Mortality and disability after hospitalisation for injuries in low-income and middle-income countries: a cohort study

Mortality and disability after injuries are high in low-income and middle-income countries (LMICs). Improving outcomes for injured patients requires knowledge of their associated factors. We aimed to assess post-injury mortality and disability and their associations with access to health care across LMICs with different injury burdens, health-care systems, and contexts.

Hospitalised patients in Ghana, Pakistan, Rwanda, and South Africa with moderate-to-severe injuries were recruited and followed up until 3 months after discharge or death. Injured patients of any age who were admitted to facilities for more than 12 h or died within 12 h of admission were included. Data were collected between Feb 17, 2023, and Aug 31, 2024, using the REDCap electronic data platform. Our primary outcome was a composite of 3-month mortality or moderate-to-severe disability (assessed using the WHO Disability Assessment Schedule). Secondary outcomes were disability at 3 months after discharge, mortality up to 3 months after discharge (including in-hospital mortality), and in-hospital mortality. In multivariable analysis, we tested the associations of these outcomes with access to health-care variables of previous health-care encounters, transport to the hospital (private vs ambulance vs other), delays in reaching the hospital, and hospital level (secondary vs tertiary), controlling for age, sex, education, wealth, and injury type and severity.

9720 patients admitted to 19 hospitals capable of providing definitive care for injuries, serving urban and rural settings, were eligible for inclusion in the study. Of those, 8858 (91·1%; 6788 male, 2047 female, and 23 [<1%] with missing sex data; median age 31 years [IQR 20-43]) were enrolled and 8687 (89·4%) completed hospital follow-up, with 5835 patients followed up at 3 months. At 3 months, 2476 (47·6%) of 5199 patients with available primary outcome data had died or were disabled. In-hospital mortality was 6·1% (531 of 8687), 3-month mortality was 9·7% (616 of 6366), and 3-month disability was 40·6% (1860 of 4583). Higher odds of the primary outcome were associated with arrival by ambulance (odds ratio 1·86, 95% CI 1·51-2·29), and lower odds were associated with a previous health-care encounter (0·61, 0·52-0·71). Hospital level (1·14, 0·96-1·35) and delays in reaching the facility (0·86, 0·74-1·00) were not associated with the primary outcome.

The high post-injury mortality and disability are associated with health system factors that must be better understood before potentially expensive service models are introduced or expanded. Investment in pre-hospital care, ambulance systems, and centralised specialist trauma centres is unlikely to achieve its intended benefits unless services are appropriately planned, integrated, coordinated, and staffed across the care pathway. High-quality routine data are also essential to guide service improvement and enable robust quasi-experimental evaluations of whether these investments improve patient outcomes, for whom, and under what circumstances.

National Institute for Health and Care Research.