Geriatrics/original research
National Study of Triage and Access to Trauma Centers for Older Adults

https://doi.org/10.1016/j.annemergmed.2019.06.018Get rights and content

Study objective

To identify predictors of undertriage among older injured Medicare beneficiaries, identify any regions in which undertriage is more likely to occur, and examine additional factors associated with undertriage at a national level.

Methods

Using 2009 to 2014 Medicare claims data, we identified older adults (≥65 years) receiving a diagnosis of traumatic injury, and linked claims with trauma center designation records from the American Trauma Society. Undertriage was defined as nontrauma centers treatment with an Injury Severity Score greater than or equal to 16, consistent with the American College of Surgeons Committee on Trauma benchmark. We used multivariable logistic regression to estimate odds of undertriage by census region, adjusting for sex, race, age, Injury Severity Score, trauma center proximity, and mode of transportation.

Results

Forty-six percent of severely injured patients (n=125,731) were treated at a nontrauma center. Compared with that for patients in the Midwest, adjusted odds of undertriage were 100% higher for patients in Southern states (odds ratio [OR] 2.00; 95% confidence interval [CI] 2.00 to 2.04) and 78% higher in Western states (OR 1.78; 95% CI 1.73 to 1.82). Compared with that for patients aged 65 to 69 years, odds of undertriage gradually increased in all age groups, reaching 57% for patients older than 80 years (OR 1.57; 95% CI 1.52 to 1.61). Distance to a trauma center was associated with increasing odds of undertriage, with 37% higher odds (OR 1.37; 95% CI 1.15 to 1.40) for older adults living more than 30 miles from a trauma center compared with patients living within 15 miles.

Conclusion

Nearly half of older adult trauma patients are undertriaged; it increases with age and distance to care and is most common in Southern and Western states. Improvements to field triage and trauma center access for older patients are urgently needed.

Introduction

Older adults (≥65 years) are the fastest-growing age group in the United States. This population is projected to increase by 105% from 2015 (47.8 million people) to 2060 (98.2 million people), which will represent nearly one quarter of the US population.1 Traumatic injury and mortality in older adults are following the same trend, with falls representing more than half (55%) of unintentional death by injury in older adults in the United States.2 Treating traumatic injuries in this population has intrinsic challenges because of concomitant preexisting medical conditions and polypharmacy, which have important implications for field triage, inpatient care, and long-term functional outcomes after trauma.3 Trauma care systems need to evolve accordingly to meet the growing burden of older adult trauma, yet limited resources are currently used to better understand and improve trauma care outcomes for older adults.

Editor’s Capsule Summary

What is already known on this topic

Injured older adults are less likely than younger ones to receive care in a trauma center.

What question this study addressed

What characteristics are associated with nontrauma center care (ie, undertriage) among older adults?

What this study adds to our knowledge

Among 7.8 million injured Medicare patients (2009 to 2014), 74% of all patients and 46% of severely injured ones were treated in a nontrauma center. Undertriage was more common in the South and West, among the oldest patients, and among patients living farther from trauma centers.

How this is relevant to clinical practice

Improving trauma center access for injured older adults may require both changes in out-of-hospital procedures and additional infrastructure or transportation capacity.

The most recent Centers for Disease Control and Prevention (CDC) guidelines for field triage of injured patients,4 updated in 2011, call for the highest level of care within the trauma system for patients meeting criteria. Level I and II trauma centers provide such care and offer definitive care for all injured patients. Moreover, the American College of Surgeons Committee on Trauma (ACS-COT) benchmarked the use of Injury Severity Score (ISS) greater than or equal to 16 nationally to define the patient population who would benefit from treatment at a Level I or II trauma center.5 Table 1 outlines key differences among trauma center levels of designation.6 These guidelines acknowledge undertriage as a problem and include special considerations for older adults because of elevated risk of poor injury outcomes. Such considerations include different thresholds for systolic blood pressure indicative of traumatic shock (≤90 mm Hg for adults <65 years and ≤110 for older adults) and increased priority for low-impact mechanisms (eg, ground-level falls). Trauma center care has been shown to lead to increased probability of survival in older adult trauma patients.7 However, several studies suggest that older adults may not fully benefit from advanced trauma care systems in the United States because numerous older adult patients are undertriaged to nontrauma centers.8, 9, 10, 11 Reported undertriage rates are variable and range from 33% to 49.9% in regional8 and multiregional10, 12 studies, with mixed findings on mortality and complications.9, 10, 13 There are 2 national studies of undertriage to our knowledge,11, 14 1 of them focusing on older adults.11 Both used encounter-level data from the Nationwide Emergency Department Sample,15 which has several key limitations related to triage decisions, including lack of information on mode of out-of-hospital transportation and the inability to determine the source of definitive care for transfer patients.

Across the United States, Medicare covers approximately 46 million Americans aged 65 years or older,16 regardless of income or health status, and therefore provides a unique analytic vantage point to better understand traumatic injury in a national sample of older adults.17 Studying undertriage among Medicare beneficiaries allows validation of previous estimates of undertriage and identifies potential determinants of undertriage, including mode of transportation and transfer status. These factors may be sensitive to policy interventions designed to ensure quality and efficiency of care as trauma health care systems grow and adapt to meet the increasing demand for services.

Our objective was to identify predictors of undertriage for older injured patients at a national level, identify any regions in which undertriage is more likely to occur, and examine additional factors associated with undertriage. We hypothesized that patient, injury severity, and geographic characteristics independently predict treatment by trauma center level.

Section snippets

Data Collection and Processing

Using Medicare claims data for inpatient and emergency department (ED) encounters from 2009 to 2014, we identified trauma patients aged 65 years or older in accordance with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for traumatic injury (800.0 to 959.9, excluding 905 to 909, 910 to 924, and 930 to 939). Medicare data were obtained from the Centers for Medicare & Medicaid Services through virtual access to the Virtual Research Data

Results

Among 7.8 million (n=7,853,415) trauma patients identified, 26.5% were treated at a trauma center and the rest at a nontrauma center (73.5%); 3.5% (n=271,717) had an ISS greater than or equal to 16, and of those, 46.3% were considered undertriaged (treated at a nontrauma center) (Figure 1). Approximately one quarter of older adults were treated at a trauma center and three quarters were treated at a nontrauma center, consistently with slight variations across age groups, sex, race, ambulance

Limitations

There are several limitations in our study. First, it was based on a retrospective review of Medicare claims data. The most relevant limitations to our study include confounding, missing data, lack of timestamps, lack of vital signs or ancillary test results reported, and that data were obtained from billing data; a more extensive description on limitations associated with this study design has been described elsewhere.17, 27, 28 Moreover, race and ethnicity information is self-reported, and as

Discussion

To our knowledge, this is the first national analysis to quantify the magnitude and identify predictors of undertriage among injured Medicare beneficiaries. Our results echo findings from previous national, regional, and state8, 9, 10, 11, 12, 14 analyses. This study offers unique subanalyses on distance traveled to receive care and mode of transportation used (ambulance versus private vehicle). Almost half of severely injured patients in our study (46%) received care at a nontrauma center

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      We found that a majority of the patients who died post-trauma and were transported to a lower-level trauma center (81%), were not identified as severely injured at the scene of injury. Most of these patients (95%) were elderly, which is in accordance with previous studies that investigated undertriaged patients [6,18,33-35]. A possible cause for underestimating injury severity in elderly is that low-energy accidents may result in serious injuries in this population [36].

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    Please see page 126 for the Editor’s Capsule Summary of this article.

    Supervising editor: Timothy F. Platts-Mills, MD, MSc. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

    Author contributions: DJS and AHH participated in the acquisition and analysis of the data. TU-L, MPJ, DJS, and AHH contributed toward the interpretation of data for the work. TU-L, MPJ, and AFH drafted the article. DJS, SRL, ZC, AS, CDN, and AHH critically revised the article for intellectual content. All authors made substantial contributions to the conception and design of the work, provided final approval of the version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. TU-L takes responsibility for the paper as a whole.

    All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This work was funded by the National Institute on Aging (grant 1R56AG048452-01A1).

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