title: Identifying targets for potential interventions to reduce rural trauma deaths: a population-based analysis.
abstract: BACKGROUND
  Rural environments have consistently been characterized by high injury mortality rates. Although injury prevention efforts might be directed to reduce the frequency or severity of injury in rural environments, it is plausible that interventions directed to improve injury care in the rural settings might also play a significant role in reducing mortality. To test this hypothesis, we set out to examine the relationship between rurality and the setting in which patient death was most likely to occur.
  
  
  METHODS
  This is a population-based retrospective cohort study evaluating all trauma deaths occurring in the province of Ontario, Canada, over the interval 2002 to 2003. Patient cohorts were defined by their potential to access trauma center care using two different approaches, rurality and timely access to trauma center care.
  
  
  RESULTS
  There were 3,486 deaths over the study interval, yielding an overall injury mortality rate of 14.6 per 100,000 person-years. Overall, more than half of deaths occurred before reaching an emergency department (ED). Prehospital deaths were twice as likely in the most rural locations and in those with limited access to timely trauma center care. However, among patients surviving long enough to reach hospital, there was a threefold increase in the risk of ED death among those injured in a region with limited access to trauma center care.
  
  
  CONCLUSIONS
  We demonstrate that a significant proportion of deaths occur in rural EDs. This study provides new insights into rural trauma deaths and suggests the potential value of targeted interventions at the policy and provider level to improve the delivery of preliminary trauma care in rural environments.
authors.affiliation: Division of Trauma and the Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. gomezjaramid@smh.toronto.on.ca
authors.forename: David
authors.initials: D
authors.lastname: Gomez
authors.forename: Myriam
authors.initials: M
authors.lastname: Berube
authors.forename: Wei
authors.initials: W
authors.lastname: Xiong
authors.forename: Najma
authors.initials: N
authors.lastname: Ahmed
authors.forename: Barbara
authors.initials: B
authors.lastname: Haas
authors.forename: Nadine
authors.initials: N
authors.lastname: Schuurman
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
mesh_terms: D000063:Accidents, Traffic / Q000401:mortality; D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002391:Catchment Area, Health / Q000706:statistics & numerical data; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D016001:Confidence Intervals; D004636:Emergency Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006780:Hospitals, Rural / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D016012:Poisson Distribution; D012189:Retrospective Studies; D012306:Risk; D012424:Rural Population / Q000706:statistics & numerical data*; D012737:Sex Factors; D014193:Trauma Centers / Q000592:standards* / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000401:mortality*; D055815:Young Adult