The US National Violent Death Reporting System: domestic and international lessons for violence injury surveillance.

OBJECTIVES: This article reviews and comments on the development, strengths and limitations of the US National Violent Death Reporting System (NVDRS) from a variety of domestic and international perspectives. METHODS: The authors were provided preliminary copies of the manuscripts in this special edition and examined them to understand and put in context the elements and uses of the NVDRS so far. Their comments are based on their reading and interpretation of these papers plus their own combined experience in injury and public health surveillance from four different countries: the US, Colombia, Australia, and South Africa. RESULTS: The NVDRS is bigger than the sum of its parts because it links existing data from multiple sources. Its adoption of modern relational database technologies offers advantages over traditional injury surveillance databases and creates new opportunities for understanding, collaboration, and partnerships. Challenges include overcoming resource limitations so that it can become a truly national system, measuring and improving its sensitivity and comparability, and the need to examine mortality in context with serious non-fatal violent events. CONCLUSIONS: The NVDRS is an important work in progress for the US. Each country should examine its own needs, traditions, resources, and existing infrastructure when deciding what kind of violence surveillance system to develop. However, collaboration in developing common definitions and classifications provides an important foundation for international comparisons.

Incomplete and biased perpetrator coding among hospitalized assaults for women in the United States.

BACKGROUND: Since 1997, hospital discharge data have included external cause of injury (E codes) for designating perpetrator relationship in assaults. For intentional injuries, guidelines require using two E codes; one for the injury mechanism and another (E967.n) identifying perpetrator relationship. Completeness and characteristics of the use of these codes have not been studied on a multistate level among states with complete E coding. METHODS: Hospital discharge data for 1997 were solicited from states with good E coding completeness. Data were received from 19 states (51.9% of women in the United States, ages 15-49). For assaulted women, a regression model was constructed to identify factors associated with perpetrator code assignment using age, payment source, pregnancy status, race, and severity as covariates. RESULTS: Among 137 887 injured hospitalized women age 15-49, there were 7402 assaults (5.4%). Among all assaults to women, perpetrator coding was poor (8.8%). Among those that were perpetrator coded, 83.7% were spouse/partner related. Age was positively associated with probability of having a perpetrator code (p<0.001). Those paid by a private source were 42.9% more likely to have a perpetrator code (p = 0.007). Pregnant women were seven times more likely to have a perpetrator code (p<0.001). Non-white women were 66.8% less likely to have a perpetrator code (p<0.001) than white women. CONCLUSIONS: The poor use of perpetrator codes in hospital discharge data minimizes their usefulness for surveillance of serious injury from intimate partner violence. An implication of this research is the need to understand the gaps and strengthen the completeness of perpetrator documentation and coding. The findings suggest caution when interpreting the results from existing hospital discharge data based intimate partner violence surveillance systems.

Characteristics of pregnant women in motor vehicle crashes.

OBJECTIVES: Motor vehicle crashes are the leading cause of hospitalized trauma during pregnancy. Maternal injury puts the fetus at great risk, yet little is known about the incidence, risks, and characteristics of pregnant women in crashes. SETTING AND METHODS: Police reported crashes were analyzed from the National Automotive Sampling System Crashworthiness Data System. Since 1995, this system recorded pregnancy/trimester status. Pregnant and non-pregnant women 15-39 years of age were compared by age, driver status, seat belt use, and treatment. Belt use and seating position were examined by trimester. RESULTS: There were 427 pregnant occupants identified (weighted n=32 810, 2.6%, SE 12 585, rate 13/1000 person years). The mean age was 24.9 compared with 24.8 years (pregnant v non-pregnant). Cases were distributed by trimester as follows: first 29.8%, second 36.4%, and third 33.8%. Pregnant women were drivers 70% of the time compared with 71% for non-pregnant women. No belt use was 14% compared with 13% (pregnant v non-pregnant). Mean injury severity was lower for pregnant women but they were more likely to transported or hospitalized. Improper belt use decreased after the first trimester and there was little change in driver proportion by trimester. Third trimester hospitalization rates increased. CONCLUSIONS: Pregnant occupants in crashes have similar profiles of restraint use, driver status, and seat position but different treatment indicators compared to non-pregnant occupants. Trimester status has relatively little impact on crash risk, seating position or restraint use. Undercounting of pregnant cases was possible, even so, 1% of all births were reported to be involved in utero in crashes. Little research has focused on developmental outcomes to infants and children previously involved in exposure to these crashes.

Fetal deaths related to maternal injury.

CONTEXT: Maternal and fetal trauma is an important cause of adverse fetal outcomes. However, systematic exclusion from US injury surveillance programs of even the most severe outcome, fetal/neonatal death, has led to a lack of understanding about frequency, causes, and prevention. OBJECTIVE: To determine the rate of traumatic fetal deaths reported in state fetal death registries and the types of trauma and physiologic diagnoses associated with these deaths. DESIGN AND SETTING: Retrospective descriptive study of fetal death certificates from 1995 through 1997 obtained from 16 states, which accounted for 55% of US live births and approximately 15 000 fetal death registrations per year. MAIN OUTCOME MEASURE: Rate of fetal injury deaths, based on fetal death certificates coded with an underlying cause of death due to maternal injury at 20 weeks' gestation or later, by cause. RESULTS: During the 3-year study period, 240 traumatic fetal injury deaths were identified (3.7 fetal deaths per 100 000 live births). Motor vehicle crashes were the leading trauma mechanism (82% of cases; 2.3 fetal deaths per 100 000 live births), followed by firearm injuries (6% of cases) and falls (3% of cases). In 3 states, reported crash-related fetal deaths exceeded that of crash-related infant deaths. Placental injury was mentioned in 100 cases (42%) and maternal death was noted in 27 cases (11%). A peak rate of 9.3 fetal deaths per 100 000 live births was observed among 15- to 19-year-old women. CONCLUSIONS: Motor vehicle crashes are the leading cause of fetal deaths related to maternal trauma. Improved tracking of traumatic fetal injury deaths is important to stimulate and guide research and efforts to reduce the risks to women and fetuses from injury during pregnancy.

The epidemiology of traumatic injury-related fetal mortality in Pennsylvania, 1995-1997: the role of motor vehicle crashes.

METHODS: Rates and causes of traumatic injury-related fetal deaths in Pennsylvania were determined from a manual review of all fetal death certificates filed from 1995 to 1997 (7,131 cases). RESULTS: Thirty one traumatic injury cases were identified (6.5/100,000 live births). Most cases (94%) could be identified from the diagnosis code of 760.5 (maternal injury) and 87% contained narratives indicating specific injury mechanisms. Motor vehicles were the leading cause of injury (81%). Placental separation was the leading diagnosis (42%). CONCLUSIONS: The ICD-9-CM code 760.5 appears to be a specific indicator of traumatic fetal death, though it is not known how sensitive an indicator it is. Though not usually E-coded, the death certificates contained enough information to allow ascertainment of injury mechanism. These are very conservative estimates of the burden of the problem. The major role that motor vehicle injuries have on reported traumatic fetal injury deaths was shown and a significant new challenge for child passenger safety advocates is indicated.

Traumatic brain injuries evaluated in U.S. emergency departments, 1992-1994.

OBJECTIVE: To describe the incidence and patient characteristics of traumatic brain injuries (TBIs) treated in U.S. emergency departments (EDs). METHODS: A secondary analysis was performed on data from the National Hospital Ambulatory Medical Care Survey administered from 1992 to 1994. An ED visit was determined to represent a case of TBI if the case record contained ICD-9-CM codes of 800.0-801.9, 803.0-804.9, or 850.0-854.1. RESULTS: The average annual estimate of new TBI treated in U.S. EDs was 1,144,807, equaling 444 per 100,000 persons (95% CI = 390 to 498), which represents approximately 3,136 new cases of TBI per day and accounts for 1.3% of all ED visits. Males were 1.6 times as likely as females to suffer TBI until the age of 65 years, when the female rate exceeded the male. The rate for blacks was 35% higher than that for whites. The highest overall incidence rate of TBI occurred in the less-than-5-year age group (1,091 per 100,000), closely followed by the more-than-85-year age group (1,026 per 100,000). Falls represented the most common mechanism of TBI injury, followed by motor vehicle-related trauma. CONCLUSIONS: This study underscores the ongoing need for effective surveillance of all types of TBI and evaluation of prevention strategies targeting high-risk individuals. It serves as a clinically grounded and ED-based corroboration of prior survey research, providing a basis for comparison of incidence rates over time and a tool with which to measure the efficacy of future interventions.

Pregnancy-associated injury hospitalizations in Pennsylvania, 1995.

STUDY OBJECTIVE: To estimate the frequency of pregnancy-associated injury hospitalization and compare rates between pregnant women and all women of reproductive age by age, race, injury mechanism, intent, and other variables. METHODS: Using International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) selection criteria applied to Pennsylvania's 1995 acute hospital discharge data, all resident women ages 15 to 44 with coexistent pregnancy and injury-related diagnoses were identified for descriptive and comparative rate calculations. RESULTS: Seven hundred sixty-one (4. 6%) of the discharges to injured women of reproductive age were associated with pregnancy. The leading injury causes among pregnant women were transportation-related (234 [33.6%]), falls (192 [26.4%]), poisonings (116 [16.0%]), and "struck by" (83 [11.4%]). Among all women 15 to 44 years, poisoning was the leading cause (32.6%) of injury, followed by transportation-related injuries (25.7%). The hospitalized injury incidence was 868 per 100,000 person-years for pregnant women versus 641 for all women ages 15 to 44 (rate ratio 1. 35, 95% confidence interval [CI] 1.25 to 1.45). Pregnant women were younger (median age 24.9 years versus 30.0 years), their mean length of stay was shorter (2.5 days versus 3.7 days), the mean injury severity score was less (3.2 versus 4.8), and the median charge per stay was lower ($4,164 versus $6,051). Rate ratios (pregnant versus all women in same age group) were significantly higher for younger women 15 to 19 years (rate ratio 2.69, 95% CI 2.49 to 3.14). Rate ratios were significantly higher for assaults (rate ratio 3.04, 95% CI 2.45 to 3.78), falls (rate ratio 2.33, 95% CI 2.01 to 2.70), motor vehicle occupant (rate ratio 2.0, 95% CI 1.73 to 2.31), and struck by (rate ratio 3.73, 95% CI 2.97 to 4.69). Rate ratios were lower for poisonings (rate ratio 0.71, 95% CI 0.59 to 0.86) and self-inflicted injuries (rate ratio 0.62, 95% CI 0.50 to 0.77). CONCLUSION: Pregnant women were more likely than all women 15 to 44 years to be hospitalized for injury and more likely to be hospitalized for assaults, falls, transportation-related, and less severe injuries, but less likely for poisonings and self-inflicted injuries. Much of the increased risk appears to be concentrated in young women. Further work is needed to establish to what extent the observed increases are the result of increased injury rates or increased hospitalization rates.

Incidence and characteristics of fall-related emergency department visits.

OBJECTIVE: Unintentional falls are the leading cause of injury and the second most common cause of unintentional injury deaths in the United States, and place a great burden on EDs. In this study, the objective was to describe the incidence and characteristics of ED visits associated with unintentional falls in the United States. METHODS: The authors performed a secondary analysis on data from the National Center for Health Statistics' National Hospital Ambulatory Medical Care Survey for 1992-1994. An ED visit was defined as fall-related if an ICD-9-CM cause of injury code was reported as E880.0-886.9 or E888. RESULTS: There were an estimated 7,946,000 fall-related ED visits per year, corresponding to an annual rate of 3.1 per 100 persons (95% CI=2.8 to 3.4). Children under 5 years of age comprised the largest proportion of visits (14%). Among those visits coded with respect to place of occurrence, the rate of visits associated with falls occurring at home (1.7/100; 95% CI=1.6 to 1.9) was significantly higher than that associated with falls occurring in all other locations combined (1.1/100; 95% CI=1.0 to 1.2). The mean injury severity score increased significantly with the age of the patient. Fall-related ED visits resulted in an estimated 860,000 hospitalizations, 62% of which involved individuals aged 65 years and older. An estimated $2.45 billion per year was paid for fall-related ED visits. Government sources paid all or part of 41% of visits. CONCLUSIONS: This study reports nationally representative data describing the incidence and characteristics of fall-related ED visits. These data expand what is known about the epidemiology of falls and help to define the burden that fall injuries place on EDs in the United States. The results of this study could serve as a benchmark to evaluate the effectiveness of future fall prevention efforts.

Incidence of dog bite injuries treated in emergency departments.

CONTEXT: Dog bites that result in injuries occur frequently, but how frequently dog bite injuries necessitate medical attention at a hospital or hospital admission is unknown. OBJECTIVE: To describe the incidence and characteristics of dog bite injuries treated in US emergency departments (EDs). DESIGN: Emergency department survey from the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1992 to 1994. PATIENTS: National probability sample of patients visiting EDs. MAIN OUTCOME MEASURE: Incidence of dog bites treated in EDs, defined as a cause of injury recorded as the E-code E906.0. RESULTS: The 3-year annualized, adjusted, and weighted estimate of new dog bite-related injury visits to US EDs was 333687, a rate of 12.9 per 10000 persons (95% confidence interval [CI], 10.5-15.4). This represents approximately 914 new dog bite injuries requiring ED visits per day. The median age of patients bitten was 15 years, with children, especially boys aged 5 to 9 years, having the highest incidence rate (60.7 per 10000 persons for boys aged 5 to 9 years). Children seen in EDs were more likely than older persons to be bitten on the face, neck, and head (73% vs 30%). We estimated that for each US dog bite fatality there are about 670 hospitalizations and 16000 ED visits. CONCLUSIONS: Dog bite injuries are an important source of injury in the US population, especially among children. Improved surveillance and prevention of dog bite-related injuries, particularly among children, are needed.

The potential of using billing data for emergency department injury surveillance.

OBJECTIVE: To determine the availability of and sample statewide ED injury information obtained from hospital billing data for the purpose of demonstrating the feasibility of information acquisition for subsequent data linkage. METHODS: A retrospective, database investigation was conducted to obtain data describing a statewide stratified sample of ED patients. The aim was to collect a computerized billing summary record for each injured ED patient seen at each sampled hospital over a 1-year period. All 215 Pennsylvania acute care hospitals in 1991 were eligible for sample selection. Data collection for the project was conducted in 1993. Participants included directors of hospital medical records and billing departments. RESULTS: Twenty-four hospitals contributed data sets from the original target goal of 31 strata. The final combined data set contained 187,404 records with injury diagnoses from approximately 616,000 ED patient visits, representing a 12% sample of all annual statewide ED visits. Age, sex, date of visit, and primary diagnosis fields were completed from the retrieved data > 99% of the time. More than two-thirds of the sampled records had a social security number, and total charges were recorded > 90% of the time. Other variables such as name and address were contained in < 50% of the records submitted. E-codes were usually not available. CONCLUSIONS: Retrospective compilation of multihospital ED billing data to create a statewide ED data sample-with the potential for injury research and probabilistic database linkage-can be accomplished; there are, however, important limitations.

Identifying homes with inadequate smoke detector protection from residential fires in Pennsylvania.

With data from the Center for Disease Control's Behavioral Risk Factor Surveillance System, we estimated the prevalence of homes with inadequate smoke detector protection from residential fires in Pennsylvania and identified the characteristics of these homes in an effort to identify useful prevention strategies for Pennsylvania and other regions with similar characteristics. Homes with inadequate smoke detector protection from residential fires were defined on three levels. Eight percent (95% CL = 6.8, 8.6) of homes lacked any installed smoke detectors, 14% (95% CL = 12.8, 15) lacked smoke detectors installed on the same floor where they slept, and 28% (95% CL = 26.6, 29.6) were found to engage in unsafe smoke detector practices. The strong predictors of unsafe smoke detector practices determined from logistic regression included black, non-Hispanic homes (OR = 1.53), homes with annual household income of less than +20,000 (OR = 1.29), and those with no children younger than 5 years old (OR = 1.55). These findings should assist policy makers in planning residential fire prevention programs for Pennsylvania, which has yet to meet the Healthy People 2000 objective regarding fire prevention.

Injury surveillance: a statewide survey of emergency department data collection practices.

STUDY OBJECTIVE: To assess current emergency department data collection practices in Pennsylvania and determine whether existing data sources can be used as part of a statewide injury surveillance system. METHODS: Separate survey questionnaires requesting information on current ED patient data collection practices and attitudes were mailed to all directors of medical records, billing, and EDs in Pennsylvania (N = 212). RESULTS: Of the medical records department respondents, 92% indicated that ED registration data are retained in a computerized information system; 94% of respondents from billing departments reported that their ED patient registration system is integrated with an ED billing system. A total of 36% of EDs surveyed use a computerized ED patient logbook, and another 27% plan to begin a computerized log within 2 years. Dictation and transcription services that permit electronic retrieval of text are being used by 26% of EDs for patient medical records. CONCLUSION: Many elements for building a statewide ED injury surveillance system are in place in Pennsylvania, but they are as yet incomplete. Future studies should examine the feasibility of integrating existing ED data systems into statewide injury surveillance systems.

Limitations of child injury data from the CPSC's National Electronic Injury Surveillance System: the case of baby walker related data.

OBJECTIVES: The US Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) is a primary source for children's consumer product injury surveillance data in the US. Differing interpretations of the emergency department based NEISS baby walker data by various parties prompted this detailed examination, reclassification, and analysis of the NEISS data to explain these discrepancies. METHODS: Case selection was performed by searching the NEISS 1982-91 database for the baby walker product code and various text strings for children less than 24 months old. False negative and false positive cases were identified and reclassified. Adjusted population rates were computed and the types and locations of hospitals contributing to the sample were examined. RESULTS: One per cent false positive and 4% false negative misclassification rates were observed. In 1991, two children's hospitals reported 14% of the baby walker related injuries, though these hospitals made up just 2% of the sample frame. Through random allocation, one state currently contains four acute care hospitals and the only two children's hospitals reporting to the NEISS system. These six hospitals contributed 18% of the walker cases whereas the state represents only 3% of the US infant population. CONCLUSIONS: Misclassification in NEISS baby walker reports is minimal, with false negatives outweighing false positives. For trend analysis of product related injuries at the frequency of occurrence observed for baby walkers, NEISS suffers from low sensitivity due to sampling error. For children's injuries, NEISS' estimates have been affected by children's hospitals coming in and out of the sample and currently reflects a random geographic imbalance because one state contributes both of the reporting children's hospitals. To overcome these problems improved multiple product coding, a unique baby walker code, and stratification of children's hospitals in an enlarged NEISS sample is recommended.

A primer on school violence prevention.

Violence has reached epidemic proportions in the United States with particularly serious health implications for school-age children and adolescents. Schools that experience the daily threat of potential student violence have their primary mission of education eroded at great cost to students. This article reviews the problem of violence in public schools and summarizes existing knowledge on school violence prevention. Violence prevention programs that use educational, regulatory, technological, or combined approaches are reviewed. Recommendations are presented addressing both policy and program needs related to control of violence in public schools. School health professionals should be active participants in violence prevention efforts. A critical need exists to carefully evaluate any planned prevention program so future efforts can be built on methods proven successful.

Fatal farm injuries among young children.

Death certificate data concerning farm-related injury deaths among children 0 to 9 years of age in Wisconsin and Illinois for the period of 1979 to 1985 were reviewed. Average annual farm-related injury death rates were 3.2 per 100,000 rural children in Wisconsin (62 deaths) and 1.5 per 100,000 in Illinois (32 deaths). Rates were three times higher among boys than girls. The occurrence of two harvest-related peaks and the absence of fatality in children less than 1 year of age suggest that presence of children on the farm when supervision is diminished is a key factor in farm-related fatalities. Moving machinery (tractors, wagons, and trucks) was the source of injury in approximately 55% of all deaths. Drowning accounted for 15% of all farm-related deaths. Two fatalities related to gravity box wagons could have easily been prevented with simple safety devices. These findings suggest a need for developing environmental interventions in farms. This will require the allocation of more resources to farm safety programs and a revision of current farm safety legislation.