Elderly patients less likely to be transported to trauma centers than younger patients

August 18, 2008

Elderly trauma patients appear to be less likely than younger patients to be transported to a trauma center, possibly because of unconscious age bias among emergency medical services personnel, according to a report in the August issue of Archives of Surgery, one of the JAMA/Archives journals.

An estimated 39 percent of all trauma patients will be age 65 years or older by the year 2050, according to background information in the article. "Evidence-based clinical practice guidelines strongly recommend that elderly trauma patients be treated as aggressively as non-elderly patients," the authors write. "However, some studies have suggested that age bias may still exist in trauma care, even in the prehospital phase of that care."

David C. Chang, Ph.D., M.P.H., M.B.A., of Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues analyzed 10 years of data from the statewide Maryland Ambulance Information System. They also surveyed emergency medical services (EMS) and trauma center personnel after presenting them with the registry findings at EMS conferences and grand rounds between 2004 and 2006. The registry identified 26,565 trauma patients, defined as those who met criteria set by the American College of Surgeons (ACS) and were declared level I status (critically ill or injured and requiring immediate attention) by EMS personnel.

More patients older than 65 were undertriaged, or not taken to a state-designated trauma center, than were younger patients (49.9 percent vs. 17.8 percent). After adjusting for other related factors, the researchers found that being 65 years or older was associated with a 52 percent reduction in likelihood of being transported to a trauma center. This decrease in transports was found to start at age 50 years, with another decrease at age 70.

A total of 166 individuals, including 127 EMS personnel and 32 medical personnel (14 attending physicians, four residents, six medical students and eight nurses), responded to the follow-up surveys. When asked about the most likely reasons for not transporting elderly patients to trauma centers, participants cited inadequate training for managing elderly patients (25.3 percent), unfamiliarity with protocol (12 percent) and possible age bias (13.4 percent) as the top three factors.

"The problem of age bias raised in this study may negate efforts to improve clinical care for elderly trauma patients within trauma centers if the system as a whole does not function properly and deliver patients appropriately to needed resources," the authors write.

"However, it may be difficult to change attitudes of age bias and may require a broad societal campaign. Nevertheless, it may be possible to address this problem without directly addressing age bias. A focus on retraining the providers about triage protocols may be sufficient," the authors conclude. "Additionally, it may be helpful to highlight the literature that now suggests that elderly trauma patients do, in fact, return to productive lives after their injury, which can eliminate the perception of futility of care that may be used consciously or subconsciously to justify age bias."
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(Arch Surg. 2008;143[8]:776-781. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: Dr. Chang was supported by an Individual National Research Service Award from the National Institute of General Medical Sciences for a portion of this study and was awarded the Maryland EMS-Geriatrics Award by the governor of Maryland in 2005. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

The JAMA Network Journals

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