Data for public health surveillance of violence-related problems Alex E. Crosby Surveillance Academy workshop 2016 National Center for Injury Prevention and Control Centers for Disease Control and Prevention "The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry.
Objectives Describe types of data available for surveillance of violence-related issues Highlight data systems that collect violence-related data Give examples from the data systems
Public Health Impact 2014 Over 59,000 people died violently in the US Six people dying each hour Nearly $50 billion in medical care and lost productivity every year 42,773 died by suicide Greater than those who die by motor vehicle crashes 10 th leading cause of death 16,324 died by homicide 16th leading cause of death
The Public Health Approach to Prevention Assess the Problem What s the problem? Identify the Causes Why did it happen? Implementation & Dissemination How do you do it? Develop & Evaluate Programs & Policies What works?
Public Health Surveillance Data used to enable effective and efficient action to be taken to prevent and control disease. (World Bank surveillance toolkit)
Burden of injury Deaths Hospitalizations Emergency Dept visits Events reported on surveys Unreported events
Public Health Burden of suicidal behavior -- United States, 2013 41,149 deaths*, rate 12.6 per 100,000 134,160 hospitalizations rate 42.4 494,169 Emergency dept. visits rate 160.5 *Source: CDC s National Vital Statistics System Source: Agency for Healthcare Research and Quality s Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS) Source: CDC s National Electronic Injury Surveillance System All Injury Program
Number and ratio of persons affected by suicidal thoughts and behavior among adults aged 18 years United States, 2013 39,894 (1) Deaths* 118,740 (3.0) 405,300 (10.2) Hospitalizations Emergency Department visits 1,312,000 (32.9) Suicide attempts 9,292,000 (232.9) Seriously considered suicide** *Source: CDC s National Vital Statistics System, Source: Agency for Healthcare Research and Quality s Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS) Source: Source: CDC s National Electronic Injury Surveillance System-All Injury Program Source: SAMHSA s National Survey on Drug Use and Health ** Source: SAMHSA s National Survey on Drug Use and Health Number in parentheses represent the ratio of deaths to other categories
National Violent Death Reporting System Mission To collect high quality detailed, timely information on all violent deaths in the US Integrates data from diverse sources Provides more information than a single source
Three Principal Data Sources +1 Death certificates Law enforcement reports including Supplementary Homicide Reports (SHRs) or National Incident-Based Reporting System (NIBRS) records Coroner and medical examiner records Crime lab reports* (not required but often included)
NVDRS (continued) The system includes: Suicides Homicides Events of undetermined intent Unintentional firearm injury deaths Legal intervention deaths (excluding executions)
MI OH NVDRS States NV OR AK CO GA MD MA NJ NC OK RI SC VA WI UT KY NM CA AZ WA Ill NY HI TX MN PA VT CT KS IA IN WV NH LA AL TN D.C. MS AR MO NE SD ND WY MT ID FL DE ME
Suicide Variables Current depressed mood Current mental health problem Other mental health diagnosis Current treatment for mental illness Ever treated for mental illness Alcohol problem Other substance problem Other addiction Job problem School problem Financial problem Anniversary of a traumatic event Person left a suicide note Disclosed intent to commit suicide History of suicide attempts Crisis in past 2 wks Physical health problem Intimate partner problem Other relationship problem Suicide of friend or family in past 5 years Other death of friend or family in past 5 years Recent criminal legal problem Eviction/loss of home
Health/Behavior information for suicide decedents by sex* - 16 states, 2010 45 40 35 Percentage 30 25 20 15 10 5 Male Female 0 Intimate partner problem Physical health problem Financial problem Left suicide note History of suicide attempts Crisis in past 2 wks Recent criminal legal problem Health or behavior category * Categories are not mutually exclusive
Mental Health information for suicide decedents by sex* - 16 states, 2010 70 60 Percentage 50 40 30 20 10 Male Female 0 Current depressed mood Current mental health problem Current mental health treatment Alcohol problem Other substance abuse problem Mental health category * Categories are not mutually exclusive
Homicide/Legal intervention Circumstance Variables Intimate partner violence related Stalking* Prostitution or sex trafficking* Gang related Justifiable self-defense/law enforcement Victim was a police officer on duty Victim was a bystander Random violence Victim was intervener assisting crime victim Victim used a weapon Mercy killing Hate crime Jealousy (lover s triangle)* Brawl Walk-by assault Drive-by shooting (homicide only) Drug Involvement
Leading circumstances among homicide/legal intervention victims -- 16 US states, 2010 Precipitating circumstance Counts Percent Precipitated by another crime 977 33.7 Argument over money/property 205 7.1 Jealousy (lover s triangle) 108 3.7 Other argument, abuse, conflict 1039 35.8 Intimate partner violence-related 479 16.5 Hate crime 6 0.2 Mentally ill suspect 57 2.0 Drive-by shooting 116 4.0 Gang-related 137 4.7 Source: Parks, et al. Surveillance of Violent Death.
Homicide-Suicide event by type NVDRS 2003-2005 Other family 7.1% Extrafamilial 10.3% Filicide 8.1% Intimate Partner + 5.9% Intimate Partner only 68.6% Source: Logan et al, 2008
Precipitating circumstances for legal intervention deaths* - U.S. 17 states, 2009-2012 40 35 30 Percentage 25 20 15 10 5 0 Alcohol use suspected Perpetrator of violence in past month Intimate partner problem Current mental health problem Current drug/alcohol problem Crisis in past 2 wks Recent criminal legal problem Category * Categories are not mutually exclusive
Circumstances of incident and weapons used in line of duty homicides U.S., 17states, 2003-2012 Circumstance* Precipitated by another crime Number % 70 55.1 Other crime in progress 51 40.1 Argument 15 11.8 Weapon Firearms 113 88.9 Motor vehicles 8 6.3 Sharp instruments 2 1.6 Explosives 2 1.6 * More that 1 circumstance can be
NVDRS Data Available to Public Public access on the Web http://wisqars.cdc.gov:8080/nvdrs/nvdrsdisplay.jsp Select variables to run your own reports Manner of death Victim/suspect relationship Weapon type Vulnerable populations Circumstances Many NVDRS states provide data / reports on the web
Web-Based Statistics www.cdc.gov/ncipc/wisq ars/default.htm Injury mortality and leading cause of death statistics available by: Intent, Method Year State Demographics Age, Sex, Race Injury morbidity Hospital emergency dept events
Why Do We Need Injury Surveillance Systems? What s the problem and how big is it? Who is at risk? How do we design research to find out how to prevent the problem and test it in a community? Assess the result of programs (e.g., changes in deaths, injuries, impairments, disabilities, lost work days, loss of ability to perform daily activities, or behaviors)?
Conclusion Assessment is a foundation for public health action Existing systems for assessing certain injuryrelated deaths are useful but have limitations Need exists for improved and expanded surveillance systems regarding self-directed violence For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.atsdr.cdc.gov
Extra slides
Public Health Surveillance ongoing systematic collection, analysis and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. Thacker & Berkelman 1988
Scope of NVDRS State Definition Unintentional Injury Deaths Intentional Injury Deaths: Suicide (including terrorism) Homicide (including terrorism) Legal intervention (excluding legal executions) Deaths of Undetermined Intent Unintentional Firearm Deaths NVDRS
Prevalence of suicidal thoughts and behavior among adults by race/ethnicity -- United States, 2012 # in 1,000s Ideation Plan Attempt % # in 1,000s % # in 1,000s % Total U.S. 9,031 3.9 2,681 1.1 1,290 0.6 Race/ethnicity White, non-hispanic 6,200 4.0 1,786 1.1 746 0.5 Black, non-hispanic 965 3.6 308 1.1 192 0.7 Hispanic 1,210 3.5 366 1.1 245 0.7 Asian, non-hispanic 322 3.3 143 1.2 61 0.5 American Indian/Alaskan Native 169 5.9 26 2.0 18 1.4 Source: SAMHSA NSDUH
Prevalence of suicidal thoughts among adults by state -- United States, 2008-2009 (U.S. avg 3.7%) Wash., D.C. Source: Substance abuse and Mental Health Services Administration NSDUH Prevalence in population 2.1 to 3.1% 3.2 to 3.9% 4.0 to 4.4% 4.5 to 6.8%
National Electronic Injury Surveillance System (NEISS) Operated by the U.S. Consumer Product Safety Commission (CPSC) CDC/CPSC interagency agreement Started October, 1978 Nationally representative sample of U.S. hospitals with > 6 beds and an emergency department (ED) First time, injury-related visits Approx. 500,000 cases per year Annualized estimates and rates of nonfatal injuries treated in U.S. hospital EDs
NEISS All Injury Program Core variables age sex race/ethnicity two-product codes primary body part affected principal diagnosis locale of injury incident Disposition narrative Additional variables intent of injury major mechanism of injury groupings coded using guidelines consistent with ICD-9- CM coding rules for external causes of injury
Self-inflicted injury among all persons by age and sex--united States, 2013 600 550 Rate per 100,000 population 500 450 400 350 300 250 200 150 100 50 0 Males Females 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Age Group in years Source: CDC WISQARS NEISS
Self-directed violence prevention Problem Description/Surveillance Deaths Death Certificates - National, State, County National Violent Death Reporting System - 32 states School-Associated Violent Death Study National
Self-directed violence prevention Problem Description/Surveillance Nonfatal injuries official records Hospital emergency department (ED) records Check with state hospital association or local hospital or trauma center Healthcare Cost and Utilization Project (HCUP) (30 states) In-patient hospitalizations Check with state hospital association HCUP (46 states in 2011)
Self-directed violence prevention Problem Description/Surveillance Nonfatal injuries - surveys Youth Risk Behavior Surveillance System (CDC) - High school students - 4 items on suicidal thoughts and behavior - National, 43 states, and 21 large urban school districts National Survey on Drug Use and Health (SAMHSA) - Adults (18+ years) - 6 items on suicidal thoughts and behavior - National, 50 states + Wash., D.C., and 33 large metropolitan areas
Population-based Surveys Youth Risk Behavior Survey Biennial survey (every other year) Administered in school computer-assisted Provides national, state, and sub-state representative estimates on a variety of health risk behaviors Suicide-related information covers a 12 month period
Percentage of high school students who Percentage of all students report suicidal behavior* by sex U.S., 14 12 10 8 6 4 2 0 1990 1991 1993 1995 1990-2013 1997 Total 1999 Source: Youth Risk Behavior Surveillance System *At least one attempt during the 12 months preceding the survey 2001 Year 2003 2005 2007 Female Male 2009 2011 2013
Suicidal ideation and behavior among high school students by category and sex* -- United States, 2013 Percentage of all students 25 20 15 10 5 0 Seriously consider suicide Suicide plan Attempted suicide^ Suicide attempt with medical Female Male Total Category Source: CDC Youth Risk Behavior Survey * During the 12 months preceding the survey ^One or more times
Suicidal behavior*^ among high school students by sexual identity# -- New York City, 2001-2009 35 30 Percent 25 20 15 10 gay or lesbian hererosexual bisexual unsure 5 0 * During the 12 months before the survey. ^ One or more times. # Among students who ever had sexual contact. Source: New York City Youth Risk Behavior Survey Results Category
Population-based Surveys National Survey on Drug Use and Health (NSDUH) Annual household survey of civilian, noninstitutionalized population aged 12 years or older Administered in-person, computer-assisted Provides national, state, and sub-state representative estimates of substance abuse and mental health issues Suicide-related information covers a 12 month period
Prevalence of suicidal thoughts and behavior among adults by sex and age group -- United States, 2014 Ideation Plan Attempt # in 1,000s % # in 1,000s % # in 1,000s % Sex Total 9,436 3.9 2,681 1.1 1,120 0.6 Male 4,437 3.9 1,144 1.0 445 0.4 Female 4,999 4.0 1,523 1.2 676 0.5 Age 18-25 yrs 2,586 7.5 806 2.3 433 1.2 26-49 yrs 3,953 4.0 1,107 1.1 491 0.5 50+ yrs 2,897 2.7 754 0.7 196 0.2 Source: SAMHSA NSDUH
Prevalence of suicidal attempts among adults aged 18 years, by state United States, 2008 2009) Wash., D.C. *U.S. average: 0.5%. Source: Natl Survey on Drug Use and Health Prevalence in population 0.1% 0.3% 0.4% 0.5% 0.5% 1.5%
Prevalence of suicidal thoughts among adults in the past year by state NSDUH, U.S., 2008-2009 10 9 Percentage of population 8 7 6 5 4 3 2 1 0 Northeast CTME MA NHNJ NY PARI VT Midwest ILIN IA KSMI MN MONE ND OHSD WI South ALAR DE DCFL GA KYLA State MD MSNC OK SCTN TX VAWV West AKAZ CA COHI ID MTNV NM ORUT WA WYUS High Low Estimate
Age-adjusted suicide rates among all persons by state -- United States, 2009 (U.S. avg 11.8) Wash., D.C. Source: Centers for Disease Control and Prevention (CDC) vital statistics Rates per 100,000 population 4.5 to 10.0 10.1 to 11.8 11.9 to 14.7 14.8 to 21.3
MI OH NVDRS States 2016 NV OR AK CO GA MD MA NJ NC OK RI SC VA WI UT KY NM Veteran New Unfunded CA AZ WA Ill NY HI TX MN PA NH CT KS IA IN WV ME + VT LA AL TN D.C. MS AR MO NE SD ND WY MT ID FL DE MN
Considerations for data on suicide-related problems Information Diverse data sources Circumstances at time of injury event Sources Emergency medical services data (EMS) Linking data between systems [e.g., law enforcement, ME/C, medical records]? Access and Dissemination Timeliness Reporting requirements