T. Uribe-Leitz1, M. P. Jarman1, D. J. Sturgeon1, J. W. Scott4, G. Ortega1, S. R. Lipsitz1, A. Salim1,3, C. D. Newgard2, A. H. Haider1,3 1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Oregon Health & Science University,Center For Policy And Research In Emergency Medicine,Portland, OREGON, USA 3Brigham And Women’s Hospital,Division Of Trauma, Burns, And Critical Care Surgery,Boston, MA, USA 4Harborview Medical Center, University of Washington,Department Of Surgery, Trauma & Surgical Critical Care,Seattle, WA, USA
Introduction: The CDC published new guidelines for field triage of injured patients in 2012. This update includes special considerations for older adults and specify the need for this vulnerable population to receive high level (Level I or Level II) trauma center (TC) care. The effect of this policy on older adults has not been analyzed. We sought to determine if the updated guidelines have improved field triage for severely injured older adult patients at a national level.
Methods: We queried Medicare claims data from 2008-2014, to identify older adults (age ≥ 65) diagnosed with traumatic injury. Under-triage was defined as Non-Trauma Center [(NTC) Level III-V, and non-trauma centers] care for patients with an injury severity score (ISS) ≥ 16, per the American College of Surgeons Committee on Trauma (ASC-COT) benchmark. We used a difference-in-difference (DID) study design, with patients transported by EMS as the exposure group compared to those not transported by EMS as the no-exposure group. The pre-exposure period was from 2009 to 2010, the post-exposure period from 2013 to 2014, and 2011 to 2012 as a washout period. We used multivariable logistic regression models to estimate the statistical significance of the association between the updated guidelines (policy change) and under-triage adjusting for age, sex, race, region, mechanism of injury (falls), Charlson Comorbidity Index, in-hospital death, ISS, and TC proximity.
Results: A total of 180,436 severely injured older adult patients were included in our analyses, from which 85,030 (47.1 %) were transported by EMS and 95,406 (52.9 %) were not transported by EMS. Older adults were distributed evenly in pre-exposure and post-exposure groups. Mean age was 81.4 (SD, 7.8) and 81.7 (SD, 8.0) respectively, 54% were female and 90% white in both groups. Pre-/Post-policy rates of under-triage were 50.2% and 47.5% for the exposed and 44.5% and 43.4% for the unexposed, in unadjusted analyses. Pre-/Post-policy rates of under-triage were 32.7% and 29.7% for the exposed and 28.6% and 27.2% for the unexposed, after adjusting for covariates of interest. The DID model revealed a policy-associated change in under-triage rate of 1.6% among older adults, p= 0.0016.
Conclusion: The release of the 2012 updates to the CDC guidelines was associated with a small significant reduction in under-triage rates among older adults. Additional multilevel strategies are required to improve access, and continue to reduce under-triage to truly serve this vulnerable population.
