[Indicators to measure the performance of emergency trauma care]

The objective of this paper was to identify the main indicators used to measure the performance in emergency trauma care. A literature review was carried out in the electronic databases: PubMEd, LILACS and Epistemónikos, including publications between January 2011 and December 31, 2021, in Spanish, English and Portuguese. A total of 962 publications were identified. When reviewing the full text, 48 articles were included. The indicators were classified in the dimensions of process and results. 100 different indicators were identified to analyze the performance of emergency trauma care. 71% were process indicators, including service time and triage. In the results dimension 29 indicators were identified; mortality was the indicator most analyzed as well as length of stay. Six indicators on the disability of injured people and 14 indicators related to satisfaction were identified, the most frequent being complaints. Various indicators have been used to assess the performance of emergency trauma care. In the results dimension, the indicators related to satisfaction and disability after injuries have been little explored. Decision-makers and those responsible for emergency care must promote performance evaluation exercises to learn about their current situation using appropriate and sensitive indicators with the available data.

Impact of accidental and intentional injuries in Mexico. Findings of the Global Burden of Disease study for 1990 and 2021

BACKGROUND

Previous analyses on the burden of disease in Mexico identified that injuries differentially affect young people, males and working-age people.

OBJECTIVE

To analyze the burden of disease due to intentional and unintentional injuries in Mexico during 1990 and 2021, at the national and state levels.

MATERIAL AND METHODS

The results of the Global Burden of Disease study for the 1990-2021 period were used to describe the burden of disease attributed to injuries in Mexico. The life years lost (YLL) due to premature mortality, years lived with disability (YLD) and disability-adjusted life years (DALY) were analyzed.

RESULTS

The burden of disease related to intentional injuries has increased, as also have YLDs and DALYs associated with unintentional injuries. Men continue to have higher mortality and DALY rates compared to women. Interpersonal violence and suicide have steadily increased. The analysis by state showed patterns with important variations.

CONCLUSIONS

Injuries generate catastrophic consequences in terms of mortality and disability in Mexico. It is necessary to promote and strengthen programs and policies in order to improve the data system and injury prevention.

The political and social contexts of global road safety: challenges for the next decade

The goal of this Series paper is to show how road safety has evolved as a global public health issue over the past two decades and to discuss the political and economic dynamics that led to this change. Specifically, the key stakeholders, influences, networks, issue framing, actor power, and synergistic interactions that have contributed to how road safety has evolved as a global public health issue will be discussed. In doing so, we capture the important chronology of events and discuss a set of challenges that highlight the complexity of road safety. We posit that the global road safety community needs to re-evaluate its role and strategy for the next decade and focus more on implementation and country action to achieve reductions in road traffic injuries. We call for an open and inclusive process to ensure that such a reflection occurs before the end of the current decade.

[Legislation on road safety in Mexico: a subnational analysisLegislação de segurança viária no México: uma análise subnacional]

Objetivo.

Realizar um diagnóstico da regulamentação federal e estadual para determinar em que medida são cumpridas as recomendações de segurança viária com relação a diferentes fatores de risco e de proteção.

Métodos.

Foi conduzida uma análise descritiva das disposições jurídicas federais e das 32 entidades federativas do México em segurança viária. Foram identificadas as entidades que dispunham de regulamentação legal sobre os principais fatores de risco (excesso de velocidade, consumo de álcool antes de dirigir, uso de celular ao dirigir) e fatores de proteção para acidentes de trânsito (uso de capacete, cinto de segurança e dispositivos de retenção infantil) e analisada sua adequação segundo as recomendações da Organização Mundial da Saúde/Organização Pan-Americana da Saúde (OMS/OPAS). Além disso, são descritos os tipos de sanções aplicadas nestas disposições.

Resultados.

Quase 10% das entidades analisadas dispõem de legislação específica para os seis fatores de risco e de proteção analisados. Observou-se que o fator de risco “consumo de álcool antes de dirigir” e o fator de proteção “uso de capacete” são os mais frequentemente incluídos na legislação estadual. A legislação é adequada em apenas duas entidades federativas (estados): Zacatecas (velocidade de condução) e Jalisco (uso de cinto de segurança, dispositivos de retenção infantil e capacete). A sanção aplicada com maior frequência é a multa.

Conclusões.

É fundamental e prioritário promover uma legislação abrangente contendo disposições adequadas que abordem critérios técnicos e científicos de proteção e prevenção bem como mecanismos apropriados de monitoramento, regulação e cumprimento da legislação.

Child and Adolescent Health From 1990 to 2015: Findings From the Global Burden of Diseases, Injuries, and Risk Factors 2015 Study

Importance

Comprehensive and timely monitoring of disease burden in all age groups, including children and adolescents, is essential for improving population health.

Objective

To quantify and describe levels and trends of mortality and nonfatal health outcomes among children and adolescents from 1990 to 2015 to provide a framework for policy discussion.

Evidence Review

Cause-specific mortality and nonfatal health outcomes were analyzed for 195 countries and territories by age group, sex, and year from 1990 to 2015 using standardized approaches for data processing and statistical modeling, with subsequent analysis of the findings to describe levels and trends across geography and time among children and adolescents 19 years or younger. A composite indicator of income, education, and fertility was developed (Socio-demographic Index [SDI]) for each geographic unit and year, which evaluates the historical association between SDI and health loss.

Findings

Global child and adolescent mortality decreased from 14.18 million (95% uncertainty interval [UI], 14.09 million to 14.28 million) deaths in 1990 to 7.26 million (95% UI, 7.14 million to 7.39 million) deaths in 2015, but progress has been unevenly distributed. Countries with a lower SDI had a larger proportion of mortality burden (75%) in 2015 than was the case in 1990 (61%). Most deaths in 2015 occurred in South Asia and sub-Saharan Africa. Global trends were driven by reductions in mortality owing to infectious, nutritional, and neonatal disorders, which in the aggregate led to a relative increase in the importance of noncommunicable diseases and injuries in explaining global disease burden. The absolute burden of disability in children and adolescents increased 4.3% (95% UI, 3.1%-5.6%) from 1990 to 2015, with much of the increase owing to population growth and improved survival for children and adolescents to older ages. Other than infectious conditions, many top causes of disability are associated with long-term sequelae of conditions present at birth (eg, neonatal disorders, congenital birth defects, and hemoglobinopathies) and complications of a variety of infections and nutritional deficiencies. Anemia, developmental intellectual disability, hearing loss, epilepsy, and vision loss are important contributors to childhood disability that can arise from multiple causes. Maternal and reproductive health remains a key cause of disease burden in adolescent females, especially in lower-SDI countries. In low-SDI countries, mortality is the primary driver of health loss for children and adolescents, whereas disability predominates in higher-SDI locations; the specific pattern of epidemiological transition varies across diseases and injuries.

Conclusions and Relevance

Consistent international attention and investment have led to sustained improvements in causes of health loss among children and adolescents in many countries, although progress has been uneven. The persistence of infectious diseases in some countries, coupled with ongoing epidemiologic transition to injuries and noncommunicable diseases, require all countries to carefully evaluate and implement appropriate strategies to maximize the health of their children and adolescents and for the international community to carefully consider which elements of child and adolescent health should be monitored.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.

METHODS

Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol.

FINDINGS

All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa.

INTERPRETATION

Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

FUNDING

Bill & Melinda Gates Foundation.

The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013

Background

The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country.

Methods

Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool. Morbidity estimation was based on inpatient and outpatient data sets, 26 cause-of-injury and 47 nature-of-injury categories, and seven follow-up studies with patient-reported long-term outcome measures.

Results

In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died from injuries. Between 1990 and 2013 the global age-standardised injury DALY rate decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22 cause-of-injury categories, including all the major injuries.

Conclusions

Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. The decline in rates for almost all injuries is so prominent that it warrants a general statement that the world is becoming a safer place to live in. However, the patterns vary widely by cause, age, sex, region and time and there are still large improvements that need to be made.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition

BACKGROUND

The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

METHODS

We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

FINDINGS

Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

INTERPRETATION

Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

FUNDING

Bill & Melinda Gates Foundation.

Road-traffic injuries: confronting disparities to address a global-health problem

Evidence suggests that the present and projected global burden of road-traffic injuries is disproportionately borne by countries that can least afford to meet the health service, economic, and societal challenges posed. Although the evidence base on which these estimates are made remains somewhat precarious in view of the limited data systems in most low-income and middle-income countries (as per the classification on the World Bank website), these projections highlight the essential need to address road-traffic injuries as a public-health priority. Most well-evaluated effective interventions do not directly focus on efforts to protect vulnerable road users, such as motorcyclists and pedestrians. Yet, these groups comprise the majority of road-traffic victims in low-income and middle-income countries, and consequently, the majority of the road-traffic victims globally. Appropriately responding to these disparities in available evidence and prevention efforts is necessary if we are to comprehensively address this global-health dilemma.

Social capital in settings with a high concentration of road traffic injuries. The case of Cuernavaca, Mexico

There exists a differential ability within local communities to maintain effective social controls to prevent road traffic injuries (RTIs) in high risks areas. In 2002 we conducted a cross-sectional study in Cuernavaca, Mexico which incorporated 339 adults living in three areas which were characterized by high RTI concentrations. Multivariate analyses demonstrated that even when participants perceived RTIs as a local problem, they expressed no expectations that community members would exert social control through their involvement in local issues and law adherence. The study revealed four key conclusions regarding the association between the low levels of social capital and RTIs: (a) public roads are used solely for transportation, are not viewed as a communal space, and consequently reciprocity is not viewed as a relevant way of controlling behaviors in public places; (b) "strong immediate personal networks" bring about a lack of reciprocity between those sharing the public space which generates uncooperative behavior; (c) high levels of residential instability hinders the identification of common problems; (d) when there exists a low level of civic commitment and a scarcity of social resources directed towards the problem, the possibilities of social control over RTIs are low.

Factores asociados con la gravedad de lesiones ocurridas en la vía pública en Cuernavaca, Morelos, México

OBJECTIVE

To identify risk factors associated with severity of injuries occurring in public streets of an urban area.

MATERIAL AND METHODS

Between February and April 2001, a cross-sectional survey was conducted among injured people seeking emergency care at three hospitals in Cuernavaca, Morelos, Mexico. Information was also obtained for those who died on accident sites. Data on the following variables were collected: age, sex, alcohol intake, day and time of injury, prehospital care, external cause and nature of injury. The Abbreviated Injury Scale (AIS) was used to define severity of injuries. Data analysis consisted of descriptive, bivariate, and multivariate regression models.

RESULTS

A total of 492 injured people were included in the study; 23 of them died on site. The main cause of injuries was road traffic accidents (52%); 72% of injuries were not severe. Variables associated with the severity of injuries were: Road traffic accidents (odds ratio [OR] 6.59, 95% confidence interval [CI] 2.52, 17.23), adjusted for age and schooling.

CONCLUSION

Road traffic injuries are the main cause of severe injuries. TheAIS is useful to assess the frequency and distribution of injury severity.

Risk factors in highway traffic accidents: a case control study

The objective of this study was to identify risk factors related to the driver, the vehicle and the environment, that are associated with motor vehicles accidents on highways. A case and control design was used where the case was: the driver of a motor vehicle who was involved in an accident while traveling on the Mexico-Cuernavaca highway; and the control was: the driver or a motor vehicle who, traveling on the highway, completed the trip without being involved in a traffic accident. Risk factors associated with the occurrence of a traffic accident (P > 0.05) were: age under 25 years, frequent travel, traveling to work, alcohol consumption, driving during the daylight, on a week-day, under adverse weather conditions and in the Mexico Cuernavaca direction of road. Risks adjusted by logistic regression were: age under 25 years odds ratio (OR) 3.01, confidence interval (CI) (95%) 1.46-6.18; work as a travel reason OR 1.74, CI 1.06 2.86; alcohol intake OR 4.70, Cl 1.62 13.6; driving under adverse weather conditions OR 5.70, CI 3.66-8.85; traveling on a week-day OR 1.84, CI 1.14-2.94; during daylight hours OR 4.23, CI 2.36-7.58 and in the Mexico Cuernavaca direction of road OR 2.69, CI 1.67 4.32. The identification of factors associated with the risk of being involved in a highway traffic accident allows us to propose primary prevention measures for this important public health problem.

Cross-national comparison of injury mortality: Los Angeles County, California and Mexico City, Mexico

BACKGROUND

Cross-national comparisons of injury mortality can suggest possible causal explanations for injuries across different countries and cultures. This study identifies differences in injury mortality between Los Angeles (LA) County, California and Mexico City DF, Mexico.

METHODS

Using LA County and Mexico City death certificate data for 1994 and 1995, injury deaths were classified according to the International Classification of Diseases Ninth Revision-Clinical Modification external cause of injury codes. Crude, gender-, and age-adjusted annual fatality rates were calculated and comparisons were made between the two regions.

RESULTS

Overall and age-adjusted injury death rates were higher for Mexico City than for LA County. Injury death rates were found to be higher for young adults in LA County and for elderly residents of Mexico City. Death rates for motor vehicle crashes, falls, and undetermined causes were higher in Mexico City, and relatively high rates of poisoning, homicide, and suicide were found for LA County. Motor vehicle crash and fall death rates in Mexico City increased beginning at about age 55, while homicide death rates were dramatically higher among young adults in LA County. The largest proportion of motor vehicle crash deaths was to motor vehicle occupants in LA County and to pedestrians in Mexico City.

CONCLUSIONS

These findings illustrate the importance of primary injury prevention in countries having underdeveloped trauma care systems and should aid in setting priorities for future work. The high frequency of pedestrian fatalities in Mexico City may be related to migration of rural populations, differing vehicle characteristics and traffic patterns, and lack of safety knowledge. Mexico City's higher rate of fall-related deaths may be due to concurrent morbidity from chronic conditions, high-risk environments, and delay in seeking medical treatment.