Prehospital transport prioritization and time-varying selection bias in traffic-related multi-patient incidents: a nationwide retrospective cohort study.

Λεπτομέρειες βιβλιογραφικής εγγραφής
Τίτλος:	Prehospital transport prioritization and time-varying selection bias in traffic-related multi-patient incidents: a nationwide retrospective cohort study.
Συγγραφείς:	Kubo A; Faculty of Emergency Medical Science, Meiji University of Integrative Medicine, 2nd Floor, Building 6, Lecturer's Office, 6-1 Hinoya, Honoda, Hiyoshi-cho, Nantan-shi, 629-0392, Kyoto, Japan. a_kubo@meiji-u.ac.jp.; Department of Emergency and Critical Care Medicine, Wakayama Medical University, Wakayama, Japan. a_kubo@meiji-u.ac.jp., Tamura S; First Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan.; Department of General Medicine, Wakayama Rosai Hospital, Wakayama, Japan., Hiraide A; Faculty of Emergency Medical Science, Meiji University of Integrative Medicine, 2nd Floor, Building 6, Lecturer's Office, 6-1 Hinoya, Honoda, Hiyoshi-cho, Nantan-shi, 629-0392, Kyoto, Japan., Morioka D; Faculty of Emergency Medical Science, Meiji University of Integrative Medicine, 2nd Floor, Building 6, Lecturer's Office, 6-1 Hinoya, Honoda, Hiyoshi-cho, Nantan-shi, 629-0392, Kyoto, Japan., Murakami R; Faculty of Risk and Crisis Management, Chiba Institute of Science, Chiba, Japan., Fukui K; Faculty of Emergency Medical Science, Meiji University of Integrative Medicine, 2nd Floor, Building 6, Lecturer's Office, 6-1 Hinoya, Honoda, Hiyoshi-cho, Nantan-shi, 629-0392, Kyoto, Japan., Inoue S; Department of Emergency and Critical Care Medicine, Wakayama Medical University, Wakayama, Japan.
Πηγή:	Critical care (London, England) [Crit Care] 2026 Aug 04; Vol. 30 (1). Date of Electronic Publication: 2026 Aug 04.
Τύπος έκδοσης:	Journal Article
Γλώσσα:	English
Στοιχεία περιοδικού:	Publisher: BioMed Central Ltd Country of Publication: England NLM ID: 9801902 Publication Model: Electronic Cited Medium: Internet ISSN: 1466-609X (Electronic) Linking ISSN: 13648535 NLM ISO Abbreviation: Crit Care Subsets: MEDLINE
Imprint Name(s):	Publication: London, UK : BioMed Central Ltd Original Publication: London : Current Science Ltd, c1997-
Ιατρικοί όροι (MeSH):	Triage/methods , Triage/standards , Triage/statistics & numerical data , Emergency Medical Services/methods , Emergency Medical Services/statistics & numerical data , Emergency Medical Services/standards , Transportation of Patients/standards , Transportation of Patients/methods , Transportation of Patients/statistics & numerical data , Accidents, Traffic/statistics & numerical data, Humans ; Retrospective Studies ; Female ; Japan ; Male ; Middle Aged ; Time Factors ; Cohort Studies ; Selection Bias ; Adult ; Aged
Περίληψη:	Background: In prehospital multi-patient traffic incidents, the first ambulance to depart -priority transport - may reflect underlying injury severity rather than a treatment effect, as more severely injured patients are systematically prioritized. Conventional statistical methods often fail to separate this severity-dependent selection from actual outcomes. We applied a "doubly robust" statistical framework (augmented inverse probability weighting, AIPW), which combines a treatment model and an outcome model, to better account for measured differences, reduce selection bias, and examine whether on-scene time modifies this association. Methods: We conducted a nationwide retrospective cohort study using emergency medical service transport records from the Fire and Disaster Management Agency of Japan (January 2021-December 2023). Of 13,821,224 records, 143,130 patients from traffic-related multi-patient incidents (TMIs; ≥2 patients per incident) with complete data were included. The exposure was priority transport. The primary outcome was physician-assessed death or critical/severe injury at hospital arrival. Marginal adjusted risk differences (RDs) were estimated using AIPW. Effect modification by on-scene time (5-60 min) was assessed by marginal standardization with cluster-bootstrap confidence intervals. Sensitivity analyses included overlap restriction and E-value quantification of unmeasured confounding. Results: Among 143,130 patients (median age 41 years; female, 50.57%), 62,769 (43.85%) underwent priority transport. Severe outcomes occurred in 4.35% of priority and 1.87% of non-priority patients. The overall RDs was 2.2% points (95% CI, 2.01-2.36). A significant interaction with on-scene time was observed (p < .001): the marginal RD was peaked at 5 min (6.4% points; 95% CI, 5.6-7.2), declined to a minimum of 1.4% points (95% CI, 1.3-1.6) at approximately 32 min, and increased modestly to 2.4% points (95% CI, 2.0-2.8) at 60 min. Sensitivity analyses confirmed result robustness, yielding an E-value of 3.76 (lower bound, 3.57). Conclusions: The association between priority transport and severe outcome was modified by on-scene time, with the largest risk difference at the shortest on-scene times. This U-shaped pattern is consistent with preferential selection of more severely injured patients for rapid transport, rather than a direct effect of transport order. Accounting for prehospital triage selection when interpreting transport-outcome associations in critical care research. (© 2026. The Author(s).)
Competing Interests:	Declarations. Ethics approval and consent to participate: This study was approved by the Institutional Review Board of Meiji University of Integrative Medicine (No. 2025-072), and the requirement for informed consent was waived. Registry data use was authorized by the Fire and Disaster Management Agency (FDMA) of Japan. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.
References:	Clin Exp Emerg Med. 2023 Mar;10(1):37-43. (PMID: 36174974) Am J Epidemiol. 2023 Sep 1;192(9):1604-1605. (PMID: 37280737) Acad Emerg Med. 2001 Jul;8(7):758-60. (PMID: 11435197) Epidemiology. 2016 May;27(3):368-77. (PMID: 26841057) Am J Epidemiol. 2008 Sep 15;168(6):656-64. (PMID: 18682488) Osong Public Health Res Perspect. 2025 Aug;16(4):381-391. (PMID: 40785380) J Trauma. 2002 Aug;53(2):201-12. (PMID: 12169923) JAMA. 2008 Sep 24;300(12):1423-31. (PMID: 18812533) Int J Biostat. 2018 Jun 8;14(1):. (PMID: 29883322) Eur J Trauma Emerg Surg. 2022 Apr;48(2):1111-1120. (PMID: 34019106) J Trauma. 2010 Feb;68(2):452-62. (PMID: 20154558) PLoS Med. 2005 Aug;2(8):e124. (PMID: 16060722) Biometrics. 2005 Dec;61(4):962-73. (PMID: 16401269) J Epidemiol Community Health. 2004 Apr;58(4):265-71. (PMID: 15026432) BJOG. 2016 Aug;123(9):1521-9. (PMID: 26411752) Circulation. 2012 Dec 11;126(24):2834-43. (PMID: 23035209) BMJ. 2007 Oct 20;335(7624):806-8. (PMID: 17947786) JAMA Netw Open. 2026 Jan 2;9(1):e2552092. (PMID: 41490108) Disaster Med Public Health Prep. 2008 Sep;2 Suppl 1:S25-34. (PMID: 18769263) JAMA Surg. 2023 Oct 01;158(10):1078-1087. (PMID: 37556154) Am J Emerg Med. 1984 Nov;2(6):537-49. (PMID: 6442155) Med Teach. 2018 Aug;40(8):803-808. (PMID: 30033794) Ann Surg. 2009 Jun;249(6):1040-6. (PMID: 19474674) Epidemiology. 2003 May;14(3):300-6. (PMID: 12859030) Circulation. 2009 Feb 10;119(5):728-34. (PMID: 19171854) Scand J Trauma Resusc Emerg Med. 2021 Aug 17;29(1):119. (PMID: 34404443) Arch Acad Emerg Med. 2022 Apr 30;10(1):e32. (PMID: 35573710) J Trauma. 2008 Sep;65(3):628-35. (PMID: 18784577) Multivariate Behav Res. 2011 May;46(3):399-424. (PMID: 21818162) N Engl J Med. 2016 Oct 27;375(17):1649-1659. (PMID: 27783922) Stat Med. 2015 Dec 10;34(28):3661-79. (PMID: 26238958) Ann Intern Med. 2017 Aug 15;167(4):268-274. (PMID: 28693043) Prehosp Emerg Care. 2013 Oct-Dec;17(4):442-57. (PMID: 23845080) Int J Epidemiol. 1996 Dec;25(6):1107-16. (PMID: 9027513) Ann Emerg Med. 2010 Mar;55(3):235-246.e4. (PMID: 19783323) Ann Intern Med. 2025 Mar;178(3):402-407. (PMID: 39961105) N Engl J Med. 2010 Mar 18;362(11):994-1004. (PMID: 20237345) Prehosp Disaster Med. 2008 Jan-Feb;23(1):3-8. (PMID: 18491654)
Contributed Indexing:	Keywords: Causal inference; Doubly robust estimation; Mass casualty incidents; Prehospital care; Selection bias; Transport prioritization; Trauma systems; Triage
Entry Date(s):	Date Created: 20261009 Date Completed: 20261009 Latest Revision: 20261015
Update Code:	20261015
PubMed Central ID:	PMC13647583
DOI:	10.1186/s13054-026-06196-2
PMID:	42850620
Βάση Δεδομένων:	MEDLINE

Full Text Finder

Περιγραφή
ISSN:	1466-609X
DOI:	10.1186/s13054-026-06196-2