1. International Comparisons of Proportion of Unspecified External Causes of Death Tsung-Hsueh (Robert) Lu, MD, MPH Institute of Public Health, College of Medicine National Cheng Kung University, Tainan, Taiwan robertlu@mail.ncku.edu.tw

2. Sep 1999 April 2003 Nov 1996

3. 台灣多重死因中文診斷 自動化輸入系統 MADE in Taiwan M ultiple-cause-of-death A utomated D ata E ntry System, 2004 version

8. Introduction 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)

9. V243 Transport accidents Mode of transport of the victim Mode of transport of counterpart Circumstances of the event and the role of the victim

10. ECD: X59 exposure to unspecified factor Accidental head injury Example One

11. ECD: V99 unspecified transport accident Head injury Example Two Transport accident

12. ECD: V244 motorcycle rider injured in collision with heavy transport vehicle or bus Head injury Example Three Motorcyclist in collision with bus

13. Research 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?

14. Materials & 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.

15. Materials & Methods (cont.) External Causes of InjuriesICD-10 Code, U/B All unintentional injuriesX59/V01-X59 Transport accidentsV89&V99/V01-V99 FallsW19/W00-W19 Accidental drowning and submersionW74/W65-W74 Other accidental threats to breathingW84/W75-W84 Exposure to smoke, fire and flamesX09/X00-X09 Intentional self-harmX84/X60-X84 AssaultY09/X85-Y09 Event of undetermined intentY34/Y10-Y34

16. Results 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.

17. 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%).

18. 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?

19. 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?

24. 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

25. Conclusions 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?

26. 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? Comments are needed! Persons?