M. P. Jarman1, T. Uribe-Leitz1, D. Sturgeon1, C. D. Newgard4, E. Goralnick1,3, Z. Cooper1,2, A. Salim1,2, A. Haider1,2 1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Trauma, Burns, And Critical Care Surgery,Boston, MA, USA 3Brigham And Women’s Hospital,Department Of Emergency Medicine,Boston, MA, USA 4Oregon Health And Science University,Department Of Emergency Medicine,Portland, OR, USA
Introduction: Despite CDC guidelines recommending triage of significantly injured older adults (age ≥ 65) to trauma center (TC) care, less than 50% of injured older adults in the US are treated at designated Level I or II trauma centers. We sought to determine potential variation in under triage patterns across the US and understand contributory factors.
Methods: Using 2012-2014 Medicare claims data, we identified all patients age ≥ 65 with inpatient or emergency department encounters for traumatic injury and an injury severity score ≥ 16, and classified patients as under triaged if they were treated at a non-TC without subsequent transfer to a TC. Incidence of traumatic injury and under triage were aggregated to the hospital referral region (HRR) level and linked with their Dartmouth Atlas characteristics and the American Hospital Association annual survey. We then used hierarchical logistic regression to estimate odds of under triage for each region and identify associated HRR-level factors (e.g. distribution of income, race, age).
Results: Odds of under triage increased by 6% for every 100,000-person increase in population per TC at the HRR level (OR: 1.06, 95% CI: 1.02, 1.09), and by 8% for every 1-percentage point increase in the proportion of HRR residents with income at/below the federal poverty line (OR: 1.08, 95% CI: 1.03, 1.13). HRR-level factors accounted for 71% of variation in odds of under triage. Population per TC alone accounted for 41% of variation in odds of under triage. No other HRR-level factors examined were associated with odds of under triage after adjusting for the population per TC. Figure 1 illustrates the geographic distribution of under triage by HRR.
Conclusion: Under triage for injured older adults varies substantially across the US. System-level factors account for most of this variation, particularly population size relative to TC capacity, and characteristics of the population each TC serves (i.e. income distribution). Efforts to reduce under triage of older adults should consider both the capacity of trauma systems, and population characteristics.
