Trauma Center Locations and Procedures a Barrier to Care for Elderly and Vulnerable Patients

Great inequalities in who gets trauma and emergency room care increase morbidity and mortality for seniors, African Americans and other groups.

    • April 29, 2011

Age and geographic location, it seems, may have a significant impact on whether you are able to get the care you need when facing a health care crisis. In a series of studies, Robert Wood Johnson Foundation Physician Faculty Scholar (2009-2012) Renee Hsia, M.D., has revealed significant disparities in access to trauma center care for several groups of people.

In one study, published in the January 2011 issue of the Archives of Surgery, “Possible Geographical Barriers to Trauma Center Access for Vulnerable Patients in the United States: An Analysis of Urban and Rural Communities,” Hsia discovered that the poor, African Americans and the foreign born encounter barriers when seeking trauma care.

“To understand what proportion of people in African American, urban or rural communities have access to a trauma center, I used the American Hospital Association Annual Survey and the U.S. Census to review 13,578 zip codes,” Hsia explains. “Our team found that these groups, as well as people often characterized as the ‘near poor’—those living at 100 to 200 percent of the poverty level—were at a much higher risk of limited access to trauma centers. Overall, a significant segment of the population [the study represented 38.4 million people] does not have access to trauma care in one hour of driving time. These particularly vulnerable groups are at a higher risk than others.”

While many of us think of urban areas as places with a large number of hospitals, “many do not have a fully functioning trauma center in the city or surrounding county. Access may also be limited by population density or traffic,” Hsia notes.

Well-versed in the needs of patients in emergency circumstances because of her work as an assistant professor in the Department of Emergency Medicine at the University of California, San Francisco School of Medicine, Hsia is also interested in how vulnerable patients—in this case, the elderly—fare when seeking trauma care.

For her second study, “Factors Associated With Trauma Center Use for Elderly Patients with Trauma,” also published in the January 2011 issue of the Archives of Surgery, Hsia and her team analyzed data on more than 430,000 trauma patients hospitalized in California over a 10-year period and discovered that the likelihood of receiving care in a trauma center, even for traumatic injuries, declines with age.

“The elderly are much less likely to get trauma center care,” Hsia explains. “People who are older than 85 have only 30 percent of the chance of people 18 to 25 of being admitted to a trauma center. This finding still holds true when looking at those with severe injuries. While the study was not designed to explore the reasons behind this, Hsia says, “the reasons for such findings could range from the pre-hospital setting to hospital setting, and everything in between. One pre-hospital reason could be that elderly patients, even with severe injuries, do not manifest illness in the same way as younger patients. They may be taking medications that mask their fast heart rate, for example. Or perhaps this suggests that triage guidelines are not well-suited for this age group. There are multiple possibilities.”

Hsia has also studied crowding in emergency departments and whether vulnerable communities experience disparities in crowding. “For this work, which was published in the February 21, 2011 Annals of Emergency Medicine, we looked at 262 hospitals and nine million visits to the emergency room using patient discharge data from the California Office of Statewide Health Planning and Development. We found that in 2007, about 2.6 percent of patients left without being seen. This does not necessarily mean that these people were not sick. The literature shows many people who leave emergency rooms have higher mortality rates and admission to intensive care units later on,” Hsia says. “In cases of heart attack, for example, people may just feel slightly sweaty with mild belly pain and some nausea. They may not be aware that these could be signs of serious disease.” Hsia and her colleagues also found that hospitals serving a large number of people with low incomes or poor insurance had far more patients who left the emergency room without being seen by a health care provider than hospitals that served high-income or well-insured patients.

Understanding Disparities in Emergency Care

As someone who speaks several languages and has lived around the world, Hsia is especially sensitive to the needs of the diverse range of patients seen in emergency medical facilities and that has helped shape her ongoing work. “In my new study, which should be published in the next few months, I’m looking at whether disadvantaged communities experience more closures of emergency departments than non-disadvantaged communities. For example, do areas that are poor or have a higher proportion of minorities have a greater chance of losing their emergency departments than others and if so, why? In my future work, I plan to continue studying access to emergency services for vulnerable populations, particularly issues regarding the adequacy of funding for hospitals that serve these communities,” Hsia says.

All of Hsia’s current studies were supported by the Robert Wood Johnson Foundation and the National Institutes of Health. “The Robert Wood Johnson Foundation was tremendously helpful in providing protected time and the support I needed to develop these ideas and take them from beginning to end,” Hsia adds.

“With my new work, I hope to show that even though a community does not need a trauma center or emergency room on every corner, we must be more conscious of how our health system is structured and what types of communities hospitals serve,” Hsia says. “Safety-net hospitals may have more pressure on their resources, so our health care system may have system-based inequities that go far beyond the patient level. These issues may be insidious and harder to see than one-on-one disparities.”

The Robert Wood Johnson Foundation Physician Faculty Scholars program provides research opportunities for junior physician faculty members through mentoring, protected time, networking and the opportunity to gain valuable research experience. The program produces academic leaders who are creative and well-positioned to improve the nation’s health and health care.

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