Building CapaCITY/É for sustainable transportation: protocol for an implementation science research program in healthy cities.

INTRODUCTION: Improving sustainable transportation options will help cities tackle growing challenges related to population health, congestion, climate change and inequity. Interventions supporting active transportation face many practical and political hurdles. Implementation science aims to understand how interventions or policies arise, how they can be translated to new contexts or scales and who benefits. Sustainable transportation interventions are complex, and existing implementation science frameworks may not be suitable. To apply and adapt implementation science for healthy cities, we have launched our mixed-methods research programme, CapaCITY/É. We aim to understand how, why and for whom sustainable transportation interventions are successful and when they are not. METHODS AND ANALYSIS: Across nine Canadian municipalities and the State of Victoria (Australia), our research will focus on two types of sustainable transportation interventions: all ages and abilities bicycle networks and motor vehicle speed management interventions. We will (1) document the implementation process and outcomes of both types of sustainable transportation interventions; (2) examine equity, health and mobility impacts of these interventions; (3) advance implementation science by developing a novel sustainable transportation implementation science framework and (4) develop tools for scaling up and scaling out sustainable transportation interventions. Training activities will develop interdisciplinary scholars and practitioners able to work at the nexus of academia and sustainable cities. ETHICS AND DISSEMINATION: This study received approval from the Simon Fraser University Office of Ethics Research (H22-03469). A Knowledge Mobilization Hub will coordinate dissemination of findings via a website; presentations to academic, community organisations and practitioner audiences; and through peer-reviewed articles.

Relationship between systolic blood pressure and mortality in older vs younger trauma patients - a retrospective multicentre observational study.

BACKGROUND: The population of older trauma patients is increasing. Those patients have heterogeneous presentations and need senior-friendly triaging tools. Systolic blood pressure (SBP) is commonly used to assess injury severity, and some authors advocated adjusting SBP threshold for older patients. We aimed to describe and compare the relationship between mortality and SBP in older trauma patients and their younger counterparts. METHODS: We included patients admitted to three level-I trauma centres and performed logistic regressions with age and SBP to obtain mortality curves. Multivariable Logistic regressions were performed to measure the association between age and mortality at different SBP ranges. Subgroup analyses were conducted for major trauma and severe traumatic brain injury admissions. RESULTS: A total of 47,661 patients were included, among which 12.9% were aged 65-74 years and 27.3% were ≥ 75 years. Overall mortality rates were 3.9%, 8.1%, and 11.7% in the groups aged 16-64, 65-74, and ≥ 75 years, respectively. The relationship between prehospital SBP and mortality was nonlinear (U-shape), mortality increased with each 10 mmHg SBP decrement from 130 to 50 mmHg and each 10-mmHg increment from 150 to 220 mmHg across all age groups. Older patients were at higher odd for mortality in all ranges of SBP. The highest OR in patients aged 65-74 years was 3.67 [95% CI: 2.08-6.45] in the 90-99 mmHg SBP range and 7.92 [95% CI: 5.13-12.23] for those aged ≥ 75 years in the 100-109 mmHg SBP range. CONCLUSION: The relationship between SBP and mortality is nonlinear, regardless of trauma severity and age. Older age was associated with a higher odd of mortality at all SBP points. Future triage tools should therefore consider SBP as a continuous rather than a dichotomized predictor.

Suicidality and protective factors among sexual and gender minority youth and adults in Canada: a cross-sectional, population-based study.

BACKGROUND: Sexual and gender minority populations experience elevated risks for suicidality. This study aimed to assess prevalence and disparities in non-fatal suicidality and potential protective factors related to social support and health care access among sexual and gender minority youth and adults and their heterosexual and cisgender counterparts in Canada. The second objective was to examine changes in the prevalence of suicidal ideation and protective factors during the COVID-19 pandemic. METHODS: Pooled data from the 2015, 2016 and 2019 Canadian Community Health Surveys were used to estimate pre-pandemic prevalence of suicidal ideation, plans and attempts, and protective factors. The study also estimated changes in the prevalence of recent suicidal ideation and protective factors in fall 2020, compared with the same period pre-pandemic. RESULTS: The prevalence of suicidality was higher among the sexual minority populations compared with the heterosexual population, and the prevalence was highest among the bisexual population, regardless of sex or age group. The pre-pandemic prevalence of recent suicidal ideation was 14.0% for the bisexual population, 5.2% for the gay/lesbian population, and 2.4% for the heterosexual population. The prevalence of lifetime suicide attempts was 16.6%, 8.6%, and 2.8% respectively. More than 40% of sexual minority populations aged 15-44 years had lifetime suicidal ideation; 64.3% and 36.5% of the gender minority population had lifetime suicidal ideation and suicide attempts. Sexual and gender minority populations had a lower prevalence of protective factors related to social support and health care access. The prevalence of recent suicidal ideation among sexual and gender minority populations increased in fall 2020, and they tended to experience longer wait times for immediate care needed. CONCLUSIONS: Sexual and gender minority populations had a higher prevalence of suicidality and less social support and health care access compared to the heterosexual and cisgender populations. The pandemic was associated with increased suicidal ideation and limited access to care for these groups. Public health interventions that target modifiable protective factors may help decrease suicidality and reduce health disparities.

Traffic-Calming Measures and Road Traffic Collisions and Injuries: a Spatiotemporal Analysis.

Traffic-calming measures (TCMs) are physical modifications to the road network aimed at making the roads safer. Although studies have reported reductions in road crashes and injuries tied to the presence of TCMs, they have been criticized for their pre-post designs. This study aims to complement our knowledge of TCMs effectiveness by assessing their impact using a longitudinal design. The implementation of eight TCMs, including curb extensions and speed humps, was evaluated at the intersections and census tract levels in Montreal, Canada from 2012 to 2019. The primary outcome was fatal or serious collisions among all road users. Inference was performed using a Bayesian implementation of Conditional Poisson regression in which random effects were used to account for the spatiotemporal variation in collisions. TCMs were generally implemented on local roads, although most collisions occurred on arterial roads. Overall, there was weak evidence that TCMs were associated with study outcomes. However, subgroup analyses of intersections on local roads suggested a reduction in collision rates due to TCMs (median IRR: 0.31; 95% Credible Interval: 0.12 - 0.86). To improve road safety, effective counterparts of TCMs on arterial roads must be identified and implemented.

Epidemiology, injury pattern and outcome of older trauma patients: A 15-year study of level-I trauma centers.

BACKGROUND: Older adults have become a significant portion of the trauma population. Exploring their specificities is crucial to better meet their specific needs. The primary objective was to evaluate the temporal changes in the incidence, demographic and trauma characteristics, injury pattern, in-hospital admission, complications, and outcome of older trauma patients. METHODS: A multicenter retrospective cohort study was conducted using the Quebec Trauma Registry. Patients aged ≥16 years admitted to one of the three adult level-I trauma centers between 2003 and 2017 were included. Descriptive analyses and trend-tests were performed to describe temporal changes. RESULTS: A total of 53,324 patients were included, and 24,822 were aged ≥65 years. The median [IQR] age increased from 57[36-77] to 67[46-82] years, and the proportion of older adults rose from 41.8% in 2003 to 54.1% in 2017. Among those, falls remain the main mechanism (84.7%-88.3%), and the proportion of severe thorax (+8.9%), head (+8.7%), and spine (+5%) injuries significantly increased over time. The proportion of severely injured older patients almost doubled (17.6%-32.3%), yet their mortality decreased (-1.0%). Their average annual bed-days consumption also increased (+15,004 and +1,437 in non-intensive care wards and ICU, respectively). CONCLUSIONS: Since 2014, older adults have represented the majority of admissions in Level-I trauma centers in Québec. Their bed-days consumption has greatly increased, and their injury pattern and severity have deeply evolved, while we showed a decrease in mortality.

Facing the future of transit ridership: shifting attitudes towards public transit and auto ownership among transit riders during COVID-19.

Public transit agencies face a transformed landscape of rider demand and political support as the COVID-19 pandemic recedes. We explore people's motivations for returning to or avoiding public transit a year into the pandemic. We draw on a March 2021 follow-up survey of over 1,900 people who rode transit regularly prior to the COVID-19 pandemic in Toronto and Vancouver, Canada, and who took part in a prior survey on the topic in May 2020. We investigate how transit demand changes associated with the pandemic relate to changes in automobile ownership and its desirability. We find that pre-COVID frequent transit users between the ages of 18-29, a part of the so-called "Gen Z," and recent immigrants are more attracted to driving due to the pandemic, with the latter group more likely to have actually purchased a vehicle. Getting COVID-19 or living with someone who did is also a strong and positive predictor of buying a car and anticipating less transit use after the pandemic. Our results suggest that COVID-19  may have increased the attractiveness of auto ownership among transit riders likely to eventually purchase cars anyway (immigrants, twentysomethings), at least in the North American context. We also conclude that getting COVID-19 or living with someone who did is a positive predictor of having bought a car. Future research should consider how having COVID-19 transformed some travelers' views, values, and behaviour. Supplementary Information: The online version contains supplementary material available at 10.1007/s11116-022-10344-2.

Trauma team leader and early mortality: An interrupted time series analysis.

BACKGROUND: The trauma team leader (TTL) is a "model" of a specifically dedicated team leader in the emergency department (ED), but its benefits are uncertain. The primary objective was to assess the impact of the TTL on 72-hour mortality. Secondary objectives included 24-hour mortality and admission delays from the ED. METHODS: Major trauma admissions (Injury Severity Score (ISS)≥12) in 3 Canadian Level-1 trauma centres were included from 2003 to 2017. The TTL program was implemented in centre 1 in 2005. An interrupted time series (ITS) analysis was performed. Analyses account for the change in patient case-mix (age, sex, and ISS). The two other centres were used as control in sensitivity analyses RESULTS: Among 20,193 recorded trauma admissions, 71.7% (n=14,479) were males. The mean age was 53.5 ± 22.0 years. The median [IQR] ISS was 22 [16-26]. TTL implementation was not associated with a change in the quarterly trends of 72-hour or 24-hour mortality: adjusted estimates with 95% CI were 0.32 [-0.22;0.86] and -0.07 [-0.56;0.41] percentage-point change. Similar results were found for the proportions of patients admitted within 8 hours of ED arrival (0.36 [-1.47;2.18]). Sensitivity analyses using the two other centres as controls yielded similar results. CONCLUSION: TTL implementation was not associated with changes in mortality or admission delays from the ED. Future studies should assess the potential impact of TTL programs on other patient-centred outcomes using different quality of care indicators.

Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic: An interrupted time series analysis.

BACKGROUND: We assessed the impact of the coronavirus disease 2019 (COVID-19) epidemic in India on the consumption of antibiotics and hydroxychloroquine (HCQ) in the private sector in 2020 compared to the expected level of use had the epidemic not occurred. METHODS AND FINDINGS: We performed interrupted time series (ITS) analyses of sales volumes reported in standard units (i.e., doses), collected at regular monthly intervals from January 2018 to December 2020 and obtained from IQVIA, India. As children are less prone to develop symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, we hypothesized a predominant increase in non-child-appropriate formulation (non-CAF) sales. COVID-19-attributable changes in the level and trend of monthly sales of total antibiotics, azithromycin, and HCQ were estimated, accounting for seasonality and lockdown period where appropriate. A total of 16,290 million doses of antibiotics were sold in India in 2020, which is slightly less than the amount in 2018 and 2019. However, the proportion of non-CAF antibiotics increased from 72.5% (95% CI: 71.8% to 73.1%) in 2019 to 76.8% (95% CI: 76.2% to 77.5%) in 2020. Our ITS analyses estimated that COVID-19 likely contributed to 216.4 million (95% CI: 68.0 to 364.8 million; P = 0.008) excess doses of non-CAF antibiotics and 38.0 million (95% CI: 26.4 to 49.2 million; P < 0.001) excess doses of non-CAF azithromycin (equivalent to a minimum of 6.2 million azithromycin treatment courses) between June and September 2020, i.e., until the peak of the first epidemic wave, after which a negative change in trend was identified. In March 2020, we estimated a COVID-19-attributable change in level of +11.1 million doses (95% CI: 9.2 to 13.0 million; P < 0.001) for HCQ sales, whereas a weak negative change in monthly trend was found for this drug. Study limitations include the lack of coverage of the public healthcare sector, the inability to distinguish antibiotic and HCQ sales in inpatient versus outpatient care, and the suboptimal number of pre- and post-epidemic data points, which could have prevented an accurate adjustment for seasonal trends despite the robustness of our statistical approaches. CONCLUSIONS: A significant increase in non-CAF antibiotic sales, and particularly azithromycin, occurred during the peak phase of the first COVID-19 epidemic wave in India, indicating the need for urgent antibiotic stewardship measures.

Social inequalities, debt, and health in the United States.

BACKGROUND: Household financial debt has more than tripled since the 1980s in the United States. The experience of indebtedness is socially structured and there is mounting evidence that debt is linked to decrements in health. However, it is unclear whether debt contributes to social disparities in health. OBJECTIVE: We examined whether household debt, measured by debt in excess of income and wealth, mediated education-based social inequalities in health, including cardiovascular risk factors (hypertension) and chronic conditions (diabetes, coronary heart disease, and psychiatric problems). METHOD: We used longitudinal data from a sample of over 10,500 adults aged 18 years and older surveyed biennially between 1999 and 2015 as part of the Panel Study of Income Dynamics (PSID). We estimated the total effect of education on our health outcomes. To assess mediation by levels of household debt, we then estimated the controlled direct effect of education through pathways not mediated by levels of household debt, after accounting for lagged time-varying confounders and loss to follow-up using marginal structural models. RESULTS: Compared to respondents with at least a high school education, respondents with less than a high school education reported higher household debts in excess of income and wealth; they also reported a higher incidence of hypertension [risk ratio (RR) = 1.25, 95%CI = 1.13, 1.39), coronary heart disease (RR = 1.42, 95%CI: 1.25, 1.62), diabetes (RR = 1.50, 95%CI: 1.34, 1.68), and psychiatric problems (RR = 1.39, 95%CI: 1.24, 1.56). Compared to the total effects, the controlled direct effects of education on health were attenuated, particularly for death or first onset of hypertension and coronary heart disease, after fixing levels of household debt-to-income and debt-to-wealth. CONCLUSION: Our results provide early evidence that household debt in excess of wealth partly mediates education-based inequalities in hypertension and coronary heart disease in the United States, with less consistent evidence for other chronic conditions.

Effectiveness of trauma centre verification: a systematic review and meta-analysis.

Background: There is a growing trend toward verification of trauma centres, but its impact remains unclear. This systematic review aimed to synthesize available evidence on the effectiveness of trauma centre verification. Methods: We conducted a systematic search of the CINAHL, Embase, HealthStar, MEDLINE and ProQuest databases, as well as the websites of key injury organizations for grey literature, from inception to June 2019, without language restrictions. Our population consisted of injured patients treated at trauma centres. The intervention was trauma centre verification. Comparison groups comprised nonverified trauma centres, or the same centre before it was first verified or re-verified. The primary outcome was in-hospital mortality; secondary outcomes included adverse events, resource use and processes of care. We computed pooled summary estimates using random-effects meta-analysis. Results: Of 5125 citations identified, 29, all conducted in the United States, satisfied our inclusion criteria. Mortality was the most frequently investigated outcome (n = 20), followed by processes of care (n = 12), resource use (n = 12) and adverse events (n = 7). The risk of bias was serious to critical in 22 studies. We observed an imprecise association between verification and decreased mortality (relative risk 0.74, 95% confidence interval 0.52 to 1.06) in severely injured patients. Conclusion: Our review showed mixed and inconsistent associations between verification and processes of care or patient outcomes. The validity of the published literature is limited by the lack of robust controls, as well as any evidence from outside the US, which precludes extrapolation to other health care jurisdictions. Quasiexperimental studies are needed to assess the impact of trauma centre verification. Systematic reviews registration: PROSPERO no. CRD42018107083.

Contexte: Le processus d'audit des centres de traumatologie gagne en popularité, mais ses effets concrets ne sont pas bien connus. La présente revue systématique a cherché à résumer les données probantes disponibles sur l'efficacité de l'audit des centres de traumatologie. Méthodes: Nous avons effectué des recherches systématiques dans les bases de données CINAHL, Embase, HealthSTAR, MEDLINE et ProQuest, de même qu'une recherche dans la littérature grise sur les sites Web d'organisations majeures du domaine des traumas, de leur création à juin 2019, sans restriction de langue. La population à l'étude était l'ensemble des patients blessés traités en centre de traumatologie. L'intervention était l'audit du centre de traumatologie. Les groupes de comparaison correspondaient aux centres de traumatologie n'ayant pas subi d'audit, ou le même centre, avant son premier audit ou un audit subséquent. Le principal résultat à l'étude était la mortalité en milieu hospitalier; les résultats secondaires étaient les événements indésirables, l'utilisation des ressources et les processus de soins. Nous avons calculé des estimations sommaires par méta-analyse à effets aléatoires sur données groupées. Résultats: Sur les 5125 citations retenues, 29 publications sur des études menées aux États-Unis répondaient à nos critères d'inclusion. La mortalité était le résultat le plus souvent à l'étude (n = 20), puis suivaient les processus de soins (n = 12), l'utilisation des ressources (n = 12) et les événements indésirables (n = 7). Le risque de biais était important ou critique dans 22 études. Nous avons observé une association imprécise entre l'audit et une baisse de la mortalité (risque relatif 0,74; intervalle de confiance à 95 % 0,52 à 1,06) chez les patients ayant subi un trauma grave. Conclusion: Notre revue a conclu qu'il y avait des associations mitigées et manquant d'uniformité entre l'audit et les processus de soins ou les issues pour les patients. La validité des données à l'étude était limitée par un manque de contrôles fiables, ainsi que par l'absence de données provenant d'autres pays que les États-Unis, ce qui empêche l'extrapolation à d'autres systèmes de santé. Des études quasi expérimentales devront être menées pour évaluer les effets de l'audit des centres de traumatologie. Enregistrement de la revue systématique: Registre PROSPERO, numéro CRD42018107083.

Impact of trauma centre accreditation on mortality and complications in a Canadian trauma system: an interrupted time series analysis.

BACKGROUND: Periodic external accreditation visits aiming to determine whether trauma centres are fulfilling the criteria for optimal care are part of most trauma systems. However, despite the growing trend towards accreditation of trauma centres, its impact on patient outcomes remains unclear. In addition, a recent systematic review found inconsistent results on the association between accreditation and patient outcomes, mostly due to the lack of robust controls. We aim to address these gaps by assessing the impact of trauma centre accreditation on patient outcomes, specifically in-hospital mortality and complications, using an interrupted time series (ITS) design. METHODS: We included all major trauma admissions to five level I and four level II trauma centres in Quebec, Canada between 2008 and 2017. In order to perform ITS, we first obtained monthly and quarterly estimates of the proportions of in-hospital mortality and complications, respectively, for level I and level II centres. Prognostic scores were used to standardise these proportions to account for changes in patient case mix and segmented regressions with autocorrelated errors were used to estimate changes in levels and trends in both outcomes following accreditation. RESULTS: There were 51 035 admissions, including 20 165 for major trauma during the study period. After accounting for changes in patient case mix and secular trend in studied outcomes, we globally did not observe an association between accreditation and patient outcomes. However, associations were heterogeneous across centres. For example, in a level II centre with worsening preaccreditation outcomes, accreditation led to -9.08 (95% CI -13.29 to -4.87) and -9.60 (95% CI -15.77 to -3.43) percentage point reductions in mortality and complications, respectively. CONCLUSION: Accreditation seemed to be beneficial for centres that were experiencing a decrease in performance preceding accreditation.

Addressing Competing Risks When Assessing the Impact of Health Services Interventions on Hospital Length of Stay.

BACKGROUND: Although hospital length of stay is generally modeled continuously, it is increasingly recommended that length of stay should be considered a time-to-event outcome (i.e., time to discharge). Additionally, in-hospital mortality is a competing risk that makes it impossible for a patient to be discharged alive. We estimated the effect of trauma center accreditation on risk of being discharged alive while considering in-hospital mortality as a competing risk. We also compared these results with those from the "naive" approach, with length of stay modeled continuously. METHODS: Data include admissions to a level I trauma center in Quebec, Canada, between 2008 and 2017. We computed standardized risk of being discharged alive at specific days by combining inverse probability weighting and the Aalen-Johansen estimator of the cumulative incidence function. We estimated effect of accreditation using pre-post, interrupted time series (ITS) analyses, and the "naive" approach. RESULTS: Among 5,300 admissions, 12% died, and 83% were discharged alive within 60 days. Following accreditation, we observed increases in risk of discharge between the 7th day (4.5% [95% CI = 2.3, 6.6]) and 30th day since admission 3.8% (95% CI = 1.5, 6.2). We also observed a stable decrease in hospital mortality, -1.9% (95% CI = -3.6, -0.11) at the 14th day. Although pre-post and ITS produced similar results, we observed contradictory associations with the naive approach. CONCLUSIONS: Treating length of stay as time to discharge allows for estimation of risk of being discharged alive at specific days after admission while accounting for competing risk of death.

Trauma system accreditation and patient outcomes in British Columbia: an interrupted time series analysis.

OBJECTIVE: We aim to assess the impact of several accreditation cycles of trauma centers on patient outcomes, specifically in-hospital mortality, complications and hospital length of stay. DESIGN: Interrupted time series. SETTING: British Columbia, Canada. PARTICIPANTS: Trauma patients admitted to all level I and level II trauma centers between January 2008 and March 2018. EXPOSURE: Accreditation. MAIN OUTCOMES AND MEASURES: We first computed quarterly estimates of the proportions of in-hospital mortality, complications and survival to discharge standardized for change in patient case-mix using prognostic scores and the Aalen-Johansen estimator of the cumulative incidence function. Piecewise regressions were then used to estimate the change in levels and trends for patient outcomes following accreditation. RESULTS: For in-hospital mortality and major complications, the impact of accreditation seems to be associated with short- and long-term reductions after the first cycle and only short-term reductions for subsequent cycles. However, the 95% confidence intervals for these estimates were wide, and we lacked the precision to consistently conclude that accreditation is beneficial. CONCLUSIONS: Applying a quasi-experimental design to time series accounting for changes in patient case-mix, our results suggest that accreditation might reduce in-hospital mortality and major complications. However, there was uncertainty around the estimates of accreditation. Further studies looking at clinical processes of care and other outcomes such as patient or health staff satisfaction are needed.

Vulnerable road-user deaths in Brazil: a Bayesian hierarchical model for spatial-temporal analysis.

Reducing the road traffic injuries burden is relevant to many sustainable development goals (SDG), in particular SDG3 - to establish good health and well-being. To describe the spatial-temporal trends and identify hotspot regions for fatal road traffic injuries, a Bayesian hierarchical Poisson model was used to analyze data on vulnerable road users (bicyclist, motorcyclist and pedestrians) in Brazil from 1999 to 2016. During the study period, mortality rates for bicyclists remained almost unchanged (0.6 per 100,000 people) but rose dramatically for motorcyclists (from 1.0 in 1999 to 6.0 per 100,000 people in 2016) and decreased for pedestrians (from 6.3 to 3.0 per 100,000 people). Spatial analyses accounting for socio-economic factors showed that the central and northeastern microregions of Brazil are hotspot areas for fatal injuries among motorcyclists while the southern areas are for pedestrians.

Evaluation of propensity score used in cardiovascular research: a cross-sectional survey and guidance document.

BACKGROUND: Propensity score (PS) methods are frequently used in cardiovascular clinical research. Previous evaluations revealed poor reporting of PS methods, however a comprehensive and current evaluation of PS use and reporting is lacking. The objectives of the present survey were to (1) evaluate the quality of PS methods in cardiovascular publications, (2) summarise PS methods and (3) propose key reporting elements for PS publications. METHODS: A PubMed search for cardiovascular PS articles published between 2010 and 2017 in high-impact general medical (top five by impact factor) and cardiovascular (top three by impact factor) journals was performed. Articles were evaluated for the reporting of PS techniques and methods. Data extraction elements were identified from the PS literature and extraction forms were pilot tested. RESULTS: Of the 306 PS articles identified, most were published in Journal of the American College of Cardiology (29%; n=88), and Circulation (27%, n=81), followed by European Heart Journal (15%; n=47). PS matching was performed most often, followed by direct adjustment, inverse probability of treatment weighting and stratification. Most studies (77%; n=193) selected variables to include in the PS model a priori. A total of 38% (n=116) of studies did not report standardised mean differences, but instead relied on hypothesis testing. For matching, 92% (n=193) of articles presented the balance of covariates. Overall, interpretations of the effect estimates corresponded to the PS method conducted or described in 49% (n=150) of the reviewed articles. DISCUSSION: Although PS methods are frequently used in high-impact medical journals, reporting of methodological details has been inconsistent. Improved reporting of PS results is warranted and these proposals should aid both researchers and consumers in the presentation and interpretation of PS methods.

State or market? How to effectively decrease alcohol-related crash fatalities and injuries.

BACKGROUND: It is estimated that more than 270 000 people die yearly in alcohol-related crashes globally. To tackle this burden, government interventions, such as laws which restrict blood alcohol concentration (BAC) levels and increase penalties for drunk drivers, have been implemented. The introduction of private-sector measures, such as ridesharing, is regarded as alternatives to reduce drunk driving and related sequelae. However, it is unclear whether state and private efforts complement each other to reduce this public health challenge. METHODS: We conducted interrupted time-series analyses using weekly alcohol-related traffic fatalities and injuries per 1 000 000 population in three urban conglomerates (Santiago, Valparaíso and Concepción) in Chile for the period 2010-2017. We selected cities in which two state interventions-the 'zero tolerance law' (ZTL), which decreased BAC, and the 'Emilia law' (EL), which increased penalties for drunk drivers-were implemented to decrease alcohol-related crashes, and where Uber ridesharing was launched. RESULTS: In Santiago, the ZTL was associated with a 29.1% decrease (95% CI 1.2 to 70.2), the EL with a 41.0% decrease (95% CI 5.5 to 93.2) and Uber with a non-significant 28.0% decrease (95% CI -6.4 to 78.5) in the level of weekly alcohol-related traffic fatalities and injuries per 1 000 000 population series. In Concepción, the EL was associated with a 28.9% reduction (95% CI 4.3 to 62.7) in the level of the same outcome. In Valparaíso, the ZTL had a -0.01 decrease (95% CI -0.02 to -0.00) in the trend of weekly alcohol-related crashes per 1 000 000 population series. CONCLUSION: In Chile, concomitant decreases of alcohol-related crashes were observed after two state interventions were implemented but not with the introduction of Uber. Relationships between public policy interventions, ridesharing and motor vehicle alcohol-related crashes differ between cities and over time, which might reflect differences in specific local characteristics.

Effectiveness of trauma centers verification: Protocol for a systematic review.

BACKGROUND: The implementation of trauma systems in many high-income countries over the last 50 years has led to important reductions in injury mortality and disability in many healthcare jurisdictions. Injury organizations including the American College of Surgeons and the Trauma Association of Canada as well as the World Health Organization provide consensus-based recommendations on resources and processes for optimal injury care. Many hospitals treating trauma patients seek verification to demonstrate that they meet these recommendations. This process may be labeled differently across jurisdictions. In Canada for example, it is called accreditation, but it has the same objective and very similar modalities. The objective of the study described in this protocol is to systematically review evidence on the effectiveness of trauma center verification for improving clinical processes and patient outcomes in injury care. METHODS: We will perform a systematic review of studies evaluating the association between trauma center verification and hospital mortality (primary outcome), as well as morbidity, resource utilization, and processes of care (secondary outcomes). We will search CINAHL, EMBASE, HealthStar, MEDLINE, and ProQuest databases, as well as key injury organization websites for gray literature. We will assess the methodological quality of studies using the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) assessment tool. We are planning to conduct a meta-analysis if feasible based on the number of included studies and their heterogeneity. We will evaluate the quality of cumulative evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group methodology. DISCUSSION: This review will provide a synthesis of the body of evidence on trauma center verification effectiveness. Results could reinforce current verification modalities and may suggest ways to optimize them. Results will be published in a peer-reviewed journal and presented at an international clinical conference. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018107083.