Practical guidelines for the registration and monitoring of serious traffic injuries, D7.1 of the H2020 project SafetyCube

BACKGROUND AND OBJECTIVES Crashes also cause numerous serious traffic injuries, resulting in considerable economic and human costs. Given the burden of injury produced by traffic, using only fatalities as an indicator to monitor road safety gives a very small picture of the health impact of traffic crashes, just the tip of the iceberg. Moreover, in several countries during the last years the number of serious traffic injuries has not been decreasing as fast as the number of fatalities. In other countries the number of serious traffic injuries has even been increasing (Berecki-Gisolf et al., 2013; IRTAD Working Group on Serious Road Traffic Casualties, 2010; Weijermars et al., 2015).Therefore, serious traffic injuries are more commonly being adopted by policy makers as an additional indicator of road safety. Reducing the number of serious traffic injuries is one of the key priorities in the road safety programme 2011-2020 of the European Commission (EC, 2010). To be able to compare performance and monitor developments in serious traffic injuries across Europe, a common definition of a serious road injury was necessary. In January 2013, the High Level Group on Road Safety, representing all EU Member States, established the definition of serious traffic injuries as road casualties with an injury level of MAIS ≥ 3. The Maximum AIS represents the most severe injury obtained by a casualty according to the Abbreviated Injury Scale (AIS). Traditionally the main source of information on traffic accidents and injuries has been the police registration. This provides the official data for statistics at national and European level (CARE Database). Data reported by police usually is very detailed about the circumstances of the crash particularly if there are people injured or killed. But on the other hand police cannot assess the severity of injuries in a reliable way, due, obviously to their training. Therefore, police based data use to classify people involved in a crash as fatality, severe injured if hospitalised more than 24 hours and slight injured if not hospitalised. Moreover, it is known that even a so clear definition as a fatality is not always well reported and produces underreporting. This is due to several factors such as lack of coverage of police at the scene or people dying at hospital not followed by police (Amoros et al., 2006; Broughton et al., 2007; Pérez et al., 2006). Hospital records of patients with road traffic injuries usually include very little information on circumstances of the crash but it does contain data about the person, the hospitalisation (date of hospitalisation and discharge, medical diagnosis, mechanism or external cause of injury, and interventions). Hospital inpatient Discharge Register (HDR) offers an opportunity to complement police data on road traffic injuries. Medical diagnoses can be used to derive information about severity of injuries. Among others, one of the possible scales to measure injury severity is the Abbreviated Injury Scale (AIS). The High Level group identified three main ways Member States can collect data on serious traffic injuries (MAIS ≥ 3): 1) by applying a correction on police data, 2) by using hospital data and 3) by using linked police and hospital data. Once one of these three ways is selected, several additional choices need to be made. In order to be able to compare injury data across different countries, it is important to understand the effects of methodological choices on the estimated numbers of serious traffic injuries. A number of questions arise: How to determine the correction factors that are to be applied to police data? How to select road traffic casualties in the hospital data and how to derive MAIS ≥ 3 casualties? How should police and hospital data be linked and how can the number of MAIS ≥ 3 casualties be determined on the basis of the linked data sources? Currently, EU member states use different procedures to determine the number of MAIS ≥ 3 traffic injuries, dependent on the available data. Given the major differences in the procedures being applied, the quality of the data differs considerably and the numbers are not yet fully comparable between countries. In order to be able to compare injury data across different countries, it is important to understand the effects of methodological choices on the estimated numbers of serious traffic injuries. Work Package 7 of SafetyCube project is dedicated to serious traffic injuries, their health impacts and their costs. One of the aims of work package 7 is to assess and improve the estimation of the number of serious traffic injuries. The aim of this deliverable (D7.1) is to report practices in Europe concerning the reporting of serious traffic injuries and to provide guidelines and recommendations applied to each of the three main ways to estimate the number of road traffic serious injuries. Specific objectives for this deliverable are to: Describe the current state of collection of data on serious traffic injuries across Europe Provide practical guidelines for the estimation of the number of serious traffic injuries for each of the three ways identified by the High Level Group Examine how the estimated number of serious traffic injuries is affected by differences in methodology

Trends and forecasts in cause-specific mortality

Mortality forecasting models are typically limited in that they pertain only to national death rates, predict only all-cause mortality, or do not capture and utilize the correlation among diseases. I have developed a novel Bayesian hierarchical model that jointly forecasts cause- specific death rates for geographic subunits. I examined the model’s effectiveness by applying it to United States vital statistics data from 1982 to 2011 that I prepared using a new cause of death reassignment algorithm. I found that the model not only generated coherent forecasts for mutually exclusive causes of death, but it also exhibited lower out-of-sample error than alternative commonly-used models for forecasting mortality. I then used the model to produce forecasts of US cause-specific mortality through 2025 and analysed the resulting trends. I found that total death rates in the US were likely to continue their decline, but at a slower rate of improvement than has been observed for the past several decades. While death rates due to major causes of death like ischaemic heart disease, stroke, and lung cancer were projected to continue trending downward, increases in causes such as unintentional injuries and mental and neurological conditions offset many of these gains. These findings suggest that the US health system will need to adapt to a changing cause composition of disease burden as its population ages in the coming decade. Forecasting research should continue to consider how to best incorporate and balance the many dimensions of mortality when producing projections.Open Acces

Can routinely collected electronic health data be used to develop novel healthcare associated infection surveillance tools?

Background: Healthcare associated infections (HCAI) pose a significant burden to health systems both within the UK and internationally. Surveillance is an essential component to any infection control programme, however traditional surveillance systems are time consuming and costly. Large amounts of electronic routine data are collected within the English NHS, yet these are not currently exploited for HCAI surveillance. Aim: To investigate whether routinely collected electronic hospital data can be exploited for HCAI surveillance within the NHS. Methods: This thesis made use of local linked electronic health data from Imperial College Healthcare NHS Trust, including information on patient admissions, discharges, diagnoses, procedures, laboratory tests, diagnostic imaging requests and traditional infection surveillance data. To establish the evidence base on surveillance and risks of HCAI, two literature reviews were carried out. Based on these, three types of innovative surveillance tools were generated and assessed for their utility and applicability. Results: The key findings were firstly the emerging importance of automated and syndromic surveillance in infection surveillance, but the lack of investigation and application of these tools within the NHS. Syndromic surveillance of surgical site infections was successful in coronary artery bypass graft patients; however it was an inappropriate methodology for caesarean section patients. Automated case detection of healthcare associated urinary tract infections, based on electronic microbiology data, demonstrated similar rates of infection to those recorded during a point prevalence survey. Routine administrative data demonstrated mixed utility in the creation of simplified risk scores or infection, with poorly performing risk models of surgical site infections but reasonable model fit for HCA UTI. Conclusion: Whilst in principle routine administrative data can be used to generate novel surveillance tools for healthcare associated infections; in reality it is not yet practical within the IT infrastructure of the NHS

Vaccine safety, vaccine effectiveness and other determinants for successful immunisation programmes

The studies in this thesis examined several key determinants for successful uptake of vaccinations in the Nordic countries, with focus on vaccine safety and vaccine effectiveness. In study I, we investigated whether disease history is a risk factor for narcolepsy after vaccination with the pandemic influenza vaccine, Pandemrix, which was circulated between 2009 and 2010. The results showed that there was no association between disease history and narcolepsy. We also found evidence for confounding by indication, with a larger number of prescriptions/diagnoses for nervous system disorders and mental and behavioural disorders when we did not adjust for the timing of vaccination or vaccination status. This could suggest that early cases of narcolepsy were initially misdiagnosed prior to narcolepsy diagnosis. In study II, we investigated the effect of the quadrivalent humanpapillomavirus (qHPV) vaccine on genital condyloma by the number of doses and time between doses. This cohort study followed young Swedish girls ages 10-27 for HPV vaccination and condyloma. The results showed that the greatest protection against condyloma was seen after two doses of qHPV vaccine with 4-7 months between dose one and two. We also found that girls, who initiated vaccination at a younger age, had a greater protection against condyloma. The results from these studies show just how complex the improvement of vaccination programmes can be. On one hand, we see the difficulties in assessing what went wrong following the introduction of a vaccine into a population– it is not always possible to predict a rare outcome from a mass vaccination campaign, so vaccine safety becomes a paramount concern from a societal perspective. We also see what happens when a vaccine proves its effectiveness in a population-based setting to the point where the number of doses can be reduced without compromising its effectiveness. Improving the vaccination programmes is, therefore, a complex multifactorial problem with many key determinants that can change depending on the vaccine in question e.g. mass vaccination versus routine vaccination

Adverse health outcomes among long-term survivors of childhood, teenage and young adult cancer

Survivors of childhood, teenage and young adult cancer are at increased risk of developing adverse health outcomes. This thesis aims to address the gaps in knowledge regarding the most severe adverse health outcomes. The Teenage and Young Adult Cancer Survivor Study (TYACSS) provides 200,945 survivors of cancer diagnosed aged 15-39 years. The PanCare Childhood and Adolescent Cancer Survivor Care and Follow-Up Studies (PanCareSurFup) provides 69,460 survivors of cancer diagnosed aged <20 years. Within the TYACSS cohort 1) cancer survivors had increased risk of developing subsequent primary neoplasms, particularly in previously irradiated sites; 2) cancer survivors who likely received cranial irradiation had increased risk of a cerebrovascular event; and 3) central nervous system tumour survivors experienced premature mortality due to neoplastic and nonneoplastic causes. Within the PanCareSurFup cohort 1) the excess number of subsequent softtissue sarcoma was low, except leiomyosarcoma after retinoblastoma; and 2) the excess number of subsequent breast cancers remained elevated beyond 40 years of age among survivors of Hodgkin lymphoma, Wilms tumour and sarcoma. This thesis focuses on the most severe adverse health outcomes among childhood, teenage and young adult cancer survivors and provides evidence for developing clinical follow-up guidelines aimed at reducing such adverse health outcomes

Explaining trends in Scottish coronary heart disease mortality between 2000 and 2010 using IMPACTSEC model: retrospective analysis using routine data.

Objective To quantify the contributions of prevention and treatment to the trends in mortality due to coronary heart disease in Scotland. Design Retrospective analysis using IMPACTSEC, a previously validated policy model, to apportion the recent decline in coronary heart disease mortality to changes in major cardiovascular risk factors and to increases in more than 40 treatments in nine non-overlapping groups of patients. Setting Scotland. Participants All adults aged 25 years or over, stratified by sex, age group, and fifths of Scottish Index of Multiple Deprivation. Main outcome measure Deaths prevented or postponed. Results 5770 fewer deaths from coronary heart disease occurred in 2010 than would be expected if the 2000 mortality rates had persisted (8042 rather than 13813). This reflected a 43% fall in coronary heart disease mortality rates (from 262 to 148 deaths per 100000). Improved treatments accounted for approximately 43% (95% confidence interval 33% to 61%) of the fall in mortality, and this benefit was evenly distributed across deprivation fifths. Notable treatment contributions came from primary prevention for hypercholesterolaemia (13%), secondary prevention drugs (11%), and chronic angina treatments (7%). Risk factor improvements accounted for approximately 39% (28% to 49%) of the fall in mortality (44% in the most deprived fifth compared with only 36% in the most affluent fifth). Reductions in systolic blood pressure contributed more than one third (37%) of the decline in mortality, with no socioeconomic patterning. Smaller contributions came from falls in total cholesterol (9%), smoking (4%), and inactivity (2%). However, increases in obesity and diabetes offset some of these benefits, potentially increasing mortality by 4% and 8% respectively. Diabetes showed strong socioeconomic patterning (12% increase in the most deprived fifth compared with 5% for the most affluent fifth). Conclusions Increases in medical treatments accounted for almost half of the large recent decline in mortality due to coronary heart disease in Scotland. Furthermore, the Scottish National Health Service seems to have delivered these benefits equitably. However, the substantial contributions from population falls in blood pressure and other risk factors were diminished by adverse trends in obesity and diabetes. Additional population-wide interventions are urgently needed to reduce coronary heart disease mortality and inequalities in future decades

Clinical decision support systems in the care of hospitalised patients with diabetes

This thesis explored the role of health informatics (decision support systems) in caring for hospitalised patients with diabetes through a systematic review and by analysing data from University Hospital Birmingham, UK. Findings from the thesis: 1) highlight the potential role of computerised physician order entry system in improving guideline based anti-diabetic medication prescription in particular insulin prescription, and their effectiveness in contributing to better glycaemic control; 2) quantify the occurrence of missed discharge diagnostic codes for diabetes using electronic prescription data and suggests 60% of this could be potentially reduced using an algorithm that could be introduced as part of the information system; 3) found that hypoglycaemia and foot disease in hospitalised diabetes patients were independently associated with higher in-hospital mortality rates and longer length of stay; 4) quantify the hypoglycaemia rates in non-diabetic patients and proposes one method of establishing a surveillance system to identify non diabetic hypoglycaemic patients; and 5) introduces a prediction model that may be useful to identify patients with diabetes at risk of poor clinical outcomes during their hospital stay

Epidemiological analysis of survivorship after childhood cancer

This thesis investigates the adverse outcomes amongst survivors of childhood cancer using the British Childhood Cancer Survivor Study (BCCSS) and the Pancare Childhood and Adolescent Cancer Survivor Care and Follow-up studies (PCSF). The specific aims were to investigate (1) adverse outcomes up to 50 years of follow-up in survivors of Wilms’ tumour; (2) risks of hospitalisations due to renal morbidities in childhood cancer survivors; (3) risk of subsequent primary neoplasms arising in the digestive system in survivors of childhood cancer; and (4) adverse outcomes beyond 50 years of follow-up in survivors of heritable retinoblastoma. This thesis demonstrated that survivors of Wilms’ tumour are at substantial risk of premature mortality, particularly for those who have survived 30 years from original diagnosis. This particular group of survivors have the highest risk of hospitalisations due to renal morbidities, such as chronic renal failure, and subsequent primary neoplasms in specific organs in the lower digestive system. Survivors of heritable retinoblastoma who received external beam radiotherapy experienced an increased risk of subsequent primary neoplasms developing above the shoulder, whereas those who received brachytherapy were similar to those who did not receive any radiotherapy and did not experience an increased risk of subsequent primary neoplasms