|4C Fall-Related Emergency Department Visits
Description | Specific Indicators | Ontario Public Health Standards (OPHS) |Corresponding Indicators from Statistics Canada and CIHI | Corresponding from Other Sources | Data Sources | Survey Questions | Alternative Data Sources | ICD Codes | Analysis Check List | Method of Calculation | Basic Categories | Indicator Comments | Definitions | Cross-References to Other Indicators | Cited References | Changes Made | Acknowledgements
- Crude ED visits rate - the total number of emergency department (ED) visits (not scheduled) for unintentional fall-related injury relative to the total population during a given year (fiscal or calendar) (usually expressed per 100,000)
- Age-specific ED visit rates - the total number of emergency department visits 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 ED visit rate (SRATE) - the number of emergency department visits 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 emergency department visits for unintentional fall-related injury to the number expected if the population had the same age-specific emergency department visitis for unintentional fall-related injury rates as Ontario
|Specific Indicators |
- Crude emergency department visit rate for unintentional fall-related injury
- Age-specific emergency department visit rates for unintentional fall-related injury
- Age-standardized emergency department visit rate (SRATE) for unintentional fall-related injury
- Standardized morbidity ratio (SMR), emergency department visits 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.|
|Outcomes Related to this Indicator |
- 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.
|Assessment and Surveillance Requirements Related to this Indicator (Prevention of Injury and Substance Misuse) |
- 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.
|Corresponding Health Indicator(s) from Statistics Canada and Canadian Institute for Health Information (CIHI) |
|Corresponding Health Indicator(s) from Other Sources |
|Data Sources (see Resources: Data Sources) |
Numerator: Emergency Visits
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].
|Alternative Data Sources |
*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.
|Analysis Check List|
- 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 'ED visits - 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 ED visits, to get only fall-related ED visits, 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 in October, 2011. 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 ED visit. Unlike other ICD-10-CA diagnostic codes, no ‘most responsible diagnosis' exists for external cause diagnosis.
- For emergency department visit tabulations through 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 includes only unscheduled ED visits. If you use the Ambulatory All Visits Main Table, you must use a filter, AM Case Type = EMG, to get only unscheduled ED visits.
- For all fall-related emergency department visits, filter for ‘ICD10 Block All Dx' and select block W00-W19.
- Select # Visit(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.
|Method of Calculation |
total number of emergency department visits for unintentional fall-related injury
| x 100,000|
total number of emergency department visits for unintentional fall-related injury in a given age group
| x 100,000|
total population in that age group
|SRATE (See Resources: Standardization of Rates)|
sum of (emergency department visits in a given age group for unintentional fall-related injury x 1991 Canadian population in that age group)
sum of 1991 Canadian population
|Standardized ratio (See Resources: Standardization of Rates)|
sum of emergency department visits for unintentional fall-related injury in the population
| x 100 |
sum of (Ontario age-specific rate x population in that age group)
|Basic Categories |
- 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.
|Indicator Comments |
- The highest proportion of fall-related ED visits were observed in females 65 and older and males younger than 20 (1).
- The mechanism of fall may vary across age groups (2). It may be informative to analyze falls by external cause. Please refer to ICD Codes section.
- Emergency department visit data will not capture those who did not seek treatment in hospital, 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.
- Even falls that older adults experience that result in less serious injuries may still contribute to a cycle of fear of falling, decreased participation and weakness/deconditioning which increases falls risk (3, 4).
- 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) or ratios (SMRs, SIRs). The crude death (or disease) rate is the number of deaths (or disease cases) divided by the number of people in the population. This rate depicts the "true" picture of death /disease in a community although it is greatly influenced by the age structure of the population. An older population would likely have a higher crude death rate whereas a younger population may have a higher crude birth rate. Age-specific rates can best describe the "true" death /disease pattern of a community and allow comparison of populations that have different age structures.
- 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.
- Emergency department visit - An ED visit occurs when a person presents the emergency department, or a hospital-based urgent care centre, either by their own means or by ambulance, and without a prior scheduled appointment. (Urgent care centres provide diagnosis and treatment for most injuries and illnesses through emergency trained doctors and other health care professionals and are a health care option for urgent, but non life-threatening illness or injury like sprains or strains. Urgent care centre visits are captured in NACRS).
|Cross-References to Other Indicators|
- Canadian Institute for Health Information. Highlights of 2009 - 2010 inpatient hospitalizations and emergency department visits. Ottawa: Canadian Institute for Health Information; 2011 [cited 2012 Jun 26]. Available from: https://secure.cihi.ca/free_products/quickstats_dad_nacrs_2009_10_highlight_en.pdf.
- 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.
- British Columbia Ministry of Health Planning. Prevention of falls and injury 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.
- 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.
Type of Review (Formal Review or Ad Hoc?)
Changes made by
July 16, 2012
Injury and substance misuse prevention sub-group
- Badal Dhar, Public Health Ontario
- Natalie Greenidge, Public Health Ontario
- Injury and Substance Misuse Prevention Subgroup
- Suzanne Fegan, KFL&A Public Health (Subgroup Lead)
- Christina Bradley, Niagara Region Public Health
- Jeremy Herring, Public Health Ontario
- Sean Marshall, Public Health Ontario
- Jayne Morrish, Parachute
- Lee-Ann Nalezyty, Northwestern Health Unit
- Michelle Policarpio, Public Health Ontario
- Narhari Timilshina, Toronto General Hospital
- Celine Butler, Timiskaming Health Unit
- Elizabeth Rael, Ministry of Health and Long-Term Care