From Our 2008 Archives

Older Patients Less Likely to Be Taken to Trauma Centers

By Alan Mozes
HealthDay Reporter

MONDAY, Aug. 18 (HealthDay News) — Older trauma patients are less likely to be transported to an official trauma center for immediate care than younger patients, a new study found.

The finding was based on a review of a decade's worth of Maryland's statewide emergency medical services (EMS) records. And it suggests that the difference in care first comes into play as patients reach age 50 and worsens again at age 70.

"I'm not sure I would call it a bias, because that word has negative connotations, but in general, people do seem to have unconscious blind spots when it comes to the elderly," said study lead author David Chang. He is an assistant professor in the department of surgery at Johns Hopkins School of Medicine and in the department of health policy and management at Johns Hopkins Bloomberg School of Public Health.

"So not only EMS staff but also those receiving patients at trauma centers are operating on subjective assumptions as to what elderly patients need, how aggressively they should be treated, and what hospitals can do for them, rather than on clear and standard protocol, codes and trauma recommendations," Chang added. "And as a result, as patients get older, they are less likely to get into a trauma center."

Chang and his team reported their findings in the August issue of the Archives of Surgery.

The findings are based on an analysis of Maryland Ambulance Information System (MAIS) statewide records from 1995 through 2004. From the database, the study authors focused on 26,565 critically injured patients who experienced major trauma requiring immediate attention (so-called "Level I" patients), with the potential to be transported to one of Maryland's officially designated trauma centers.

The researchers found that about 18 percent of trauma patients under the age of 65 were "under-triaged," or not taken to a trauma center. Conversely, almost 50 percent of patients over the age of 65 were similarly undertreated.

A follow-up survey of 127 EMS workers and 32 medical personnel (including doctors, nurses, and medical students) revealed that the top three reasons for not transporting an older patient to a trauma center were: a lack of sufficient training for handling such patients (more than 25 percent); not knowing trauma protocols (12 percent); and potential age bias (just over 13 percent).

"So the hope now is to identify this blind-spot problem, so that we can maybe help EMS staff try to catch on and adjust their thinking and attitudes and, in turn, change their behavior," Chang said.

Dr. Ron M. Walls, chairman of the department of emergency medicine at Brigham and Women's Hospital in Boston, expressed some surprise at the study's conclusions.

"I think in general that most providers tend to worry more about the elderly and recognize that they are more at risk and want to get them better care," said Walls, who's also a professor of emergency medicine at Harvard Medical School. "And I have to say that I've certainly never seen any evidence of an elderly bias in my practice before -- here in Boston or elsewhere. So, it makes me wonder if there are other factors at play that the research didn't get at."

"For example, older people often have complex medical problems and very strong relationships with doctors at a particular center," Walls added. "So EMS providers might perfectly well decide to take an older patient to where they are best known, or even respond to a patient request to do so, whether or not that center is a trauma center."

Chang pointed out that since his study focused solely on patients with major trauma, it would be "highly unlikely that these patient would have been able, or have the time, to express any preference of care."

Walls said that, patient preference aside, no studies have shown that elderly survival is better at a trauma center. "And there might be a subset of patients that do better elsewhere," he said. "So, in my opinion, what the study primarily tells us is that further research is needed."

In a second study published in the same issue of the journal, a survey from the University of Connecticut School of Medicine found that trauma patients and caregivers alike seem to prefer palliative care, rather than aggressive critical care, if doctors believe that the latter is pointless.

Both groups didn't agree on all issues, however. While more than 72 percent of the public said trauma patients have the right to demand care not ordered by a doctor, only 44 percent of physicians thought so. Similarly, while about 61 percent of the public thought a person in a persistent vegetative state could be saved by a miracle or divine intervention, that opinion was shared by just 20 percent of medical professionals.

SOURCES: David Chang, Ph.D., M.P.H., MBA, assistant professor, department of surgery, Johns Hopkins School of Medicine, and assistant professor, department of health policy and management, Johns Hopkins Bloomberg School of Public Health, Baltimore; Ron M. Walls, M.D., chairman, department of emergency medicine, Brigham and Women's Hospital, Boston; August 2008, Archives of Surgery

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