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Citation
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Horst MA, Morgan ME, Vernon TM, Bradburn EH, Cook AD, Shtayyeh T, D'Andrea L, Rogers FB. J. Trauma Acute Care Surg. 2020; ePub(ePub): ePub. |
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Affiliation
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Trauma & Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA. |
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Abstract
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BACKGROUND: Those aged >65 represent the fastest growing demographic in the U.S. As such, their care has been emphasized by trauma entities such as the ACSCOT. Unfortunately, much of that focus has been of their care once they reach the hospital with little attention on the access of geriatric trauma patients (GTPs) to trauma centers (TCs). We sought to determine the rate of geriatric undertriage (UT) to TCs within a mature trauma system and hypothesized that there would be variation and clustering of the geriatric undertriage rate (UTR) within a mature trauma system due to the admission of GTP to non-trauma centers.
METHODS: From 2003-2015, all geriatric (age>65) admissions with an Injury Severity Score (ISS) >9 from the PTSF registry and those meeting trauma criteria (ICD-9: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. UTR was defined as patients not admitted to TCs (n=27) divided by the total number of patients as from the PHC4 database. PHC4 contains all inpatient admissions within PA while PTSF reports admissions to PA TCs. The zip code of residence was used to aggregate calculations of UTR as well as other aggregate patient and census demographics and UTR was categorized into lower, middle box and upper quartiles. ArcGIS Desktop and GeoDa were used for geospatial mapping of UT with a spatial empirical Bayesian smoothed UTR and Stata for statistical analyses.
RESULTS: PTSF had 58,336 cases while PHC4 had 111,626 that met inclusion criteria, resulting in a median (Q1-Q3) smoothed UTR of 50.5% (38.2%-60.1%) across PA zip code areas (ZCTA). Geospatial mapping reveals significant clusters of UT regions with high UTR in some of the rural regions with limited access to a TC. The lowest quartile UTR regions tended to have higher population density relative to the middle or upper quartile UTR regions. At the patient level, the lowest UTR regions had more racial and ethnic diversity, a higher injury severity and higher rates of treatment at a TC. UTR regions that were closer to NTCs had a higher odds of being in the upper UTR quartile; 4.48 (2.52-7.99) for NTC < 200 beds and 8.53 (4.70-15.47) for NTC ≥ 200 compared to ZCTA with a TC as the closest hospital.
CONCLUSIONS: There are significant clusters of geriatric undertriage within a mature trauma system. Increased emphasis needs to focus prehospital on identifying the severely-injured geriatric patient including specific geriatric triage protocols. LEVEL OF EVIDENCE: Epidemiological; Level III.
Language: en |