International International Comparisons of Comparisons of Proportion of Proportion of Unspecified External Unspecified External Causes of Death Causes of Death Tsung-Hsueh (Robert) Lu, MD, MPH

Institute of Public Health, College of MedicineNational Cheng Kung University, Tainan, Taiwan

robertlu@mail.ncku.edu.tw

Sep 1999

April 2003

Nov 1996

台灣多重死因中文診斷自動化輸入系統MADE in Taiwan

Multiple-cause-of-death AutomatedData Entry System , 2004 version

IntroductionIntroduction IDEALLY, external causes of death (ECD)

provide information of circumstances related to the occurrence of injury events, which provide important information for injury prevention. (Users)

REALISTICALLY, certifiers (medical examiners and coroners) did not provide sufficient information for ideal external causes coding. (Producers)

V243Transport accidentsTransport accidents

Transport accidents

Mode of transport of the victim Mode of transport

of counterpart

Circumstances of the event and

the role of the victim

ECD: X59 exposure to ECD: X59 exposure to unspecified factorunspecified factor

Accidental head injury

Example OneExample One

ECD: V99 unspecified transport ECD: V99 unspecified transport accidentaccident

Head injury

Example TwoExample Two

Transport accident

ECD: V244 motorcycle rider ECD: V244 motorcycle rider injured in collision with heavy injured in collision with heavy transport vehicle or bustransport vehicle or bus

Head injury

Example ThreeExample Three

Motorcyclist in collision with bus

Research QuestionsResearch Questions What’s the proportion of injury deaths

of which the information reported could only be coded as “unspecified”? ---- an indicator of insufficiency of specific information the certifiers reported on the death certificates

Did this proportion differ by country? Did this proportion differ by ECD?

Materials & MethodsMaterials & Methods The number of deaths registered in

the year 2001 for each three-character code in Chapter XX (External causes of morbidity and mortality) of the ICD-10 were provided by four countries participating in the ICE (International Collaborate Efforts on Automating Mortality Statistics), i.e., Australia, Sweden, Taiwan and the United States.

Materials & Methods Materials & Methods (cont.)(cont.)External Causes of Injuries ICD-10 Code, U/B

All unintentional injuries X59/V01-X59

Transport accidents V89&V99/V01-V99Falls W19/W00-W19Accidental drowning and

submersion W74/W65-W74Other accidental threats to

breathing W84/W75-W84Exposure to smoke, fire and flames X09/X00-X09Intentional self-harm X84/X60-X84Assault Y09/X85-Y09Event of undetermined intent Y34/Y10-Y34

ResultsResults Sweden (32.5%) had the highest

proportion of unspecified code (ICD-10 code X59), followed by Australia (16.6%), Taiwan (13.2%) and the USA (7.2%).

The percentage of unspecified code was relatively high in falls and unintentional drowning and was relatively low in accidental poisoning, intentional self-harm and event of undetermined intent.

Results (cont.)Results (cont.) Sweden had highest unspecified

percentage (63.7%) of deaths from falls, followed by Australia with 55.5%, the USA (50.9%) and Taiwan (49.1%) . The proportion increased with age in each country (Table 2).

Taiwan had an extremely high percentage of unspecified codes in transport accidents (86.5%), accidental drowning (98.7%) and fire and flame (98.7%).

Swe

USASwe

USA

AusSwe

USA

AusTwn

Aus

Twn

Twn

0

20

40

60

80

100

0All unintentional injuries Transport accidents Falls

Perc

enta

ge o

f uns

peci

fied

codi

ng,

%

Why the % in Aus & Swe are relatively high compared with US?

Why all countries had relatively high % in falls?

Why the % in Aus & Swe are relatively low compared with US?

Persons?

Explaining the variations Differences in the system of medical

examiners and coroners? Differences in the training of medical

examiners and coroners? Differences in the format of death

certificate? Differences in the query system?

Taiwan’s attempts to improve Communicating with the medical

examiners, coroners, and prosecutors. Querying the certifiers for more specific

information for coding. Revising the format of death certificate. Interviewing the families of the deceased

to collect detail information. Building the National Coroners

Information System like those in Australia

ConclusionsConclusions According to our findings, there were

certain gaps between the ‘ideal’ and the ‘reality’ in classifying injury deaths among the four ICE participating countries.

Should the ‘users’ slow down the pace a little bit and spend more time with the ‘producers’ to improve the quality of data entry?

Swe

USASwe

USA

AusSwe

USA

AusTwn

Aus

Twn

Twn

0

20

40

60

80

100

0All unintentional injuries Transport accidents Falls

Perc

enta

ge o

f uns

peci

fied

codi

ng,

%

Why the % in Aus & Swe are relatively high compared with US?

Why all countries had relatively high % in falls?

Why the % in Aus & Swe are relatively low compared with US?

CommentComments are s are

needed!needed!

Persons?