Early Hospital Mortality among Adult Trauma Patients Significantly Declined between 1998-2011: Three Single-Centre Cohorts from Mumbai, India

Abstract

BackgroundTraumatic injury causes more than five million deaths each year of which about 90% occur in low- and middle-income countries (LMIC). Hospital trauma mortality has been significantly reduced in high-income countries, but to what extent similar results have been achieved in LMIC has not been studied in detail. Here, we assessed if early hospital mortality in patients with trauma has changed over time in an urban lower middle-income setting.MethodsWe conducted a retrospective study of patients admitted due to trauma in 1998, 2002, and 2011 to a large public hospital in Mumbai, India. Our outcome measure was early hospital mortality, defined as death between admission and 24-hours. We used multivariate logistic regression to assess the association between time and early hospital mortality, adjusting for patient case-mix. Injury severity was quantified using International Classification of Diseases-derived Injury Severity Score (ICISS). Major trauma was defined as ICISS<0.90.ResultsWe analysed data on 4189 patients out of which 86.5% were males. A majority of patients were between 15 and 55 years old and 36.5% had major trauma. Overall early hospital mortality was 8.9% in 1998, 6.0% in 2002, and 8.1% in 2011. Among major trauma patients, early hospital mortality was 13.4%, in 1998, 11.3% in 2002, and 10.9% in 2011. Compared to trauma patients admitted in 1998, those admitted in 2011 had lower odds for early hospital mortality (OR = 0.56, 95% CI = 0.41–0.76) including those with major trauma (OR = 0.57, 95% CI = 0.41–0.78).ConclusionsWe observed a significant reduction in early hospital mortality among patients with major trauma between 1998 and 2011. Improved survival was evident only after we adjusted for patient case-mix. This finding highlights the importance of risk-adjustment when studying longitudinal mortality trends.

Patterns of injury mechanism at a tertiary trauma center in Mumbai, India: Opportunities for injury prevention

“…Our findings are similar to those of several single-site, hospital-based cross-sectional studies reporting on patterns of injuries and clinical outcomes in India (Deshmukh et al, 2012;Farooqui et al, 2013;Goel, Kumar, & Bagga, 2004;Radjou et al, 2012;Rastogi, Meena, Sharma, & Singh, 2014;Uthkarsh et al, 2012). These studies all report predominantly young adult male victims of trauma.…”

“…In many cases, two-wheeled vehicles account for the majority of RTIs, suggesting regional variation in road traffic users (Deshmukh et al, 2012;Rastogi et al, 2014;Uthkarsh et al, 2012). Finally, several other studies from academic trauma referral centers noted mortality rates of 31-% to 33%, which were much higher than predicted when adjusting for injury severity (Deshmukh et al, 2012;Goel et al, 2004). These rates reflect the severely injured cohort of patients being treated and the system-wide challenges in providing effective trauma care in this context.…”

“…LTMGH receives the bulk of patients with road traffic injuries from the outskirts of the city due to its proximity to a major highway into Mumbai. LTMGH has an institutional trauma registry in operation since 1998 (Gerdin et al, 2014;Murlidhar & Roy, 2004).…”

Choice of injury scoring system in low- and middle-income countries: Lessons from Mumbai

“…When stratifying MGAP scores as low (23)(24)(25)(26)(27)(28)(29), intermediate (18)(19)(20)(21)(22) and high (3-17) risk for death, the in-hospital mortality rates were uniformly higher than in the original validation cohort of the MGAP score in France (Table 3). The area under the ROC curve for the MGAP score in the French validation cohort was 0.90, compared with 0.85 in the subset of patients with sufficient data to Fig.…”

“…Because ISS is a composite of AIS values, incomplete patient evaluation can result in underestimation of injury severity, which is a common threat in low-and middle-income countries due to lack of radiographic, intra-operative or autopsy data [22]. Several studies have used modified approaches to calculate ISS in low-and middle-income countries, such as retrospective analyses of billing codes or estimations based on initial clinical presentation [23,24]. However, even when full diagnostic information is available, ISS calculation is a labour-intensive process that requires specially trained staff, which is often unsustainable in low-and middle-income countries [7].…”