Trauma care bias found

Study reports that older patients receive worse treatment for injuries

August 19, 2008|By Kelly Brewington | Kelly Brewington,Sun reporter

Patients older than 65 are much less likely to be taken to a Maryland trauma center than younger patients with the same medical emergencies, according to a new report by Johns Hopkins researchers. And unconscious age bias could be a factor in the disparity, the researchers said.

The study, published yesterday in the journal Archives of Surgery, sought to quantify a question that has been explored anecdotally: Are elderly trauma patients treated with the same vigor as their younger counterparts? In short, the study found, they are not.

Researchers from the Johns Hopkins Schools of Medicine and Bloomberg School of Public Health analyzed data of about 26,000 trauma patients statewide from 1995 through 2004. Using data from the Maryland Ambulance Information System, the researchers compared the treatment of patients with similar medical trauma. Then they interviewed 166 emergency medical and trauma center personnel. The study found that 50 percent of patients 65 and older were not taken to trauma centers as opposed to 18 percent of younger patients. While the disparity was notable for patients 65 and older, researchers found that it began at age 50.

In interviews, EMS and medical professionals mentioned lack of training, unfamiliarity with transportation protocol and possible age bias as the biggest factors for the disparity.

"We use the word bias in certain areas of our study. But we also talk about blind spots," said Dr. David C. Chang, an instructor of surgery at the medical school and the study's lead author. "People are operating on assumptions of what old is and what elderly patients need."

State emergency medical officials said they have been providing more training to combat the problem.

Robert R. Bass, executive director of the Maryland Institute for Emergency Medical Services, which manages statewide emergency medical services, helped analyze the data for the report. He said the agency first became aware of disparities after similar data were published a decade ago.

"We were surprised that this was a recurrence of something we saw in the late 1990s. ... This is something we have to revisit periodically," he said. "And we want to share it with other states and EMS systems because if it's happening in Maryland, it's likely happening everywhere."

In fact, in the past year, the agency included age as a factor in its guidelines for determining when to take patients to trauma centers. The change was advised by the American College of Surgeons' Committee on Trauma.

As baby boomers age, medical experts nationwide are tackling the complexity of their care, said Chang. By 2050, about 39 percent of trauma patients will be 65 or older.

"Trauma is often seen as a disease of the young," he said. "But that's changing. You have a fairly active aging population that is playing sports, being active and getting injured."

Age bias itself is difficult to nail down, he said. While emergency medical personnel listed it as a possible factor in surveys, few were willing to elaborate.

"No one ever admits they have a bias - they say they know someone who does something biased," said Chang, who has spent the past two years traveling the state educating emergency medical experts on the disparities. "Basically, it's difficult to get a handle on what bias is. So instead of defining bias, we wanted to show that people behaved differently and find a way to fix the problem."

Chang said anecdotal stories about car crashes where younger patients are taken to trauma centers while older patients go to community hospitals are common.

But the reasons behind such decisions are complex. In some cases, paramedics assume an elderly patient would prefer a familiar hospital where the patient knows the doctors. In a few cases, EMS workers said they were not welcomed by trauma officials when arriving with an elderly patient. And young trauma doctors may perceive an elderly patient's fall as less exciting than a gunshot wound, even though the injuries can be equally severe.

"Sometimes the younger doctors see a person being evaluated, and it turns out to be negative and the patient is sent home," Chang said. "And they think that was a waste of time."

Dealing with elderly trauma patients can prove challenging, said Dr. Thomas M. Scalea, physician in chief at Shock Trauma.

"Part of the problem is everybody's got aches and pains. It's hard to tell: Is that a broken hip or something else?" he said.

For example, an 85-year-old patient who is disoriented after an injury might not be cause for alarm, while a 25-year-with the same symptoms will often strike a doctor as abnormal.

"But they both might have brain injury," Scalea said. "This is much more complicated in older people. There are many issues that make injury in the elderly much more difficult to get your arms around."

Scalea said experts have considered establishing specialized trauma centers for the elderly, similar to centers that exist to treat trauma in children. For now, however, the data should alert experts to the needs of elderly trauma patients, he said.

"If you pick up a medical journal, people like to publish their successes," he said. "But it's important to publish data like this so we can do better."

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