International Journal of Injury Control and Safety Promotion, 2014 http://dx.doi.org/10.1080/17457300.2014.908225
Descriptive epidemiology of injury cases: findings from a pilot injury surveillance system in Abu Dhabi M. Hafizur Rahmana*, Katharine A. Allena, Adnan A. Hydera and Health Authority of Abu Dhabib a
International Injury Research Unit (IIRU), Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; bHealth Authority Abu Dhabi, Abu Dhabi, United Arab Emirates (Received 9 October 2013; accepted 11 February 2014) Considering the high burden of injuries, the Health Authority - Abu Dhabi developed a draft electronic and paper-based injury and poisoning notification system (IPNS) to generate better data on the nature and severity of injuries. The pilot testing and evaluation of IPNS was conducted with the specific objectives to (1) identify the characteristics of injury cases, (2) explore potential risk factors, (3) illustrate the nature and type of data, and (4) the working mechanism of data collection. Data were collected from selected hospitals on patient demographics, injury information and clinical assessment. Descriptive, bivariate and multivariate analyses were conducted. Of 4226 injury cases, nearly three-fourths were male, majority were non-UAE nationals, and the mean age was 21.9. Multivariate findings suggested that compared to UAE nationals, non-UAE nationals were 27% more likely to experience fatal, severe or moderate injuries (p ¼ 0.01). Individuals with health insurance were 31% less likely to suffer a fatal, severe or moderate injury compared to those having no health insurance (p < 0.001). This is the first systematically standardised collection of injury data across three facilities in Abu Dhabi, and provides initial information on characteristics and injury risk factors that will help identify the need for evidence-based intervention for injury prevention and control. Keywords: injury; trauma; injury epidemiology; Abu Dhabi; UAE; surveillance
Introduction Injuries, unintentional or intentional, constitute a major public health problem, killing more than 5 million people worldwide each year and causing many more cases of disability (Chandran, Hyder, & Peek-Asa, 2010; Lopez, Mathers, Ezzati, Jamison, & Murray 2006; Peden, McGee, Krug, & World Health Organization, 2002). In the Emirate of Abu Dhabi injuries and poisoning are the second leading cause of death and disability (Health Authority Abu Dhabi, 2010). In 2009, injury and poisoning accounted for 680 out of 2988 deaths (approximately 23%) in the Emirate with only cardiovascular diseases responsible for slightly more deaths (24%) (Health Authority of Abu Dhabi, 2009). About 67% of all fatal injuries in the Emirate were due to road traffic injuries, followed by occupational injuries (12.1%), home injuries (8.4%), suicides (7.5%) and drowning (1.9%) (Health Authority of Abu Dhabi, 2009). These injuries are also increasingly playing a major part as important causes of trauma and a burden on the community and the health care system of the Emirate (Barss, Addley, Grivna, Stanculescu, & Abu-Zidan, 2009; Bener, Hyder, & Schenk, 2007; El-Sadig, Norman, Lloyd, Romilly, & Bener, 2002). To develop effective prevention strategies, better data and an understanding of the local epidemiology of these *Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
injuries are crucial. In particular, it is necessary to know the numbers, types, severity and the circumstances in which these injuries occur (Holder et al., 2001; Peden, 2009). Such information will indicate the severity of existing injuries and highlight which prevention measures are most needed and where they should be implemented (Peden & World Health Organization, 2004; Runyan, 1998). Such details will also allow for effective prioritisation and allocation of health resources (Lavis, Wilson, Oxman, Lewin, & Fretheim, 2009; Oxman, Lavis, Lewin, & Fretheim, 2009). Trauma registries and injury surveillance systems have become particularly helpful in collecting and providing such data (Stone, Morrison, & Ohn, 1998). In 2001, the World Health Organization (WHO) published the injury surveillance guidelines in order to help public health practitioners develop, implement and maintain strong injury surveillance systems (Holder et al., 2001). With the use of such guidelines, numerous countries, including developed and developing ones, have successfully established their own surveillance systems (Hyder et al., 2009; Liu, Li, Cui, Liu, & Jackson, 2009; Schultz et al., 2007). These previous efforts have highlighted the effective uses of such systems in better understanding local and regional injury burdens (Hyder et al., 2009; Liu et al., 2009).
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M.H. Rahman et al.
Considering the high burden of injuries in Abu Dhabi and the need for better data to inform prevention strategies, the Health Authority - Abu Dhabi (HAAD) developed a draft electronic and paper-based injury and poisoning notification system (IPNS) in 2009. The purpose of this system was to collect and provide ongoing evidence-based injury data including the nature and severity of injury as well as extended injury information for strategy development and resource allocation on injury prevention. In order to test the feasibility of the electronic system, a 10-month pilot study was conducted in three selected hospitals prior to implementation within all the concerned health care facilities in Abu Dhabi Emirate. This paper highlights the findings from the pilot project. The objectives of the pilot study were to preliminarily identify: (1) the characteristics of injury cases according to demographic profile and other characteristics including place of injury, activity at time of injury, mechanism of injury and severity of injury; (2) risk factors associated with injuries in the Emirate of Abu Dhabi; (3) the nature and type of data collected within the IPNS; and (4) the working mechanism of data collection. Methods In order to obtain a profile of the leading causes of death and hospital treatment due to injury in Abu Dhabi, an electronic and paper-based IPNS was established in 2009 by HAAD. This system was based on the (WHO) injury surveillance guidelines and International Classification of External Causes of Injuries (Fingerhut, Harrison, & Mulder, 2004; Holder et al., 2001). The IPNS included a paper-based data capture form and an online electronic form. IPNS was designed as an emergency department (ED)-based injury surveillance system. For the purposes of this pilot, an injury case was defined as individuals who present for the first time to the ED with a condition resulting from an external cause (ICD-9 CM code 800–999). Their visit and injury details were recorded using an ED data capture form (Figure 1). An individual with multiple bodily injuries was counted only as one case. Individuals returning for follow-up visits from a pre-existing or pre-recorded injury were not counted. Data were collected on patient demographics, injury information and clinical assessment, and the ED data capture forms were then submitted to HAAD through the electronic notification system accessible through a secure Internet access site. The online system includes a dynamic pull-down menu to facilitate data entry and compliance of data input. Five training workshops on data collection and data entry were conducted for physicians, nurses and trainees who had primary responsibility for completing these tasks at the participating hospitals. Data were collected from three hospitals in Abu Dhabi including Al Ain, Al Noor
and Madinat Zayed. Al Ain and Madinat Zayed are public hospitals and Al Noor is a private one. The selection of these hospitals was based on the decision of HAAD to pilot test the system in a variety of settings, including private and public hospitals located in each of the three main HAAD regions of the Emirate (Abu Dhabi, eastern region and Al Gharbia/western region). These hospitals were chosen to be fairly representative of the injury burden seen in each of these three regions. In addition, the willingness of these facilities to assist with the pilot was a contributing factor to their final inclusion. Data submitted to HAAD through the electronic notification system were transferred to STATA for cleaning and analysis. Data cleaning was completed while consistency checks were also undertaken. Data collected throughout the pilot phase (30 September 2010 to 24 July 2011) were analysed and are presented in this paper. Descriptive analysis (frequency distribution, mean, mode, median) including graphical distribution of data was conducted. Frequency distributions were carried out to identify the characteristics of injury cases according to demographic profile, place of injury, activity at the time of injury and mechanism of injury. Cross-tabulation and appropriate statistical test (chi-square) were conducted to ascertain if significant differences existed at the p < 0.05 level. Bivariate and multivariate logistic regression analyses were conducted with two different outcomes including: (1) whether the recorded case encountered a fatal, severe and moderate injury, and (2) whether the case was admitted to the hospital due to the injury. Age, gender, nationality (UAE or non-UAE) and health insurance status (having health insurance or not) were included as independent variables. Logistic regression models were also used to ascertain measures of association by examining the odds ratios between the outcome and each of the independent variables. While bivariate analysis was used to identify the significant factors to be included in the multivariate models, multivariate analysis was conducted to ascertain the independent risk factors after adjusting for other competing factors. Data analysis was conducted using STATA statistical software version 10 (StataCorp, 2009). The Johns Hopkins Bloomberg School of Public Health’s Institutional Review Board and HAAD approved this study. The data used for this analysis were de-identified and did not contain any identifying links to study participants. All of the data were stored and protected within a secure HAAD internal information technology system. Results The pilot study covered three hospitals in Abu Dhabi over a 10-month period. 4226 records were entered into IPNS and analysed. The key findings are presented below.
International Journal of Injury Control and Safety Promotion
3
Figure 1. HAAD injury surveillance system – injury and poisoning notification form.
More than one-third of the injury cases were between 25 and 44 years of age, with the mean age being 21.9 years. Nearly three-fourths of the cases were male (72.4%), and the majority were non-UAE citizens (71.6%). The majority of injury cases were from other
countries in the WHO Eastern Mediterranean Region ((EMRO) 68.8%) followed by the WHO South East Asia Region (SEARO) (17.4%). The majority of EMRO injury cases came from Egypt (8.68%), Pakistan (8.12%), Jordan (5.35%) and the UAE (28.47%); whereas majority of
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M.H. Rahman et al.
Figure 1. Continued
SEARO injury cases came from Bangladesh (8.04%) and India (7.84%) (Table 1). When cases were analysed by the place of injury, the majority (62%) of individuals reported that the injury took place at home. The workplace, which includes
industrial and construction sites, was the second leading place of injury (16.7%) (Table 2). The reported activity during the time of injury for almost two-thirds of the injury cases was leisure and approximately 15% reported to have been working when the injury occurred (Table 2).
International Journal of Injury Control and Safety Promotion
5
Figure 1. Continued
While 97% of the injuries were reported to be unintentional, over half of the respondents reported a fall as the mechanism of injury and 10% mentioned that the injury was caused by a falling object (Table 3). Intentional Table 1. Basic characteristics of injured persons in the pilot study (N ¼ 4226). Characteristic Age group
Descriptive epidemiology of injury cases: findings from a pilot injury surveillance system in Abu Dhabi M. Hafizur Rahmana*, Katharine A. Allena, Adnan A. Hydera and Health Authority of Abu Dhabib a
International Injury Research Unit (IIRU), Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; bHealth Authority Abu Dhabi, Abu Dhabi, United Arab Emirates (Received 9 October 2013; accepted 11 February 2014) Considering the high burden of injuries, the Health Authority - Abu Dhabi developed a draft electronic and paper-based injury and poisoning notification system (IPNS) to generate better data on the nature and severity of injuries. The pilot testing and evaluation of IPNS was conducted with the specific objectives to (1) identify the characteristics of injury cases, (2) explore potential risk factors, (3) illustrate the nature and type of data, and (4) the working mechanism of data collection. Data were collected from selected hospitals on patient demographics, injury information and clinical assessment. Descriptive, bivariate and multivariate analyses were conducted. Of 4226 injury cases, nearly three-fourths were male, majority were non-UAE nationals, and the mean age was 21.9. Multivariate findings suggested that compared to UAE nationals, non-UAE nationals were 27% more likely to experience fatal, severe or moderate injuries (p ¼ 0.01). Individuals with health insurance were 31% less likely to suffer a fatal, severe or moderate injury compared to those having no health insurance (p < 0.001). This is the first systematically standardised collection of injury data across three facilities in Abu Dhabi, and provides initial information on characteristics and injury risk factors that will help identify the need for evidence-based intervention for injury prevention and control. Keywords: injury; trauma; injury epidemiology; Abu Dhabi; UAE; surveillance
Introduction Injuries, unintentional or intentional, constitute a major public health problem, killing more than 5 million people worldwide each year and causing many more cases of disability (Chandran, Hyder, & Peek-Asa, 2010; Lopez, Mathers, Ezzati, Jamison, & Murray 2006; Peden, McGee, Krug, & World Health Organization, 2002). In the Emirate of Abu Dhabi injuries and poisoning are the second leading cause of death and disability (Health Authority Abu Dhabi, 2010). In 2009, injury and poisoning accounted for 680 out of 2988 deaths (approximately 23%) in the Emirate with only cardiovascular diseases responsible for slightly more deaths (24%) (Health Authority of Abu Dhabi, 2009). About 67% of all fatal injuries in the Emirate were due to road traffic injuries, followed by occupational injuries (12.1%), home injuries (8.4%), suicides (7.5%) and drowning (1.9%) (Health Authority of Abu Dhabi, 2009). These injuries are also increasingly playing a major part as important causes of trauma and a burden on the community and the health care system of the Emirate (Barss, Addley, Grivna, Stanculescu, & Abu-Zidan, 2009; Bener, Hyder, & Schenk, 2007; El-Sadig, Norman, Lloyd, Romilly, & Bener, 2002). To develop effective prevention strategies, better data and an understanding of the local epidemiology of these *Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
injuries are crucial. In particular, it is necessary to know the numbers, types, severity and the circumstances in which these injuries occur (Holder et al., 2001; Peden, 2009). Such information will indicate the severity of existing injuries and highlight which prevention measures are most needed and where they should be implemented (Peden & World Health Organization, 2004; Runyan, 1998). Such details will also allow for effective prioritisation and allocation of health resources (Lavis, Wilson, Oxman, Lewin, & Fretheim, 2009; Oxman, Lavis, Lewin, & Fretheim, 2009). Trauma registries and injury surveillance systems have become particularly helpful in collecting and providing such data (Stone, Morrison, & Ohn, 1998). In 2001, the World Health Organization (WHO) published the injury surveillance guidelines in order to help public health practitioners develop, implement and maintain strong injury surveillance systems (Holder et al., 2001). With the use of such guidelines, numerous countries, including developed and developing ones, have successfully established their own surveillance systems (Hyder et al., 2009; Liu, Li, Cui, Liu, & Jackson, 2009; Schultz et al., 2007). These previous efforts have highlighted the effective uses of such systems in better understanding local and regional injury burdens (Hyder et al., 2009; Liu et al., 2009).
2
M.H. Rahman et al.
Considering the high burden of injuries in Abu Dhabi and the need for better data to inform prevention strategies, the Health Authority - Abu Dhabi (HAAD) developed a draft electronic and paper-based injury and poisoning notification system (IPNS) in 2009. The purpose of this system was to collect and provide ongoing evidence-based injury data including the nature and severity of injury as well as extended injury information for strategy development and resource allocation on injury prevention. In order to test the feasibility of the electronic system, a 10-month pilot study was conducted in three selected hospitals prior to implementation within all the concerned health care facilities in Abu Dhabi Emirate. This paper highlights the findings from the pilot project. The objectives of the pilot study were to preliminarily identify: (1) the characteristics of injury cases according to demographic profile and other characteristics including place of injury, activity at time of injury, mechanism of injury and severity of injury; (2) risk factors associated with injuries in the Emirate of Abu Dhabi; (3) the nature and type of data collected within the IPNS; and (4) the working mechanism of data collection. Methods In order to obtain a profile of the leading causes of death and hospital treatment due to injury in Abu Dhabi, an electronic and paper-based IPNS was established in 2009 by HAAD. This system was based on the (WHO) injury surveillance guidelines and International Classification of External Causes of Injuries (Fingerhut, Harrison, & Mulder, 2004; Holder et al., 2001). The IPNS included a paper-based data capture form and an online electronic form. IPNS was designed as an emergency department (ED)-based injury surveillance system. For the purposes of this pilot, an injury case was defined as individuals who present for the first time to the ED with a condition resulting from an external cause (ICD-9 CM code 800–999). Their visit and injury details were recorded using an ED data capture form (Figure 1). An individual with multiple bodily injuries was counted only as one case. Individuals returning for follow-up visits from a pre-existing or pre-recorded injury were not counted. Data were collected on patient demographics, injury information and clinical assessment, and the ED data capture forms were then submitted to HAAD through the electronic notification system accessible through a secure Internet access site. The online system includes a dynamic pull-down menu to facilitate data entry and compliance of data input. Five training workshops on data collection and data entry were conducted for physicians, nurses and trainees who had primary responsibility for completing these tasks at the participating hospitals. Data were collected from three hospitals in Abu Dhabi including Al Ain, Al Noor
and Madinat Zayed. Al Ain and Madinat Zayed are public hospitals and Al Noor is a private one. The selection of these hospitals was based on the decision of HAAD to pilot test the system in a variety of settings, including private and public hospitals located in each of the three main HAAD regions of the Emirate (Abu Dhabi, eastern region and Al Gharbia/western region). These hospitals were chosen to be fairly representative of the injury burden seen in each of these three regions. In addition, the willingness of these facilities to assist with the pilot was a contributing factor to their final inclusion. Data submitted to HAAD through the electronic notification system were transferred to STATA for cleaning and analysis. Data cleaning was completed while consistency checks were also undertaken. Data collected throughout the pilot phase (30 September 2010 to 24 July 2011) were analysed and are presented in this paper. Descriptive analysis (frequency distribution, mean, mode, median) including graphical distribution of data was conducted. Frequency distributions were carried out to identify the characteristics of injury cases according to demographic profile, place of injury, activity at the time of injury and mechanism of injury. Cross-tabulation and appropriate statistical test (chi-square) were conducted to ascertain if significant differences existed at the p < 0.05 level. Bivariate and multivariate logistic regression analyses were conducted with two different outcomes including: (1) whether the recorded case encountered a fatal, severe and moderate injury, and (2) whether the case was admitted to the hospital due to the injury. Age, gender, nationality (UAE or non-UAE) and health insurance status (having health insurance or not) were included as independent variables. Logistic regression models were also used to ascertain measures of association by examining the odds ratios between the outcome and each of the independent variables. While bivariate analysis was used to identify the significant factors to be included in the multivariate models, multivariate analysis was conducted to ascertain the independent risk factors after adjusting for other competing factors. Data analysis was conducted using STATA statistical software version 10 (StataCorp, 2009). The Johns Hopkins Bloomberg School of Public Health’s Institutional Review Board and HAAD approved this study. The data used for this analysis were de-identified and did not contain any identifying links to study participants. All of the data were stored and protected within a secure HAAD internal information technology system. Results The pilot study covered three hospitals in Abu Dhabi over a 10-month period. 4226 records were entered into IPNS and analysed. The key findings are presented below.
International Journal of Injury Control and Safety Promotion
3
Figure 1. HAAD injury surveillance system – injury and poisoning notification form.
More than one-third of the injury cases were between 25 and 44 years of age, with the mean age being 21.9 years. Nearly three-fourths of the cases were male (72.4%), and the majority were non-UAE citizens (71.6%). The majority of injury cases were from other
countries in the WHO Eastern Mediterranean Region ((EMRO) 68.8%) followed by the WHO South East Asia Region (SEARO) (17.4%). The majority of EMRO injury cases came from Egypt (8.68%), Pakistan (8.12%), Jordan (5.35%) and the UAE (28.47%); whereas majority of
4
M.H. Rahman et al.
Figure 1. Continued
SEARO injury cases came from Bangladesh (8.04%) and India (7.84%) (Table 1). When cases were analysed by the place of injury, the majority (62%) of individuals reported that the injury took place at home. The workplace, which includes
industrial and construction sites, was the second leading place of injury (16.7%) (Table 2). The reported activity during the time of injury for almost two-thirds of the injury cases was leisure and approximately 15% reported to have been working when the injury occurred (Table 2).
International Journal of Injury Control and Safety Promotion
5
Figure 1. Continued
While 97% of the injuries were reported to be unintentional, over half of the respondents reported a fall as the mechanism of injury and 10% mentioned that the injury was caused by a falling object (Table 3). Intentional Table 1. Basic characteristics of injured persons in the pilot study (N ¼ 4226). Characteristic Age group
