The ICD injury matrices Margaret Warner & Ari Minino

The ICD injury matrices Margaret Warner & Ari Minino National Conference on Health Statistics Learning institute, 2012

ICD coding (Injury-centric view) Injury conditions/events Nature of injury codes Body region & diagnosis e.g. Intracranial injury, upper extremity fracture External cause of injury codes (E-code) Cause & intent e.g. Unintentional fall, firearm suicide All non-injury codes diagnoses Usually used for co-morbid conditions e.g. diabetes

What are the ICD Injury matrices? External cause codes and nature of injury codes are multi-axial (i.e. describe more than one dimension). The ICD Injury matrices are frameworks designed to organize ICD coded injury data into meaningful groups and to standardize tabulations in either dimension External cause matrix categorizes ICD codes by cause & intent. Nature of injury matrix categorizes ICD codes by nature & body region.

Objectives of ICD matrices To facilitate national and international comparability in the presentation of injury statistics. To standardize retrieval of injury cases for epidemiological, clinical and management oriented analyses. To create a bridge between classification systems (e.g. ICD-9 and ICD-10). To eliminate some of the variations in classification between jurisdictions and over time, by creating broader groupings of cause categories.

Process for creating the ICD matrices Jointly developed by the Injury Control and Emergency Health Services (ICEHS) section of the American Public Health Association and the International Collaborative Effort (ICE) on Injury Statistics ICD-9 matrices was developed first and ICD-9CM and ICD-10 was designed to be similar to the ICD-9 matrix Draft matrices were reviewed by injury researchers, injury prevention practitioners, and others prior to finalization

ICD Injury matrices ICD Revisions & modifications External cause of injury ICD–9 ICD–10 Matrix Matrix Matrix Barell Matrix Injury Mortality Diagnosis Matrix ICD–10-CM In development In development ICD–9–CM Nature of injury

External cause code structure Intent-Mechanism-Object W06 (Accidental) Fall involving bed Intent V41 Mechanism (Accidental) Car occupant injured in collision with pedal cycle Mechanism Intent X42 Object Object Accidental poisoning by and exposure to narcotics and psychodysleptics Intent Mechanism Object

External cause of injury matrix Mechanism Intent E 0 1 D IC r e xt a c l a n o c e s u s e d

External cause of injury matrix Intent Mechanism Unintentional Suicide Homicide Undetermined All injury Cut / pierce Drowning . . . Suffocation Unspecified 0 1 ICD e s u a c l a n r e t x E s e cod Legal intervention/ war

External cause-of-injury mortality matrix NVSS, 2009 Cut/Pierce Drowning Fall Fire/Flame Hot object/Substance Firearm Machinery Motor Vehicle Traffic Other Pedal cyclist Other Pedestrian Other land transport Other transport Natural/Environmental Overexertion Poisoning Struck by or against Suffocation Other specified, classifiable Injury Other specified, not elsewhere classified Unspecified Injury Total UNINTENTIONAL 125 3,517 24,792 2,756 67 554 608 34,485 256 1,110 1,398 1,006 1,327 10 31,758 776 5,939 1,389 SUICIDE 669 389 685 161 18,735 . 104 6,398 1 9,000 332 HOMICIDE 1,874 41 18 91 2 11,493 60 87 132 543 226 UNDETERMINED LEGAL/WAR 20 264 67 117 1 232 . 19 3,349 1 163 19 333 53 TOTAL 2,688 4,211 25,562 3,125 70 31,347 608 34,485 256 1,110 1,581 1,006 1,327 10 41,592 910 15,645 2,019 1,050 246 504 200 31 2,031 5,098 118,021 189 36,909 1,728 16,799 553 5,005 3 420 7,571 177,154

Leading causes of death

Leading causes of injury: United States, 1999--2009 50,000 45,000 40,000 Poisoning 35,000 30,000 Motor Vehicle Traffic 25,000 Firearm 20,000 Fall 15,000 10,000 5,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 SOURCE: CDC/NCHS, National Vital Statistics System; Suffocation

Firearm deaths by intent, 2009 20,000 18,000 Number of deaths 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Suicide SOURCE: CDC/NCHS, National Vital Statistics System; Homicide Unintentional Undetermined

Matrix for international comparisons Example: Unintentional drowning death rates Country Rate per 100,000 Australia 9.9 United Kingdom 3.4 United States 11.1 The UK must have a great prevention program! Source: Bhalla, K., Harrison, J., Fingerhut, L., Shahraz, S., Abraham, J., Hsiu-Yeh, P., on behalf of the GBD Injury Expert Group, The Global Injury Mortality Database, Version 2.0, Released on October 21 2009, Available from www.globalburdenofinjuries.org

Drowning rates per million population for selected countries 12 Australia United Kingdom USA 10 8 6 4 2 0 Accident Suicide Homicide Undetermined Source: Bhalla, K., Harrison, J., Fingerhut, L., Shahraz, S., Abraham, J., Hsiu-Yeh, P., on behalf of the GBD Injury Expert Group, The Global Injury Mortality Database, Version 2.0, Released on October 21 2009, Available from www.globalburdenofinjuries.org

Nature of injury code structure Less structured than external cause codes Body region by Nature of Injury Body region Nature of Injury S72.0 Fracture of neck of femur S06.5 Traumatic subdural hemorrhage Hip TBI Fracture Internal organ T31.9 Burns involving 90% or more of body surface S28.0 Crushed chest Multiple body regions Thorax Burn ICD-10 Description Crush

Injury Mortality Diagnosis Matrix Body Region Nature of Injury ‘ 0 -1 D IC ’ T ‘ r o ’ S s e d co

Injury Mortality Diagnosis Matrix Nature of Injury Fractures Dislocations Internal Open Wound Body Region Head/Neck Spine/Upper Back Torso . . . Unclassifiable Unspecified ‘ 0 -1 D IC ’ T ‘ r o ’ S s e d co . . .

Any mention of body region Firearm homicide and suicide, 2009 18,000 Head & neck Torso Multiple 16,000 Number of deaths 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Suicide SOURCE: CDC/NCHS, National Vital Statistics System; Homicide Other

More information (and SAS code) Available at NCHS Injury Data & Resources www.cdc.gov/nchs/injury/injury tools.htm

Drug poisoning mortality Margaret Warner & Ari Minino National Conference on Health Statistics Learning institute, 2012

Motor vehicle traffic and poisoning death rates United States, 1999--2009 18 Deaths per 100,000 population 16 14 Motor vehicle traffic 12 10 8 6 4 2 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 SOURCE: CDC/NCHS, National Vital Statistics System Poisoning

Poisoning and drug poisoning death rates United States, 1999--2009 16 Deaths per 100,000 population 14 Poisoning 12 10 8 6 4 2 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 SOURCE: CDC/NCHS, National Vital Statistics System Drug poisoning

Drug poisoning death rates by intent United States, 1999--2009 Deaths per 100,000 population 10 9 8 7 6 Unintentional 5 Suicide 4 3 Undetermined 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 SOURCE: CDC/NCHS, National Vital Statistics System

Drug poisoning death rates Massachusetts, 1999--2009 Unintentional poisoning Number of deaths 900 800 700 600 500 400 300 200 100 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 SOURCE: CDC/NCHS, National Vital Statistics System

Drug poisoning death rates by intent: Massachusetts, 1999--2009 Undetermined Suicide Unintentional poisoning Number of deaths 1,200 1,000 800 600 400 200 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 SOURCE: CDC/NCHS, National Vital Statistics System

Drugs in multiple causes (aka T-codes) Drug category ICD-10 code Natural and semi-synthetic opioid analgesics (aka “Other opioids”) T40.2 Methadone Synthetic opioid analgesics, excluding methadone (aka “Other synthetic narcotics”) T40.3 T40.4 Heroin Cocaine T40.1 T40.5 Other and unspecified drug(s) T50.9 Types of drug Morphine Oxycodone Hydrocodone Opioid Methadone analgesics Fentanyl Propoxyphene Meperidine Heroin Cocaine Drugs Polypharmacy

Drug poisoning deaths United States, 1999--2009 18,000 16,000 Any opioid analgesic1 Number of deaths 14,000 12,000 10,000 8,000 Specified drug(s) other than opioid analgesic Only non-specified drug(s) 6,000 4,000 2,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 NOTES: Drug categories are mutually exclusive. 1. Opioid analgesics include natural and semi-synthetic opioid analgesics (e.g. morphine, oxycodone, hydrocodone) and synthetic opioid analgesics (e.g. methadone, fentanyl). Some deaths in which the drug was poorly specified or unspecified may involve opioid analgesics. SOURCE: CDC/NCHS, National Vital Statistics System

Drug poisoning deaths by type of drug United States, 1999--2009 12,000 Number of deaths 10,000 Natural and semisynthetic opioid analgesic 8,000 Methadone 6,000 Cocaine 4,000 Heroin 2,000 Synthetic opioid analgesic, excluding methadone 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 NOTES: Opioid analgesic categories are not mutually exclusive. Deaths involving more than one opioid analgesic category shown in this figure are counted multiple times. Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http:// www.cdc.gov/nchs/data/databriefs/db81.htm

Poisoning Surveillance Matrix for ICD 10 From Safe States Injury Surveillance Workgroup 7 Conceptual & operational definitions of poisoning SAS programming code See http://safestates.org/displaycommon.cfm?an 1&subarticlenbr 236