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Globally, road traffic accidents (RTAs) remain a major cause of death, particularly among individuals aged 15–30 years. While Sweden has been at the forefront of traffic safety through the Vision Zero initiative, in-hospital management remains crucial in determining RTA outcomes. Drawing on North American evidence suggesting improved survival at trauma centres, the Swedish healthcare system has increasingly emphasised trauma centralisation. However, comprehensive national data from Sweden are scarce. Given the country’s unique demographic and geographic characteristics, including vast sparsely populated areas, direct comparisons with other Western systems are challenging. We analysed the epidemiology and risk factors for 30-day mortality among 95,954 RTA-related hospital admissions in Sweden between 2008 and 2021. Predictors included the ICD-based Injury Severity Score (ICISS), age, sex, Charlson Comorbidity Index (CCI), year of event, and hospital level. Mortality risk was modelled using explainable artificial intelligence (XAI) via Extreme Gradient Boosting (XGBoost) with SHapley Additive exPlanations (SHAP), alongside conventional multivariable logistic regression for comparison. The most influential predictors of 30-day mortality, in descending order, were ICISS, age, CCI, event year, hospital level, and sex. A clear trend toward centralisation was observed, with Level 1 hospitals admitting the most severely injured patients. However, after risk adjustment, the hospital level was not independently associated with 30-day mortality. The XAI model outperformed logistic regression in both discrimination and calibration, confirming these findings. This study represents a comprehensive national analysis of in-hospital outcomes following RTAs in Europe. ICISS, age, sex, and comorbidity influenced mortality risk, while overall survival improved over time. The assumption that trauma centralisation confers a universal survival advantage does not appear to hold in the Swedish context. These findings underscore the need to re-evaluate trauma system design under Scandinavian conditions—ensuring that timely access to hospital care is not compromised by centralisation.

Abstract Background Traffic incidents are still a major contributor to hospital admissions and trauma-related mortality. The aim of this nationwide study was to examine risk-adjusted traffic injury mortality to determine whether hospital type was an independent survival factor. Methods Data on all patients admitted to Swedish hospitals with traffic-related injuries, based on International Classification of Diseases codes, between 2001 and 2011 were extracted from the Swedish inpatient and cause of death registries. Using the binary outcome measure of death or survival, data were analysed using logistic regression, adjusting for age, sex, comorbidity, severity of injury and hospital type. The severity of injury was established using the International Classification of Diseases Injury Severity Score (ICISS). Results The final study population consisted of 152,693 hospital admissions. Young individuals (0–25 years of age) were overrepresented, accounting for 41% of traffic-related injuries. Men were overrepresented in all age categories. Fatalities at university hospitals had the lowest mean (SD) ICISS 0.68 (0.19). Regional and county hospitals had mean ICISS 0.75 (0.15) and 0.77 (0.15), respectively, for fatal traffic incidents. The crude overall mortality in the study population was 1193, with a mean ICISS 0.72 (0.17). Fatalities at university hospitals had the lowest mean ICISS 0.68 (0.19). Regional and county hospitals had mean ICISS 0.75 (0.15) and 0.77 (0.15), respectively, for fatal traffic incidents. When regional and county hospitals were merged into one group and its risk-adjusted mortality compared with university hospitals, no significant difference was found. A comparison between hospital groups with the most severely injured patients (ICISS ≤0.85) also did not show a significant difference (odds ratio, 1.13; 95% confidence interval, 0.97–1.32). Conclusions This study shows that, in Sweden, the type of hospital does not influence risk adjusted traffic related mortality, where the most severely injured patients are transported to the university hospitals and centralization of treatment is common.