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The ICD-10 injury diagnosis matrix: Grouping S and T codes by bodyregion and nature of injury Paul R. Jones and Bruce A. Lawrence Pacific Institute for Research and Evaluation Lois A. Fingerhut National Center for Health Statistics November, 2004 |
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BackgroundICD-10, like its predecessor ICD-9, contains so many detailed codes that it is often difficult to see the forest for the trees. Researchers, epidemiologists, and public health administrators, therefore, often rely on various methods for grouping codes into more manageable categories. For injury research, one of the most useful tools has been the Barell Matrix (Barell et al., 2001), which categorizes ICD-9-CM injury morbidity codes by body region and nature of injury. Since 1999, mortality data have been coded in ICD-10. A successor to the Barell Matrix for use with ICD-10 injury mortality diagnosis codes would be a new tool to aid researchers and policymakers. |
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BackgroundBody Sites Body Sites Body Sites Body Sites Body Sites Body Sites Body Sites Nature of Injury Nature of Injury 1 Amputation 2 Burn 3 Blood Vessel 4 Crush 5 Dislocation 6 Foreign Body 7 Fracture 8 Internal Injury 9 Multiple 10 Muscle/Tendon 11 Nerve 12 Open Wound 13 Other Ext Eff 14 Other Spec 15 Poisoning 16 Sprain/strain 17 Super/cont 18 Toxic effect 19 Unspecified 1 1 Head 20 Abd+ low bk + pelv 39 Lower ext other Lower ext other 2 2 Face 21 Trunk other 40 Unspecified Unspecified 3 3 Eye 22 Shouldr/upp arm 41 Multi regions Multi regions 4 4 Neck 23 Elbow 42 Systemic Systemic 5 5 Head+Neck 24 Forearm Forearm Forearm Forearm 6 6 SC-neck 25 Wrist/hand Wrist/hand Wrist/hand Wrist/hand 7 7 SC-upper back 26 Fingers Fingers Fingers Fingers 8 8 SC-lower back 27 Upper ext mult Upper ext mult Upper ext mult Upper ext mult 9 9 SC-other 28 Upper ext other Upper ext other Upper ext other Upper ext other 10 10 SC-Multiple 29 Hip Hip Hip 11 11 VC-neck 30 Thigh Thigh Thigh 12 12 VC-upper back 31 Hip + thigh Hip + thigh Hip + thigh Hip + thigh 13 13 VC-lower back 32 Upp leg + thigh Upp leg + thigh Upp leg + thigh Upp leg + thigh 14 14 VC-lower back + pelv 33 Knee Knee Knee 15 15 VC-other 34 Lower leg Lower leg Lower leg Lower leg 16 16 Thorax 35 Foot Foot Foot 17 17 Abdomen 36 Ankle Ankle Ankle 18 18 Pelvis 37 Ankle + foot Ankle + foot Ankle + foot Ankle + foot 19 19 Lower back + pelv 38 Toes Toes Toes |
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Coding and Validating the AlgorithmA draft of the ICD-10 injury diagnosis matrix was first provided by Lois A. Fingerhut (NCHS). That draft was based on earlier work by Richard Hockey in Australia. The matrix classifies all injury ‘S’ and ‘T’ codes by body region and nature of injury. With 19 nature-of-injury categories and 42 body-region categories, it is somewhat more detailed than the original Barell Matrix. Like the original, it also provides for collapsing the body regions into broader categories. PIRE translated the matrix into a SAS algorithm, which can operate on any valid ICD-10 S or T code. |
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In order to validate the algorithm, we first tested it against theICD-10 coded Multiple Cause of Death (MCOD) data for 2000. For records containing an injury diagnosis (i.e., an S or T code), we selected the injury diagnosis from the entity axis assigned by the death certificate as the earliest injury diagnosis in the chain of causes leading to death. We ran this classifying diagnosis (Dx0) through our algorithm. The algorithm successfully assigned nature-of-injury and body-region codes to each case. |
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Data & MethodsWe next applied the algorithm to the 1999-2001 MCOD data. We selected all cases with at least one injury diagnosis on the record axis. This gave us 540,748 cases, which broke down by age and sex as follows: AGE AGE SEX SEX SEX Female Male Total 50 or younger 71,959 (13.3%) 218,909 (40.5%) 290,868 (53.8%) Over 50 113,097 (20.9%) 136,783 (25.3%) 249,880 (46.2%) Total 185,056 (34.2%) 355,692 (65.8%) 540,748 (100.0%) |
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For every injury death, we applied the algorithm to each injurydiagnosis on the record axis (except superficial injuries, which were judged to be unlikely to cause death). In order to avoid double counting deaths with multiple injury diagnoses, we gave each diagnosis a weight equal to the reciprocal of the number of injury diagnoses on the record. Example: a death that involved a head fracture and a crushed thorax would be counted as half a death from head fracture and half a death from crushed thorax. By diagnosis matrix cell, we then computed the weighted numbers of cases across all injury deaths. |
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ResultsTop 5 Nature of Injury Categories Top 5 Body Region Categories Top 10 Injury Diagnosis Categories as a function of Nature of Injury and Body Region |
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Top 5 Nature of Injury CategoriesRemaining Categories 24.3% Unspecified Injury 26.1% Other External Effects1 9.1% Open Wound 15.8% Poisoning 10.9% Fracture 13.8% Note. 1 = E.g., asphyxiation, drowning. |
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Top 5 Body Region CategoriesMultiple Regions 10.2% Remaining Categories 24.9% Systemic1 23.5% Unspecified Region 8.3% Head 23.7% Trunk, Other 9.4% Note. 1 = E.g., foreign body, poisoning, external effects. |
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Top 10 Injury Diagnosis Categories as a function of Nature of Injuryand Body Region 9.1 |
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Incidence of Most Common Fatal Injury Diagnoses by Age and Sex 1 2 3 4 5 6 7 8 9 10 11 12 50 or younger 50 or younger 50 or younger Older than 50 Older than 50 Older than 50 All ages All ages All ages Female Male Total Female Male Total Female Male Total Poisoning 20.4% 14.8% 16.2% 4.9% 4.6% 4.8% 11.0% 10.9% 10.9% Other external effects @ 10.4% 12.8% 12.2% 4.1% 6.8% 5.6% 6.5% 10.5% 9.1% Unspecified injury of head 10.8% 9.9% 10.1% 5.3% 7.7% 6.6% 7.4% 9.0% 8.5% Unspecified injury of multiple regions 12.2% 10.2% 10.7% 5.1% 6.5% 5.9% 7.8% 8.8% 8.5% Foreign body in trunk, other # 2.5% 1.4% 1.7% 17.5% 14.1% 15.7% 11.7% 6.3% 8.1% Open wound of head 6.2% 10.7% 9.6% 1.6% 9.0% 5.7% 3.4% 10.0% 7.8% Hip fracture 0.1% 0.0% 0.0% 22.1% 10.1% 15.6% 13.6% 3.9% 7.2% Internal injury of head & 3.6% 3.7% 3.7% 7.6% 8.4% 8.1% 6.1% 5.5% 5.7% Unspecified injury of unspecified region 6.4% 5.4% 5.6% 3.6% 4.6% 4.2% 4.7% 5.1% 5.0% Toxic effects 4.6% 4.0% 4.2% 2.1% 3.0% 2.6% 3.1% 3.6% 3.4% Open wound of thorax 2.4% 4.4% 3.9% 0.5% 2.0% 1.3% 1.2% 3.5% 2.7% Unspecified injury of thorax 2.4% 2.5% 2.4% 1.7% 2.4% 2.1% 1.9% 2.4% 2.3% Other 18.1% 20.3% 19.8% 23.8% 20.6% 22.1% 21.6% 20.4% 20.8% Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% @ Mostly asphyxiation and drowning # Mostly associated with choking & Brain injury |
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Some injury categories were concentrated in people over 50: Fracturesof the hip were especially prevalent among women over 50, accounting for 22.1% of all injury-related deaths - the highest ranking category for this demographic group. For men over 50, hip fractures accounted for 10.2% of injury deaths. For people under 50, however, hip fracture deaths were almost nonexistent. Foreign body in the trunk accounted for 15.7% of all injury deaths of people over 50, but only 1.7% for those 50 or under. These are mostly choking deaths. Internal injuries of the head (brain injuries) accounted for 8.1% of injury deaths of people over 50, but only 3.7% for ages 50 and under. |
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Other fatal injury categories were more common among people 50 andunder: Among people age 50 or less, the biggest fatal injury category was poisoning, which, together with toxic effects, accounted for 20.3% of all injury deaths. Poisoning and toxic effects were more prevalent among women (25.0%) than among men (18.8%). They were less common among people over 50 (7.4%). Other external effects (mostly drowning and asphyxiation) accounted for 12.2% of injury deaths among those 50 or under, but only 5.6% among those over 50. Unspecified injuries of multiple regions accounted for 10.7% of injury deaths among those 50 or less, but only 5.9% among those over 50. |
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Other fatal injury categories were more common among people 50 andunder (continued): Unspecified head injuries accounted for 10.1% of injury deaths among those 50 or less, but only 6.6% among those over 50. Open wounds were more common among males than females. Open wounds of the head accounted for 10.0% of injury deaths among men and 3.4% among women. Open wounds of the thorax accounted for 3.5% of injury deaths among men and 1.2% among women. |
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5.4% of injury death certificates lacked any injury diagnosesSome coroners and MEs follow the convention (which is permitted by coding rules) of letting a cause code represent the injury without any accompanying injury diagnosis code. Of the cases with at least one injury diagnosis code (the sub-sample used elsewhere in this study), 70.3% had a single injury diagnosis 19.6% had two injury diagnoses 6.4% had three injury diagnoses, and 3.6% had four or more injury diagnoses. Internal organ injuries of the head (i.e., brain injuries) and unspecified injuries of the thorax were especially likely to be accompanied by at least one other injury diagnosis (51.1% and 56.5%, respectively). |
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DiscussionThis exercise gave a clearer picture of a known weakness of ICD-10 coded data - the heavy reliance on “multiple” and “unspecified” categories that are of little use to researchers. In our injury-coded data, 31.5% of deaths with injury diagnoses have a multiple or unspecified code for either the nature of injury or the body region, and 13.6% have both. |
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ConclusionThe SAS algorithm successfully assigned body region and nature of injury classifications to a multi-year ICD-10 coded mortality dataset. This new injury diagnosis matrix and the SAS algorithm that embodies it will constitute a useful tool for the description and analysis of fatal injury data. The matrix will serve as an initial injury classification benchmark for ICD-10 (and, later, during the transition to ICD-10-CM coding for medical data). |
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The algorithm proved robust against a large mortality dataset thatcould reasonably be expected to provide a sufficient test, but it should be validated against other datasets before being widely circulated. The heavy use of “multiple” and “unspecified” diagnoses will be a challenge to those using these ICD-10 coded data for injury research. |
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