Déterminants de l'accès à un système de traumatologie intégré : une étude de cohorte rétrospective

Peu de données sont disponibles quant à l’accès aux soins dans les systèmes de traumatologie intégrés. Nous avons conduit une étude de cohorte populationnelle rétrospective pour décrire l’accès, identifier ses déterminants et évaluer pour les traumatismes majeurs, l’influence de cet accès sur la mortalité et la durée de séjour hospitalières. Tous les adultes admis pour traumatisme dans un hôpital du Québec entre 2006 et 2011 ont été inclus. L’accès était de 75% pour toute la population et 90% pour les traumatismes majeurs. Le lieu de résidence, mécanisme du traumatisme, nombre de blessures, sévérité du traumatisme et l’âge étaient les déterminants les plus importants de l’accès. La mortalité et la durée de séjour pour les patients n’ayant pas accès au système étaient globalement semblables à celles des patients ayant accès. Le système de traumatologie du Québec semble bien fonctionner en offrant des soins aux patients qui en ont vraiment besoin.Few data are available on access to integrated trauma systems. We therefore conducted a population-based retrospective cohort study to firstly describe access to trauma care, identify its determinants in an integrated trauma system and secondly evaluate among major trauma admissions, the influence of access on hospital mortality and length of stay (LOS). We included all adults admitted to acute care hospitals for trauma in the province of Québec between 2006 and 2011 using an administrative hospital discharge database. Of the 136,653 injury admissions selected, 75% were treated within the trauma system. Among major trauma (n=25,522), 90% had access to specialized trauma care. The region of residence followed by mechanism of injury, number of trauma diagnoses, injury severity and age were the most important determinants of access to trauma care. Mortality and LOS for the small proportion of patients treated in non-designated centers were similar to those of patients treated in trauma centers. These studies provide evidence that the Québec trauma system performs well in its mandate to offer appropriate treatment to victims of injury that require specialized care

Impact of Trauma System Structure on Injury Outcomes : A Systematic Review and Meta-Analysis

The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.Peer reviewe

Impact of Trauma System Structure on Injury Outcomes : A Systematic Review and Meta-Analysis

The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.Peer reviewe

Child labour and health: a systematic review

ObjectivesThis study aimed to synthesise the available knowledge, identify unexplored areas and discuss general limits of the published evidence. We focused on outcomes commonly hypothesised to be affected by child labour: nutritional status, harmful exposures and injuries.MethodsFour electronic databases (EMBASE, MEDLINE, Scopus, ISI Web of Science) were searched in November 2017. All articles published since 1996, without restrictions on language, were considered for inclusion.ResultsOut of the 1090 abstracts initially identified by the search, 78 articles were selected for inclusion and reviewed. Most of the studies were conducted in Asia and South America, and only a third of them compared working children to a control group of non-working children. Child labour appears to be associated with poor nutritional status, diseases due to harmful exposures, and a higher prevalence of injuries.ConclusionsDespite evidence for a negative relation between child work and health, the cross-sectional design of most studies limits the causal interpretation of existing findings. More rigorous observational studies are needed to confirm and better quantify these associations