designing and implementing surveillance systems in indian country

1

Designing and Implementing Surveillance Systems in Indian Country

Introduction

2

Introductions

• Who are you?• Where are you from?• What do you do?• Do you have any experience in injury

surveillance?

Introduction

3

Course Learning Objectives• Review the concepts and framework of injury

prevention

• Learn to assess injury data sources and use data to describe the injury problem

• Learn how to build partnerships or a coalition to support the injury surveillance system

Introduction

4

Course Learning Objectives• Learn how to determine the appropriate methodology for the

surveillance system

• Learn how to define and develop an analysis plan for the surveillance data

• Learn to use injury surveillance data to inform injury prevention

• Learn how to define an evaluation plan for the surveillance system and monitor prevention activities

Introduction

5

About the Course Manual

• Pre-test on Page 3• Post-test Page 107• Larger versions of charts in Appendix 6

Introduction

6

What is an InjurySurveillance System?

Introduction

7

What is an Injury Surveillance System?

• Ongoing systematic collection, analysis and interpretation of injury data for use in planning, implementing and evaluating prevention activities

• Injury prevention programs use the data to assess the need for new policies or programs and to evaluate the effectiveness of those that already exist

Introduction

8

Questions for Class

• Why do you want to develop an injury surveillance system?

• What do you plan to do with the data you collect?

Introduction

9

• Create a surveillance system• Goal to show how each step or concept could be

applied• Choose a scenario• Work in groups• Complete worksheet after each section or at the

end of the course • Share with group

About the Course Exercise

Introduction

10

Step 1: Understand the Concepts and Framework of Injury Prevention

Section 1

11

Objectives for Section 1• Review the concepts, definitions and classification of

injuries• Review the burden and the cost of injury• Understand the conceptual models for

understanding and preventing injuries• Introduce the steps to developing an injury

surveillance system• Understand the ethical considerations associated

with injury surveillanceSection 1

12

Injury Problem in the United States

• Unintentional & Intentional Injuries in 2010– 3rd leading cause of death – all ages– Leading cause of death in ages 15-34 – Cost an estimated $403 billion annually in medical

expenses and lost productivity

Section 1

13

Injury Problem in Indian Country

• Unintentional & Intentional Injuries in 2010– 3rd Leading Cause of Death – all ages– Leading cause of death in ages 15-34

Section 1

14

Injury Definition

Damage to the body caused by:

• Exposure to an outside force or • Lack of something essential or

• Uncontrolled release of mechanical energy Section 1

15

Injury Definition

Injuries

Disease

Are Not the Same As

Section 1

16

Injury Definition

Injury vs. DiseaseInjury: Broken toe caused by a jackhammer

Disease: Tendonitis of the elbow caused by years of exposure to the vibration of a jackhammer

Section 1

17

Injury Definition

Injury vs. DiseaseInjury Disease

A child is bitten by a dog and requires ten stitches to his leg

A child contracts rabies after a dog bite

A firefighter suffers smoke inhalation while fighting a wildfire

A former uranium miner contracts lung cancer from years of exposure to uranium dust

Section 1

18

Injury Definition

Injuries

Accidents

Are Not

Section 1

19

Injury ClassificationUnintentional

• Fall• Car Crash• Dog Bites• Burns• Drowning

Intentional• Suicide• Stabbing• Gun Shot

Section 1

20

Injury Classification

Unintentional Injury• Occur without the intent of anyone involved• 5th leading cause of death in US -- all ages• In Indian Country

– 3rd leading cause of death all ages– Leading cause of death under age 44

Section 1

21

• Physical damage to the body• Caused by

– Excessive force or– Exposure to external agents, such as poison or– Deprivation of an essential elements, such as air

or warmth• Damage is not done deliberately


Unintentional Injury

Section 1

22

• Can be inflicted by a number of mechanisms, including: – Mechanical– Radiant – Thermal – Electrical – Chemical


Unintentional Injury

Section 1

23


Intentional Injury• Deliberate harm to oneself or another• Includes

– Domestic violence– Child or elder abuse– Suicide attempts

Section 1

24

• In US (2010) – 10th Leading Cause of Death – all ages– Leading Cause of Death – ages 15-34

• In Indian Country (2010)– 6th leading cause of death – all ages– Leading cause of death – ages 15-34– Account for 28% of all injury deaths


Intentional Injury

Section 1

25

• World Health Organization divides intentional injuries in three categories– Self-directed– Interpersonal– Collective


Intentional Injury

Section 1

26

• Nature of Intentional Injuries– Physical violence– Sexual violence– Psychological violence– Deprivation or neglect


Intentional Injury

Section 1

27

Death 180,811

Hospitalization* 2.4 million

Ambulatory Care* Visits to physicians offices, outpatient care and

emergency department

80.2 million

US 2010

Burden of Injury Injury Severity Pyramid

Section 1

28

The Burden of Injury in Indian Country

• 2,523 deaths in 2010• 66,612 years of potential life lost in 2010• Cost an Estimated $2.1 billion

– Medical care– Rehabilitation cost– Lost wages and productivity

Section 1

29

Burden of InjuryLifetime Cost of AI/AN Injuries

Medical Costs

Productivity Loss

AdministrativeCosts

Total Costs

($ Millions)All Injuries $489 $1,477 $211 $2,176Motor Vehicle

285 610 83 978

Suicide 19 156 20 194

Falls 30 89 16 135

Homicides 16 94 19 129

Fires 19 30 7 56

Section 1

30

Interventions that Save Money in Indian Country

• DUI Laws• Personal Flotation Devices• Smoke Detectors• Bike Helmets• Primary Seat Belt Laws• Livestock Control• Child Car Seat Program

Financial Benefits of Injury Prevention

Section 1

31

Financial Benefits of Injury Prevention

Cost Outcome Analysis

InterventionCost per

UnitCost

Savings

Sobriety Checkpoints $12,000 per checkpoint

$82,000 per checkpoint

Battery-Operated Smoke Alarms $44 per alarm $770 per alarm

Bicycle Helmets for ages 3-14 $12 per helmet

$580 per helmet

Child Safety Seat Distribution, Ages 0-4 $52 per seat $2,200 per seat

Section 1

32

Conceptual Models for Understanding and Preventing Injury

Public Health Approach

Section 1

33

Host

Agent Environment


EPI Triad

Section 1

34


EPI Triad• Offers three opportunities for intervention

– Host: Injured Person– Agent: Mechanism that inflicted the injury– Environment: Physical and social environment in

which the injury occurred

Section 1

35

Conceptual Models for Understanding and Preventing InjuryHaddon Matrix

Host Agent Physical & Social Environment

Factors in a motor vehicle crash

Phase

Pre Event Alcohol consumption, fatigue, experience

Brakes, tires, steering

DUI laws (social), road conditions (physical), speed limit (social)

Event Seat belt use, age, sex Speed at impact, automatic restraints

Median barriers, roadside embankments (both physical)

Post Event Physical condition, disabilities

Integrity of fuel system

Emergency communications (social), transport systems (social), distance to medical service (physical)

Section 1

36

Societal Community Relationship Individual

Section 1


Ecological Model for Understanding Violence

37

• Interaction of biology, behavior and environment

• Changes over the course of life• Violence prevention a continuum of activities

Section 1



38

• Looks at factors on four levels– Individual– Relationship– Community– Societal

Section 1



39

• Individual Level– Biological and personal factors, such as age,

education, income, substance abuse, history of abuse

– Prevention strategies would promote attitudes, behaviors or beliefs to prevent violence



Section 1

40

• Relationship Level – Includes peers, partners and family members– Prevention strategies would promote healthy

relationships

Section 1



41

• Community Level– Includes settings, such as schools, workplace and

neighborhood– Prevention strategies designed to impact system

could include marketing campaigns to promote healthy relationships

Section 1



42

• Societal Level– Include societal or cultural norms, policies that

maintain economic or social inequalities– Prevention strategies aimed at policy

Section 1



43Section 1

• Energy damage and the 10 countermeasures strategies by Dr. William Haddon, Jr.

• The Social Ecological Model: A Framework for Prevention Centers for Disease Control and Prevention

• The Ecological Model and Risk Protection Factors Centers for Disease Control and Prevention


For More Information

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1067540/?page=1

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1067540/?page=1

http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html



http://www.ctfalliance.org/images/initiatives/CDC_Ecological_Model.pdf

http://www.ctfalliance.org/images/initiatives/CDC_Ecological_Model.pdf

44

1. Review the concepts and

framework of injury prevention

2. Assess injury data sources and define the injury

problem

3. Build a partnership or

coalition to support the injury

surveillance system and prevention

activities

4. Determine the appropriate

methodology for the surveillance system

5. Define and develop an analysis

plan for the surveillance data

6. Use injury surveillance data to

inform injury prevention

7. Define an evaluation plan for

the surveillance system and monitor prevention activities

Steps to Developing an

Injury Surveillance

System

Section 1

45

Steps to Developing a Surveillance System

Important Things to Remember• These steps are a guide• Not every step will be achievable or feasible• Implement as much as you can• Modify steps as need be• Seek the help of experts

Section 1

46


Ethical and Cultural Considerations• Privacy • Confidentiality• Privacy Act of 1974• HIPAA

Section 1

47


Ethical and Cultural Considerations• Institutional Review Boards• Cultural Concerns

Section 1

48

Summary of Section 1

• Questions?

• What did you already know?

• What did you learn that was new?

• Complete Question 1 on Final Exercise

Section 1

49

Step 2: Assess Injury Data Sources and Describe Injury Problem

Section 2

50Section 2

Objectives for Section 2

• Identify injury data sources and the strengths and weaknesses of each

• Identify available data sources that can provide information to your surveillance system

• Use data to describe the size of the injury problem

51Section 2

Overview of Common Data SourcesDeath Certificates• Pros

– Inexpensive– Readily accessible

• Cons– May not contain enough information– Not all tribal or IHS facilities report to state– Not a good guide to determining overall problem or

medical consequences

52Section 2

Hospitalization Records• Pros

– Combined with mortality data, can provide a better picture of injury problem

• Cons– Access more difficult– Coding inconsistent– Difficult to determine ethnicity of victim– May require manual review of records

Overview of Common Data Sources

53Section 2

Outpatient Visits Records• Pros

– Good source of supplementary information on specific injuries

• Cons– Injuries that require hospitalization may be treated at non-

IHS/non-tribal facilities– May need to combine with contract health care records for a

better picture– Access may be difficult


54Section 2

CDC WISQARS™• Interactive• Online database• Fatal and nonfatal injuries• Information from variety of trusted sources


55Section 2

WISQARS™• Pros

– Search, sort, and view injury data– Create reports, charts and maps based on

mechanism, body region, nature of injury, geographic location, sex, race/ethnicity, age

• Con– Morbidity data not available for AI/AN population


56Section 2

• Police Reports• Records of Occupational Injuries• State Data Sources• National Data Sources• Local Newspaper Accounts• See Appendix 2 for Matrix of Data Sources

Other Common Data Sources

57

Common Data Sources for

Investigating an Injury in Indian

Country

Forensic Medicine/Coroner

may conduct autopsy,but

autopsies are not always done

Transportation Office collects information

related to victims, vehicles and

circumstances

Law Enforcement: BIA Police, Tribal Police, Country or

State Police

Local EMS

District Attorney attends all cases of injury deaths and

collects information on

victims, suspects and circumstances

State Data Sources

Section 2

58Section 2

Its usefulness for injury surveillance, research and practices.

Estimates of its accuracy, completeness and representativeness

Timeliness of the data Resource requirements. (How long will it take

you to collect the data? How much will it cost?) Simplicity

Determining the Strength and Weaknesses of Each Data Source

59Section 2

Determining the Strengths and Weaknesses of Each Data Source

JurisdictionWho collected the data and why?

60Section 2

Determining the Strengths and Weaknesses of Each Data Source

Information Taken at the Scene

Preliminary Reports, Certificates, Etc.

Database

Method and FlowHow was the data collected? Where does it go?

61Section 2

Data Assessment Exercise• Time: 30-45 minutes• Purpose: What specific things would you want to see

in a database.• You have been offered access to a locally run

database on youth activity• What specific questions would you ask to determine

the strengths and weaknesses of this data source?– Keep previously discussed considerations in mind

62Section 2

Identify Data Sources to Include in the System

• Consider the injury you’re tracking• Consider the goal of your surveillance system• Quality of the data• Existing sources

63Section 2


Preliminary Data Analysis• Develop a strategy to ensure cases are not

counted more than once• Start with the analysis of a broad category,

such as interpersonal violence• Then go more in depth if possible

64Section 2

Identify Data Sources to Include in the SystemCompare Frequency with Data from

Different Sources

• You may find discrepancies• Identify the mission/goal of the institution

collecting the data• Compare it with the goal of the surveillance

system

65


Linkage with Other Data SourcesAdvantages• Supplemental data• More comprehensive

descriptions • Highlights the completeness• Improved data quality

Disadvantages• Personal identifiers• Interagency politics• Different storage media• Worse data quality• Duplications

Section 2

66Section 2

• Who is being injured• How they are being injured• Cause of injury• Severity of injury

Using Data to Define the Injury Problem

67Section 2

Using Data to Define the Injury Problem

• Determining the frequency of the leading causes of death

• Determine the frequency of injury deaths

68Section 2

10 Leading Causes of Death - 2010General US Population American Indian/Alaska Native

Rank Cause of Death Number Rank Cause of Death Number

1 Heart Disease 597,689 1 Malignant Neoplasms 2,962

2 Malignant Neoplasms 574,743 2 Heart Disease 2,793

3Chronic Low. Respiratory Disease 138,080 3 Unintentional Injury 1,701

4 Cerebrovascular 129,476 4 Diabetes Mellitus 857

5 Unintentional Injury 120,859 5 Liver Disease 787

6 Alzheimer's Disease 83,494 6Chronic Low. Respiratory Disease 702

7 Diabetes Mellitus 69,071 7 Cerebrovascular 559

8 Nephritis 50,476 8 Suicide 469

9 Influenza & Pneumonia 50,097 9 Nephritis 33910 Suicide 38,364 10 Influenza & Pneumonia 326

69Section 2

10 Leading Causes of AI/AN Injury Deaths 2010Rank Cause of Death Number

1 Unintentional MV Traffic 610

2 Unintentional Poisoning 521

3 Suicide Suffocation 206

4 Suicide Firearm 178

5 Unintentional Fall 161

6 Homicide Firearm 113

7 Unintentional Suffocation 69

8 Unintentional Drowning 68

9 Suicide Poisoning 64

10 Unintentional Natural/ Environment 62

70Section 2

Why Determine the Leading Cause of Injury Deaths

• Monitor trends • Identify high risk groups or communities • Make comparison among groups. • Motivate stakeholders to support injury

prevention • Help in building a coalition

71Section 2


• Questions?



• Questions 2 and 3 of course exercise.

72

Step 3: Build Partnerships or Coalition to Support the Injury Surveillance System,

Data Collection and Prevention Activities

Section 3

73Section 3

Section 3 Objectives

• Identify partners to include in the system • Identify local, regional and national

organizations working on injury prevention in your area

• Define the existing social, legal and political framework in which an injury surveillance system and prevention activities may be established.

74Section 3

Considerations for Coalition/Partnerships

• Commitment of lead agency• Effective core planning group• Planned recruitment of coalition

members/partners• Structure of coalition or partnership• Roles• Mission and goals• Leadership

75Section 3

Identify Partners/Coalition Members

• Who would contribute to success of system?• Who has access to data sources you need?• What is the quality of their data?• What other support do you need?• Whose objectives overlap with yours?• Can you share or link data?• What expertise do you need?

76Section 3

Identify State and Local Organizations Working in Injury Prevention

• Health care providers • Police departments• Fire departments• Schools• Social service agencies• Government agencies• Local IP coalition• State death review team

77Section 3

Determine the Existing Social, Legal, and Political Framework

78Section 3


• Questions?• What did you already know? • What did you learn that was new?• Questions 3, 4 and 5 of course exercise.

79

Step 4: Determine the Appropriate Methodology for Your Surveillance System

Section 4

80Section 4


• Define the injury events and data elements to include in the system

• Develop the data collection instrument and determine data collection frequency

• Plan for systemization, maintenance and data security

• Define the functions and skill sets for key positions in your surveillance system

81Section 4

Considerations When Developing Methodology

• Potential for intervention• What do you want the system to do?• The size and type of the injury problem• Available data sources• Access to information• Political priorities• Sustainability

82Section 4

Keep the data collection plan in mind– Identify your topic– Narrow your focus– Identify a specific question– Anticipate data needs– Develop and pre-test your data collection

instrument

Considerations When Developing Methodology

83Section 4

Defining Injury Events

What are Your Objectives• Identifying emerging hazards• Describing injury patterns to justify the need

for intervention • Assessing the impact of a prevention program• Determining the health care costs associated

with injury• Describe the magnitude of the injury problem

84Section 4


Case Definition• Needs to be clearly stated and easily understood• Use comparable definitions as those used elsewhere • Contain a clear statement of the following

– Person– Place– Time– Intentionality: intentional/unintentional– Age grouping– Severity– Optional: Injury Code

85

Defining an Injury Event

A Closer Look at Injury Severity• Important to determine severity for case definition• Severity is based on the level of medical

intervention required– Deaths– Hospitalization– Emergency Department (ED) visits– Outpatient visits

• Advantages and disadvantages for each

Section 4

86

Defining Injury EventsInjury Severity - Death

Advantages• Data is readily accessible • Cause of death is consistently

reported • Race or ethnicity information is

usually availableDisadvantages• Rare event• Not a good guide to ascertaining

overall injury problem or medical consequences

• Influenced by small numbers• Potential for racial misclassification

Section 4

Death

180,811

Hospitalization 2.4 million

Ambulatory Care Visits to physicians offices, out-patient

care and emergency department

80.2 million

87

Defining Injury EventsInjury Severity - Hospitalization

Advantages• Combined with mortality data, offers a better

picture of overall problem• Disability and healthcare costs can be better

described• Staff can collect data• Patients and family can be interviewed

Disadvantages• Access to data is more difficult• Privacy is more of a consideration• Records may be manual• Inconsistent, incomplete or incorrect coding • Race or ethnicity information is sometimes not

available• May not be representative of problem

Section 4

Death 180,811




80.2 million

88


Injury Severity – ED VisitsAdvantages• Combined with other data, helps provide the big

picture• Casts the net wider• Useful for specialized studies• Staff can collect data• Patients and family can be interviewed

Disadvantages• Large number of cases may be difficult to

handle• Access to data may be difficult• Records may be manual• Inconsistent, incomplete or incorrect coding • Race or ethnicity information not readily

available from non-local sources

Section 4

Death 180,811




80.2 million

89

Defining Injury EventsInjury Severity – Out-patient Visits

Advantages• May be a primary source of injury data if

there is no hospital• May be good for specialized injuries, such

as sports related injuries or eye injuries• Might be good supplemental information• Might be the only source of data for

some

Disadvantages• Difficult access• Privacy issues • Race or ethnicity information is not

readily available

Section 4

Death 180,811




80.2 million

90


A Closer Look at Injury Codes• What is an injury code?

– Part of standardized codes used by the health sector to classify diseases and health conditions

– Used worldwide, including IHS and tribal health care– ICD-9 CM = International Classification of Disease ,

Version 9, Clinical Modification• Supplemental Classification of External Causes of Injury and

Poisoning (E-Codes)– ICD-10/CM = International Classification of Disease,

version 10, Clinical Modification

Section 4

91


More about ICD Codes• Used for health data management and to

improve healthcare• Updated periodically for new conditions and

system changes• Sometimes easier to query data system using

specific codes

Section 4

92

ICD-9 CM• Used to code non-fatal events (doctor’s visits and

hospitalizations)– Diagnosis codes (injury or illness - fractures, diabetes, etc.)– External cause codes = E-codes (used for what caused

injury - fall, car crash, etc.)• Used US-wide from 1999-2014• Primary user = those who assign codes

– Training required• Secondary user = those who utilize coded data

Section 4

93Section 4

Anatomy of an E-Code

X X X . YE

Injury Category Specificity

E = External cause

94

ICD-9 Code Example

• Example:– 804.12 (injury)– E813.1 (cause of injury)

813.1EMotor vehicle traffic accidentinvolving collision with other vehicle

Passenger

E = External cause

Section 4

95

ICD-10 CM

• October 1, 2014, the ICD-9 code sets will be replaced by ICD-10 code sets

• More codes for more specificity• Used in the US for coding fatal illness and injury• Primary user = those who assign codes

– Training required• Secondary user=those who utilize coded data• ICD-9 codes valid through 10/2014

Section 4

96

X X X . XXX X

EncounterSpecificity: Cause, Anatomic Site, Severity

Injury Category

Anatomy of an ICD-10 Code

Section 4

97

ICD-10 Code ExampleS02.91X A

S06.332 A

V54

Section 4

Skull Fracture Initial Encounter

Laceration, Loss of Consciousness Initial Encounter

Occupant of a pick-up truck or van injured in collision with a heavy transport vehicle or bus

98

Defining an Injury Event

Using ICD-CodesAdvantages• Ability to identify trends• Ability to describe the specific

causes and contributing factors • Standardization of descriptions

that can aid in sharing data or linking databases

• As of October 1, 2014 all Indian Health Service/Tribal/Urban programs must use ICD-10 codes on all HIPAA electronic record transactions.

Disadvantages• Not all records may be coded• Records can be miscoded or

inconsistently coded• Poor chart information results in

non-specific code• Don’t always provide the desired

specificity • You must stay apprised of updates• Previously not required for billing,

so seen by some coders as unnecessary

Section 4

99

Defining an Injury EventDetermining if Injury Codes Should be Included

in Case Definition• Does your data source (clinic, hospital, trauma

registry, etc.) use ICD codes?• Are you looking for specific types of injuries?• Does your data source assign a code to most

injuries?• Are you confident in the completeness, accuracy,

and specificity of the coded data?• Yes? Consider including codes in the case definition.

Section 4

100

For More Information on ICD-9 or ICD-10 Codes

• Contact your Area Office for training options.• Check these references:

– American Academy of Professional Codershttp://www.aapc.com/

– World Health Organizationhttp://www.who.int/classifications/icd/en/

– CDC National Center for Health Statisticshttp://www.cdc.gov/nchs/icd.htm

– CDC article on improving E-codinghttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5701a1.htm

Section 4

http://www.aapc.com/

http://www.who.int/classifications/icd/en/

http://www.cdc.gov/nchs/icd.htm

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5701a1.htm

101

Case Definition Exercise• Purpose: Practice developing a case definition• Time for exercise: 30 minutes

– Develop case definition to include the following:• Person, injury type(s), place, time, intent, severity

– Report back to the group. Include how/why decisions were made for each.

• Example:All confirmed fractures (outpatient and inpatient) resulting from a fall from a horse during a rodeo, including all genders and ages, from 2010-2013, with treatment paid for by tribal health.

Section 4

102Section 4

• It’s not necessary to be all encompassing• Start small; track the most severe injuries• Expand or phase in other levels when you can

You can initiate prevention without knowing everything about every injury in your

community

Defining Injury EventsImportant Things to Remember

103Section 4

Determine the Variables in Your System

• Variables = Data for each injury event• Determines the data collected• Determines data collection form

Keep injury prevention goal in mind

104Section 4

• Name or other identifier• Age and sex• Marital Status• Education Level


105Section 4

• Employment Level • BAC - Nice to have, but rarely available• Occupant Protection for Transportation


106Section 4

• Time• Place• Circumstances surrounding the injury event


107Section 4

Data Collection Instrument and Data Collection Frequency

Designing a Form• Define what you want in your system first• Keep it simple• Only include the data you need • Make sure it is well-designed and easy to read• Decide whether or not to pre-code the form

PRE-TEST YOUR FORM!

108Section 4

• Frequency of Data Collection• Active vs. Passive Data


Collecting Data

109Section 4

• Decide what you want out of your system• Define the case• Determine your variables• Develop your form• Consider how HIPAA/Privacy issues may

impact your collection efforts• Test your form


Data Collection Planning Summary

110Section 4

Determining the Type of Surveillance System

• Universal surveillance• Surveillance based on samples of cases• Surveillance based on a review of institutional

registries• Survey-based surveillance• Sentinel surveillance

111Section 4

Setting Up an Electronic Database

• Seek the assistance of a programmer, epidemiologist or statistician

• Epi Info 2002 – Free software available through CDC– http://wwwn.cdc.gov/epiinfo/7/index.htm

• Make sure all paper records with identifiers are locked away

http://wwwn.cdc.gov/epiinfo/7/index.htm

112Section 4

Systemization & Maintenance

• Reducing errors • Improving the system’s scope and services

through routine maintenance, emergency maintenance

• Safeguarding the system

113Section 4

Systemization and Maintenance

Improving the System’s ScopeConsiderations:• A schedule for backing up data and files • Secure environment for records• Written requests for emergency maintenance • Logs to record emergency maintenance • Establishing a protocol• Documenting all maintenance

114Section 4


Ways of Safeguarding Your System• Limit access to one person (with backup)• Install the database on two computers• Keep a second copy of the database off site.

115Section 4


Threats to a Database• Human error• Mechanical failure• Malicious damage• Cyber crime• Invasion of privacy• Computer viruses

Seek the assistance of a programmer in protecting the database when needed.

116Section 4


Protocol

• Procedures for obtaining and securing data• Maintenance procedures • Rules for data storage• Rules for password creation and protection • All documents that detail any changes

117Section 4

Define Staff Roles

• Coordinate system activities• Establish contact • Data entry• Quality control • Analysis • Preparation of reports

118Section 4

People to Assist• Consider consultations with a few people • District or area IP specialists can help

– Obtain data– Review policy– Identify best use of data– Strategize– Speaking engagements– Showing support– Local approval– Tribal politics

119Section 4

Discussion of Forms & Protocols

• Time 30-45 minutes• Compare the different forms in Appendix 3• Compare the different protocols in Appendix 4• For each discuss the following

– What is similar? What is different?– What are advantages and disadvantages of each?– What is most likely to work for you?– Why?

120Section 4


• Questions?• What did you already know? • What did you learn that was new?• Complete questions 6-11 on the course

exercise

121

Step 5: Define and Develop an Analysis Plan; Develop a Plan for Disseminating

ResultsSection 5

122Section 5


• Calculate injury indicators such as frequency, percentages and crude, specific and adjusted rates

• Calculate Years of Potential Life Lost• Describe the geographical analysis of the data• Define a plan to disseminate and

communicate the data

123Section 5

Data Analysis & Interpretation

Epidemiological Concepts and Terms• Epidemiology• Population-based• Injuries are not random• Morbidity v. Mortality• Risk• Endemic vs. Epidemic

124Section 5

Who Where When

What Why How

Epidemiology“The study of the distribution and determinants of health-related states or events in specified populations and the application of this study to control health problems.” A Dictionary of Epidemiology


Epidemiological Concepts and Terms

125Section 5

Epidemiology is POPULATION-BASED (concerned with the community, not the individual)



126Section 5

Injuries are not random:There are causes for injuries and ways to reduce them.



127Section 5

Risk:“The probability that an event will occur.”

A Dictionary of Epidemiology



128Section 5

Risk Factor:A trait or behavior or exposure that could

increase the probability of an injury event

Sometimes a risk factor can be modified by an intervention to reduce the probability of an

injury event



129Section 5

• Endemic: – Present in the community at all time– Infrequent– Typically restricted to a locality

• Epidemic– Sudden and – Severe



130Section 5


Analysis – General Concepts• Analysis involves:

– Basic statistics (the counting)– Interpretation (what does it mean)

131Section 5

• To analyze:– Separate into elements or constituent parts– Separate the parts of the whole so as to reveal their

relation to it and to one another– Examine critically or step-by-step

• No set formula, rule or methodology … analysis is as much an art as it is a science

• Look for patterns, clusters, the unusual, unexpected• Progress to more complex analysis as necessary


Analysis – General Concepts

132Section 5

Basic Rules to Consider• Indicate the “N” (number of data items in the

data set or “n” (number of data items in the data subset)

• Small numbers do not mean “bad results” … just qualify or acknowledge the “N” upfront



133Section 5

Two Common Misconceptions to Avoid• A computer does not think for you. It does the

counting; you have to interpret the numbers.• Correlation does not necessarily imply

causation – For example: HRT does not equal reduce risk of

heart disease



134Section 5

Data Analysis and Interpretation

Basic Statistics• Numeric Value• Midpoint (measure of central tendencies)• Proportions

You don’t have to be a statistician to utilize basic statistics to help you describe and

understand injury data

135Section 5

Numeric Value• Very common• Easy to understand• Value of one variable cannot be

compared to the same variable in a different population

• Does not indicate risk


Basic Statistics

136Section 5

Midpoint (measure of central tendencies)• Mode• Median• Mean


Basic Statistics

137Section 5

Measure of Central Tendencies – ExampleSevere fall injury patients in 2012 at XYZ locationPatient ages in order from youngest to oldest:

5, 6, 6, 7, 8, 8, 15, 75, 77, 77, 77, 82, 93– Mode (most frequent patient age) – 77– Median (middle most age) – 15 – Mean (average age) – 41.2


Basic Statistics

138Section 5

Measure of Central Tendencies Cont.• Mode rarely used in epidemiology• Median used less commonly than mean• Mean

– More commonly used but– Influenced by value outliers

• Measures of central tendencies can be misleading


Basic Statistics

139Section 5

Proportional Distribution• Commonly used• Simple calculation• Sum of all values = 100%• Can be misleading• Not a measure of risk


Basic Statistics

140Introduction

Proportional Distribution Example32 severe fall injury patients 2012 – 2013 Younger than 10 12 cases or 37.5% (12/32)Older than 65 15 cases or 47% (15/32)10 – 18 4 cases or 12.5% (4/32)41 1 case or 3% (1/32)


Basic Statistics

141Section 5


Basic Statistics - Rates

“… comparing apples to oranges …”

142Section 5

Rate: “An expression of the frequency with which an event occurs in a defined population over a specific period and converted to a whole number by multiplying by some power of 10 (usually 10,000 or 100,000).”

A Dictionary of Epidemiology



143Section 5

Community A

Community B

Community C

Rate

150 per 100,000

100 per 100,000

500 per 100,000



144Section 5

Types of Rates

• Incidence Rate – new cases

• Prevalence Rate – new and existing cases

• Specific Rate – number of events in sub-group

145Section 5

Rate per 100,000

(same exposure period)



146Section 5

Combine population when calculating a rate for a multi-year period.Example Injury Death Rate for a community from 2008-2010Cases in 2008 + Cases in 2009 + Cases in 2010

Divided byPopulation in 2008 + Population in 2009 + Population in 2010



147Section 5

Rate



148Section 5

• Crude Rate• Specific Rate• Adjusted Rate



149Section 5

Specific Rate of Suicide for AI/AN Population -- 2010Age Group Suicides (2010) Population Rate10 to 14 14 372,896 3.7515 to 19 70 393,320 17.820 to 24 88 362,892 24.2525 to 29 51 340,576 14.9730 to 34 49 311,098 15.7535 to 39 37 292,412 12.6540 to 44 38 280,013 13.5745 to 49 45 283,889 15.8550 to 54 32 253,858 12.6155 to 59 20 197,306 10.1460 to 64 8 148,434 5.3965 to 69 6 97,909 6.1370 to 74 5 66,019 7.5775 to 79 2 43,090 4.6480 to 84 3 26,959 11.1385+ 1 21,237 4.71All Ages 469 4,263,538 11

150Section 5

Some general considerations• Accurate Numerator• Estimated Denominator• Used Primarily for Comparison• Indicator of risk



151Section 5

• Purpose: Practice calculating rates• Time: 1 hour• Get out your calculators• Refer back to the equations on slides 145, 146

and 147• Work through the rate exercises on the

handout


Rate Calculation Exercise

152Section 5

YPLL = Years of Potential Life Lost• Measure of Premature Death• YPLL = 65 – age at death


Years of Potential Life Lost

153Section 5

Years of Potential Life Lost Before Age 65 American Indian/Alaska Native Population - 2010Cause of Death YPLL PercentAll Causes 167,928 100.0%Unintentional Injury 43,055 25.6%Suicide 14,730 8.8%Heart Disease 14,689 8.7%Malignant Neoplasms 14,524 8.6%Liver Disease 11,290 6.7%Homicide 8,827 5.3%Perinatal Period 7,604 4.5%Congenital Anomalies 7,209 4.3%Diabetes Mellitus 4,307 2.6%Influenza & Pneumonia 2,340 1.4%All Others 39,353 23.4%

154Section 5

Depicts data using maps• Spot Map - dot or symbol where injury occurred• Area or Choropleth Map - regions are shaded or

marked proportionally to the data being depicted• Pin or Cluster Map - way of indicating road traffic

hazards or crash prone locations along roads


Geographic Analysis of Data

155Section 5

156Section 5

• Epidemiology serves as a foundation• Many data analysis methods• Importance of rates• Need to interpret results and explain what

they mean• Utilize available resources• Communicate your findings


Summary

157Section 5

Communicate Results

Surveillance can only achieve results if the information is communicated to the appropriate people.

158Section 5

Communicate Results

Steps to Take• Determine who will get the information• Check with each tribe within your surveillance

system • Develop the message • Select the format• Market the message• Evaluate the impact

159Section 5

Surveillance System Report

• A means to convey the results of the surveillance system to all the stakeholders

• Consider the needs to the stakeholders when making decisions about design and frequency

160Section 5

Surveillance System ReportConsiderations for inclusion• Introduction• Leading causes of death• Leading causes of injury deaths• Leading causes of morbidity if available• YPLL • Cost of injuries• Priority injuries• Recommendations for intervention

161Section 5

Surveillance System Report

Recipients• Stakeholders, decision makers, law enforcement,

public health directors, school officials, etc. • Hospital, emergency departments, health clinics• Health professionals in the scientific community• Scientific/academic researchers• Grassroots organizations

162Section 5

Surveillance System ReportsDelivery method• Health department newsletters• PSAs• Press releases• Flyers• Periodicals/annual reports• Presentations• Newspapers• Websites

163Section 5


• Questions?• What did you already know? • What did you learn that was new?• Complete all the questions on the course

exercise

164

Step 6: Use Surveillance Data to Inform Injury Prevention

Section 6

165Section 6

Objectives for Section 6• Understand the use of surveillance data to identify

priority injuries.• Understand models that help identify risk factors

and intervention strategies for priority injuries. • Understand the models for identifying the most

appropriate interventions for the injuries in your tribe or community.

• Understand how to tie surveillance to action and funding.

166Section 6

Use of Surveillance Data to Establish Priority Injuries

• Show severity of injuries• Show magnitude of injuries• Provide perspective• Track trend of injuries over time• Inform local, regional and national authorities

167Section 6

Remember:• It’s not necessary to know everything to begin

prevention efforts• Start small• Use the data you have available

You can work on prevention activities without knowing everything about an injury problem or just using the

data you have available

Use of Surveillance Data to Establish Priority Injuries

168Section 6

• Event Importance – Magnitude– Severity – Trend– Cost

• Prevention Control Capacity– Potential for controlling the event– Local interest

Criteria for Identifying Priority Injuries

169Section 6

Criteria to Prioritize Injury Events

High Importance + Good Control/Prevention = High Priority for Prevention and Control

High Importance + Low Control/Prevention = Further Research

170Section 6

Low Importance + Good Control and Prevention Capacity = Low Priority for Prevention and Control


171Section 6

Low Importance + Low Control and Prevention Capacity = Not a Priority


172Section 6

Criteria to Prioritize an Injury EventInformation that Will Help in Setting Priorities

General Information to Determine the Importance of an Injury Event• Leading causes of death• Number, proportion, and crude and adjusted

rates• YPLL from injuries by intention• Trend of injuries over a minimum of five years

173Section 6

Specific Information to Determine the Importance of an Injury Event• Homicide: crude and specific rates by age

group and gender and mechanism• MV deaths: crude and specific rates by age

group, gender and road user • Leading causes of injury morbidity

Criteria to Prioritize an Injury Event

Information that Will Help in Setting Priorities

174Section 6

Specific Information Cont.• Costs • Disability Adjusted Life Years = YPPL + Years of

Productive Life Lost due to disability – For more information on calculating this indicator

see the World Health Organization website (www.who.org)


http://www.who.org/

175Section 6

Information that will help in determining the prevention control capacity• Costs to prevent and control problem• Local interest• Information on activities to control injuries• Control possibilities or vulnerabilities


176

Identifying Potential Interventions & Strategies to Prevent Priority Injuries

• The Haddon Matrix• The Ecological Model for Violence-Related

Injuries• Intervention Decision Matrix

Section 6

177

Identifying Potential Interventions & Strategies

Haddon Matrix for Unintentional Injuries

• Identify risk factors• Identify potential interventions that

– Target each factor – Column– Influence each phase -- Row

Section 6

178

Host (human) Agent (dog) PhysicalEnvironment

SocialEnvironment

Pre-Event Teach children about dogs

Teach how to respond to aggressive dogs

Train/socialize Dogs

Spay and neuter dogs

Maintain dogs in fenced yard or use

electronic fenceUse gate alarm to

indicate when gate is open

Increase community awareness

Initiate dog control lawsSpaying, neutering and

vaccination program

Event Stand still, yell for help

Put bike or other object in front of you

Protect head, face and neck

Identify aggressive

behavior before bite occurs

Muzzle dangerous dogs

Respond to alarm indicating gate is

openEnforce dog control laws

Post-Event

First aid/trauma careRabies vaccine

Evaluate dogs

Impound dogsto observe for

rabies

Medical attention

Rehabilitation

Maintain community surveillance for dog bites

Report incidentsRepeat prevention

measures

The Haddon Matrix used to identify prevention strategies for childhood dog bites

179Section 6

• Helps to organize the levels of influence that affect behavior – Individual– Relationship– Community– Society

• Distinguishes among the multitude of influences on violence


The Ecological Model for Intentional Injuries

180

Level Potential Interventions Individual

Programs to increase access to prenatal and postnatal carePreschool enrichment programsPerpetrator programs Victim care and support Building of social skills

Relationship

Home visitationSkill training programs on parentingSupportive relationship with a positive adult role modelHome-school partnership programs to promote parental involvementPeer mediation of students helping other students resolve disputes

Community

Extracurricular activitiesGang prevention programsReducing the availability of alcohol

Society

Reducing income inequalityReducing media violenceHaving laws prohibiting illegal transfers of guns to adolescentsReforming educational systemStrengthening and improving police and judicial systems

The Ecological Model used to identify prevention strategies for youth violence

181Section 6

• Help identify and choose among intervention options & identify long-term goals

• Originally considers 7 elements• 5 elements for this course

– Effectiveness,– Cost– Sustainability– Political & Social Acceptability – Possible unintended consequences


The Intervention Decision Matrix

182Section 6

• Effectiveness– Is the intervention useful for preventing injuries?– Has it been evaluated?

• Cost – Is the proposal affordable?– Are there enough resources to develop the

proposal?– Is the investment justifiable?



183Section 6

• Sustainability – Continuation of program– Continuation of program impact

• Social and Political Acceptability – Political context– Accepted by community leaders

• Possible unintended consequences



184Section 6

Elements Score

1. Effectiveness 1. Not proven effective 2. Moderately effective 3. Highly effective

2. Cost 1. High cost 2. Medium cost 3. Low cost

3. Sustainability 1. Low sustainability 2. Medium sustainability

3. High sustainability

4. Social and political acceptability

1. Low acceptability 2. Medium acceptability

3. High acceptability

5. Possible unintended consequences

1. Known consequences 2. Unknown or unclear whether there are consequences

3. No consequences

Identifying Potential Interventions & StrategiesThe Intervention Decision Matrix

185Section 6

Decision Criteria Possible InterventionsLeash Laws Ban Dogs Pick up Strays

Effectiveness Cost Sustainability Social & Political Acceptability

Unintended consequences

Intervention Rating

Identifying Potential Interventions & StrategiesThe Intervention Decision Matrix

186Section 6

Tie Surveillance to Action and Funding

• Injury Prevention• Policy Change• Improved Data Collection • Funding to Support

Prevention Efforts

187Section 6

• Use your experiences• How has surveillance been tied to action

and/or funding• Consider

– Improved data systems– Policy changes– Grants received– Interventions

Discussion of How Surveillance Can Lead to Action and Funding

188Section 6


• Questions?• What did you already know? • What did you learn that was new?

189Section 7

Step 7: Define an Evaluation Plan for your Surveillance System and Monitor Prevention

Activities

Section 7

190Section 7


• Know the steps to evaluating the system.• Be able to use surveillance to monitor

prevention activities

191Section 7

Evaluation Process

• Engage stakeholders• Describe the surveillance system • Determine a process • Gather evidence about performance

192Section 7

Factors to Consider When Evaluating Your System

• Simplicity• Flexibility• Data Quality• Acceptability• Timeliness• Stability• Sensitivity• Representativeness

193Section 7

Important Steps• Communicate your findings to the appropriate

people • Keep notes about any changes you

make to the system

194Section 7

Use Surveillance Data to Monitor Prevention Activities

• Changes after the prevention implemented• Trend before and after a strategy is applied• Impact of strategies applied for purposes other

than injury prevention that could impact the results

• Over or under representation of certain groups • Over or under representation of injury events

195Section 7

Summary of Section 7• Questions?



• Complete the Final Exercise. Share your decisions. Discuss potential challenges and solutions.

• Complete the post test. Compare your answers to pre test.

designing and implementing surveillance systems in indian country

Documents

injury surveillance

injury problem

framework of injury

interpretation of injury

injury data sources

surveillance systemgoal

injurysurveillance system

indian country designing