SURVEILLANCE OF INTENTIONAL INJURIES USING HOSPITAL DISCHARGE DATA. Jay S. Buechner, Ph.D. Rhode Island Department of Health

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1 SURVEILLANCE OF INTENTIONAL INJURIES USING HOSPITAL DISCHARGE DATA Jay S. Buechner, Ph.D. Rhode Island Department of Health Background. Hospital discharge data systems have great potential for injury surveillance if the external cause of injury is reported and coded according to the International Classification of Diseases (9th Revision) for each discharge with an injury diagnosis. In the past decade, several states have mandated the reporting of external cause codes (E-codes) on their hospital discharge data systems in order to meet this potential. Rhode Island is one state that has done so, and in the most recent year of data, hospitals have reported E-codes for 98 percent of discharges with a principal diagnosis of injury. E-codes typically contain information on the the type of incident resulting in injury (e.g., motor vehicle collision with bicycle), the person injured (e.g., bicyclist), and whether the injury was intentional, i.e., purposefully inflicted by an individual on himself (self-inflicted) or on another person (assault). It is important to identify intentional injuries because the prevention of these injuries requires injury control interventions that are fundamentally different from those employed in the prevention of unintentional injuries. Distinguishing between intentional and unintentional injuries among hospital inpatients based on discharge data requires that the intent to injure be correctly determined and reported. There are many impediments to obtaining accurate information on intent in hospitals. The information is not likely to be relevant to the patient's treatment or to obtaining reimbursement. The hospital has no official responsibility to make an ascertainment of intent, beyond requirements to report gun-shot wounds, possible child abuse, etc. The sources of information available to medical personnel are often not adequate for accurate determination; the patient may be too severely injured to speak and/or may lack recall, the emergency vehicle personnel or other transporters may likely not have witnessed the injury, and most descriptive information is likely to be through third parties and provided under stressful conditions. Finally, patients and others may withold or misrepresent circumstances for legal or personal reasons. In order to evaluate the accuracy of hospital reporting of intent to injure, the external cause codes on hospital discharge data must be compared with a "gold standard" for intent. For injury deaths occurring in Rhode Island, that standard is provided by the Office of State Medical Examiners (OSME), whose specific role in injury deaths is to investigate all deaths occurring under suspicious circumstances and to ascertain intent for legal purposes. To that end, a medical examiner fills out the cause of death field for approximately 85% of all injury deaths and reviews the cause of death for approximately another 10% of injury deaths, so that 95% of injury deaths are investigated by the OSME. Those injury deaths not accepted for review and/or investigation include, for example, deaths from choking after a natural event such as a heart attack or stroke and deaths from hip fractures that occur well after the injury. The objective of this study is to link hospital discharge records for injury inpatients discharged dead to the corresponding death certificate, which contains the coded cause of death information provided by the OSME, and compare the information on external cause of injury from the two sources, with a primary focus on the reporting of intent. By this methodology, the information on intent for a small subset of injury hospitalizations can be compared to a "gold standard" for that information.

2 Methods. Rhode Island occurrence deaths during the five-year period October 1, September 30, 1995 (the most recent five years for which hospital discharge data are available), with an underlying cause of death (UCOD) in the category injury and poisoning were identified and extracted from Rhode Island Vital Records data files. Injury deaths were defined as deaths with UCOD in the ICD-9 external cause code range , excluding medical and surgical misadventures ( ), medical and surgical complications ( ) and adverse drug reactions ( ). From the hospital discharge data for the same time period, all records where the patient was discharged dead were extracted, including both injury and non-injury discharges. Since no personal identifiers are available on Rhode Island hospital discharge data, records were linked by matching corresponding items, including hospital; day, month, and year of birth; day, month, and year of death (or discharge); sex; and census tract of residence. "Exact matches" agreed on all items, "near-exact matches" agreed on all items except census tract, and "matches by inspection" disagreed on one or more items other than census tract but could nevertheless be matched with an acceptable level of certainty. The linked file so created was the basis for examining external cause of injury as reported by the hospital in comparison to the UCOD. In particular, E-codes reported on the hospital data records were categorized into unintentional injuries, suicides, homicides, and injuries of undetermined intent, as were UCOD codes. The extent to which the hospital-reported E-code agreed with the UCOD on intent to injure was the basis for determining the accuracy of the hospitals' reporting of intent. Results. Of 1,957 injury deaths occurring in Rhode Island during the five-year period examined, 495 were matched to records of inpatients discharged dead. 251 (50.7%) of the linked cases were exact matches, 203 (41.0%) were near-exact matches, and 41 (8.3%) were matched by inspection (Table 1). The high proportion of near-exact matches indicates that census tract coding in the hospitals was often erroneous. (Census tracts on Vital Records are assigned consistently by address-matching software.) Matches by inspection included cases where the full birth date was not recorded or differed on the two records, where the discharge date was one day after the date of death (reflecting hospital policy for room charges), and where other minor differences could be rectified. The linked file of inpatient deaths differed substantially from the full injury mortality file in several demographic characteristics (Table 2). Inpatients were more likely to be female, to be elderly, and to be white non- Hispanic, and were less likely to be young adults and to be Rhode Island residents. Inpatients also differed from other injury decedents in their pattern of underlying cause of death (Figure 1). The inpatient file included a much higher proportion of deaths from falls and much lower proportions of suicides and homicides. (It should be noted that the low numbers of intentional injury deaths reduces the analytical power of the database for this study.) The observed differences in the cause of death pattern reflect the age-sex patterns seen in Table 2, notably the high proportions among inpatient deaths of elderly persons and females, who comprise the majority of victims of falls, and the low proportions of males and young adults, who comprise the majority of homicide and suicide victims. The rate of reporting external cause of injury codes on the hospital discharge record for the linked database was 64.2 percent, yielding 318 cases available for this analysis. For all hospital discharges with a principal diagnosis of injury during the period October 1, 1994, through September 30, 1995, the E-coding rate was 86.3%, increasing from 66.5% during the first year to 98.0% during the last year. For injury patients discharged dead, the E- coding rate during the five-year period was 74.9%. However, E-coding rates

3 for homicides (83%) and suicides (90%) were higher than for unintentional injury deaths (61%) and for deaths of undetermined intent (50%). One possible reason for the relatively low E-coding rate among the linked cases is the high proportion (53%) of patients with multiple injury and co-morbidity diagnoses that fill all seven available diagnosis fields, often "bumping" the E-code from the reported record. The E-coding rate for cases with entries in all seven diagnosis fields was 53%, compared to 77% for cases with six or fewer diagnoses, a rate more typical of injury patients who died in the hospital. Of the 318 linked cases with E-codes reported in the hospital record, there were 55 cases (17%) in which the E-code and the UCOD were from different sections in the ICD-9 classification of external causes of injury (Figure 2). Most likely to be reported incorrectly on the hospital record were deaths with a UCOD of unintentional poisoning (75% incorrect), cases of undetermined intent (56%), homicides (38%), and suicides (25%). On over half (30) of the cases where the hospital generated E-code was incorrect, there was a difference in the reported intent to injure. Among cases where agreement between the two sources was better, there were 109 deaths (34%) where the E- code and the UCOD were different but fell within the same section; for 23 of these there was agreement in the first three digits of the two codes. In the remaining 154 cases (48%) the two codes were identical. In both of the latter groups, the two sources agreed on intent to injure. Among the 30 cases where intent was reported differently in the two databases, hospitals were equally likely to report intentional injuries as unintentional injuries (5 cases) as they were to report unintentional injuries as intentional (5 cases) (Table 3). Interestingly, the E-codes for undetermined intent were more likely to be used for underlying cause of death than on the hospital discharge record. In most cases when it appeared on the hospital record, it was incorrectly assigned (5 cases out of 9). Based on information from the subset of cases analyzed in this study, the reporting of injuries as unintentional by hospitals is somewhat more likely to be accurate accurate than the reporting of injuries as intentional, either self-inflicted injuries or assaults (Table 4). Of injury deaths established as unintentional on the death certificate, hospitals correctly reported intent on 96 percent. Of deaths declared suicides, intent was correctly reported in only 87 percent of cases, and of homicides, in 94 percent. Discussion. Although the results of this study are based on small numbers of cases, hospital reporting of intent follows expected patterns. Intentional injuries are sometimes reported as unintentional or of undetermined intent. Unintentional injuries are more often reported correctly by hospitals. To investigate the source of the observed inaccuracies in reporting intent in hospital discharge data, it would be necessary to review the medical records for the cases where the reported intent differed from that on the death certificate. The cause could then be isolated either to incorrect or missing information in the record or to the interpretation of the coder in assigning cause. In this study, the number of cases available for review was insufficient to support such additional investigation; the maximum number of cases in any misclassification cell was 9 (Table 3). Such investigation will be more profitable when larger numbers of cases with disagreeing reports of intent can be identified. Nevertheless, the information provided here is a first demonstration of the magnitude and direction of the inaccuracies in hospital reporting of intent to injure.

4 Table 1. Results of Linkage Procedure Applied to Injury Death Records and Injury Hospital Discharges, Rhode Island, October September Matched Cases Type of Match Number Percent Automated Exact* Near-Exact* By Inspection* Total *See text for definition.

5 Table 2. Characteristics of Injury Deaths Occurring in Rhode Island, All Injury Deaths and Hospital Inpatient Deaths, October September All Inpatient Injury Deaths Characteristic Deaths (Linked) Percent Female Percent White, not Hispanic Percent Ages Percent Ages Percent RI Residents Number of Deaths 1,

6 Table 3. Correspondence of Intent Reported on the Hospital Discharge Record to Intent Reported on the Death Certificate, Inpatient Injury Deaths, Rhode Island, October September Intent (Hospital Record) Intent (Death Unin- Unde- Certificate) tentional Suicide Homicide termined Total Unintentional Suicide Homicide Undetermined Total

7 Table 4. Proportion of Inpatient Injury Deaths for Which Intent is Correctly Reported in the External Cause of Injury Code on the Hospital Discharge Record, Rhode Island, October September Correctly Reported Intent (Death Number Certificate) of Deaths Number Percent Unintentional Suicide Homicide

8 Figure Captions Figure 1. Figure 2. Injury Deaths Occurring in Rhode Island, by Cause of Death, All Injury Deaths and Hospital Inpatient Deaths, October September Correspondence of External Cause of Injury Reported on the Hospital Discharge Record to Cause of Death Reported on the Death Certificate, Inpatient Injury Deaths, Rhode Island, October September 1995.

9 Motor Vehicle 22% Fall 15% Other Unintentional 18% Undetermined Intent 14% Homicide 10% Suicide 21% Motor Vehicle 23% Fall 42% Undetermined Intent 4% Homicide 6% Suicide 8% Other Unintentional 17% All Injury Deaths (N = 1,957) Inpatient Injury Deaths (N = 495)

10 No Agreement 17% Identical 48% Same Group 27% (N = 318) 3-Digit Agreement 7%

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