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Original Article |

Factors Associated With Trauma Center Use for Elderly Patients With Trauma:  A Statewide Analysis, 1999-2008 FREE

Renee Y. Hsia, MD, MSc; Ewen Wang, MD; Olga Saynina, MS; Paul Wise, MD, MPH; Andrew Auerbach, MD, MPH
[+] Author Affiliations

Author Affiliations: Department of Emergency Medicine (Dr Hsia), Department of Medicine, Division of General Internal Medicine (Dr P[[eacute]]rez-Stable), and Department of Medicine, Division of Hospital Medicine (Dr Auerbach), University of California, San Francisco, and Department of Surgery, Division of Emergency Medicine (Dr Wang), and Center for Health Policy and Center for Primary Care Outcomes Research (Ms Saynina and Dr Wise), Stanford University, Stanford, California.


Arch Surg. 2011;146(5):585-592. doi:10.1001/archsurg.2010.311.
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Published online

As the US population ages, elderly persons account for an increasing number of trauma patients. Morbidity and mortality from traumatic injury are higher in elderly patients compared with younger patients.1,2 It is well known that the care found in trauma centers benefits appropriately triaged patients36 and is reserved for the most severely injured patients.7

Early studies suggest that elderly patients may be less likely to be admitted to a trauma center after an injury than are younger patients.8,9 Decreased referral to trauma centers may be related to a lack of referral centers, but elderly patients would not be affected disproportionately if this were the case. Alternatively, decreased referral may result because standard trauma triage criteria are inappropriate or less accurate in older patients.1014

Few population-based data describe the public health effect of trauma in elderly patients or how often elderly patients receive care at a trauma center. Existing studies are either single-site studies or do not account for system-level factors known to influence likelihood of admission to a trauma center, specifically proximity to a trauma center and trauma center availability within county of residence. Trends of longer life spans and an aging baby boomer population forecast a doubling of older American adults to 71 million in the next 25 years (20% of the US population). It is therefore critical to understand current trends in the care of injured elderly patients.15

We analyzed data from the state of California to determine the likelihood of admission to a trauma center for injured elderly persons after adjusting for patient risk factors and hospital and system-level factors. Different trauma types have different prognoses that could account for differences in admission rates, so we also considered likelihood of admission to trauma center in these groups by injury type (blunt injury, penetrating injury, and falls) and injury severity. We hypothesized that differences in likelihood of admission might be explained by these factors. Finally, we calculated the risks of death associated with admission to a nontrauma center vs a trauma center.

STUDY DESIGN AND DATA SOURCES

Our study was a retrospective analysis of adults (age, >18 years) hospitalized for trauma at acute care hospitals in California between January 1, 1999, and December 31, 2008. We combined and analyzed data from 3 separate data sets focusing on the state of California. The California Office of Statewide Planning and Development (OSHPD) patient discharge database contains discharge records from all nonfederal, licensed California hospitals, which are mandated to report all hospitalizations. Demographic variables include patient age, sex, zip code, and county of residence, International Classification of Diseases Ninth Revision (ICD-9) codes for principal diagnosis and up to 24 other diagnoses, as well as disposition variables.16

We identified which hospitals in our OSHPD patient-level data were level I or II trauma centers from the California Department of Health trauma center database.17 Because trauma center designation could change from one year to another, we assigned trauma center designation according to the patient's date of admission and hospital identifiers. We then linked the 2000 US census zip-code level income information to our study data set.

SUBJECTS

We selected adult patients admitted for traumatic injury using previously published criteria, defined by the principal or secondary diagnosis ICD-9 codes of 800-904.9, 910-929.9, and 950-959.9.18 To focus on acute trauma, we used an algorithm from previously published work1921 and excluded patients without external causes of injury codes (E codes), with scheduled admissions, or admitted for late effects of injury. Patients with ICD-9 codes for drowning, bites and stings, overexertion, poisonings or suffocation and patients whose sole ICD-9 codes indicative of injury were minor injuries (eg, sprains and strains, contusion with intact skin surface, or foreign body) were also excluded. Patients in California who have burns are often cared for at regional burn centers, so we also excluded patients whose principal diagnosis indicated a burn. Finally, because hip fractures are extremely common among the elderly and may not require all trauma center services, we excluded patients with closed hip fractures using prespecified ICD-9 codes.22,23 This accounted for 97 006 visits, or 18.4% of what would have been our sample (n = 527 087). Excluding these closed hip fractures reduces the likelihood of exaggerated findings of bias against the provision of trauma center care for elderly patients given the large percentage of elderly patients with hip fractures (41.5% in what would have been our sample, compared with 4.0% of nonelderly patients) and is consistent with studies of injured elderly persons24 who could receive adequate care in nontrauma centers.

PREDICTOR VARIABLES

We used 2 separate predictors to represent elderly patients in our study because there are few clear definitions of “elderly” in relationship to trauma. The first was a dichotomous variable using 65 years of age as a cutoff.25,26 We also constructed a categorical variable representing a series of standard age groupings27: 18-25 years, 26-45 years, 46-65 years, 66-85 years, and older than 85 years. This latter construction allowed us to examine whether associations were more or less powerful in standardized age groups.2529

ADJUSTMENT VARIABLES
Severity and Mechanism of Injury

Injury Severity Scores (ISSs) were calculated for patients using an International Classification of Diseases, Ninth Revision, Clinical Modification translation of the ISSs by Tri-Analytics (Bel Air, Maryland) using the “ignore unknowns” and “low severity” mapping options.30 If an ISS could not be computed, the patient was excluded. The ISS was then stratified into mild (ISS, 1-4), moderate (ISS, 5-15), and severe (ISS, >15) categories as suggested by MacKenzie et al.31 The mechanism of injury was determined from the principal ICD-9 code and from the E code, using the recommended framework for E-code groupings for injury mortality and morbidity from the Centers for Disease Control and Prevention.18

Comorbidity

Because elderly patients likely have comorbidities that affect their overall prognosis, we calculated the Elixhauser Index, described and validated elsewhere in the literature,32 for each patient.

Proximity to a Trauma Center

Whether a trauma center was located in a patient's county of residence was determined by comparing the patient's resident zip code to a list of zip codes for counties with a trauma center-designated hospital. We performed this analysis for each year because the designation of trauma center for a hospital can change over time. The geographic proximity of the patient's residence to a trauma center was calculated in miles (to convert miles to kilometers, multiply by 1.6) as the shortest distance between the centroid of the patient's zip code and the centroid of the nearest trauma center zip code, according to the method of Phibbs and Luft.33 Distance categories were chosen based on previous studies.19,20

Socioeconomic Measures

Insurance status was known from the medical record of each visit and was categorized into 5 categories: Medicare, Medicaid, private, uninsured or self-pay, and other. Household income was determined using the median household income for the patient's resident zip code, and 3 strata were created based on multiples of the 2000 federal poverty level or $18 850. Income strata were set according to previous literature20: (1) below 2 times the federal poverty level, (2) 2 to 3 times the federal poverty level, and (4) above 3 times the federal poverty level.

PRIMARY DATA ANALYSES

We first characterized our sample using univariable techniques and then compared age groups using bivariable methods, to compare the relative likelihood of receiving trauma center care as stratified by age. We then performed multivariable logistic regression analyses using an a priori selection model to assess the factors influencing the probability that patients received care at a trauma center. The demographic factors that were analyzed for inclusion in the regression model were age, sex, race/ethnicity, and insurance type. Injury characteristics in the model included injury severity (mild, moderate, or severe), type of injury (penetrating injury, blunt injury, or fall), and Elixhauser Index. System variables included proximity to trauma hospital (0-10 miles, 11-25 miles, 26-50 miles, or >50 miles), availability of trauma center in the county, and metropolitan statistical area status (urban or rural).

For our mortality predictions, we accounted for observable differences between our 2 groups of patients (those treated at trauma centers and those treated at nontrauma centers) using the previously described method of propensity scores or the inverse probability of treatment weighting approach.31,34 Briefly, the conditional probability of being admitted to a trauma center is calculated based on the known demographic and clinical characteristics of each patient. The data are weighted according to the reciprocal of this score to create a population in which the likelihood of admission to a trauma center is not confounded by other covariates and the effect of trauma center care reflects that of the original population.

We used SAS version 8.2 (SAS Institute, Cary, North Carolina). This protocol was approved by the institutional review boards for human research at Stanford University and the University of California, San Francisco.

CHARACTERISTICS OF STUDY SUBJECTS

Of the 430 081 patients admitted to California acute care hospitals for trauma-related diagnoses, 27% were older than 65 years. There were several notable differences in characteristics between the 2 groups (Table 1). Most trauma patients in the nonelderly group were men (63.0%); however, in the elderly group, this proportion was reversed: 65.2% of elderly trauma patients were women (P < .001). The nonelderly group had a higher proportion of trauma patients who were black than did the elderly group (7.0% vs 2.1%; P < .001). Similarly, there were fewer trauma patients who were white in the nonelderly group compared with the elderly group (32.8% vs 66.4%; P < .001).

Table Graphic Jump LocationTable 1. Characteristics of Patients in Sample, 1999-2008

When patients were stratified by injury severity, there were fewer severely injured elderly patients than nonelderly patients (3.9% vs 7.3%; P < .001) but slightly more moderately injured elderly patients than nonelderly patients (41.4% vs 39.3%; P < .001). More elderly patients had a higher number of comorbidities. By mechanism, the elderly patients had a disproportionate number of falls (Figure 1) compared with the nonelderly patients (81.5% vs 28.3; P < .001). More than 93% of injuries in those 85 years of age or older are due to falls, compared with 14% in those 18-25 years of age.

Place holder to copy figure label and caption
Figure 1.

Percentage of trauma injuries by mechanism of injury, stratified by age group.

Graphic Jump Location

Distance to trauma center, metropolitan statistical area status, and availability of trauma center within county of residence were similar between groups. However, a much larger percentage of the elderly patients were admitted to nontrauma centers compared with the nonelderly patients (71.1% vs 36.8; P < .001). A higher proportion of the elderly patients than nonelderly patients (3.9% vs 2.1%; P < .001) also died in the hospital after admission for their injuries.

LIKELIHOOD OF RECEIVING CARE IN A TRAUMA CENTER VS A NONTRAUMA CENTER

We first constructed bivariate models of the likelihood of an elderly patient (defined first in the binary definition as being older than 65 years of age) vs a nonelderly patient (defined first in the binary definition as being between 18 and 65 years of age) being admitted to a trauma center. With this method, the odds ratio (OR) of an injured elderly patient compared with a nonelderly patient receiving care in a trauma center was 0.23 (95% confidence interval [CI], 0.18-0.29).

The results of our multivariable regression model of older patients as defined by the binary categorization of older or younger than 65 years demonstrated that, even after adjusting for available patient-level risk factors and access to a trauma center, patients older than 65 years still had a dramatically decreased likelihood (OR, 0.53; 95% CI, 0.45-0.63) of being admitted to a trauma center compared with patients 65 years of age or younger.

We then examined the proportion of injured patients admitted to a trauma center by age categories (Figure 2) and saw a linear relationship between age and referral likelihood. Even after controlling for predictors, increasing age showed a profound association with lower likelihood of trauma center referral in the multivariable regression (Table 2). The linear trend of the inverse association of age and likelihood of admission to trauma center persisted: patients aged 46-65 years had a 0.57 odds (95% CI, 0.54-0.60) of receiving trauma care compared with the referent population aged 18-25 years; patients 66-85 years of age had an OR of 0.35 (95% CI, 0.30-0.41); and patients 85 years or older had an OR of 0.30 (95% CI, 0.25-0.36).

Place holder to copy figure label and caption
Figure 2.

Percentage of injured patients admitted to trauma center (TC) by age group, stratified by year.

Graphic Jump Location
Table Graphic Jump LocationTable 2. Multivariate Model of Likelihood of Admission to Trauma Center

As a secondary aim, we sought to determine whether these differences in likelihood of admission varied across injury type (blunt injury, penetrating injury, and falls) as well as injury severity, because certain mechanisms or certain levels of severity could trigger more alarm in both the prehospital and in-hospital setting. We found, contrary to our hypothesis, that this pattern of decreased likelihood of receiving care in a trauma center for older patients was unchanged even in the adjusted multivariable analyses when stratified by injury type and severity (Figures 3 and 4).

Place holder to copy figure label and caption
Figure 3.

Likelihood of admission to trauma center (TC) by mechanism of injury, stratified by age group. Likelihood of admission to TC for blunt trauma (n = 167 652) (A), penetrating trauma (n = 77 843) (B), and fall (n = 167 652) (C).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Likelihood of admission to trauma center (TC) by injury severity, stratified by age group. Likelihood of admission to TC for mild trauma (n = 231 200) (A), moderate trauma (n = 171 504) (B), and severe trauma (n = 27 378) (C).

Graphic Jump Location
SENSITIVITY ANALYSES

Given that protocols of trauma transport may differ across emergency medical services that are county-based in California, we performed additional modeling to include clustering by county. Our results were robust to clustering by county as well as over time. We also performed these analyses to include all levels of trauma centers (ie, levels I-IV) and did not find that this significantly altered our results; older patients did not only have a decreased likelihood of receiving care in level I and II trauma centers. Models to account for interaction of age (considering both binary and ordinal definitions) with injury severity (considering continuous and categorical definitions) did not change our results.

Additionally, we ran stratified analyses of these models by age group to determine whether certain factors were more or less predictive of admission to trauma center. For patients 18-65 years of age, those living within a county with a trauma center had a 6.4 odds (95% CI, 3.1-13.3) of being admitted to a trauma center. For patients older than 65 year, those living within a county with a trauma center had 3.9 odds (95% CI, 2.0-7.6) of being admitted to a trauma center. In other words, the availability of a trauma center in one's county was less beneficial for elderly patients than nonelderly patients.

Elderly patients in California have a lower likelihood of receiving trauma center care, after controlling for injury severity, insurance, income, proximity to a trauma center, and availability of a trauma center within the patient's county. We show not simply a disparity for the oldest patients but rather a proportional decrease in likelihood of receiving trauma center care according to age. This disparity of who receives trauma care persists across a variety of trauma types, from blunt injury, penetrating injury, to falls. Furthermore, the decreased likelihood of trauma care for the elderly is not only present for mild trauma but also, when examined separately, for moderate and severe trauma. Finally, we show that these disparities have continued over time.

Our study confirms findings from smaller studies suggesting that elderly patients are less likely to be admitted to a trauma center for their injuries9,13 and extends these findings in 2 significant ways. First, we account for structural factors not usually considered in other studies, including regional availability of trauma centers and proximity to trauma center, which are both known to affect the likelihood of admission to a trauma center. Second, our study provides a truly population-level view of the growing public health problem posed by disparities in access to trauma care. Our data suggest that elderly trauma patients have a lower likelihood of being taken to a trauma center (suggesting prehospital bias)35 or of being transferred to a trauma center once taken to a nontrauma center (in-hospital bias).36

Although we have fewer data to discern potential mechanisms underlying referral biases, we do know that the proportion of elderly patients experiencing isolated, low-severity injury has been increasing20 and that there is agreement that these patients benefit less from trauma care.7 It is important to note, however, that our methods excluded patients with hip and femur fractures, and that our findings were consistent across all levels of injury severity. In addition, these explanations would not sufficiently explain the consistency of our findings even when evaluating only severely injured patients.

An additional, more insidious, possibility of why elderly patients may have a lower likelihood of receiving care in a trauma care is the conscious or subconscious undertriage of care in the elderly population due to less valuation of years of life lost. There is a very real concern of age-based referral bias and age-based rationing of care, which has been documented in areas other than trauma.3739 Because elderly patients have higher mortality rates from trauma compared with younger patients, it is possible that, as posited in other diseases such as myocardial infarction,37 more aggressive intervention could theoretically be more beneficial for an older population, as suggested by our findings of decreased in-hospital mortality for hospitalized elderly patients with severe trauma compared with nonelderly patients.

A natural extension of this work would seek to clarify the precise reasons underlying the disparity found in our study. Elderly patients may have unclear or benign initial clinical presentations, leading to undertriage,4042 or a lack of compliance with trauma triage rules may be at play.12 The American College of Surgeons and the Centers for Disease Control and Prevention have recommended that trauma patients older than 55 years should automatically be taken to a designated trauma center regardless of severity of injury.43,44 Other studies40,45 have suggested that trauma patients older than 60 years or 70 years should be considered as fulfilling a criterion for automatic trauma activation. However, such broad inclusion criteria would have significant implications for the delivery of care and possible overtriage,46 given the limited resources available for trauma care. Currently, there is much debate in the emergency and trauma community about inappropriate trauma “activations” (which alert the hospital to the need for trauma resources such as the surgical and anesthesia team) from the field during the prehospital phase,4749 or while in hospital,50 and unnecessary transfers that deplete the hospital of needed resources and other patients.51 In fact, studies of centers that do have age as a criterion for automatic trauma activation demonstrate that such regulation can result in unnecessary and costly initiations of a multidisciplinary response.52

Ironically, overtriage has also been suggested to be detrimental to the patient's health.53,54 From previous studies of pediatric patients in which age has been considered a criterion for an automatic trauma response,5558 it has been found that age (specifically young age) may not be an appropriate sole criterion for requiring a higher level of trauma care. There is, however, some literature suggesting a tiered approach to trauma center activation once a patient has reached the emergency department for a range of patient characteristics.59,60 Overall, triage protocols and their effects on undertriage and overtriage must be evaluated for all age ranges to study the effects on the primary patient as well as other patients within the hospital and system that account for appropriate resource utilization.6163

Our study has a number of limitations. We captured hospital admissions, which represent only a portion of the patients seen by emergency medical teams. Because patients must be admitted to the hospital to be represented in this database, our data do not include trauma patients discharged from the emergency department who generally have low injury severity and mortality rates64 or patients who died before admission and who, by definition, have high mortality and likely high injury severity rates.

Second, our adjustment for trauma severity was based on administrative data; a full range of clinical variables cannot be taken into account. Although the ISS has been validated for trauma patients in general (predicting both mortality and hospital stay) and correlates with tools using clinical data, it is important to note that ISS is not linear and has not been validated in the subset of geriatric patients.65,66

Finally, we use trauma center designations provided by the OSHPD, which does not conform to what many trauma surgeons consider the gold standard of categorization as stated by the American College of Surgeons Committee on Trauma.67 We were unable to use these categorizations because verification of these centers by the American College of Surgeons began after the period of our study. We do not, however, expect systematically differential reporting or categorization, so it is highly unlikely that this limitation affects our results.

In our analysis of elderly trauma patients admitted to acute care hospitals, we have demonstrated that there is a significant correlation between age and the likelihood of admission to a trauma center such that increasing age ominously decreases the likelihood of trauma center admission, even among those with moderate and severe injury. This disparity in the treatment of elderly trauma patients is alarming, because demographic trends forecast that the proportion of injured elderly patients will only increase in the years to come. The elderly patients who are at risk for higher mortality from their injuries may in fact be a subpopulation that is most likely to benefit from more aggressive care. Controlled studies of prehospital triage of elderly patients as well as provider beliefs about trauma triage in elderly patients are important for designing interventions to better target available resources such as trauma centers for injured elderly patients.

Correspondence: Renee Y. Hsia, MD, MSc, Department of Emergency Medicine, University of California, San Francisco General Hospital, 1001 Potrero Ave, 1E21, San Francisco, CA 94110 (renee.hsia@emergency.ucsf.edu).

Accepted for Publication: October 28, 2010.

Published Online: January 17, 2011. doi:10.1001/archsurg.2010.311

Author Contributions: Dr Hsia had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hsia, Wang, Wise, and Auerbach. Acquisition of data: Wang, Wise, and Auerbach. Analysis and interpretation of data: Hsia, Wang, Saynina, Wise, Pérez-Stable, and Auerbach. Drafting of the manuscript: Hsia and Auerbach. Critical revision of the manuscript for important intellectual content: Wang, Saynina, Wise, Pérez-Stable, and Auerbach. Statistical analysis: Saynina and Auerbach. Obtained funding: Hsia and Pérez-Stable. Administrative, technical, and material support: Hsia, Wang, Wise, Pérez-Stable, and Auerbach. Study supervision: Pérez-Stable and Auerbach.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant P30-AG15272 from the Resource Centers for Minority Aging Research program funded by the National Institute on Aging (Drs Hsia and Pérez-Stable), by NIH/NCRR/OD UCSF-CTSI grant KL2 RR024130 (Dr Hsia) and NIH/NICHD grant K23 HD051595 (Dr Wang) from the National Institutes of Health, and by the Robert Wood Johnson Foundation Physician Faculty Scholars (Dr Hsia).

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the opinions of any of the funding agencies.

Additional Contributions: We thank David Wang, MD, for his help with this article.

McGwin  G  JrMelton  SMMay  AKRue  LW Long-term survival in the elderly after trauma. J Trauma 2000;49 (3) 470- 476
PubMed Link to Article
Hannan  ELWaller  CHFarrell  LSRosati  C Elderly trauma inpatients in New York state: 1994-1998. J Trauma 2004;56 (6) 1297- 1304
PubMed Link to Article
Mann  NCCahn  RMMullins  RJBrand  DMJurkovich  GJ Survival among injured geriatric patients during construction of a statewide trauma system. J Trauma 2001;50 (6) 1111- 1116
PubMed Link to Article
DiRusso  SHolly  CKamath  R  et al.  Preparation and achievement of American College of Surgeons level I trauma verification raises hospital performance and improves patient outcome. J Trauma 2001;51 (2) 294- 300
PubMed Link to Article
Meldon  SWReilly  MDrew  BLMancuso  CFallon  W  Jr Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers. J Trauma 2002;52 (1) 79- 84
PubMed Link to Article
Scheetz  LJ Differences in survival, length of stay, and discharge disposition of older trauma patients admitted to trauma centers and nontrauma center hospitals. J Nurs Scholarsh 2005;37 (4) 361- 366
PubMed Link to Article
Liberman  MMulder  DSSampalis  JS Increasing volume of patients at level I trauma centres: is there a need for triage modification in elderly patients with injuries of low severity? Can J Surg 2003;46 (6) 446- 452
PubMed
Tepas  JJ  IIIVeldenz  HCLottenberg  L  et al.  Elderly injury: a profile of trauma experience in the Sunshine (Retirement) State. J Trauma 2000;48 (4) 581- 586
PubMed Link to Article
Scheetz  LJ Trauma center versus non-trauma center admissions in adult trauma victims by age and gender. Prehosp Emerg Care 2004;8 (3) 268- 272
PubMed
Phillips  SRond  PC  IIIKelly  SMSwartz  PD The failure of triage criteria to identify geriatric patients with trauma: results from the Florida Trauma Triage Study. J Trauma 1996;40 (2) 278- 283
PubMed Link to Article
Ma  MHMacKenzie  EJAlcorta  RKelen  GD Compliance with prehospital triage protocols for major trauma patients. J Trauma 1999;46 (1) 168- 175
PubMed Link to Article
Báez  AALane  PLSorondo  B System compliance with out-of-hospital trauma triage criteria. J Trauma 2003;54 (2) 344- 351
PubMed Link to Article
Lane  PSorondo  BKelly  JJ Geriatric trauma patients: are they receiving trauma center care? Acad Emerg Med 2003;10 (3) 244- 250
PubMed
Zimmer-Gembeck  MJSouthard  PAHedges  JR  et al.  Triage in an established trauma system. J Trauma 1995;39 (5) 922- 928
PubMed Link to Article
Centers for Disease Control and Prevention and the Merck Co Foundation The State of Aging and Health in America 2007.  Whitehouse Station, NJ: The Merck Co Foundation; 2007
Office of Statewide Health Planning and Development California Inpatient Data Reporting Manual: Medical Information Reporting for California.  Sacramento, CA: Office of Statewide Health Planning and Development; 2007
 Trauma Centers in California. California Emergency Medical Services Web site.http://www.emsa.ca.gov/systems/trauma/files/DesignatedTraumaCenters.pdf. Accessed February 2, 2009
 Recommended framework for presenting injury mortality data. MMWR Recomm Rep 1997;46 (RR-14) 1- 30
PubMed
Wang  NEChan  JMahlow  PWise  PH Trauma center utilization for children in California 1998-2004: trends and areas for further analysis. Acad Emerg Med 2007;14 (4) 309- 315
PubMed
Hsia  RYWang  ETorres  HSaynina  OWise  PH Disparities in trauma center access despite increasing utilization: data from California, 1999 to 2006. J Trauma 2010;68 (1) 217- 224
PubMed Link to Article
Wang  NESaynina  OKuntz-Duriseti  KMahlow  PWise  PH Variability in pediatric utilization of trauma facilities in California: 1999 to 2005. Ann Emerg Med 2008;52 (6) 607- 615
PubMed Link to Article
Wolinsky  FDBentler  SELiu  L  et al.  Recent hospitalization and the risk of hip fracture among older Americans. J Gerontol A Biol Sci Med Sci 2009;64 (2) 249- 255
PubMed Link to Article
Wolinsky  FDFitzgerald  JF Subsequent hip fracture among older adults. Am J Public Health 1994;84 (8) 1316- 1318
PubMed Link to Article
Aitken  LMBurmeister  ELang  JChaboyer  WRichmond  TS Characteristics and outcomes of injured older adults after hospital admission. J Am Geriatr Soc 2010;58 (3) 442- 449
PubMed Link to Article
Champion  HRCopes  WSBuyer  DFlanagan  MEBain  LSacco  WJ Major trauma in geriatric patients. Am J Public Health 1989;79 (9) 1278- 1282
PubMed Link to Article
Grossman  MDMiller  DScaff  DWArcona  S When is an elder old? effect of preexisting conditions on mortality in geriatric trauma. J Trauma 2002;52 (2) 242- 246
PubMed Link to Article
Fry  CL The ages of adulthood: a question of numbers. J Gerontol 1976;31 (2) 170- 177
PubMed Link to Article
Day  RJVinen  JHewitt-Falls  E Major trauma outcomes in the elderly. Med J Aust 1994;160 (11) 675- 678
PubMed
Battistella  FDDin  AMPerez  L Trauma patients 75 years and older: long-term follow-up results justify aggressive management. J Trauma 1998;44 (4) 618- 623
PubMed Link to Article
Mackenzie  ESacco  WJ ICDMAP-90 Software and Users Guide.  Baltimore, MD: The Johns Hopkins University and Trianalytics; 1997
MacKenzie  EJRivara  FPJurkovich  GJ  et al.  A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354 (4) 366- 378
PubMed Link to Article
Elixhauser  ASteiner  CHarris  DRCoffey  RM Comorbidity measures for use with administrative data. Med Care 1998;36 (1) 8- 27
PubMed Link to Article
Phibbs  CSLuft  HS Correlation of travel time on roads versus straight line distance. Med Care Res Rev 1995;52 (4) 532- 542
PubMed Link to Article
Robins  JMHernán  MABrumback  B Marginal structural models and causal inference in epidemiology. Epidemiology 2000;11 (5) 550- 560
PubMed Link to Article
Chang  DCBass  RRCornwell  EEMackenzie  EJ Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg 2008;143 (8) 776- 782
PubMed Link to Article
Utter  GHVictorino  GPWisner  DH Interhospital transfer occurs more slowly for elderly acute trauma patients. J Emerg Med 2008;35 (4) 415- 420
PubMed Link to Article
Stone  PHThompson  BAnderson  HV  et al.  Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: the TIMI III registry. JAMA 1996;275 (14) 1104- 1112
PubMed Link to Article
Michaels  JAGalland  RB Case mix and outcome of patients referred to the vascular service at a district general hospital. Ann R Coll Surg Engl 1993;75 (5) 358- 361
PubMed
Tate  ARNicholson  ACassell  JA Are GPs under-investigating older patients presenting with symptoms of ovarian cancer? observational study using General Practice Research Database. Br J Cancer 2010;102 (6) 947- 951
PubMed Link to Article
Demetriades  DSava  JAlo  K  et al.  Old age as a criterion for trauma team activation. J Trauma 2001;51 (4) 754- 757
PubMed Link to Article
Perdue  PWWatts  DDKaufmann  CRTrask  AL Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death. J Trauma 1998;45 (4) 805- 810
PubMed Link to Article
Richmond  TSKauder  DStrumpf  NMeredith  T Characteristics and outcomes of serious traumatic injury in older adults. J Am Geriatr Soc 2002;50 (2) 215- 222
PubMed Link to Article
American College of Surgeons Committee on Trauma Advanced Trauma Life Support for Doctors.  Chicago, IL: American College of Surgeons; 2004
Sasser  SMHunt  RCSullivent  EE  et al. Centers for Disease Control and Prevention (CDC), Guidelines for field triage of injured patients, recommendations of the national expert panel on field triage [published correction appears in MMWR Recomm Rep. 2009 Feb 27;58(7):172]. MMWR Recomm Rep 2009;58 (RR-1) 1- 35
PubMed
Shifflette  VKLorenzo  MMangram  AJTruitt  MSAmos  JDDunn  EL Should age be a factor to change from a level II to a level I trauma activation? J Trauma 2010;69 (1) 88- 92
PubMed Link to Article
Lehmann  RKArthurs  ZMCuadrado  DGCasey  LEBeekley  ACMartin  MJ Trauma team activation: simplified criteria safely reduces overtriage. Am J Surg 2007;193 (5) 630- 635
PubMed Link to Article
Willette  PABeery  PR  IIHartman  JFWright  ML Does a category II trauma activation warrant the initial presence of an attending trauma surgeon? J Emerg Med 2010;39 (3) 356- 365
PubMed Link to Article
Sasada  M On-scene medical decision making and overtriage. Br J Surg 1994;81 (5) 775- 776
PubMed Link to Article
Shatney  CHHoman  SJSherck  JPHo  CC The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system. J Trauma 2002;53 (5) 817- 822
PubMed Link to Article
Shapiro  MJ McCormack  JEJen  J Let the surgeon sleep: trauma team activation for severe hypotension. J Trauma 2008;65 (6) 1245- 1252
PubMed Link to Article
Terregino  CAReid  JCMarburger  RKLeipold  CGRoss  SE Secondary emergency department triage (supertriage) and trauma team activation: effects on resource utilization and patient care. J Trauma 1997;43 (1) 61- 64
PubMed Link to Article
Kohn  MAHammel  JMBretz  SWStangby  A Trauma team activation criteria as predictors of patient disposition from the emergency department. Acad Emerg Med 2004;11 (1) 1- 9
PubMed Link to Article
Armstrong  JHHammond  JHirshberg  AFrykberg  ER Is overtriage associated with increased mortality? the evidence says “yes.” Disaster Med Public Health Prep 2008;2 (1) 4- 6
PubMed Link to Article
Hupert  NHollingsworth  EXiong  W Is overtriage associated with increased mortality? insights from a simulation model of mass casualty trauma care. Disaster Med Public Health Prep 2007;1 ((suppl 1)) S14- S24
PubMed Link to Article
Bevan  COfficer  CCrameri  JPalmer  CBabl  FE Reducing “cry wolf”: changing trauma team activation at a pediatric trauma centre. J Trauma 2009;66 (3) 698- 702
PubMed Link to Article
Dowd  MD McAneney  CLacher  MRuddy  RM Maximizing the sensitivity and specificity of pediatric trauma team activation criteria. Acad Emerg Med 2000;7 (10) 1119- 1125
PubMed Link to Article
Qazi  KKempf  JAChristopher  NCGerson  LW Paramedic judgment of the need for trauma team activation for pediatric patients. Acad Emerg Med 1998;5 (10) 1002- 1007
PubMed Link to Article
Qazi  KWright  MSKippes  C Stable pediatric blunt trauma patients: is trauma team activation always necessary? J Trauma 1998;45 (3) 562- 564
PubMed Link to Article
Kouzminova  NShatney  CPalm  E McCullough  MSherck  J The efficacy of a two-tiered trauma activation system at a level I trauma center. J Trauma 2009;67 (4) 829- 833
PubMed Link to Article
Shatney  CHSensaki  K Trauma team activation for 'mechanism of injury' blunt trauma victims: time for a change? J Trauma 1994;37 (2) 275- 282
PubMed Link to Article
Raynaud  LBorne  MCoste  SDaban  JLTourtier  JP Triage protocol: both undertriage and overtriage need to be evaluated. J Trauma 2010;69 (4) 998
PubMed Link to Article
Ciesla  DJSava  JAStreet  JH  IIIJordan  MH Secondary overtriage: a consequence of an immature trauma system. J Am Coll Surg 2008;206 (1) 131- 137
PubMed Link to Article
DiDomenico  PBPietzsch  JBPaté-Cornell  ME Bayesian assessment of overtriage and undertriage at a level I trauma centre. Philos Transact A Math Phys Eng Sci 2008;366 (1874) 2265- 2277
PubMed Link to Article
Ferrera  PCBartfield  JMD’Andrea  CC Geriatric trauma: outcomes of elderly patients discharged from the ED. Am J Emerg Med 1999;17 (7) 629- 632
PubMed Link to Article
Callaway  DWWolfe  R Geriatric trauma. Emerg Med Clin North Am 2007;25 (3) 837- 860
PubMed Link to Article
Tay  SYSloan  EPZun  LZaret  P Comparison of the New Injury Severity Score and the Injury Severity Score. J Trauma 2004;56 (1) 162- 164
PubMed Link to Article
 Trauma Information Exchange Program (TIEP) report. Trauma Centers by State or Regional Designation/Certification and ACS Verification Status by Level of Trauma Care. American Trauma Society Web site.http://www.amtrauma.org/tiep/reports/DesignationStatus.jsp. Accessed February 2, 2009

Figures

Place holder to copy figure label and caption
Figure 1.

Percentage of trauma injuries by mechanism of injury, stratified by age group.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Percentage of injured patients admitted to trauma center (TC) by age group, stratified by year.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Likelihood of admission to trauma center (TC) by mechanism of injury, stratified by age group. Likelihood of admission to TC for blunt trauma (n = 167 652) (A), penetrating trauma (n = 77 843) (B), and fall (n = 167 652) (C).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Likelihood of admission to trauma center (TC) by injury severity, stratified by age group. Likelihood of admission to TC for mild trauma (n = 231 200) (A), moderate trauma (n = 171 504) (B), and severe trauma (n = 27 378) (C).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Characteristics of Patients in Sample, 1999-2008
Table Graphic Jump LocationTable 2. Multivariate Model of Likelihood of Admission to Trauma Center

References

McGwin  G  JrMelton  SMMay  AKRue  LW Long-term survival in the elderly after trauma. J Trauma 2000;49 (3) 470- 476
PubMed Link to Article
Hannan  ELWaller  CHFarrell  LSRosati  C Elderly trauma inpatients in New York state: 1994-1998. J Trauma 2004;56 (6) 1297- 1304
PubMed Link to Article
Mann  NCCahn  RMMullins  RJBrand  DMJurkovich  GJ Survival among injured geriatric patients during construction of a statewide trauma system. J Trauma 2001;50 (6) 1111- 1116
PubMed Link to Article
DiRusso  SHolly  CKamath  R  et al.  Preparation and achievement of American College of Surgeons level I trauma verification raises hospital performance and improves patient outcome. J Trauma 2001;51 (2) 294- 300
PubMed Link to Article
Meldon  SWReilly  MDrew  BLMancuso  CFallon  W  Jr Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers. J Trauma 2002;52 (1) 79- 84
PubMed Link to Article
Scheetz  LJ Differences in survival, length of stay, and discharge disposition of older trauma patients admitted to trauma centers and nontrauma center hospitals. J Nurs Scholarsh 2005;37 (4) 361- 366
PubMed Link to Article
Liberman  MMulder  DSSampalis  JS Increasing volume of patients at level I trauma centres: is there a need for triage modification in elderly patients with injuries of low severity? Can J Surg 2003;46 (6) 446- 452
PubMed
Tepas  JJ  IIIVeldenz  HCLottenberg  L  et al.  Elderly injury: a profile of trauma experience in the Sunshine (Retirement) State. J Trauma 2000;48 (4) 581- 586
PubMed Link to Article
Scheetz  LJ Trauma center versus non-trauma center admissions in adult trauma victims by age and gender. Prehosp Emerg Care 2004;8 (3) 268- 272
PubMed
Phillips  SRond  PC  IIIKelly  SMSwartz  PD The failure of triage criteria to identify geriatric patients with trauma: results from the Florida Trauma Triage Study. J Trauma 1996;40 (2) 278- 283
PubMed Link to Article
Ma  MHMacKenzie  EJAlcorta  RKelen  GD Compliance with prehospital triage protocols for major trauma patients. J Trauma 1999;46 (1) 168- 175
PubMed Link to Article
Báez  AALane  PLSorondo  B System compliance with out-of-hospital trauma triage criteria. J Trauma 2003;54 (2) 344- 351
PubMed Link to Article
Lane  PSorondo  BKelly  JJ Geriatric trauma patients: are they receiving trauma center care? Acad Emerg Med 2003;10 (3) 244- 250
PubMed
Zimmer-Gembeck  MJSouthard  PAHedges  JR  et al.  Triage in an established trauma system. J Trauma 1995;39 (5) 922- 928
PubMed Link to Article
Centers for Disease Control and Prevention and the Merck Co Foundation The State of Aging and Health in America 2007.  Whitehouse Station, NJ: The Merck Co Foundation; 2007
Office of Statewide Health Planning and Development California Inpatient Data Reporting Manual: Medical Information Reporting for California.  Sacramento, CA: Office of Statewide Health Planning and Development; 2007
 Trauma Centers in California. California Emergency Medical Services Web site.http://www.emsa.ca.gov/systems/trauma/files/DesignatedTraumaCenters.pdf. Accessed February 2, 2009
 Recommended framework for presenting injury mortality data. MMWR Recomm Rep 1997;46 (RR-14) 1- 30
PubMed
Wang  NEChan  JMahlow  PWise  PH Trauma center utilization for children in California 1998-2004: trends and areas for further analysis. Acad Emerg Med 2007;14 (4) 309- 315
PubMed
Hsia  RYWang  ETorres  HSaynina  OWise  PH Disparities in trauma center access despite increasing utilization: data from California, 1999 to 2006. J Trauma 2010;68 (1) 217- 224
PubMed Link to Article
Wang  NESaynina  OKuntz-Duriseti  KMahlow  PWise  PH Variability in pediatric utilization of trauma facilities in California: 1999 to 2005. Ann Emerg Med 2008;52 (6) 607- 615
PubMed Link to Article
Wolinsky  FDBentler  SELiu  L  et al.  Recent hospitalization and the risk of hip fracture among older Americans. J Gerontol A Biol Sci Med Sci 2009;64 (2) 249- 255
PubMed Link to Article
Wolinsky  FDFitzgerald  JF Subsequent hip fracture among older adults. Am J Public Health 1994;84 (8) 1316- 1318
PubMed Link to Article
Aitken  LMBurmeister  ELang  JChaboyer  WRichmond  TS Characteristics and outcomes of injured older adults after hospital admission. J Am Geriatr Soc 2010;58 (3) 442- 449
PubMed Link to Article
Champion  HRCopes  WSBuyer  DFlanagan  MEBain  LSacco  WJ Major trauma in geriatric patients. Am J Public Health 1989;79 (9) 1278- 1282
PubMed Link to Article
Grossman  MDMiller  DScaff  DWArcona  S When is an elder old? effect of preexisting conditions on mortality in geriatric trauma. J Trauma 2002;52 (2) 242- 246
PubMed Link to Article
Fry  CL The ages of adulthood: a question of numbers. J Gerontol 1976;31 (2) 170- 177
PubMed Link to Article
Day  RJVinen  JHewitt-Falls  E Major trauma outcomes in the elderly. Med J Aust 1994;160 (11) 675- 678
PubMed
Battistella  FDDin  AMPerez  L Trauma patients 75 years and older: long-term follow-up results justify aggressive management. J Trauma 1998;44 (4) 618- 623
PubMed Link to Article
Mackenzie  ESacco  WJ ICDMAP-90 Software and Users Guide.  Baltimore, MD: The Johns Hopkins University and Trianalytics; 1997
MacKenzie  EJRivara  FPJurkovich  GJ  et al.  A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354 (4) 366- 378
PubMed Link to Article
Elixhauser  ASteiner  CHarris  DRCoffey  RM Comorbidity measures for use with administrative data. Med Care 1998;36 (1) 8- 27
PubMed Link to Article
Phibbs  CSLuft  HS Correlation of travel time on roads versus straight line distance. Med Care Res Rev 1995;52 (4) 532- 542
PubMed Link to Article
Robins  JMHernán  MABrumback  B Marginal structural models and causal inference in epidemiology. Epidemiology 2000;11 (5) 550- 560
PubMed Link to Article
Chang  DCBass  RRCornwell  EEMackenzie  EJ Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg 2008;143 (8) 776- 782
PubMed Link to Article
Utter  GHVictorino  GPWisner  DH Interhospital transfer occurs more slowly for elderly acute trauma patients. J Emerg Med 2008;35 (4) 415- 420
PubMed Link to Article
Stone  PHThompson  BAnderson  HV  et al.  Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: the TIMI III registry. JAMA 1996;275 (14) 1104- 1112
PubMed Link to Article
Michaels  JAGalland  RB Case mix and outcome of patients referred to the vascular service at a district general hospital. Ann R Coll Surg Engl 1993;75 (5) 358- 361
PubMed
Tate  ARNicholson  ACassell  JA Are GPs under-investigating older patients presenting with symptoms of ovarian cancer? observational study using General Practice Research Database. Br J Cancer 2010;102 (6) 947- 951
PubMed Link to Article
Demetriades  DSava  JAlo  K  et al.  Old age as a criterion for trauma team activation. J Trauma 2001;51 (4) 754- 757
PubMed Link to Article
Perdue  PWWatts  DDKaufmann  CRTrask  AL Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death. J Trauma 1998;45 (4) 805- 810
PubMed Link to Article
Richmond  TSKauder  DStrumpf  NMeredith  T Characteristics and outcomes of serious traumatic injury in older adults. J Am Geriatr Soc 2002;50 (2) 215- 222
PubMed Link to Article
American College of Surgeons Committee on Trauma Advanced Trauma Life Support for Doctors.  Chicago, IL: American College of Surgeons; 2004
Sasser  SMHunt  RCSullivent  EE  et al. Centers for Disease Control and Prevention (CDC), Guidelines for field triage of injured patients, recommendations of the national expert panel on field triage [published correction appears in MMWR Recomm Rep. 2009 Feb 27;58(7):172]. MMWR Recomm Rep 2009;58 (RR-1) 1- 35
PubMed
Shifflette  VKLorenzo  MMangram  AJTruitt  MSAmos  JDDunn  EL Should age be a factor to change from a level II to a level I trauma activation? J Trauma 2010;69 (1) 88- 92
PubMed Link to Article
Lehmann  RKArthurs  ZMCuadrado  DGCasey  LEBeekley  ACMartin  MJ Trauma team activation: simplified criteria safely reduces overtriage. Am J Surg 2007;193 (5) 630- 635
PubMed Link to Article
Willette  PABeery  PR  IIHartman  JFWright  ML Does a category II trauma activation warrant the initial presence of an attending trauma surgeon? J Emerg Med 2010;39 (3) 356- 365
PubMed Link to Article
Sasada  M On-scene medical decision making and overtriage. Br J Surg 1994;81 (5) 775- 776
PubMed Link to Article
Shatney  CHHoman  SJSherck  JPHo  CC The utility of helicopter transport of trauma patients from the injury scene in an urban trauma system. J Trauma 2002;53 (5) 817- 822
PubMed Link to Article
Shapiro  MJ McCormack  JEJen  J Let the surgeon sleep: trauma team activation for severe hypotension. J Trauma 2008;65 (6) 1245- 1252
PubMed Link to Article
Terregino  CAReid  JCMarburger  RKLeipold  CGRoss  SE Secondary emergency department triage (supertriage) and trauma team activation: effects on resource utilization and patient care. J Trauma 1997;43 (1) 61- 64
PubMed Link to Article
Kohn  MAHammel  JMBretz  SWStangby  A Trauma team activation criteria as predictors of patient disposition from the emergency department. Acad Emerg Med 2004;11 (1) 1- 9
PubMed Link to Article
Armstrong  JHHammond  JHirshberg  AFrykberg  ER Is overtriage associated with increased mortality? the evidence says “yes.” Disaster Med Public Health Prep 2008;2 (1) 4- 6
PubMed Link to Article
Hupert  NHollingsworth  EXiong  W Is overtriage associated with increased mortality? insights from a simulation model of mass casualty trauma care. Disaster Med Public Health Prep 2007;1 ((suppl 1)) S14- S24
PubMed Link to Article
Bevan  COfficer  CCrameri  JPalmer  CBabl  FE Reducing “cry wolf”: changing trauma team activation at a pediatric trauma centre. J Trauma 2009;66 (3) 698- 702
PubMed Link to Article
Dowd  MD McAneney  CLacher  MRuddy  RM Maximizing the sensitivity and specificity of pediatric trauma team activation criteria. Acad Emerg Med 2000;7 (10) 1119- 1125
PubMed Link to Article
Qazi  KKempf  JAChristopher  NCGerson  LW Paramedic judgment of the need for trauma team activation for pediatric patients. Acad Emerg Med 1998;5 (10) 1002- 1007
PubMed Link to Article
Qazi  KWright  MSKippes  C Stable pediatric blunt trauma patients: is trauma team activation always necessary? J Trauma 1998;45 (3) 562- 564
PubMed Link to Article
Kouzminova  NShatney  CPalm  E McCullough  MSherck  J The efficacy of a two-tiered trauma activation system at a level I trauma center. J Trauma 2009;67 (4) 829- 833
PubMed Link to Article
Shatney  CHSensaki  K Trauma team activation for 'mechanism of injury' blunt trauma victims: time for a change? J Trauma 1994;37 (2) 275- 282
PubMed Link to Article
Raynaud  LBorne  MCoste  SDaban  JLTourtier  JP Triage protocol: both undertriage and overtriage need to be evaluated. J Trauma 2010;69 (4) 998
PubMed Link to Article
Ciesla  DJSava  JAStreet  JH  IIIJordan  MH Secondary overtriage: a consequence of an immature trauma system. J Am Coll Surg 2008;206 (1) 131- 137
PubMed Link to Article
DiDomenico  PBPietzsch  JBPaté-Cornell  ME Bayesian assessment of overtriage and undertriage at a level I trauma centre. Philos Transact A Math Phys Eng Sci 2008;366 (1874) 2265- 2277
PubMed Link to Article
Ferrera  PCBartfield  JMD’Andrea  CC Geriatric trauma: outcomes of elderly patients discharged from the ED. Am J Emerg Med 1999;17 (7) 629- 632
PubMed Link to Article
Callaway  DWWolfe  R Geriatric trauma. Emerg Med Clin North Am 2007;25 (3) 837- 860
PubMed Link to Article
Tay  SYSloan  EPZun  LZaret  P Comparison of the New Injury Severity Score and the Injury Severity Score. J Trauma 2004;56 (1) 162- 164
PubMed Link to Article
 Trauma Information Exchange Program (TIEP) report. Trauma Centers by State or Regional Designation/Certification and ACS Verification Status by Level of Trauma Care. American Trauma Society Web site.http://www.amtrauma.org/tiep/reports/DesignationStatus.jsp. Accessed February 2, 2009

Correspondence

CME


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