• Avital Yohann, Ian Kratzke, Brittney Williams, and Anthony Charles.
• Department of Surgery, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, United States.
• Injury. 2022 Mar 1; 53 (3): 885894885-894.

IntroductionInjuries are a leading cause of disability and death worldwide, and low- and middle-income countries (LMICs) are disproportionately burdened by trauma. Prior studies have shown that transfer status (direct transfer from injury scene to a referral hospital versus indirect transfer from another facility to a referral hospital) may affect patient outcomes. The purpose of this study is to evaluate the relationship between transfer status and trauma patient outcomes in LMICs by conducting a systematic review and meta-analysis.MethodsWe performed a systematic search to identify studies from LMICs that evaluated the relationship between transfer status and trauma patient outcomes. We extracted data on study country, design, patient characteristics, and outcomes. We report results in the form of a narrative summary stratified by type of outcome. We also performed a meta-analysis of studies that reported mortality by transfer status. We calculated a pooled odds ratio of mortality among indirectly transferred (IT) versus directly transferred (DT) patients using random-effects modeling.ResultsWe included 17 observational studies from 9 LMICs in this systematic review. Outcomes assessed were time from injury to arrival at a referral hospital, post-trauma functional status, hospital length of stay, and mortality. IT patients took between 0.6 and 37.9 h longer to arrive at referral hospitals than DT patients. Hospital length of stay was up to 6 days longer for IT patients than DT patients. The pooled odds ratio of mortality among IT patients compared to DT patients was 1.55 (95% CI 1.12 - 2.15; p = 0.009).ConclusionTrauma patients in LMICs who are indirectly transferred to referral hospitals have significantly higher mortality rates than patients who present directly to referral hospitals. These results conflict with findings from HICs and reflect the relative immaturity of trauma systems in LMICs. Strategies to narrow the mortality gap between IT and DT patients include improving prehospital and primary hospital care and developing more efficient transfer protocols.Copyright © 2021 Elsevier Ltd. All rights reserved.

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