The present study described the epidemiology and outcomes of hospitalized violence-related traumatic injuries in Qatar. Although the number of victims increased over the years, the hospitalization rate was decreasing, as there was 60% population growth in the study duration. The hospitalization rate estimated based on the present study was 4.6 per 100,000 population per year. Significantly higher rate was found in males and in younger population, specifically in 25-34 years age-group. Notably, pediatric (<18y) population represented 7% of the victims. In agreement with the population distribution by nationality in Qatar, South Asians were the principal victims in our study. Multivariable analysis showed that male gender and BAC positivity were predictors for interpersonal violence whereas Asian nationality was predictor of self-inflicted violence. One fifth of cases were refereed to psychiatric consultation; three-quarter of them was self-inflicted violence victims. The admission GCS and ISS were independent predictors of mortality in hospitalized violence related trauma patients in our analysis.
Interpersonal violence was the major contributor in most of victims followed by self-inflicted injuries. More than one out of five patients were proven to be under alcohol abuse and had a mean BAC level corresponding to the central nervous system depression level. Head and chest injuries were the most common severe injuries. The ISS data showed that polytrauma was not much frequent in our study population. Two out of seven patients required ICU admission. In-hospital mortality was 6.4%.
As per our knowledge, this is a pioneer trauma registry-based study conducted on violence-related trauma in the Qatar. Such studies based on trauma registry data are very rare in the Arabian Gulf region. A hospital-based retrospective study in Jordan demonstrated that violence (71%) was the most frequent cause of ED visits followed by road traffic injuries (23%) [17]
Bala et al studied the prevalence of physical fighting and its associated factors among adolescent population in Qatar [18]. This study was based on a student health survey in school to determine the prevalence and factors associated with being engaged in a physical fight. On the other hand, authors from Saudi Arabia reported factors of intimate partner violence against Saudi women based on survey among participants attended primary healthcare clinics [19]. Similarly, Barnawi estimated the prevalence of different types of domestic violence and its associated risk factors among Saudi women attending a primary care center [20].
The Osman et al study from the United Arab Emirates (UAE) was the only trauma registry- based study on violence published from the Arabian Gulf region, which was specific for interpersonal violence [21]. Notably, the majority of patients in our study were victims of interpersonal violence. Both studies (from Qatar and Saudi Arabia) were based on trauma hospitalization; however, a significant number of admissions were mild cases, which is evident from our overall ISS. Osman et al estimated that the interpersonal violence-related hospitalization rate in Saudi Arabia was 6.7 per 100,000 population, higher than the rate estimated in our study [21].
The UAE study findings on violence-related trauma by age and gender were comparable to our findings. The mean age in the UAE and our study was 30 and 31 years respectively. Similarly, male predominance among the victims was also evident in the UAE (85%) and Jordan (87%) based studies [17, 21]. Male predominance in our study was over 90%; more predominant in patients admitted following interpersonal injuries. Our study demonstrated that females were more likely to involve in self-inflicted injuries by showing higher proportion of females in this group when compared to interpersonal violence group.
Blunt injuries were common in our study population, especially in self-inflicted injuries. This is in contrast to studies from level 1 trauma centers in Western settings where a large number of penetrating injuries especially by gunshots are more common. In addition to the differences in geographical, cultural and religious backgrounds in the Middle Eastern settings, factors such as urbanization, crime rates, and legislation concerning firearm use could contribute to these existing variations. Dijkink et al recently demonstrated that the proportion of admitted patients with gunshot wounds was almost twice as high in level 1 trauma centers in the United States when compared to level 1 trauma centers in Netherlands, even though the geographical areas in both countries had comparable urbanization and violent crime rates [22].
Overall in-hospital mortality rate was 6.4% in our study. On the other hand, there were no deaths reported in the UAE study. The in-hospital mortality rate reported in our study can be related to the severity of injuries. Nearly 28% of our patients required ICU admission whereas the UAE based study revealed that less than 3% were admitted to the ICU [21].
Strength and limitation: The major strength of our study was its internal and external validity since the data were obtained from the national trauma registry and therefore our findings provides information on hospitalized violence victims in Qatar. In the process of submitting our registry data to TQIP, the submission file goes through validation and the file will be checked, a submission frequency report will provided for reference, and the file will be rejected if any major errors are found for correction. The TQIP reports are reviewed to pick up any outliers to review and correct any errors that might have been missed and then resubmit the changes.
The main limitation of the study was the retrospective design of the study; however it provided valuable information about the epidemiology and pattern of the hospitalized violence-related injuries in Qatar. Also, selection bias cannot be ruled out as in some situations the victims may not be willing to report the occurrence of violence and minor injuries may not attend HTC. Although the frequency of hospital visits following violence-related injuries by nationality data was available, the nationality-wise population data by year was unavailable and therefore the disproportionate burden of injuries were not estimated based on the rate. In addition, several other important socio-economic data were unavailable; however, the available data addressed the main objectives of the study. The present study excluded those who died at the site of injury or on arrival to the ED and therefore the data represent those with comparatively less severe injuries. In addition, the population structure in Qatar showed that females make up approximately a quarter of total population [23]. Changes in population growth rates over the years due to the influx of foreign workers recruited for the major development projects in Qatar could explain the changes in the rates of violence related injuries across the study period [23].