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Internationally comparable diagnosis-specific survival probabilities for calculation of the ICD-10–based Injury Severity Score

Gedeborg, Rolf MD, PhD; Warner, Margaret PhD; Chen, Li-Hui PhD; Gulliver, Pauline PhD; Cryer, Colin PhD; Robitaille, Yvonne PhD; Bauer, Robert PhD; Ubeda, Clotilde MD, MSc; Lauritsen, Jens MD, PhD; Harrison, James MBBS, MPH; Henley, Geoff; Langley, John PhD

Journal of Trauma and Acute Care Surgery: February 2014 - Volume 76 - Issue 2 - p 358–365
doi: 10.1097/TA.0b013e3182a9cd31
Original Article

BACKGROUND The International Statistical Classification of Diseases, 10th Revision (ICD-10)–based Injury Severity Score (ICISS) performs well but requires diagnosis-specific survival probabilities (DSPs), which are empirically derived, for its calculation. The objective was to examine if DSPs based on data pooled from several countries could increase accuracy, precision, utility, and international comparability of DSPs and ICISS.

METHODS Australia, Argentina, Austria, Canada, Denmark, New Zealand, and Sweden provided ICD-10–coded injury hospital discharge data, including in-hospital mortality status. Data from the seven countries were pooled using four different methods to create an international collaborative effort ICISS (ICE-ICISS). The ability of the ICISS to predict mortality using the country-specific DSPs and the pooled DSPs was estimated and compared.

RESULTS The pooled DSPs were based on a total of 3,966,550 observations of injury diagnoses from the seven countries. The proportion of injury diagnoses having at least 100 discharges to calculate the DSP varied from 12% to 48% in the country-specific data set and was 66% in the pooled data set. When compared with using a country’s own DSPs for ICISS calculation, the pooled DSPs resulted in somewhat reduced discrimination in predicting mortality (difference in c statistic varied from 0.006 to 0.04). Calibration was generally good when the predicted mortality risk was less than 20%. When Danish and Swedish data were used, ICISS was combined with age and sex in a logistic regression model to predict in-hospital mortality. Including age and sex improved both discrimination and calibration substantially, and the differences from using country-specific or pooled DSPs were minor.

CONCLUSION Pooling data from seven countries generated empirically derived DSPs. These pooled DSPs facilitate international comparisons and enables the use of ICISS in all settings where ICD-10 hospital discharge diagnoses are available. The modest reduction in performance of the ICE-ICISS compared with the country-specific scores is unlikely to outweigh the benefit of internationally comparable Injury Severity Scores possible with pooled data.

LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.

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From the Department of Surgical Sciences, Anesthesiology and Intensive Care (R.G.), and Uppsala Clinical Research Center (R.G.), Uppsala University, Uppsala, Sweden; National Center for Health Statistics (M.W., L.-H.C.), Centers for Disease Control and Prevention, Hyattsville, Maryland; Injury Prevention Research Unit (P.G., C.C., J.L.), University of Otago, Dunedin, New Zealand; Institut national de santé publique du Québec (INSPQ) (Y.R.), Montréal, Québec, Canada; Austrian Road Safety Board (R.B.), Research and Knowledge Management, Vienna, Austria; Programa de Prevención de Lesiones por Causas Externas (C.U.), Instituto Nacional de Epidemiología, Dr “J.H.Jara,” ANLIS Malbran, Argentina; Accident Analysis Group (J.L.), Odense University Hospital and IST/Biostatistics University of Southern Denmark, Odense C, Denmark; Research Centre for Injury Studies (J.H., G.H.), Flinders University, Adelaide, Australia.

Submitted: April 10, 2013, Revised: August 9, 2013, Accepted: August 12, 2013, Published online: January 6, 2014.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Rolf Gedeborg, MD, PhD, Uppsala Clinical Research Center, Uppsala University. UCR/Scheele, Dag Hammarskjölds väg 50A, 3tr. Science Park, SE-751 85 Uppsala, Sweden; email:

© 2014 Lippincott Williams & Wilkins, Inc.