• Crude hospitalization rate - the number of hospital admissions for unintentional fall-related injury relative to the total population during a given year (fiscal or calendar) (usually expressed per 100,000).
• Age-specific hospitalization rates - the number of hospital admissions for unintentional fall-related injury in a given age group per population in that age group during a given year (fiscal or calendar) (usually expressed per 100,000).
• Age-standardized hospitalization rate (SRATE) - the number of hospitalizations for unintentional fall-related injury per 100,000 population that would occur in the population if it had the same age distribution as the 1991 Canadian population.
• Standardized morbidity ratio (SMR) - the ratio of observed hospitalizations for unintentional fall-related injury to the number expected if the population had the same age-specific hospitalization rates for unintentional falls as Ontario. 

Specific Indicators

• Crude hospitalization rate for unintentional fall-related injury
• Age-specific hospitalization rates for unintentional fall-related injury
• Age-standardized hospitalization rate (SRATE) for unintentional fall-related injury
• Standardized morbidity ratio (SMR) for unintentional fall-related Injury

Ontario Public Health Standards (OPHS)

The Ontario Public Health Standards (OPHS) establish requirements for the fundamental public health programs and services carried out by boards of health, which include assessment and surveillance, health promotion and policy development, disease and injury prevention, and health protection. The OPHS consist of one Foundational Standard and 13 Program Standards that articulate broad societal goals that result from the activities undertaken by boards of health and many others, including community partners, non-governmental organizations, and governmental bodies. These results have been expressed in terms of two levels of outcomes: societal outcomes and board of health outcomes. Societal outcomes entail changes in health status, organizations, systems, norms, policies, environments, and practices and result from the work of many sectors of society, including boards of health, for the improvement of the overall health of the population. Board of health outcomes are the results of endeavours by boards of health and often focus on changes in awareness, knowledge, attitudes, skills, practices, environments, and policies. Boards of health are accountable for these outcomes. The standards also outline the requirements that boards of health must implement to achieve the stated results.

• Board of Health Outcome (Prevention of Injury and Substance Misuse): the board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services for the prevention of injury and substance misuse.
• Board of Health Outcome (Foundational Standard): the public, community partners and health care providers are aware of relevant and current population health information.

• The board of health shall conduct epidemiological analysis of surveillance data....in the areas of injury and substance misuse outcomes, including falls across the lifespan.

http://www.ontario.ca/publichealthstandards

• None

•  None

Numerator: National Ambulatory Care Reporting System 
Original source: National Ambulatory Care Reporting System (NACRS), Canadian Institute for Health Information (CIHI)
Distributed by: Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH ONTARIO (IntelliHEALTH)
Suggested citation (see Data Citation Notes): Ambulatory Emergency External Cause [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].


Denominator: Population Estimates
Original source: Statistics Canada
Distributed by: Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH ONTARIO (IntelliHEALTH)
Suggested citation (see Data Citation Notes):  Population Estimates [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].

• Ontario Trauma Registry
• Discharge Abstract Database (DAD) (Hospitalization) Note: for those interested in using hospitalization data from DAD, to avoid double counting of those patients that were admitted to one hospital and then transferred to another (e.g. to a regional trauma hospital), please use the ‘Inpatient Discharges All Tables' and add in the following filter when extracting hospital discharge data:
• 'Transfer from Institution Type' not equal to #1 - which is 'acute care facilities'
• Please refer to Indicator Comments for rationale for choice of data source.

• Unintentional Fall Codes (ICD-9: E880-E888); (ICD-10: W00-W19):
• W00: Fall on same level involving ice and snow
• W01: Fall on same level from sliping, tripping or stumbling
• W02: Fall involving ice-skates, skis, sport boards and in-line skates
• W03: Other fall on same level due to collision with, or pushing by, another person
• W04: Fall while being carried or supported by another person
• W05: Fall involving wheelchair and other types of devices
• W06: Fall involving bed
• W07: Fall involving chair
• W08: Fall involving other furniture
• W09*: Fall involving playground equipment
• W10: Fall on and from stairs and steps
• W11: Fall on and from ladder
• W12: Fall on and from scaffolding
• W13: Fall from, out of or through building or structure
• W14: Fall from tree
• W15: Fall from cliff
• W16: Diving or jumping into water causing injury other than drowning or submersion
• W17: Otherfall from one level to another
• W18: Other fall on same level
• W19: Unspecified fall

*Prior to the year 2009, the only code available for 'falls involving playground equipment' was W09. From 2009 and onwards, subcategories were introduced (eg. W09.03 is fall involving teeter totter) and code range for falls involving playground equipment is from W09.01-W09.09.

• The IntelliHEALTH licensing agreement does not require suppression of small cells, but caution should be used when reporting at a level that could identify individuals, (e.g. reporting at the postal code level by age and sex). Please note that privacy policies may vary by organization. Prior to releasing data, ensure adherence to the privacy policy of your organization.
• Aggregation (e.g. combining years, age groups, categories) should also be considered when small numbers result in unstable rates.
• IntelliHEALTH Ontario is developing a complete set of pre-defined reports for injury-related Core Indicators, (i.e., templates that permit standardized queries by local public health agencies). Registered IntelliHEALTH users can find a predefined report called 'Hospitalization - Ext Cause of Injury - PHU indicator list' in the APHEO Public Health Indicator folder in the Standard Reports section. This report will provide all injury-related hospitalizations, to get only fall-related hospitalizations, please filter for fall codes W00-W19 as described below.
• An 'Ambulatory Visits User Guide' is available within IntelliHEALTH.
• The Report Inventory and Webinar Materials tab contains information on pre-defined reports and webinar materials, including information on external causes of injury from a webinar on the pre-defined report titled 'Emergency Visits - External Causes of Injury - PHU'. The webinar material provides guidance on how to extract external cause hospitalization and mortality data.  A Tips & Tricks webinar on Dec. 16, 2011, also provides some useful information on hospitalizations and emergency room visits. 
• It is important to note that an individual can have more than one external cause diagnosis for each hospitalization. Unlike with other ICD-10-CA diagnostic codes, no ‘most responsible diagnosis' exists for external cause diagnosis.
• For in-patient separation in IntelliHEALTH, use Ambulatory Emergency External Cause (Chapter 20) source from the '04 Ambulatory visits' folder. Please note that this source differs from the Ambulatory All Visits Main Table in that it only includes unscheduled ED visits. If using the Ambulatory All Visits Main Table, the filter "AM Case Type = EMG" must be used to extract only unscheduled ED visits.
• For all fall-related emergency hospitalization, filter for ‘ICD10 Block All Dx' and select the falls block W00-W19.
• To select clients admitted as inpatients, use the 'Disposition Status' variables = '6' - (i.e.'Client admitted as inpatient to critical care unit/operating room in reporting facility direct from amb care visit functional center') OR = '7' ('Client admitted as inpatient to other units in reporting facility direct from amb. care visit functional') OR = '8' (Transferred to another acute care facility directly from an ambulatory care visit functional centre).
• Select # Visits (D) measure.
• Distinct counts - a patient can have more than one diagnosis code for one visit (eg. cardiovascular disease). In such cases, one code is deemed ‘the most responsible diagnosis code' or main problem Dx (or MRDx is some data sources). Diagnoses that are identified as due to external causes (eg. fractured elbow) also have a companion "external cause" ICD-10-CA code. A person can have more than one external cause diagnosis for one visit. However, unlike the diagnoses codes mentioned above, external cause diagnoses do not have a main problem diagnosis in emergency (or other hospital) data. Thus, the external cause diagnoses are only included in the multi-record per visit data sources such as the Ambulatory Emergency External Cause (Chapter 20) source. Because the source has multiple records per visit, only distinct counts (# Visits (D)) can be used in order tally number of visits. IntelliHEALTH can now create crosstab tables and sum across distinct counts for external causes (Note: because the column total is a distinct count, it may be smaller than the sum of the cells within the column). For more information, please see the Report Inventory and Webinar Materials and Training sections within IntelliHEALTH.
• Use the pre-defined filter to select the appropriate geography (e.g. public health unit, LHIN) before running the report. Hospital information (hospital name, PHU or LHIN) can also be selected in the report.
• Note that ambulatory care data (and in-patient data) are reported by fiscal year (April 1 - March 31). Any changes in the source data occur on a fiscal year basis (e.g., ICD10 reporting began on April 1, 2002) and will affect reporting by calendar year.
• 'Place of occurrence' may also be used for codes W00-Y34 to identify place of external cause. Please note that there may be a large number of patient records where place of occurrence is missing or categorized as ‘9', unspecified place.
• NOTE**Intellihealth has made a change and will now expose both historical data and current fiscal year data in the NACRS maps - folder 04. In practice, you will need to pay close attention to year filtering when creating reports using maps in folder 04 - as the most recent year may not have a complete year of data.

• Suggested Age Groups:
• <1-19 yr, 20-44, 45-64, 65-74, 75+. (IntelliHEALTH Chronic Disease age groups -Age Group (CD)) or
• <1, 1-4, then 5 yr groups to 90+. (IntelliHEALTH Infant + 5-yr age groups - (inf,5yr))
  *Note: Health units may choose to merge age categories due to small numbers, or change age categories depending on the specific analysis questions. Examples of other potential age categories include:
• '<1, 1-4 could be changed to "0-4"
• ‘Youth' could be analyzed as '15-24', a common category for analyzing self-harm data
• ‘Seniors/Older adults' could be analyzed as ages "65+"
• Sex: male, female and total
• Place of occurrence (e.g. home, school, residential facility, sports or athletic area)
• Geographic areas of residence: Ontario, public health unit, municipality, and smaller areas of geography based on aggregated postal code

• Falls-related injury is the most frequent cause of unintentional injury hospitalization in Canada, and at 37% and 84% is the leading cause of all injury hospitalizations for children/youth and older Canadians respectively (1, 2).
• Rates of hospitalization for unintentional falls vary based on age, sex and socioeconomic status: older women and individuals of lower socioeconomic status are more likely to be hospitalized for injuries resulting from unintentional falls (1 - 5).
• In older adults, the rates of hospitalization and mortality for unintentional fall-related injury increase with increasing age after 65 (6, 7).
• Hospitalization data will not capture those treated and released from emergency departments, those treated in doctors' offices or clinics, or those who did not seek treatment in hospital for a fall-related injury and therefore will underestimate burden of fall-related injury.
• Falls resulting in less serious injuries in older adults may still contribute to a cycle of fear of falling, decreased participation and weakness/deconditioning which increases falls risk (6, 8).
• The mechanism of fall may vary across age groups (9). It may be informative to analyze falls by external cause. Please refer to ICD10 Codes.
• A person may be hospitalized for more than one occurrence of the same injury classification or discharged from more than one hospital for the same injury event in a given time period. Therefore, hospitalization data cannot be used to measure the incidence of a specific injury.
• Hospitalization data will not capture those who did not seek treatment for an injury in a hospital and will therefore underestimate burden of injury.
• ICD-10-CA has a greater level of specificity and different code titles than ICD-9. CIHI does not endorse forward conversions because of differences in the classification systems. Refer to Resources: ICD-10-CA for more information.
• To best understand mortality or disease trends in a population, it is important to determine crude rates, age-specific rates and age-standardized rates (SRATES) and/or ratios (SMRs, SIRs). Although the crude death (or disease) rate depicts the "true" picture of death /disease in a community, it is greatly influenced by the age structure of the population: an older population would likely have a higher crude death rate. Age-specific rates can best describe the "true" death/disease pattern within particular age groups of a community, and allow for comparison of age groups across populations that have different age structures.
• Since many age-specific rates are cumbersome to present, age standardized rates have the advantage of providing a single summary number that allows different populations to be compared; however, they present an "artificial" picture of the death/disease pattern in a community. For more information about standardization, refer to the Resources section: Standardization of Rates.

 Choice of Data Source:

• NACRS, and not DAD, captures admissions to acute care psychiatric beds. For this reason, NACRS is used to derive the Intentional Self-Harm-Related Hospitalization Core Indicator. For consistency, NACRS is also the recommended data source for all other injury-related hospitalization indicators (i.e. Injury-Related Hospitalization, Fall-Related Hospitalization and Neurotrauma-Related Hospitalization).
• More timely information is provided through NACRS as injury data are based on admission to an inpatient bed from the emergency department. Discharge information following injury-related hospitalization obtained from the DAD may not be captured in the same year in which the injury occurred for some patients (especially those hospitalized for a prolonged period of time).
• All non-elective hospital admissions (i.e. including all hospital admissions for injury) must first be admitted to the emergency department and thus, will be captured in NACRS. Sometimes a patient seen in one ED can be transferred to another acute care facility. Ideally, a person that is transferred to another acute care facility will enter through the ED and receive a NACRS record with the new facility, however, this does not always occur. Thus, we recommend the inclusion of disposition status code '8', even though this may result in some over-counting of visits. Over-counting varied between 7% and 10% over the past several years in Ontario.
• Note that injury events found in DAD will not be identical to those found in NACRS:
• DAD also captures injury events that occur in acute care (e.g. a fracture from a fall in hospital will not be captured in NACRS). However, in-care injury events reflect patient safety within hospitals rather community safety, which is of greater public health concern.
• ICD-10-CA codes assigned based on emergency department presentation may differ from those assigned on discharge after hospitalization.

• Hospitalization - in this indicator, a hospitalization occurs when a patient is admitted as an inpatient after being seen in the emergency department for an unscheduled visit.

Cross-References to Other Sections

All-Cause Hospitalization (Section 3: Mortality, Morbidity and Health-Related Quality of Life)
Injury-Related Hospitalization (Section 4C: Injury Prevention and Substance Misuse Prevention)
• Self-Reported Injury (Section 4C: Injury Prevention and Substance Misuse Prevention)
• Child and Adolescent Hospitalization (Section 6C: Child and Adolescent Health)
• Population Estimates (Section 1: Population)

1. Canadian Institute for Health Information. National Trauma Registry 2006 injury hospitalizations highlights report. Ottawa: Canadian Institute for Health Information; 2007 [cited 26 Jun 2012]. Available from: https://secure.cihi.ca/free_products/ntr_highlights_2006_en.pdf.  
2. Canadian Institute for Health Information. National Trauma Registry 2007 injury hospitalizations highlights report. In Focus: pediatric injury hospitalizations in Canada, 2005 - 2006. Ottawa: Canadian Institute for Health Information; 2008 [cited 26 Jun 2012].  Available from: https://secure.cihi.ca/free_products/ntr_highlights_2007_en.pdf.  
3. Canadian Institute for Health Information. Injury hospitalizations and socio-economic status. 2010. Available from: https://secure.cihi.ca/free_products/Injury_aib_vE4CCF_v3_en.pdf.
4. Public Health Agency of Canada. Report on seniors' falls in Canada. Ottawa: Her Majesty the Queen in Right of Canada; 2005 [cited 2012 Jun 26]. Available from: http://publications.gc.ca/collections/Collection/HP25-1-2005E.pdf.
5. Faelker T, Pickett W, Brison RJ. Socioeconomic differences in childhood injury: a population based epidemiologic study in Ontario, Canada. Inj Prev. 2000 [cited 2012 Jun 26] (6);203-8. Available from: http://www.yorku.ca/alison3/SES%20and%20childhood%20injury%20Ontario.pdf.
6. British Columbia Ministry of Health Planning. Prevention of falls and injuries among the elderly. Victoria: British Columbia Ministry of Health Planning, Office of the Provincial Health Officer; 2005 [cited 2012 Jun 26]. Available from: http://www.health.gov.bc.ca/library/publications/year/2004/falls.pdf.
7. Scott V, Wagar L, Elliott S. Falls and related injuries among older Canadians. Ottawa: Her Majesty the Queen in Right of Canada; 2010 [cited 2012 Jun 26]. Available from: http://www.hiphealth.ca/media/research_cemfia_phac_epi_and_inventor_20100610.pdf.
8. Scheffer AC, Schuurmans MJ, Van Dijk N, Van Der Hooft T. Fear of falling: measurement strategy, prevalence, risk factors and consequences. Age and ageing. 2008 [cited 2012 Jun 26];28:19-24. Available from: http://ageing.oxfordjournals.org/content/37/1/19.full.pdf+html.
9. Minino AM, Anderson RN. Deaths: Injuries, 2002. Natl Vital Stat Rep. 2006 [cited 2012 Jun 26]; 54(10):1-124. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_10.pdf.