title: Surgical risks associated with winter sport tourism.
abstract: BACKGROUND
  Mass tourism during winter in mountain areas may cause significant clustering of body injuries leading to increasing emergency admissions at hospital. We aimed at assessing if surgical safety and efficiency was maintained in this particular context.
  
  
  METHODS
  We selected all emergency admissions of open surgery performed in French hospitals between 2010 and 2012. After identifying mountain areas with increasing volume of surgical stays during winter, we considered seasonal variations in surgical outcomes using a difference-in-differences study design. We computed multilevel regressions to evaluate whether significant increase in emergency cases had an effect on surgical mortality, complications and length of stay. Clustering effect of patients within hospitals was integrated in analysis and surgical outcomes were adjusted for both patient and hospital characteristics.
  
  
  RESULTS
  A total of 381 hospitals had 559,052 inpatient stays related to emergency open surgery over 3 years. Compared to other geographical areas, a significant peak of activity was noted during winter in mountainous hospitals (Alps, Pyrenees, Vosges), ranging 6-77% volume increase. Peak was mainly explained by tourists' influx (+124.5%, 4,351/3,496) and increased need for orthopaedic procedures (+36.8%, 4,731/12,873). After controlling for potential confounders, patients did not experience increased risk for postoperative death (ratio of OR 1.01, 95%CI 0.89-1.14, p = 0.891), thromboembolism (0.95, 0.77-1.17, p = 0.621) or sepsis (0.98, 0.85-1.12, p = 0.748). Length of stay was unaltered (1.00, 0.99-1.02, p = 0.716).
  
  
  CONCLUSIONS
  Surgical outcomes are not compromised during winter in French mountain areas despite a substantial influx of major emergencies.
authors.affiliation: Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, Rhône, France; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, Rhône, France.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Sanchez
authors.affiliation: Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, Rhône, France.
authors.forename: Cécile
authors.initials: C
authors.lastname: Payet
authors.affiliation: Hospices Civils de Lyon, Centre Hospitalier Lyon Sud-Service de Chirurgie Générale et Endocrinienne, Pierre Bénite, Rhône, France; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Sud, Lyon, Rhône, France; Health Services and Performance Research Lab, Lyon, France.
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Lifante
authors.affiliation: Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, Rhône, France; Health Services and Performance Research Lab, Lyon, France.
authors.forename: Stéphanie
authors.initials: S
authors.lastname: Polazzi
authors.affiliation: Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, Rhône, France.
authors.forename: François
authors.initials: F
authors.lastname: Chollet
authors.affiliation: Center for Surgery and Public Health, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Carty
authors.affiliation: Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, Rhône, France; Center for Surgery and Public Health, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts, United States of America; Université Claude Bernard Lyon 1, EAM Santé-Individu-Société 4128, Lyon, Rhône, France; Health Services and Performance Research Lab, Lyon, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: Duclos
mesh_terms: D000328:Adult; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005602:France; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009141:Musculoskeletal System / Q000293:injuries / Q000601:surgery*; D019637:Orthopedic Procedures / Q000401:mortality / Q000706:statistics & numerical data*; D011183:Postoperative Complications; D012306:Risk; D012621:Seasons; D018805:Sepsis / Q000209:etiology / Q000401:mortality / Q000601:surgery; D038161:Snow Sports / Q000293:injuries*; D016019:Survival Analysis; D013923:Thromboembolism / Q000209:etiology / Q000401:mortality / Q000601:surgery; D014195:Travel