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The movement towards trauma care regionalization in Quebec was initiated in 1990, with formal designation of three level I trauma centers in 1993. The purpose of this study is to evaluate the impact of trauma center designation on mortality. The study design is that of a two-cohort study, one assembled during 1987 when designation was not in effect, and the other during the first 5 months of designation. The study focuses on patients that fulfilled the following criteria: i) arrived alive at the hospital, and ii) were admitted. The outcome measures are adjusted mortality, and excess mortality as measured by the TRISS methodology. A total of 158 patients treated in 1987, and 288 treated in 1993, were identified. The mean age of the patients treated in 1993 was significantly higher (40.0, +/- 18.1), when compared with the 1987 group (30.9 +/- 18.1; p < 0.001). Patients in the 1987 cohort had a significantly higher proportion of injuries caused by stabbing (p = 0.02), and a significantly lower proportion caused by falls (p = 0.003). The 1987 cohort had a higher rate of abdominal injuries (p = 0.0001), and external injuries (p = 0.0001), and a significantly lower rate of head or neck injuries (p = 0.003), and injuries to the extremities (p = 0.0001). The mean Injury Severity Score (ISS) for the 1987 cohort was 14.96 (+/- 12.36), and 15.49 (+/- 11.61) in 1993 (p = 0.65). The crude mortality rate was 20% for 1987, and 10% for 1993. The crude odds ratio for mortality in 1987 was 2.10 with 95% confidence intervals between 1.22 and 3.62 (p = 0.006). The ISS-based z scores for these two cohorts were 3.62 (p = 0.0002), and 0.68 (p = 0.49) respectively. The Standardized Mortality Rates (95% confidence intervals) were 1.64 (1.10-2.53) for 1987, and 1.11 (0.75-1.59) for 1993, indicating a statistically significant reduction in excess mortality (p < 0.05). Multiple Logistic Regression, adjusting for patient age, ISS, body regions injured, and mechanism of injury, showed a significantly higher mortality risk for the 1987 cohort (relative odds = 3.25, p = 0.009). These data show that the process of trauma center designation has significantly improved the survival of the patients treated in these facilities. This is likely due to increased surgical staffing, nursing support, and availability of the required high level technology at the designated hospitals.