Description | Specific Indicators | Ontario Public Health Standards | Corresponding Health Indicator(s) from Statistics Canada and CIHI| Corresponding Indicator(s) from Other Sources | Data Sources |  Alternative Data Sources | ICD Codes | Analysis Check List | Method of Calculation |  Basic Categories | Indicator Comments | Definitions | Cross-References to Other Sections | Cited References | Other References | Changes Made | Acknowledgements

• The crude hospitalization rate - the total number of hospitalizations for intentional self-harm relative to the total population during a given year (fiscal or calendar) (usually expressed per 100,000). 
• Age-specific hospitalization rates - the total number of hospitalizations for intentional self-harm in a given age group per population in that age group during a given year (fiscal or calendar) (usually expressed per 100,000).
• The age-standardized hospitalization rate (SRATE) - the number of hospitalizations for intentional self-harm per 100,000 population that would occur in the population if it had the same age distribution as the 1991 Canadian population.
• The standardized hospitalization ratio is the ratio of observed hospitalizations for intentional self-harm to the number expected if the population had the same age-specific hospitalization rates as Ontario.

• Age-specific self-harm-related hospitalization rates
• Age-standardized self-harm-related hospitalization rate
• Standardized hospitalization ratio for self-harm hospitalization

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.

http://www.ontario.ca/publichealthstandards

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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].

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• ICD-10-CA: Intentional self-harm - X60-X84, Y87.0 
• ICD-9: Suicide and self-inflicted injury - E950.0 to E959.9

• 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 called 'Hospitalization - Ext Cause of Injury - PHU indicator data list' in the APHEO Public Health Indicator folder in the Standard Reports section. This report will provide all injury-related hospitalizations, to get only suicide hospitalizations, please filter on ‘ICD10_All_prob_Dx_code'= is between values (inclusive) X60 to X59 or = Y87.0.
• The IntelliHEALTH User Guides tab contains an ‘An Ambulatory Visits User Guide'.
• The Report Inventory and Webinar Materials tab contains information on external causes of injury from a webinar on the pre-defined report titled ‘Ambulatory Visits: Emergency Visits - External Causes of Injury - PHU'. The webinar material provides guidance on how to extract external cause hospitalization and mortality data.
• It is important to note that an individual can have more than one external cause diagnosis for each hospitalization, unlike with other ICD-10 diagnostic codes, no ‘most responsible diagnosis' exists for external cause diagnosis.
• For inpatient hospitalizations 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 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 intentional self harm hospitalizations, filter for ‘ICD10 Block All Dx' and select blocks X60-X84 (Filter A).
• Add in a filter on ‘ICD10-CA Problem (4 char) All Dx' to filter equal to for 'Y870' (Filter B). (Please note: decimal points normally found in these ICD10-CA codes (e.g. ‘Y87.0') have been removed as four character ICD10-CA codes must be entered into IntelliHEALTH without decimal points)
• In the ‘Combine filter', cases must consist of Filter A or Filter B.  If using other custom filters (e.g. Filter C), brackets must be used around this request. e.g. (Filter A or Filter B) AND Filter C. 
• The ‘ICD10 Block All Dx' and ‘ICD10-CA Problem (4 char) All Dx' MUST be hidden under the Assign Data option, in order to avoid double counting.
• 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 cases where place of occurrence is missing or not specfied.
• 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:
• 10-19 yr, 20-44, 45-64, 65-74, 75+. (IntelliHEALTH Chronic Disease age groups -Age Group (CD)) or
• 5 yr groups from 10 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:
• ‘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.

• Each year many youth and young adults attempt suicide. While some of those attempts may go unrecognized, in 2005 there were more than 5,000 hospitalizations of Canadian (excluding Quebec, for which comparable data were not available) youth and young adults that were specifically classified as attempted suicide (2).  Females accounted for two-thirds (66%) of those suicide attempts.
• Assessing the incidence of attempted suicide is difficult. The majority of suicide attempts are not serious enough to be admitted to hospital for treatment; hospitals tend to only admit the most serious attempters (3). Individuals may also be hospitalized for their own protection or to identify the factors that gave rise to the suicide attempt. Attempted suicide that does not cause serious injury is often treated in the community. Hospitalization data may only provide part of the picture and should be interpreted with caution (4).
• It is important to recognize that some individuals may be repeatedly hospitalized for the same condition, particularly those related to mental health.
• Hospitalization data does not include the care for suicide attempts that is received in hospital emergency departments (5).  
• 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 floor 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), whether or not transferred from another health institution, must first be admitted to the emergency department and thus, will be captured in NARCS.
• Note that injury events found in DAD will not be identical to those found in NARCS:
• 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.
• The report, "Profile of Suicide and Suicide Attempts in Adolescents and Young Adults in Ontario", by the Central West Health Planning Information Network, describes many of the data quality issues that can make interpreting local suicide data suicide problematic, including changes in definitions and procedures over time (1).
• 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 the emergency department for an unscheduled visit.

• All-cause hospitalization (Section 3: Mortality, Morbidity and Health-Related Quality of Life)
• Child and adolescent hospitalization (Section 6C: Child and Adolescent Health)
• Suicidal Thoughts and Attempts (Section 4C: Injury Prevention and Substance Misuse Prevention)
• Suicide Mortality (Section 4C: Injury Prevention and Substance Misuse Prevention)
• Population Estimates (Section 1: Population)

1. Central West Health Planning Information Network. Profile of Suicide and Suicide Attempts In Adolescents and Young Adults in Ontario. Hamilton: Central West Health Planning Information Network;2003 [cited 2012 May 22]. Available from: http://www.apheo.ca/resources/indicators/2003%20Suicide%20Report.pdf.
2. Public Health Agency of Canada [homepage on the Internet]. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2011. Ottawa: Public Health Agency of Canada; 2011 Oct 25 [cited 2012 May 22]. Chapter 3, The health and well-being of Canadian Youth and Young Adults. Available from: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2011/cphorsphc-respcacsp-06-eng.php.
3. Holley HL, Fick G, Love EJ. Suicide following an inpatient hospitalization for a suicide attempt: a Canadian follow-up study. Soc Psychiatry Epidemiology. 1998;33(11):543-551.
4. Health Canada. A report on mental illnesses in Canada. Ottawa, ON: Health Canada Editorial Board Mental Illnesses in Canada; c2002 [cited 2012 May 22]. Available from: http://www.cpa.ca/cpasite/userfiles/Documents/Practice_Page/reports_mental_illness_e.pdf.
5. Langlois S., Morrison, P. Suicide deaths and suicide attempts. Health Reports. 2002 [cited 2012 May 22];13(2):9-22. Available from: http://www.statcan.gc.ca/pub/82-003-x/2001002/article/6060-eng.pdf.

1. Cornell University Bronfenbrenner Center for Translational Research [homepage on the Internet]. Ithaca: Cornell University Bronfenbrenner Center for Translational Research; c2012 [cited 2012 May 22]. What do we know about self-injury? Available from: www.crpsib.com/whatissi.asp.
2. Health Canada. Suicide in Canada: Update of the report of the task force on suicide in Canada. Ottawa, ON: Her Majesty the Queen in Right of Canada; 1994 [cited 2012 May 22]. Available from: http://www.phac-aspc.gc.ca/mh-sm/pdf/suicid_e.pdf.
3. Diekstra RFW, Gulbinat W. The epidemiology of suicidal behaviour: a review of three continents. World Health Stat Q. 1993;46(1):52-68.
4. Cutcliffe JR. Research endeavors into suicide: a need to shift the emphasis. Br J Nurs. 2003;12(2):92-99.
5. Ward M. Mental health in Northern Ontario. Short report #5. Sudbury, ON: Northern Health Information Partnership; 2005 [cited 2012 May 22]. Available from: http://www.apheo.ca/resources/indicators/MentalHealthinNorthernOntario.pdf. 
6. Canadian Association for Suicide Prevention. CASP blueprint for a Canadian national suicide prevention strategy. Winnipeg, MB: Canadian Association for Suicide Prevention; 2004 [2012 May 22]. Available at: http://www.suicideprevention.ca/.
7. Region of Peel Health Department. State of the Region's health 2004: focus on suicide. Brampton, ON: Region of Peel Health Department; 2004 [cited 2012 May 22]. Available from: http://www.region.peel.on.ca/health/health-status-report/focusonsuicide/index.htm.