# The effect of the introduction of ICD-10 on trends in mortality from injury and poisoning in England and Wales

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2 Box one Box two BRIDGE CODING STUDY: METHODS To understand trends in cause-specific mortality spanning the change from ICD-9 to ICD-10, we need to measure the effect of this change on the proportion of deaths attributed to different causes of death. This is done using bridge coding, that is coding a sample of death certificates independently to both ICD-9 and ICD-10, and comparing the resulting underlying causes of death. The first step in this process is to identify equivalent codes or code groups in the two revisions which represent the same causes. In most cases this is not contentious, and the same groupings have been used by various authors and national statistics offices. The results are then presented as comparability ratios of the numbers of deaths assigned to a given disease or group of diseases in the two revisions. These are simply the ratio of the number of deaths coded to a cause in ICD-10 to the number coded to the equivalent cause in ICD-9. They measure the net effect of all changes to a particular cause of death. Confidence intervals have also been produced for these ratios; the method used to do this has been described elsewhere. 1 These comparability ratios can then be used to adjust comparisons of cause-specific mortality rates at or near the time of the changeover. They cannot be used before 1993, as ONS used a different interpretation of the rules to select the underlying cause of death from the international interpretation between 1984 and EXTERNAL CAUSES OF MORTALITY The external cause of injury codes form Chapter 20 of the ICD, and are prefixed with the letters V, W, X and Y. They are no longer a MAIN CHANGES IN ICD-10 ICD-10 represents the greatest change in the ICD in over 50 years. The main changes are: The first character of each code is now alphabetic rather than numeric this has enabled the expansion of the number of codes to provide for recently recognised conditions and more detail about common diseases. Some diseases and groups of conditions have been moved between broad groups (ICD Chapters) to another to reflect current ideas of aetiology and pathology. There have been several changes to the rules governing selection of the underlying cause of death. There are now only 5 rules instead of 9. The changes in the application of Rule 3 have the biggest impact. This rule allows a condition which is reported in either Part I or II of the death certificate to take precedence over the condition selected using the other coding rules if it is obviously a direct consequence of that condition. In ICD-10 the list of conditions affected by Rule 3 is more clearly defined than in ICD-9 and is also broader in scope. This internationally agreed interpretation is used in the automated coding software produced by the National Centre for Health Statistics (NCHS) in the US, used in, Scotland and an increasing number of other countries. The impact of this is to reduce the number of deaths assigned to conditions such as pneumonia and to increase the number of deaths assigned to chronic debilitating diseases. In, about 20 per cent of deaths mention pneumonia so the effect of this rule change is large. supplementary chapter of the ICD, as they were in ICD-9, when they were prefixed with an E. Table 1 gives comparability ratios for the external causes examined in this article. Table 1 Comparability ratios for selected external causes of mortality, 1999 ICD-10 code ICD-9 code Comparability Ratio (with 95 per cent confidence interval) Males V01 Y89 E800 E999 External causes of mortality (0.994, 1.003) V01 X59 E800 E928, excluding E870 E879 Accidents (0.989, 1.003) V01 V99 E800 E848 Transport accidents (0.991, 1.005) V01 V89 E800 E829 Land transport accidents (0.994, 1.007) W00 W19 E880 E888 Falls (and fractures, cause unspecified in ICD-9) (0.694, 0.744) W65 W74 E910 Accidental drowning and submersion (0.942, 1.049) X00 X09 E890 E899 Exposure to smoke, fire and flames (0.934, 1.003) X40 X49 E850 E869 Accidental poisoning by and exposure to noxious substances (0.987, 1.031) X40 X44 E850 E858 Accidental poisoning by drugs and medicaments (0.983, 1.020) X60 X84 E950 E959 Intentional self-harm (0.998, 1.001) X85 Y09 E960 E969 Assault (0.981, 1.041) Y10 Y34 E980 E989 Injury and poisoning of undetermined intent (1.000, 1.020) Females V01 Y89 E800 E999 External causes of mortality (0.999, 1.017) V01 X59 E800 E928, excluding E870 E879 Accidents (1.000, 1.023) V01 V99 E800 E848 Transport accidents (0.997, 1.017) V01 V89 E800 E829 Land transport accidents (0.995, 1.014) W00 W19 E880 E888 Falls (and fractures, cause unspecified in ICD-9) (0.437, 0.476) W65 W74 E910 Accidental drowning and submersion (0.904, 1.057) X00 X09 E890 E899 Exposure to smoke, fire and flames (0.929, 1.016) X40 X49 E850 E869 Accidental poisoning by and exposure to noxious substances (0.966, 1.042) X40 X44 E850 E858 Accidental poisoning by drugs and medicaments (0.964, 1.037) X60 X84 E950 E959 Intentional self-harm (0.996, 1.001) X85 Y09 E960 E969 Assault (0.972, 1.009) Y10 Y34 E980 E989 Injury and poisoning of undetermined intent (0.999, 1.029) 11 National Statistics

3 Suicide, homicide and injury/poisoning of undetermined intent (ICD-10 X60 X84, X85 Y09, Y10 Y34; ICD-9 E950 E959, E960 E969, E980 E989) Suicide, homicide and injury/poisoning of undetermined intent are based on the verdict of the coroner, so overall numbers allocated to each of these causes have not changed in ICD-10 compared with ICD- 9. The codes do vary at the third and fourth digit level. Table 2 gives comparable codes for the most common methods for suicide, homicide and open verdicts (undetermined intent). One major difference between ICD-9 and ICD-10 is that suicides and poisoning of undetermined intent involving carbon monoxide poisoning from car exhausts are no longer identifiable in ICD-10. In ICD-9, external cause codes E952.0 and E982.0 specified motor vehicle exhausts. This could be combined with main injury code 986, toxic effect of carbon monoxide. In ICD-10 codes X67 and Y17 are used for the external cause for these deaths. These are simply poisoning with other gases. The main injury code T58 specifies carbon monoxide, but not the source of it. The same is true for accidental mortality, where E868.2 specified a motor vehicle exhaust in ICD-9, but in ICD-10 the broader X47, accidental poisoning with other gases, is used instead. Codes for late effects of suicide, homicide and injury of undetermined intent are now combined in one code, Y87. They are not placed with the relevant sections of suicide, homicide or undetermined intent as they were in ICD-9. There are small numbers of deaths allocated to these codes in any one year, so their exclusion has a negligible effect on analysis of trends. This also applies to late effects of accidents. However, there are subdivisions for suicide, homicide and undetermined intent within the late effects section, so these deaths can be added to the main groups if required. This has not been done in routine tabulations published by ONS. Accidental drowning and submersion (ICD-10 W65 W74, ICD-9 E910) The number of deaths coded to accidental drowning does not change as a result of introducing ICD-10. At a more detailed level of coding (3 or 4 digit level) the focus of the classification has shifted. In ICD-10 the detail is on the type of water involved (for example bathtub, swimming pool, river, lake) and, in the case of bathtub and swimming pool incidents, the classification distinguishes between normal activity (bathing, swimming) from unintended activity (falls). In ICD-9 the emphasis was on obtaining detail of the nature of the activity being undertaken at the time of the event, for example swimming, water-skiing, diving, other sport or recreational activities, and in bathtub. Therefore, information on the activity prior to the incident is lost in ICD-10. Accidental exposure to smoke, fire and flames (ICD-10 X00 X09, ICD-9 E890 E899) Accidental exposure to smoke, fire and flames also has comparability ratios that are not significantly different from 1. There are some changes within the broad category, however. Secondary fires caused by explosions are included in the group in ICD-9 but not in ICD-10, where they are coded to W35 W40. Falls (ICD-10 W00 W19, ICD-9 E880 E888) The standard grouping for falls in ICD-10 identifies 30 per cent fewer deaths for males and over 50 per cent fewer for females when compared to the ICD-9 standard group. Table 3 shows that this is because in ICD-9 deaths coded to fracture of unspecified cause (E887) were included in the total for falls deaths (E880 E888), whereas in ICD-10 they are coded to exposure to unspecified factor (X59), along with other deaths where not enough information was provided to assign a more specific code. Some deaths due to injury do have very little information provided about them on the death certificate from the coroner or doctor. In these cases in ICD-10 the code X59 is assigned to the death. In ICD-9, the limited detail provided may have been sufficient to assign an apparently more specific code. Our analysis shows that over 1,700 female deaths were assigned to the X59 code in the bridge coding study, compared to just over 700 male deaths (Table 4). This is likely to be as a result of the fact that more of these deaths occur at older ages, and more deaths at older ages are to females. These deaths do not always have inquests, as many coroners take the view that no public interest is served by investigating them through a judicial process. For example, in, in 2000, 43 per cent of deaths from falls did not have an inquest. Most of the deaths coded to X59 in ICD-10 (1,200 for females and nearly 400 for males) were previously coded as fracture of unspecified cause (E887) in Table 2 Classification of methods: Suicide, Open verdicts, Homicide Suicide Open Homicide ICD-10 ICD-9 ICD-10 ICD-9 ICD-10 ICD-9 Drug poisoning X60 X64 E950.0 E950.5 Y10 Y14 E980.0 E980.5 X85 E962.0 Other poisoning, including alcohol, gases and vapours X65 X69 E950.6 E952.9 Y15 Y19 E980.6 E982.9 X86 X90 E962.1 E962.9 Hanging, strangulation and suffocation X70 E953 Y20 E983 X91 E963 Drowning and submersion X71 E954 Y21 E984 X92 E964 Firearms and explosives X72 X75 E955 Y22 Y25 E985 X93 X96 E965 Smoke, fire, flames and exposure to steam and hot objects X76 X77 E958.1 E958.2 Y26 Y27 E988.1 E988.2 X97 X98 E968.0, E968.3 Cutting/piercing/sharp and blunt objects X78 X79 E956 Y28 Y29 E986 X99 Y00 E966, E968.2 Falling from a high place X80 E957 Y30 E987 Y01 E968.1 Falling/lying/being pushed before moving object X81 E958.0 Y31 E988.0 Y02 No equivalent Crashing of motor vehicle X82 E958.5 Coded to relevant section Coded to Y03 if murder verdict given. If verdict is in Land Transport Accidents causing death by dangerous driving, coded to relevant section in Land Transport Accidents Other and unspecified X83 X84 E958.3 E958.4, Y33 Y34 E988.3 E988.4, Y04 Y09 E967, E968.4 means E958.6 E958.9 E988.6 E988.9 E968.9 National Statistics 12

4 Table 3 Numbers of deaths allocated to falls in ICD-9 and ICD-10, 1999 ICD-10 code ICD-9 code Falls W00 W19 Osteoporosis /pathological Unspecified accident X59 Other Total fracture M80 M81 Falls E880 E886, E888 2, ,237 Fracture of unspecified cause E , ,819 Osteoporosis /pathological fracture , ,343 Unspecified accident E Other Total 2,253 1,710 2,473 Table 4 Numbers of deaths coded to X59 in ICD-10 by their ICD-9 code, 1999 Figure 1 Age-standardised* accidental falls mortality rates, ICD-9 code Males Females Total Disease ( ) Fracture of unspecified cause (E887) 392 1,214 1,606 Unspecified accident (E928.9) Other accident Total 764 1,709 2,473 ICD-9, so this particularly affects trends in falls deaths. A further 400 were assigned to unspecified accident (E928.9) in ICD-9. Overall, there were 4.5 times as many deaths assigned to the code for unspecified injury in ICD-10 than in ICD Rate per 100, Males W00 W19, E880 E888 Females W00 W19, E880 E888 Males W00 W19, E880 E886,E888 When fractures of unspecified cause are included in the ICD-9 grouping for falls, the comparability ratios are 0.72 for males and 0.46 for females, compared to 1.02 and 1.00 when they are excluded. Figure 1 shows the trends in falls deaths from 1993 to 2001 when these deaths are both included and excluded. This clearly illustrates that excluding E887 deaths from the falls group in ICD-9 accounts for the differences between ICD-9 and ICD-10. Table 5 shows age-specific comparability ratios for falls. This shows that the ratio declines with age, indicating that older age groups are much more affected by this change than younger age groups. This is because at younger ages, fracture of unspecified cause is much less common as a cause of death, under 1,000 deaths in under 75s compared with over 11,000 in those aged 75 and over. In order to examine trends in mortality from falls, it is therefore important to exclude those deaths coded to E887 in ICD-9. However, it is often thought to be likely that many of the deaths coded to E887 were the result of a fall, but that the fall had simply not been stated on the death certificate. Around 70 per cent of deaths coded to E887 in ICD-9 had fractured neck of femur as their secondary cause. Most were at advanced ages, when these fractures can follow relatively minor force, or even occur without any appreciable force, because of osteoporosis. It is very unlikely that the external cause of injury would not be mentioned Table 5 Age-specific comparability ratios for falls (ICD-10 W00 W19, ICD-9 E880 E888), 1999 Comparability Ratio (with 95 per cent confidence interval) Under 75s and over Males (0.924, 0.985) (0.621, 0.709) (0.372, 0.469) Females (0.721, 0.815) (0.507, 0.583) (0.311, 0.360) Females W00 W19, E880 E886, E * Directly age-standardised to the European Standard Population. on the certificate if they were due to motor vehicle crashes, assaults or incidents requiring investigation by police or inquest. These deaths were grouped with falls in ICD-9, because preventing osteoporosis, falls and their consequences was considered to be the most useful public health approach to preventing these fracture deaths. The secondary cause codes for fractures, or for fractured neck of femur, could therefore be used in ICD-10 to identify these possible falls from all of the deaths coded to X59 as the underlying cause of death. Eighty per cent of deaths where the underlying cause was X59 and the secondary cause was a fracture had been coded to E887 in ICD-9, with the others mainly being coded to diseases in ICD-9. If deaths coded to X59 with a fracture as secondary cause are counted with falls in ICD-10, this leads to an overall increase of about 4 per cent in the number of deaths attributed to falls. This is due to the application of Rule 3 to some deaths previously coded as diseases in ICD-9. These are conditions, such as pneumonia or cardiac arrest, which would have appeared alone in Part I of the death certificate with an accidental injury in Part II. In ICD-9, in England and Wales, the condition in Part I is selected as the underlying cause of death if the death was certified without an inquest being held (i.e. the death did not have a verdict of accidental death). In ICD-10 pneumonia is considered to be a direct consequence of the accidental injury, so the injury is selected as the underlying cause of death. Additionally, cardiac arrest is regarded as an ill-defined condition in ICD-10, and therefore 13 National Statistics

5 preference is given to the injury in Part II. Box 3 gives some examples of this. This illustrates that changes to the classification and changes to the rules can interact, making interpretation of trends more difficult. Comparability ratios measure the net effect of all these changes together. In other countries, falls deaths have been affected by another change in coding rules in ICD-10, which allows fractures to be due to osteoporosis even if a fall was also mentioned on the death certificate. This approach was already being used in prior to the introduction of ICD-10 and so only a very small number of deaths classified as falls in ICD-9 were reclassified as due to osteoporosis in ICD-10. Box three EXAMPLES OF DEATHS WITH TERMINAL CONDITIONS AS THE UNDERLYING CAUSE IN ICD-9 AND X59 IN ICD-10 1a 1b II Bronchopneumonia Supracondylar fracture right femur, dementia Underlying cause ICD Bronchopneumonia, organism unspecified ICD-10 X59.9 Exposure to unspecified factor 1a 1b II Cardiac arrest Atrial fibrillation Fractured neck of femur (repaired) Underlying cause ICD Atrial fibrillation and flutter ICD-10 X59.9 Exposure to unspecified factor 1a 1b II Pulmonary embolism Deep vein thrombosis Fracture neck of left femur Underlying cause ICD Pulmonary embolism ICD-10 X59.9 Exposure to unspecified factor Land transport accidents (ICD-10 V01 V89, ICD-9 E800 E829) The changes to mortality from land transport accidents are caused by two separate factors. These are a change in the axis of the classification compared with ICD-9 and an increase in the level of detail required to assign a specific code to the death. These changes are described in this section. In ICD-10 the axis of classification focuses on the injured party, rather than the type of vehicle involved. The first subdivisions (the second digit) are for the victim s mode of transport, for example pedestrian, cyclist or occupant. The third digit refers to the circumstances of the accident, for example collision or non-collision. The fourth digit identifies the activity of the victim, for example driver or passenger and whether the incident occurred in a traffic (on the road) or non-traffic situation. This is different from ICD-9, where the first piece of information was the vehicle and whether or not the incident was traffic-related, so the classification referred to rail and motor accidents. Only at the fourth digit was the situation of the victim (pedestrian, car occupant, motor cyclist, or pedal cyclist) described. It is therefore possible in ICD-10 to quickly identify the number of pedestrians or cyclists injured. Consequently, it is not however possible to obtain an exact equivalent in ICD-10 to the motor vehicle traffic accidents group in ICD-9. Table 6 clearly shows the change in the axis of classification, with motor vehicle traffic accidents being spread throughout the V01 V89 codes. The majority of these deaths are to car occupants, pedestrians or motorcycle riders. Annex 1 identifies codes in ICD-9 and ICD-10 for some of the main different types of land transport accident. Using ICD-10, as described above, the situation of the victim is the main axis of classification. Figure 2 shows trends in land transport accidents involving pedestrians, pedal cyclists, motor cyclists, drivers and passengers. Comparability between ICD-9 and ICD-10 is good for pedestrians, pedal cyclists and motor cyclists, with ratios very close to or exactly one. The identification of passengers and drivers is more complex. In ICD-9 they were grouped together at the fourth digit level. In ICD-10 at the third digit level, the type of vehicle is specified, eg car, van, bus, and again at the fourth digit level passengers and drivers are identified. Table 6 Number of deaths assigned to land transport accidents in ICD-9 and ICD-10, 1999 ICD-9 code and name E800 E807 E810 E819 E820 E825 E826 E829 ICD-10 code and name Railway Motor Vehicle Motor Vehicle Other Road Other Total Accidents Traffic Accidents Non-traffic Accidents Vehicle Accidents V01 V09 Pedestrian injured in transport accident V10 V19 Pedal cyclist injured in transport accident V20 V29 Motorcycle rider injured in transport accident V30 V39 Occupant of three-wheeled motor vehicle injured in transport accident 2 2 V40 V49 Car occupant injured in transport accident 1, ,376 V50 V59 Occupant of pick-up truck or van injured in transport accident V60 V69 Occupant of heavy transport vehicle injured in transport accident V70 V79 Bus occupant injured in transport accident V80 V89 Other land transport accidents Other Total 56 2, National Statistics 14

6 In ICD-10 the number of drivers identified is reduced by about 15 per cent, and the number of passengers by 35 per cent (Table 7). This is because some of the deaths coded as passenger or driver in ICD-9 have been coded to car occupant [any] injured in unspecified traffic accident (V49.9). This is because they are vehicle accidents which do not state whether or not they involved a collision. The codes allocated in ICD-10 only allow the passenger or driver to be identified if it is stated on the death certificate whether or not the accident involved a collision. Figure 3 therefore shows adjusted rates for drivers and passengers. This shows an apparent decline in mortality in 2001 for male and female drivers is translated into an increase when the data are adjusted using comparability ratios, and a substantial apparent decline in mortality for female passengers becomes less pronounced. Another issue surrounding the level of detail required is that for a death to be coded as a motor vehicle accident, ICD-10 coding rules require the word motor or the type of vehicle, such as car or van, to be listed on the death certificate. For example, if the death certificate lists road traffic accident or head-on collision, but the type of vehicle is not stated, the Table 7 Comparability ratios for land transport accidents by victim type, 1999 Comparability Ratio (with 95 per cent confidence interval) Males Females Pedestrians (1.020, 1.069) (0.995, 1.037) Cyclists (0.958, 1.028) (1.000, 1.000) Motorcyclists (0.990, 1.023) (0.869, 1.150) Drivers (0.806, 0.860) (0.779, 0.902) Passengers (0.592, 0.722) (0.606, 0.730) cause of death is coded as other land transport accident. A reduction of 3 5 per cent is seen in road traffic accidents and 6 7 per cent in motor vehicle traffic accidents due to the allocation of these deaths to nonspecific codes (Table 8). Table 8 Comparability ratios for land transport accidents, road traffic accidents and motor vehicle traffic accidents, 1999 Comparability Ratio (with 95 per cent confidence interval) Males Females Land transport accidents (0.994, 1.007) (0.995, 1.014) Road traffic accidents (0.976, 0.992) (0.950, 0.981) Motor vehicle traffic accidents (0.947, 0.967) (0.935, 0.970) In routine publications, ONS will therefore use the land transport accidents group as a whole to present trend information. When looking at different types of these accidents, it is important to be aware of potential inconsistencies between ICD-9 and ICD-10, as described above. In, more than 95 per cent of land transport accidents are motor vehicle traffic accidents. Other data can also be examined to look at trends, for example from the Department for Transport. Christophersen and colleagues have looked at the comparability of these data with routine mortality data. 3 SECONDARY CAUSES OF MORTALITY The secondary causes of mortality, which describe the main injury incurred, are found in Chapter 19, prefixed with an S or a T. S codes classify injuries relating to a single body region. T codes classify Figure 2 Age-standardised* land transport accident mortality rates, Males 3.5 Females Rate per 100, Rate per 100, Year Year Pedestrian Pedal cyclist Driver Passenger Motorcyclist * Directly age-standardised to the European Standard Population. 15 National Statistics

12 Annex 1 ICD CODES USED TO IDENTIFY DIFFERENT TYPES OF LAND TRANSPORT ACCIDENT ICD-9 ICD-10 Pedestrian E800 E807 (.2), E810 E819 (.7), E820 E825 (.7) V01 V09 Pedal cyclist E800 E807 (.3), E810 E819 (.6), E820 E825 (.6), E826 V10 V19 Driver E810 E819 (.0), E820 E825 (.0) V30 V38 (.0) (.5), V39 (.0) (.4), V40 V48 (.0) (.5), V49 (.0) (.4), V50 V58 (.0) (.5), V59 (.0) (.4), V60 V68 (.0) (.5), V69 (.0) (.4), V70 V78 (.0) (.5), V79 (.0) (.4), V86 (.0) (.5) Passenger E810 E819 (.1), E820 E825 (.1) V30 V38 (.1) (.6), V39 (.1) (.5), V40 V48 (.1) (.6), V49 (.1) (.5), V50 V58 (.1) (.6), V59 (.1) (.5), V60 V68 (.1) (.6), V69 (.1) (.5), V70 V78 (.1) (.6), V79 (.1) (.5), V86 (.1) (.6) Motorcyclist E810 E819 (.2) (.3), E820 E825 (.2) (.3) V20 V29 Road traffic accident E810 E819, E826 E829 V01 V06 (.1), V09 (.2) (.3), V10 V29 (.4) (.5) (.9), V19.6, V29.6, V30 V38 (.5) (.6) (.7) (.9), V39 (.4) (.5) (.6) (.9), V40 V48 (.5) (.6) (.7) (.9), V49 (.4) (.5) (.6) (.9), V50 V58 (.5) (.6) (.7) (.9), V59 (.4) (.5) (.6) (.9), V60 V68 (.5) (.6) (.7) (.9), V69 (.4) (.5) (.6) (.9), V70 V78 (.5) (.6) (.7) (.9), V79 (.4) (.5) (.6) (.9), V80 (.3) (.4) (.5), V81 V82 (.1), V83 V86 (.0) (.1) (.2) (.3), V87, V89 (.2) (.3) Motor vehicle traffic accident E810 E819 V02 V04 (.1), V09.2, V12 V14 (.4) (.5) (.9), V19 (.4) (.5) (.6), V20 V28 (.4) (.5) (.9), V29 (.4) (.5) (.6) (.9), V30 V38 (.5) (.6) (.7) (.9), V39 (.4) (.5) (.6) (.9), V40 V48 (.5) (.6) (.7) (.9), V49 (.4) (.5) (.6) (.9), V50 V58 (.5) (.6) (.7) (.9), V59 (.4) (.5) (.6) (.9), V60 V68 (.5) (.6) (.7) (.9), V69 (.4) (.5) (.6) (.9), V70 V78 (.5) (.6) (.7) (.9), V79 (.4) (.5) (.6) (.9), V80 (.3) (.4) (.5), V81 V82 (.1), V86 (.0) (.1) (.2) (.3), V87 (.0) (.8), V National Statistics

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