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Open Access

Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis

Stas Amato, Levi Bonnell, Monali Mohan, Nobhojit Roy, Ajai Malhotra
DOI: 10.1136/tsaco-2021-000719 Published 18 November 2021
Stas Amato
1Department of General Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
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Levi Bonnell
2Department of General Internal Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
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Monali Mohan
3Department of Health Systems Strengthening, Care India, Bihar, Patna, India
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Nobhojit Roy
4The George Institute for Global Health, New Delhi, India
5WHO Collaborating Centre for Research in Surgical Care Delivery, Mumbai, India
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Ajai Malhotra
1Department of General Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
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  • Figure 1
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    Figure 1

    Patient flow diagram of NTDB and TITCO patients starting with over 2.6 million patients from the two databases and resulting in 687 407 patients. There is overlap between the exclusion categories, which were applied in parallel. The numbers presented are the true numbers for each category and not of sequential exclusion. NTDB, National Trauma Data Bank; TITCO, Towards Improved Trauma Care Outcomes.

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    Figure 2

    Multivariate logistic regression of independent predictors of mortality represented by a forest plot with the ORs and 95% CIs of independent predictors. All variables were significant (p<0.001). GCS, Glasgow Coma Scale; ISS, Injury Severity Score; SBP, systolic blood pressure.

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    Figure 3

    The odds of mortality in India from multivariate logistic regression models for each ISS category represented by a forest plot with 95% CIs. All ISS categories were significant (p<0.001).

Tables

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  • Table 1

    Patient demographic, physiologic, anatomic and outcome characteristics

    USA (NTDB)India (TITCO)P value
    Demographic   
     Age mean (SD)48.0 (20.5)38.7 (15.8)<0.001
     Sex (% male)68.983.4<0.001
    Mechanism   
     Fall (%)31.330.4<0.001
     Road traffic injury (%)37.849.3<0.001
     Penetrating (%)11.04.8<0.001
     Firearm injury (%)5.60<0.001
    Physiologic   
     RR median (IQR)18 (16–20)20 (18–22)<0.001
     Respiratory distress (RR <10 or >29) (%)6.827.2<0.001
     SBP median (IQR)136 (120–152)118 (110–130)<0.001
     Shock (SBP <90) (%)4.16.3<0.001
     GCS median (IQR)15 (14–15)15 (8–15)<0.001
     Altered mental status (GCS ≤13) (%)16.444.5<0.001
    Anatomic   
     AIS head ≥3 (%)25.754.7<0.001
     AIS face ≥3 (%)0.20.10.150
     AIS chest ≥3 (%)22.58.1<0.001
     AIS abdomen ≥3 (%)5.54.9<0.001
     AIS extremity ≥3 (%)9.78.2<0.001
     AIS external ≥3 (%)0.030.25<0.001
     ISS median (IQR)9 (5–17)9 (9–14)<0.001
     ISS ≥25 (%)11.87.5<0.001
    Outcome   
     Mortality (%)2.823.2<0.001
    • AIS, Abbreviated Injury Scale; ISS, Injury Severity Scale; NTDB, National Trauma Data Bank; SBP, systolic blood pressure; TITCO, Towards Improved Trauma Care Outcomes.

  • Table 2

    Odds of mortality in India by demographic, physiologic, and anatomic characteristics

    OR95% CIP value
    Demographic
     Ages 18–3913.74(12.61 to 14.96)<0.001
     Ages 40–6415.29(13.87 to 16.87)<0.001
     Age >659.50(8.00 to 11.30)<0.001
     Males13.76(12.90 to 14.69)<0.001
     Females13.82(11.94 to 15.99)<0.001
    Mechanism
     Fall14.50(12.92 to 16.28)<0.001
     Road traffic injury18.17(16.68 to 19.79)<0.001
     Penetrating4.95(3.31 to 7.39)<0.001
    Physiologic
     RR <10 or >298.05(7.24 to 8.95)<0.001
     RR ≥10 or ≤2915.65(14.57 to 16.82)<0.001
     SBP <9010.17(8.79 to 11.77)<0.001
     SBP ≥9014.66(13.75 to 15.64)<0.001
     GCS ≤1310.61(9.94 to 11.35)<0.001
     GCS >1322.59(20.06 to 25.44)<0.001
    Anatomic
     Head (AIS 1–2)57.79(44.58 to 74.91)<0.001
     Head (AIS 3–6)9.02(8.39 to 9.69)<0.001
     Face (AIS 1–2)20.02(17.37 to 23.09)<0.001
     Face (AIS 3–6)2.53(0.48 to 13.35)0.272
     Chest (AIS 1–2)20.78(16.23 to 26.63)<0.001
     Chest (AIS 3–6)10.76(8.90 to 13.00)<0.001
     Abdomen (AIS 1–2)14.93(11.58 to 19.25)<0.001
     Abdomen (AIS 3–6)8.06(6.35 to 10.22)<0.001
     Extremity (AIS 1–2)17.62(15.08 to 20.59)<0.001
     Extremity (AIS 3–6)16.50(13.74 to 19.82)<0.001
     External (AIS 1–2)15.57(14.08 to 17.22)<0.001
     External (AIS 3–6)6.26(2.14 to 18.31)0.001
    • AIS, Abbreviated Injury Scale; GCS, Glasgow Coma Scale; SBP, systolic blood pressure.

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Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis
Stas Amato, Levi Bonnell, Monali Mohan, Nobhojit Roy, Ajai Malhotra
Trauma Surg Acute Care Open Nov 2021, 6 (1) e000719; DOI: 10.1136/tsaco-2021-000719

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Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis
Stas Amato, Levi Bonnell, Monali Mohan, Nobhojit Roy, Ajai Malhotra
Trauma Surg Acute Care Open Nov 2021, 6 (1) e000719; DOI: 10.1136/tsaco-2021-000719
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Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis
Stas Amato, Levi Bonnell, Monali Mohan, Nobhojit Roy, Ajai Malhotra
Trauma Surgery & Acute Care Open Nov 2021, 6 (1) e000719; DOI: 10.1136/tsaco-2021-000719
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