Abstract
Background:
Children with major trauma have better outcomes when treated in pediatric trauma centres, but population-based data on access to these centres in Canada are lacking. We aimed to estimate the proportion of children with major trauma who accessed a pediatric trauma centre in Canada (through direct transport or transfer) and compare access across provinces.
Methods:
We conducted a population-based cohort study of children (aged < 16 yr) who were admitted to hospital after a major trauma (Injury Severity Score > 12) in 9 Canadian provinces (excluding Quebec) from 2016 to 2021. We estimated the adjusted incidence of access to a pediatric trauma centre across provinces using robust Poisson regression and examined the effect of age and injury severity in subgroup analyses.
Results:
Of 3007 children with major trauma, 2335 (77.6%) were directly transported (n = 879, 29.2%) or transferred (n = 1456, 48.4%) to a pediatric trauma centre. Crude access to pediatric trauma centres was higher for younger children (80.9% among those aged 0 to 5 yr, 81.7% among those aged 6 to 12 yr, 69.9% among those aged 13 to 15 yr) and those with critical injuries (88.8%). Adjusted pediatric trauma centre access was lower in British Columbia (relative risk [RR] 0.68, 95% confidence interval [CI] 0.63 to 0.74), the Atlantic provinces (RR 0.80, 95% CI 0.73 to 0.88), and Saskatchewan (RR 0.77, 95% CI 0.69 to 0.86) than Ontario, but was higher in Alberta (RR 1.06, 95% CI 1.02 to 1.10) and Manitoba (RR 1.14, 95% CI 1.09 to 1.19). Interprovincial differences were present across all subgroups (p < 0.0001).
Interpretation:
Across 9 Canadian provinces, 1 in 4 children with major trauma did not receive care in a pediatric trauma centre. These results suggest the opportunity for improvement in Canadian trauma systems to ensure that all children receive optimal injury care.
Trauma is the leading cause of death and of potential years of life lost among children and youth in Canada.1,2 In 2018, trauma led to 818 166 emergency department visits, 14 237 hospitalizations, 3574 patients left with disabilities, and 202 deaths among those aged 0 to 14 years, with an estimated economic burden of 2.9 billion dollars.1 Timely access to appropriate trauma care increases the likelihood of a good outcome after major trauma. To address this challenge in Canada, provincial trauma systems have been progressively established since the 1980s, the result of a coordinated effort to deliver high-quality health care to all injured people.3,4 These include networks of acute care hospitals designated by level of care to provide optimal geographic coverage.4 Level I and II trauma centres offer the highest level of care and are further designated as adult or pediatric trauma centres.4 The latter have human and material resources adapted to the unique physical and psychological needs of children and their families.5
A recent meta-analysis demonstrated a 41% reduction in the odds of death for children with major trauma treated in pediatric trauma centres, compared with those treated in adult centres, as well as significant reductions in emergency surgeries and imaging.6 However, population-based data on access to pediatric trauma centres in Canada are limited. Access to care can be operationalized as potential (i.e., relative to population need) versus realized (characterized by the use of a given health care service) access.7 Existing studies have focused on potential access to pediatric trauma centres in the United States8–10 and in Canada11 using geospatial analyses, or on realized access to pediatric trauma centres in the US.12 Data on realized access to pediatric trauma centres in Canada could inform policy, system design, and processes of care, thereby improving equity and the quality of trauma care for children.
We aimed to estimate the proportion of children with major trauma who accessed a pediatric trauma centre in Canada (through direct transport or transfer) and compare access across provinces and according to age, injury severity, body region injured, and mechanism of injury.
Methods
We conducted a population-based retrospective cohort study. We have reported the study in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and the Reporting of Studies Conducted Using Observational Routinely Collected Health Data (RECORD) checklists.13,14
We included all children younger than 16 years (the age cut-off used for transport or transfer to a pediatric trauma centre in most Canadian trauma systems)5 who were admitted to an acute care hospital between Apr. 1, 2016, and Mar. 31, 2021, with a primary diagnosis of injury (Canadian version of the International Classification of Diseases and Related Health Problems, 10th Revision [ICD-10-CA]15 S00 to T14). We included data from 9 provinces. We could not include data from Quebec because of provincial data sharing restrictions. We did not use data from the territories as patient volumes were not sufficient to generate meaningful results. We excluded admissions for burns, frostbite, drowning, poisoning, complications of medical care, and late effects of injury, as these conditions are not typically indications for transport to a pediatric trauma centre.16 We used the Injury Severity Score (ISS) to identify major trauma, defined as an ISS greater than 12.5 The ISS is based on the Abbreviated Injury Scale (https://www.aaam.org/abbreviated-injury-scale-ais/), an anatomical-based classification system specific to injuries that includes a measure of injury severity for each injury code. We calculated the ISS using ICD-10-CA to Abbreviated Injury Scale matching algorithms, validated with Canadian hospital discharge data.17 We excluded observations with missing data on the ISS (4%). Data were extracted from the Discharge Abstract Database, held by the Canadian Institute for Health Information (CIHI), and linked to a file identifying hospitals designated as pediatric trauma centres or adult Level I and II trauma centres across Canada, provided by our research team (Appendix 1, Table S1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.250625/tab-related-content).18 This information was obtained from the Trauma Association of Canada website and updated by members of our advisory committee, including 2 members of the Trauma Association of Canada’s board of directors.
The outcome of interest was access to a pediatric trauma centre, defined as admission to a pediatric trauma centre after either direct transportation from the scene or transfer from another acute care hospital. Canadian province was our exposure of interest. We grouped the 4 Atlantic provinces together because Nova Scotia and Newfoundland and Labrador are the only Atlantic provinces with a pediatric trauma centre. The pediatric trauma centre in Nova Scotia serves Prince Edward Island and New Brunswick.19 We selected Ontario as the reference for analyses as it is the province with the largest population.
Statistical analysis
We calculated crude proportions of access nationally and by province. We then estimated adjusted relative risks (RRs) of access with 95% confidence intervals (CIs) using a robust Poisson model, including the following adjustment variables based on the literature6 and consultation with experts: age (0 to 5 yr, 6 to 12 yr, 13 to 15 yr), biological sex, body regions of severe injuries (head, spine, thorax, abdomen, upper extremities, lower extremities), injury mechanism (motor vehicle collision, fall, other), injury severity (ISS 13 to 15, 16 to 24, ≥ 25, and ICD-based ISS),20 and year of admission (2016 to 2021). We conducted subgroup analyses for age (0 to 5 yr, 6 to 12 yr, 13 to 15 yr), body regions of severe injuries (head, thorax and abdomen, extremities), injury severity (ISS 13 to 15, 16 to 24, ≥ 25), and mechanism of injury (motor vehicle collision, fall, other). We verified model assumptions and collinearity statistics. We performed analyses with SAS software (version 9.4 for Windows; SAS Institute).
Ethics approval
The study was approved by the CHU de Québec-Université Laval Research Ethics Board (no. 131281).
Results
Between Apr. 1, 2016, and Mar. 31, 2021, 3007 children were admitted to an acute care hospital in the 9 Canadian provinces after major trauma. The average age was 9.2 (standard deviation 4.4) years, 1913 (63.6%) were male, and 546 (18.2%) had critical injuries (ISS ≥ 25; Table 1). Severe injuries were most frequently to the head (60.7%) and thorax (32.6%), and 47.2% of children were injured in motor vehicle collisions. The distributions of biological sex (p = 0.7), age (p = 0.1), and injury severity (p = 0.2) were similar across provinces, but we observed significant interprovincial differences in proportions of severe head (p = 0.04) and abdominal injuries (p = 0.008) and injury mechanisms (p = 0.0003).
Table 1:
Characteristics of children with major trauma admitted to an acute care hospital in Canada between 2016 and 2021
| Variable | No. (%) of patients | p value* | ||||||
|---|---|---|---|---|---|---|---|---|
| BC n = 487 |
AB n = 621 |
SK n = 205 |
MB n = 219 |
ON n = 1237 |
ATL n = 238 |
All n = 3007 |
||
| Sex | 0.7 | |||||||
| Female | 172 (35.3) | 231 (37.2) | 71 (34.6) | 89 (40.6) | 451 (36.5) | 80 (33.6) | 1094 (36.4) | |
| Male | 315 (64.7) | 390 (62.8) | 134 (65.4) | 130 (59.4) | 786 (63.5) | 158 (66.4) | 1913 (63.6) | |
| Age group, yr | 0.1 | |||||||
| 0–5 | 140 (28.7) | 160 (25.8) | 45 (21.9) | 60 (27.4) | 346 (28.0) | 55 (23.1) | 806 (26.8) | |
| 6–12 | 179 (36.8) | 283 (45.6) | 86 (41.9) | 87 (39.7) | 495 (40.0) | 91 (38.2) | 1221 (40.6) | |
| 13–15 | 168 (34.5) | 178 (28.6) | 74 (36.1) | 72 (32.9) | 396 (32.0) | 92 (38.6) | 980 (32.6) | |
| ISS | 0.2 | |||||||
| 13–15 | 77 (15.8) | 116 (18.7) | 35 (17.1) | 28 (12.8) | 184 (14.9) | 41 (17.3) | 481 (16.0) | |
| 16–24 | 322 (66.1) | 381 (61.3) | 144 (70.2) | 154 (70.3) | 824 (66.6) | 155 (65.1) | 1980 (65.8) | |
| ≥ 25 | 88 (18.1) | 124 (20.0) | 26 (12.7) | 37 (16.9) | 229 (18.5) | 42 (17.6) | 546 (18.2) | |
| Body regions of severe injuries† | ||||||||
| Head | 284 (58.3) | 355 (57.2) | 133 (64.9) | 133 (60.7) | 785 (63.5) | 135 (42.9) | 1825 (60.7) | 0.04 |
| Spine | 10 (2.1) | 10 (1.6) | 1–4¶ | 6 (2.7) | 26 (2.1) | 1–4¶ | 59 (2.0) | 0.9 |
| Thorax | 142 (29.2) | 219 (35.3) | 62 (30.2) | 74 (33.8) | 392 (31.7) | 91 (38.2) | 980 (32.6) | 0.1 |
| Abdomen | 92 (18.9) | 85 (13.7) | 18 (8.8) | 26 (11.9) | 169 (13.7) | 30 (12.6) | 420 (14.0) | 0.008 |
| Extremities | 67 (13.8) | 88 (14.2) | 29 (14.2) | 27 (12.3) | 181 (14.6) | 38 (16.0) | 430 (14.3) | 0.9 |
| Mechanism of injury | 0.0003 | |||||||
| MVC | 209 (42.9) | 287 (46.2) | 104 (50.7) | 105 (47.9) | 582 (47.0) | 133 (55.9) | 1420 (47.2) | |
| Fall | 175 (35.9) | 171 (27.5) | 60 (29.3) | 50 (22.8) | 394 (31.8) | 56 (23.5) | 906 (30.1) | |
| Other‡ | 103 (21.1) | 163 (26.2) | 41 (20.0) | 64 (29.2) | 261 (21.1) | 49 (20.6) | 681 (22.6) | |
| Comorbidity§ | 21 (4.3) | 13 (2.1) | 1–4¶ | 1–4¶ | 34 (2.7) | 1–4¶ | 79 (2.6) | 0.1 |
| Calendar year | 0.5 | |||||||
| 2016 | 77 (15.8) | 95 (15.3) | 32 (15.6) | 38 (17.3) | 184 (14.9) | 34 (14.3) | 460 (15.3) | |
| 2017 | 97 (19.9) | 124 (20.0) | 50 (24.4) | 42 (19.2) | 243 (19.6) | 66 (27.7) | 622 (20.7) | |
| 2018 | 103 (21.1) | 126 (20.3) | 37 (18.0) | 45 (20.5) | 242 (19.6) | 39 (16.4) | 592 (19.7) | |
| 2019 | 91 (18.7) | 117 (18.8) | 31 (15.1) | 45 (20.5) | 275 (22.2) | 45 (18.9) | 604 (20.1) | |
| 2020 | 94 (19.3) | 137 (22.1) | 44 (21.5) | 41 (18.7) | 244 (19.7) | 49 (20.6) | 609 (20.2) | |
| 2021 | 25 (5.1) | 22 (3.5) | 11 (5.4) | 8 (3.6) | 49 (4.0) | 5 (2.1) | 120 (4.0) | |
Note: ATL = Atlantic provinces (Prince Edward Island, New Brunswick, Nova Scotia, Newfoundland and Labrador), ICD-10-CA = International Classification of Diseases and Related Health Problems, 10th Revision, ISS = Injury Severity Score, MVC = motor vehicle collision.
χ2 test comparing proportions across provinces.
Abbreviated Injury Scale score of 3 or greater.
Includes being struck against, cut, or pierced and other unintentional and intentional injuries.
Comoribidy was defined as at least 1 of Charlson comorbidity identified by ICD-10-CA codes (https://cdn-links.lww.com/permalink/ijg/a/ijg_2021_10_20_singh_jog-d-21-0381_sdc1.pdf).
Cell sizes less than 5 are suppressed and shown as ranges (1–4) to protect confidentiality.
Pediatric trauma centre access
Of the 3007 children admitted to a Canadian hospital for major trauma between 2016 and 2021, 2335 (78%) were directly transported (n = 879, 29%) or transferred (n = 1456, 48.4%) to a pediatric trauma centre (Table 2). The remaining patients were admitted to either a level I or II adult trauma centre (10%) or an acute care hospital that was not a designated trauma hospital (12%). Crude (Table 3) and adjusted (Appendix 1, Table S2) access was higher for children aged 0 to 5 years (crude access 80.9%; RR 1.19, 95% CI 1.12 to 1.27) and those aged 6 to 12 years (crude access 81.7%; RR 1.17, 95% CI 1.12 to 1.22) than for those aged 13 to 15 years (crude access 69.9%) and for children with critical injuries (crude access 88.8%, RR 1.16, 95% CI 1.09 to 1.23 for ISS ≥ 25) than for those with less severe injuries (crude access 73.0% for ISS 13–15 and 75.7% for ISS 16–24).
Table 2:
Children with major trauma admitted to an acute care hospital in Canada, 2016 to 2021, according to method of transport and definitive care hospital
| Method of transport | No. (%) of patients by definitive hospital* | |||
|---|---|---|---|---|
| Pediatric TC n = 2335 |
Adult level I or II n = 300–304† |
Other hospitals n = 372 |
Total n = 3007 |
|
| Direct transport | 879 (29.2) | 204 (6.8) | 295 (9.8) | 1378 (45.8) |
| Transfer from pediatric TC | 5 (0.2) | 11 (0.4) | 5 (0.2) | 21 (0.7) |
| Transfer from adult level I or II TC | 45 (1.5) | 1–4† | 6 (0.2) | 50–54 (1.7)† |
| Transfer from other acute care hospitals | 1406 (46.8) | 84 (2.8) | 66 (2.2) | 1556 (51.8) |
Note: TC = trauma centre.
Percentages calculated from total of 3007 patients.
Cell sizes less than 5 are suppressed and shown as ranges (1–4) to protect confidentiality.
Table 3:
Children with major trauma who had access to a pediatric trauma centre in Canada (directly transported or transferred) by province, age category, injury severity, body region injury, and injury mechanism, 2016 to 2021
| Variable | No. (%) of patients* | ||||||
|---|---|---|---|---|---|---|---|
| BC n = 487 |
AB n = 621 |
SK n = 205 |
MB n = 219 |
ON n = 1237 |
ATL n = 238 |
All n = 3007 |
|
| All children with access | 274 (56.3) | 546 (87.9) | 127 (62.0) | 207 (94.5) | 1027 (83.0) | 154 (64.7) | 2335 (77.7) |
| Age, yr | |||||||
| 0–5 | 94 (67.1) | 147 (91.9) | 29 (64.4) | 55 (91.7) | 289 (83.5) | 38 (69.1) | 652 (80.9) |
| 6–12 | 112 (62.6) | 249 (88.0) | 57 (66.3) | 84 (96.6) | 432 (87.3) | 64 (70.3) | 998 (81.7) |
| 13–15 | 68 (40.5) | 150 (84.3) | 41 (55.4) | 68 (94.4) | 306 (77.3) | 52 (56.5) | 685 (69.9) |
| ISS | |||||||
| 13–15 | 31 (40.2) | 93 (80.2) | 21 (60.0) | 27 (96.4) | 152 (82.6) | 27 (65.8) | 351 (73.0) |
| 16–24 | 175 (54.3) | 335 (88.0) | 89 (61.8) | 143 (92.8) | 663 (80.5) | 94 (60.6) | 1499 (75.7) |
| ≥ 25 | 68 (77.3) | 118 (95.2) | 17 (65.3) | 37 (100) | 212 (92.6) | 33 (78.6) | 485 (88.8) |
| Body regions of severe injuries† | |||||||
| Head | 159 (56.0) | 310 (87.3) | 80 (60.2) | 126 (94.7) | 648 (82.6) | 89 (65.9) | 1412 (77.4) |
| Spine | 7 (70.0) | 8 (80.0) | 1–4§ | 6 (100) | 26 (81.3) | 1–4§ | 50–54§ |
| Thorax | 81 (57.0) | 198 (90.4) | 43 (69.4) | 71 (96.0) | 331 (84.4) | 57 (62.4) | 781 (79.7) |
| Abdomen | 69 (75.0) | 75 (88.2) | 9 (50.0) | 24 (92.3) | 156 (92.3) | 23 (76.7) | 356 (84.8) |
| Extremities | 38 (56.7) | 83 (94.3) | 20 (69.0) | 25 (95.6) | 162 (89.5) | 26 (68.4) | 348 (80.9) |
| Other | 10 (47.6) | 37 (88.1) | 12 (75.0) | 18 (90.0) | 50 (83.3) | 11 (73.3) | 138 (79.3) |
| Mechanism of injury | |||||||
| MVC | 115 (55.0) | 254 (88.5) | 71 (68.3) | 102 (97.1) | 497 (85.4) | 85 (63.9) | 1124 (79.1) |
| Fall | 98 (56.0) | 148 (86.5) | 33 (55.0) | 45 (90.0) | 318 (80.7) | 29 (51.8) | 671 (74.1) |
| Other‡ | 61 (59.2) | 144 (88.3) | 23 (56.1) | 60 (93.8) | 212 (81.2) | 40 (81.6) | 540 (79.3) |
Note: ATL = Atlantic provinces (Prince Edward Island, New Brunswick, Nova Scotia, Newfoundland and Labrador), ISS = Injury Severity Score, MVC = motor vehicle collision.
Percentages represent children with access to a pediatric trauma centre relative to subgroup total, as listed in Table 1 (e.g., 94 [67.1%] of the 140 BC children aged 0–5 years had access to a pediatric trauma centre).
Abbreviated Injury Scale score of 3 or greater.
Includes being struck against, cut, or pierced and other unintentional and intentional injuries.
Cell sizes less than 5 are suppressed and shown as ranges (1–4) to protect confidentiality.
Crude access to pediatric trauma centres was highest in Manitoba (94.5%) and Alberta (87.9%) and lowest in the Atlantic provinces (64.7%), Saskatchewan (62.0%) and British Columbia (56.3%, Table 3). We observed statistically significant (p < 0.001) variations in adjusted access to pediatric trauma centres among provinces (Figure 1 and Appendix 1, Table S2). Compared with Ontario (crude access 83.0%), the adjusted incidence of pediatric trauma centre access was lower in BC (RR 0.68, 95% CI 0.63 to 0.74), the Atlantic provinces (RR 0.80, 95% CI 0.73 to 0.88), and Saskatchewan (RR 0.77, 95% CI 0.69 to 0.86), but was higher in Alberta (RR 1.06, 95% CI 1.02 to 1.10) and Manitoba (RR 1.14, 95% CI 1.09 to 1.19).
Figure 1:
Adjusted relative risk (RR) of access* to pediatric trauma centres for children admitted to a hospital with major trauma in Canada, 2016 to 2021, with Ontario as the reference. Note: ATL = Atlantic provinces (Prince Edward Island, New Brunswick, Nova Scotia, Newfoundland and Labrador), CI = confidence interval. *Including those transported directly to and those transferred to a pediatric trauma centre from another acute care hospital, adjusted for age, sex, injury mechanism, body regions with severe injuries, injury severity, and admission year.
Significant interprovincial differences in adjusted access to a pediatric trauma centre were present for all subgroups by age, injury severity, and injury mechanism (p < 0.0001) but we observed a significant interaction between province and age (p = 0.001) and province and injury severity (p = 0.0004; Appendix 1, Table S3). Interactions were not significant for body region or injury mechanism.
Interpretation
In this population-based retrospective cohort study, we found that 1 in 4 children who sustained major trauma in 9 Canadian provinces between 2016 and 2022 did not access a pediatric trauma centre. After adjustment, access was significantly lower in BC, Saskatchewan, and the Atlantic provinces and significantly higher in Alberta and Manitoba than in Ontario. Although access was higher for children aged 12 years or younger and those with critical injuries, it varied little by injury mechanism. We observed interprovincial differences for children of all age groups and injury severities.
The proportion of realized access observed in our study (77%) is comparable to the proportion of potential 1-hour access reported in the US for 2019 (73%)9 and 2020 (74%),10,21 but higher than the proportion of potential access reported in Canada in 2016 (65%).11 More notably, our observed proportion is higher than that observed in the US in 2006 (59%).12 This latter disparity may reflect important advances in trauma systems across North America over the past 2 decades,22 as well as the publication of guidelines in the late 2010s that emphasized prioritizing the transport of pediatric patients with major trauma to pediatric trauma centres.23,24 Consistent with our findings, the US study on realized access also observed variations between regions, and that younger children and those with more severe injuries were more likely to access a pediatric trauma centre.12 A recent meta-analysis6 and population-based Canadian study25 found that access to pediatric trauma centres for adolescents with major trauma was not associated with a significant improvement in mortality, suggesting that pediatric trauma center access could be prioritized for younger children who are more likely to benefit from specialized pediatric care.
Interprovincial variations may relate to differences in the geographic coverage of trauma centres. This hypothesis is supported by the fact that Alberta, Manitoba, and Ontario — the provinces with the highest adjusted rates of realized access — have also been reported to have the highest potential 1-hour access to pediatric trauma centres at 66%, 66%, and 75%, respectively.11 Ontario and Alberta have 0.37 and 0.32 pediatric trauma centres, respectively per 10 000 km2, compared with 0.11 in BC.26 Manitoba has 0.38 pediatric trauma centres per 10 000 population younger than 15 years, compared with 0.14 in BC.26 In Saskatchewan and the Atlantic provinces, where only 27% to 48% of children are within a 1-hour drive of a pediatric trauma centre, realized access was also significantly lower than the national average. This limited access is exacerbated in Prince Edward Island and New Brunswick, where children with major trauma must be transferred to neighbouring provinces owing to the lack of provincial pediatric trauma centres. However, potential access and realized access do not fully align, suggesting that geographic coverage only partly explains provincial variations and that other factors — such as prehospital triage, interhospital transfer protocols, and lack of pediatric readiness in nonpediatric hospitals — likely play a role.
Given the strong evidence of improved clinical outcomes associated with care in pediatric trauma centres,6 access to these centres in Canada must be improved urgently. Since most severely injured children first present to nonpediatric hospitals, the most effective strategies lie in strengthening decision support in prehospital environments and nonpediatric hospitals, not in costly new infrastructure. Provincial trauma program leaders should immediately integrate evidence-based implementation strategies in Canadian trauma systems. These should include a standardized prehospital triage tool adapted to pediatric populations, such as that outlined in the 2021 American College of Surgeons national guideline for the field triage of injured patients, which incorporates evidence-based pediatric-specific criteria and was developed by a panel of experts including pediatric trauma clinicians (pending validation).16 Other strategies should include pediatric readiness assessments21 for nonpediatric hospitals (moderate-quality evidence)27 and teleconsultation pathways between referring hospitals and pediatric trauma centres (low-quality evidence but promising).28,29
In addition to improving access, such strategies may contribute to reducing unnecessary transfers for children with low-acuity injuries that can be managed in nonpediatric centres closer to their homes.
In the short term, researchers should aim to develop decision rules to guide interhospital transfer for pediatric trauma patients, examine the barriers and facilitators to access using a positive deviance approach,30 and examine the role of social determinants such as race and ethnicity, as these factors have been shown to influence access to trauma care.10
In the medium term, policy-makers and national agencies — including the Trauma Association of Canada, CIHI, and provincial health ministries — should establish a national trauma database by aggregating provincial trauma registry data31 and facilitating linkage to national emergency department and hospital discharge data to enable benchmarking, equity monitoring, and targeted investment.
Limitations
This study has several limitations related to the use of administrative data. We relied on a proxy measure of injury severity, based on mapping ICD codes to Abbreviated Injury Scale codes. This approach may have caused misclassification of major trauma, leading to selection bias and residual confounding in provincial comparisons. Furthermore, we were unable to adjust for clinical variables, such as hemodynamic stability and level of consciousness, which could have introduced further residual confounding. However, misclassification is likely to have been consistent across provinces. The lack of significant interprovincial variation in age and injury severity distributions and the fact that we observed similar results in both adjusted and unadjusted analyses suggest that residual confounding likely had only a small effect on our findings. With available data, we were unable to establish whether those who were initially admitted to a hospital that was not a pediatric trauma hospital and then transferred would have been better off had they been directly transported to a pediatric trauma centre. We did not have data on time to transfer, and we could not distinguish intraprovincial from interprovincial transfers. Finally, data were unavailable for Quebec, representing around 23% of the Canadian population, which limits generalizability of the study’s findings to the whole of Canada.
Conclusion
One in 4 children with major trauma do not receive care in a pediatric trauma centre in Canada, and that access varies considerably across provinces. Immediate implementation of evidence-based strategies to improve care for children with major trauma, coupled with targeted research and national data coordination, would save lives and provide more equitable trauma care for children in Canada, regardless of where they live.
Supplementary Information
Footnotes
Competing interests: Gabrielle Freire and Thomas Stelfox report funding from the Canadian Institute for Health Research (CIHR). Natalie Yanchar reports payment for expert testimony of a pediatric all-terrain vehicle mortality review. Roger Zemek has received funding from CIHR, the Ontario Neurotrauma Foundation, Physician Services Incorporated Foundation, Children’s Hospital of Eastern Ontario Foundation, Ontario Brain Institute, the National Football League, the Ontario Ministry of Health, the Public Health Agency of Canada, Health Canada, Parachute Canada, and Ontario Strategy for Patient-Oriented Research Support Unit. Roger Zemek is also supported by a Tier 1 Clinical Research Chair in Pediatric Concussion from University of Ottawa. Roger Zemek sits on the board of directors for North American Brain Injury Society and is a founding partner and a minority shareholder of 360 Concussion Care (a learning health system and network of interdisciplinary concussion clinics in Ontario). Brett Burstein reports funding from the Fonds de recherche du Québec — Santé (FRQS) and BioMerieux Canada, as well as an honorarium from Thermo Fisher Scientific. Simon Berthelot reports funding from FRQS. Bourke Tillmann reports funding from the Sunnybrook Research Institute and Sunnybrook Health Sciences Centre, an honorarium from the Emergency Medicine Update, and travel support from the Canadian Anesthesiologists’ Society. No other competing interests were declared.
This article has been peer reviewed.
Contributors: Alexandra Lapierre, Carmel Awlise, and Lynne Moore contributed to the conception and design of the work, as well as to the acquisition and analysis of data. All of the authors contributed to the interpretation of the data. Alexandra Lapierre, Carmel Awlise, and Lynne Moore drafted the manuscript. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work. Alexandra Lapierre and Carmel Awlise are joint first authors with equal contribution.
Funding: This study was funded by the Canadian Institutes of Health Research (no. 461381) and the Fonds de recherche du Québec — Santé (no. 139004). The funders had no role in study planning, conduct, data interpretation, or presentation.
Data sharing: As per the Canadian Institute for Health Information’s data restrictions, data cannot be shared. However, statistical analysis programs are available on request.
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