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In Italy there are no accepted standards for trauma care nor dedicated programs for quality assessment on a national scale, like trauma registries. At the same time there seems to be a north–south gradient in the quality of health care. We hypothesized that geographical inequalities of health-care quality may affect trauma mortality.Retrospective comparison of hospital mortality by Cox regression in three main areas of Italy adjusted for age, Glasgow Coma Scale and source of admission. A leading national database on patients admitted to intensive care units (ICU) in the years 2002–2005 was used. 9162 adult trauma cases admitted to the ICU from the emergency department were included.There is a significant north–south gradient of risk. Compared to the north, the risk of death is about 60% higher in the south and about 30% higher in the central region. These figures are similar in both referral centres and other hospitals and both in the head-injured only and total injured cases.Despite the limitations of this study, mainly related to sampling issues, risk-adjustment and incomplete follow-up, the large geographic differences in mortality that we found highlight likely deficiencies in the quality of trauma care that deserve further accurate assessment.