Frequency
Designing a Form
•
•
•
•
•
Define what you want in your system first
Keep it simple
Only include the data you need
Make sure it is well-designed and easy to read
Decide whether or not to pre-code the form
PRE-TEST YOUR FORM!
Section 4
107
Data Collection Instrument and Data Collection Frequency
Collecting Data
• Frequency of Data Collection
• Active vs. Passive Data
Section 4
108
Data Collection Instrument and Data Collection Frequency
Data Collection Planning Summary
•
•
•
•
•
Decide what you want out of your system
Define the case
Determine your variables
Develop your form
Consider how HIPAA/Privacy issues may
impact your collection efforts
• Test your form
Section 4
109
Determining the Type of Surveillance
System
• Universal surveillance
• Surveillance based on samples of cases
• Surveillance based on a review of institutional
registries
• Survey-based surveillance
• Sentinel surveillance
Section 4
110
Setting Up an Electronic Database
• Seek the assistance of a programmer,
epidemiologist or statistician
• Epi Info 2002
– Free software available through CDC
– http://wwwn.cdc.gov/epiinfo/7/index.htm
• Make sure all paper records with identifiers
are locked away
Section 4
111
Systemization & Maintenance
• Reducing errors
• Improving the system’s scope and services
through routine maintenance, emergency
maintenance
• Safeguarding the system
Section 4
112
Systemization and Maintenance
Improving the System’s Scope
Considerations:
• A schedule for backing up data and files
• Secure environment for records
• Written requests for emergency maintenance
• Logs to record emergency maintenance
• Establishing a protocol
• Documenting all maintenance
Section 4
113
Systemization and Maintenance
Ways of Safeguarding Your System
• Limit access to one person (with backup)
• Install the database on two computers
• Keep a second copy of the database off site.
Section 4
114
Systemization and Maintenance
Threats to a Database
•
•
•
•
•
•
Human error
Mechanical failure
Malicious damage
Cyber crime
Invasion of privacy
Computer viruses
Seek the assistance of a programmer in protecting the
database when needed.
Section 4
115
Systemization and Maintenance
Protocol
•
•
•
•
•
Procedures for obtaining and securing data
Maintenance procedures
Rules for data storage
Rules for password creation and protection
All documents that detail any changes
Section 4
116
Define Staff Roles
•
•
•
•
•
•
Coordinate system activities
Establish contact
Data entry
Quality control
Analysis
Preparation of reports
Section 4
117
People to Assist
• Consider consultations with a few people
• District or area IP specialists can help
–
–
–
–
–
–
–
–
Obtain data
Review policy
Identify best use of data
Strategize
Speaking engagements
Showing support
Local approval
Tribal politics
Section 4
118
Discussion of Forms & Protocols
•
•
•
•
Time 30-45 minutes
Compare the different forms in Appendix 3
Compare the different protocols in Appendix 4
For each discuss the following
– What is similar? What is different?
– What are advantages and disadvantages of each?
– What is most likely to work for you?
– Why?
Section 4
119
Summary of Section 4
•
•
•
•
Questions?
What did you already know?
What did you learn that was new?
Complete questions 6-11 on the course
exercise
Section 4
120
Step 5: Define and Develop an
Analysis Plan; Develop a Plan for
Disseminating Results
Section 5
121
Section 5 Objectives
• Calculate injury indicators such as frequency,
percentages and crude, specific and adjusted
rates
• Calculate Years of Potential Life Lost
• Describe the geographical analysis of the data
• Define a plan to disseminate and
communicate the data
Section 5
122
Data Analysis & Interpretation
Epidemiological Concepts and Terms
•
•
•
•
•
•
Epidemiology
Population-based
Injuries are not random
Morbidity v. Mortality
Risk
Endemic vs. Epidemic
Section 5
123
Data Analysis & Interpretation
Epidemiological Concepts and Terms
Epidemiology
“The study of the distribution and determinants of
health-related states or events in specified populations
and the application of this study to control health
problems.” A Dictionary of Epidemiology
 Who
 Where
 When
Section 5
 What
 Why
 How
124
Data Analysis & Interpretation
Epidemiological Concepts and Terms
Epidemiology is POPULATION-BASED (concerned
with the community, not the individual)
Section 5
125
Data Analysis & Interpretation
Epidemiological Concepts and Terms
Injuries are not random:
There are causes for injuries and ways to
reduce them.
Section 5
126
Data Analysis & Interpretation
Epidemiological Concepts and Terms
Risk:
“The probability that an event will occur.”
A Dictionary of Epidemiology
Section 5
127
Data Analysis & Interpretation
Epidemiological Concepts and Terms
Risk Factor:
A trait or behavior or exposure that could
increase the probability of an injury event
Sometimes a risk factor can be modified by an
intervention to reduce the probability of an
injury event
Section 5
128
Data Analysis & Interpretation
Epidemiological Concepts and Terms
• Endemic:
– Present in the community at all time
– Infrequent
– Typically restricted to a locality
• Epidemic
– Sudden and
– Severe
Section 5
129
Data Analysis & Interpretation
Analysis – General Concepts
• Analysis involves:
– Basic statistics (the counting)
– Interpretation (what does it mean)
Section 5
130
Data Analysis & Interpretation
Analysis – General Concepts
• To analyze:
– Separate into elements or constituent parts
– Separate the parts of the whole so as to reveal their
relation to it and to one another
– Examine critically or step-by-step
• No set formula, rule or methodology … analysis is
as much an art as it is a science
• Look for patterns, clusters, the unusual,
unexpected
• Progress to more complex analysis as necessary
Section 5
131
Data Analysis & Interpretation
Analysis – General Concepts
Basic Rules to Consider
• Indicate the “N” (number of data items in the
data set or “n” (number of data items in the
data subset)
• Small numbers do not mean “bad results” …
just qualify or acknowledge the “N” upfront
Section 5
132
Data Analysis & Interpretation
Analysis – General Concepts
Two Common Misconceptions to Avoid
• A computer does not think for you. It does the
counting; you have to interpret the numbers.
• Correlation does not necessarily imply
causation
– For example: HRT does not equal reduce risk of
heart disease
Section 5
133
Data Analysis and Interpretation
Basic Statistics
• Numeric Value
• Midpoint (measure of central tendencies)
• Proportions
You don’t have to be a statistician to utilize
basic statistics to help you describe and
understand injury data
Section 5
134
Data Analysis and Interpretation
Basic Statistics
Numeric Value
• Very common
• Easy to understand
• Value of one variable cannot be
compared to the same variable in a
different population
• Does not indicate risk
Section 5
135
Data Analysis and Interpretation
Basic Statistics
Midpoint (measure of central tendencies)
• Mode
• Median
• Mean
Section 5
136
Data Analysis and Interpretation
Basic Statistics
Measure of Central Tendencies – Example
Severe fall injury patients in 2012 at XYZ location
Patient ages in order from youngest to oldest:
5, 6, 6, 7, 8, 8, 15, 75, 77, 77, 77, 82, 93
– Mode (most frequent patient age) – 77
– Median (middle most age) – 15
– Mean (average age) – 41.2
Section 5
137
Data Analysis and Interpretation
Basic Statistics
Measure of Central Tendencies Cont.
• Mode rarely used in epidemiology
• Median used less commonly than mean
• Mean
– More commonly used but
– Influenced by value outliers
• Measures of central tendencies can be
misleading
Section 5
138
Data Analysis and Interpretation
Basic Statistics
Proportional Distribution
• Commonly used
• Simple calculation
• Sum of all values = 100%
• Can be misleading
• Not a measure of risk
Section 5
139
Data Analysis and Interpretation
Basic Statistics
Proportional Distribution Example
32 severe fall injury patients 2012 – 2013
Younger than 10
12 cases or 37.5% (12/32)
Older than 65
15 cases or 47% (15/32)
10 – 18
4 cases or 12.5% (4/32)
41
1 case or 3% (1/32)
Introduction
140
Data Analysis and Interpretation
Basic Statistics - Rates
“… comparing apples to oranges …”
Section 5
141
Data Analysis and Interpretation
Basic Statistics - Rates
Rate:
“An expression of the frequency with which an
event occurs in a defined population over a
specific period and converted to a whole
number by multiplying by some power of 10
(usually 10,000 or 100,000).”
A Dictionary of Epidemiology
Section 5
142
Data Analysis and Interpretation
Basic Statistics - Rates
Rate
Section 5
Community A
150 per 100,000
Community B
100 per 100,000
Community C
500 per 100,000
143
Types of Rates
• Incidence Rate – new cases
• Prevalence Rate – new and existing cases
• Specific Rate – number of events in sub-group
Section 5
144
Data Analysis and Interpretation
Basic Statistics - Rates
Rate per 100,000
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑠𝑒𝑠
𝑋 10ⁿ 𝑜𝑟 𝐾
𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑟𝑖𝑠𝑘
(same exposure period)
Section 5
145
Data Analysis and Interpretation
Basic Statistics - Rates
Combine population when calculating a rate for a
multi-year period.
Example
Injury Death Rate for a community from 2008-2010
Cases in 2008 + Cases in 2009 + Cases in 2010
Divided by
Population in 2008 + Population in 2009 +
Population in 2010
Section 5
146
Data Analysis and Interpretation
Rate
Basic Statistics - Rates
17 𝑐𝑎𝑠𝑒𝑠
13,000 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑋
𝑠𝑎𝑚𝑒 𝑡𝑖𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
Section 5
100,000 𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝑃𝑜𝑝. = 131 𝑝𝑒𝑟 100,000 𝑝𝑜𝑝.
147
Data Analysis and Interpretation
Basic Statistics - Rates
• Crude Rate
• Specific Rate
• Adjusted Rate
Section 5
148
Age Group
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85+
Section
5
All Ages
Specific Rate of Suicide for AI/AN Population -- 2010
Suicides (2010)
Population
Rate
14
372,896
3.75
70
393,320
17.8
88
362,892
24.25
51
340,576
14.97
49
311,098
15.75
37
292,412
12.65
38
280,013
13.57
45
283,889
15.85
32
253,858
12.61
20
197,306
10.14
8
148,434
5.39
6
97,909
6.13
5
66,019
7.57
2
43,090
4.64
3
26,959
11.13
1
21,237
4.71
469
4,263,538
11
149
Data Analysis and Interpretation
Basic Statistics - Rates
Some general considerations
• Accurate Numerator
• Estimated Denominator
• Used Primarily for Comparison
• Indicator of risk
Section 5
150
Data Analysis and Interpretation
Rate Calculation Exercise
•
•
•
•
Purpose: Practice calculating rates
Time: 1 hour
Get out your calculators
Refer back to the equations on slides 145, 146
and 147
• Work through the rate exercises on the
handout
Section 5
151
Data Analysis and Interpretation
Years of Potential Life Lost
YPLL = Years of Potential Life Lost
• Measure of Premature Death
• YPLL = 65 – age at death
Section 5
152
Years of Potential Life Lost Before Age 65
American Indian/Alaska Native Population - 2010
Cause of Death
All Causes
Unintentional Injury
Suicide
Heart Disease
Malignant Neoplasms
Liver Disease
Homicide
Perinatal Period
Congenital Anomalies
Diabetes Mellitus
Influenza & Pneumonia
All Others
Section 5
YPLL
167,928
43,055
14,730
14,689
14,524
11,290
8,827
7,604
7,209
4,307
2,340
39,353
Percent
100.0%
25.6%
8.8%
8.7%
8.6%
6.7%
5.3%
4.5%
4.3%
2.6%
1.4%
23.4%
153
Data Analysis and Interpretation
Geographic Analysis of Data
Depicts data using maps
• Spot Map - dot or symbol where injury occurred
• Area or Choropleth Map - regions are shaded or
marked proportionally to the data being depicted
• Pin or Cluster Map - way of indicating road traffic
hazards or crash prone locations along roads
Section 5
154
Section 5
155
Data Analysis and Interpretation
Summary
•
•
•
•
Epidemiology serves as a foundation
Many data analysis methods
Importance of rates
Need to interpret results and explain what
they mean
• Utilize available resources
• Communicate your findings
Section 5
156
Communicate Results
Surveillance can only achieve results if the
information is communicated to the appropriate
people.
Section 5
157
Communicate Results
Steps to Take
• Determine who will get the information
• Check with each tribe within your surveillance
system
• Develop the message
• Select the format
• Market the message
• Evaluate the impact
Section 5
158
Surveillance System Report
• A means to convey the results of the
surveillance system to all the stakeholders
• Consider the needs to the stakeholders when
making decisions about design and frequency
Section 5
159
Surveillance System Report
Considerations for inclusion
• Introduction
• Leading causes of death
• Leading causes of injury deaths
• Leading causes of morbidity if available
• YPLL
• Cost of injuries
• Priority injuries
• Recommendations for intervention
Section 5
160
Surveillance System Report
Recipients
• Stakeholders, decision makers, law enforcement,
public health directors, school officials, etc.
• Hospital, emergency departments, health clinics
• Health professionals in the scientific community
• Scientific/academic researchers
• Grassroots organizations
Section 5
161
Surveillance System Reports
Delivery method
• Health department newsletters
• PSAs
• Press releases
• Flyers
• Periodicals/annual reports
• Presentations
• Newspapers
• Websites
Section 5
162
Summary of Section 5
•
•
•
•
Questions?
What did you already know?
What did you learn that was new?
Complete all the questions on the course
exercise
Section 5
163
Step 6: Use Surveillance Data to
Inform Injury Prevention
Section 6
164
Objectives for Section 6
• Understand the use of surveillance data to
identify priority injuries.
• Understand models that help identify risk factors
and intervention strategies for priority injuries.
• Understand the models for identifying the most
appropriate interventions for the injuries in your
tribe or community.
• Understand how to tie surveillance to action and
funding.
Section 6
165
Use of Surveillance Data to Establish
Priority Injuries
•
•
•
•
•
Show severity of injuries
Show magnitude of injuries
Provide perspective
Track trend of injuries over time
Inform local, regional and national authorities
Section 6
166
Use of Surveillance Data to Establish
Priority Injuries
Remember:
• It’s not necessary to know everything to begin
prevention efforts
• Start small
• Use the data you have available
You can work on prevention activities without knowing
everything about an injury problem or just using the
data you have available
Section 6
167
Criteria for Identifying Priority Injuries
• Event Importance
– Magnitude
– Severity
– Trend
– Cost
• Prevention Control Capacity
– Potential for controlling the event
– Local interest
Section 6
168
Criteria to Prioritize Injury Events
High Importance + Good Control/Prevention =
High Priority for Prevention and Control
High Importance + Low Control/Prevention =
Further Research
Section 6
169
Criteria to Prioritize Injury Events
Low Importance + Good Control and Prevention
Capacity = Low Priority for Prevention and
Control
Section 6
170
Criteria to Prioritize Injury Events
Low Importance + Low Control and Prevention
Capacity = Not a Priority
Section 6
171
Criteria to Prioritize an Injury Event
Information that Will Help in Setting
Priorities
General Information to Determine the
Importance of an Injury Event
• Leading causes of death
• Number, proportion, and crude and adjusted
rates
• YPLL from injuries by intention
• Trend of injuries over a minimum of five years
Section 6
172
Criteria to Prioritize an Injury Event
Information that Will Help in Setting
Priorities
Specific Information to Determine the
Importance of an Injury Event
• Homicide: crude and specific rates by age
group and gender and mechanism
• MV deaths: crude and specific rates by age
group, gender and road user
• Leading causes of injury morbidity
Section 6
173
Criteria to Prioritize an Injury Event
Information that Will Help in Setting
Priorities
Specific Information Cont.
• Costs
• Disability Adjusted Life Years = YPPL + Years of
Productive Life Lost due to disability
– For more information on calculating this indicator
see the World Health Organization website
(www.who.org)
Section 6
174
Criteria to Prioritize an Injury Event
Information that Will Help in Setting
Priorities
Information that will help in determining the
prevention control capacity
• Costs to prevent and control problem
• Local interest
• Information on activities to control injuries
• Control possibilities or vulnerabilities
Section 6
175
Identifying Potential Interventions &
Strategies to Prevent Priority Injuries
• The Haddon Matrix
• The Ecological Model for Violence-Related
Injuries
• Intervention Decision Matrix
Section 6
176
Identifying Potential Interventions & Strategies
Haddon Matrix for Unintentional
Injuries
• Identify risk factors
• Identify potential interventions that
– Target each factor – Column
– Influence each phase -- Row
Section 6
177
The Haddon Matrix used to identify prevention strategies
for childhood dog bites
Physical
Environment
Social
Environment
Train/socialize
Dogs
Spay and neuter
dogs
Maintain dogs in
fenced yard or use
electronic fence
Use gate alarm to
indicate when gate
is open
Increase community
awareness
Initiate dog control laws
Spaying, neutering and
vaccination program
Stand still, yell for
help
Put bike or other
object in front of you
Protect head, face
and neck
Identify
aggressive
behavior before
bite occurs
Muzzle
dangerous dogs
Respond to alarm
indicating gate is
open
First aid/trauma care
Rabies vaccine
Evaluate dogs
Medical attention
Impound dogs
to observe for
rabies
Rehabilitation
Host (human)
Agent (dog)
Pre-Event
Teach children about
dogs
Teach how to respond
to aggressive dogs
Event
PostEvent
Enforce dog control laws
Maintain community
surveillance for dog bites
Report incidents
Repeat prevention
measures 178
Identifying Potential Interventions & Strategies
The Ecological Model for Intentional
Injuries
• Helps to organize the levels of influence that
affect behavior
–
–
–
–
Individual
Relationship
Community
Society
• Distinguishes among the multitude of influences
on violence
Section 6
179
The Ecological Model used to identify prevention strategies
for youth violence
Level
Individual
Relationship
Community
Society
Potential Interventions
Programs to increase access to prenatal and postnatal care
Preschool enrichment programs
Perpetrator programs Victim care
and support Building of social skills
Home visitation
Skill training programs on parenting
Supportive relationship with a positive adult role model
Home-school partnership programs to promote parental involvement
Peer mediation of students helping other students resolve disputes
Extracurricular activities
Gang prevention programs
Reducing the availability of alcohol
Reducing income inequality
Reducing media violence
Having laws prohibiting illegal transfers of guns to adolescents
Reforming educational system
Strengthening and improving police and judicial systems
180
Identifying Potential Interventions & Strategies
The Intervention Decision Matrix
• Help identify and choose among intervention
options & identify long-term goals
• Originally considers 7 elements
• 5 elements for this course
–
–
–
–
–
Effectiveness,
Cost
Sustainability
Political & Social Acceptability
Possible unintended consequences
Section 6
181
Identifying Potential Interventions & Strategies
The Intervention Decision Matrix
• Effectiveness
– Is the intervention useful for preventing injuries?
– Has it been evaluated?
• Cost
– Is the proposal affordable?
– Are there enough resources to develop the
proposal?
– Is the investment justifiable?
Section 6
182
Identifying Potential Interventions & Strategies
The Intervention Decision Matrix
• Sustainability
– Continuation of program
– Continuation of program impact
• Social and Political Acceptability
– Political context
– Accepted by community leaders
• Possible unintended consequences
Section 6
183
Identifying Potential Interventions & Strategies
The Intervention Decision Matrix
Elements
Score
1. Effectiveness
1. Not proven effective
2. Moderately effective 3. Highly effective
2. Cost
1. High cost
2. Medium cost
3. Low cost
2. Medium
sustainability
2. Medium
acceptability
3. High sustainability
3. Sustainability 1. Low sustainability
4. Social and
political
acceptability
1. Low acceptability
5. Possible
unintended
consequences
1. Known consequences 2. Unknown or
unclear whether
there are
consequences
Section 6
3. High acceptability
3. No consequences
184
Identifying Potential Interventions & Strategies
The Intervention Decision Matrix
Decision Criteria
Possible Interventions
Leash Laws
Ban Dogs
Pick up Strays
Effectiveness
Cost
Sustainability
Social &
Political Acceptability
Unintended
consequences
Intervention Rating
Section 6
185
Tie Surveillance to Action and Funding
•
•
•
•
Injury Prevention
Policy Change
Improved Data Collection
Funding to Support
Prevention Efforts
Section 6
186
Discussion of How Surveillance Can
Lead to Action and Funding
• Use your experiences
• How has surveillance been tied to action
and/or funding
• Consider
– Improved data systems
– Policy changes
– Grants received
– Interventions
Section 6
187
Summary of Section 6
• Questions?
• What did you already know?
• What did you learn that was new?
Section 6
188
Step 7: Define an Evaluation Plan for
your Surveillance System and
Monitor Prevention Activities
Section 7
Section 7
189
Section 7 Objectives
• Know the steps to evaluating the system.
• Be able to use surveillance to monitor
prevention activities
Section 7
190
Evaluation Process
•
•
•
•
Engage stakeholders
Describe the surveillance system
Determine a process
Gather evidence about performance
Section 7
191
Factors to Consider When Evaluating
Your System
•
•
•
•
•
•
•
•
Simplicity
Flexibility
Data Quality
Acceptability
Timeliness
Stability
Sensitivity
Representativeness
Section 7
192
Important Steps
• Communicate your findings to the appropriate
people
• Keep notes about any changes you
make to the system
Section 7
193
Use Surveillance Data to Monitor
Prevention Activities
• Changes after the prevention implemented
• Trend before and after a strategy is applied
• Impact of strategies applied for purposes
other than injury prevention that could impact
the results
• Over or under representation of certain
groups
• Over or under representation of injury events
Section 7
194
Summary of Section 7
• Questions?
• What did you already know?
• What did you learn that was new?
• Complete the Final Exercise. Share your decisions. Discuss
potential challenges and solutions.
• Complete the post test. Compare your answers to pre test.
Section 7
195