Studies Find Inequalities in Trauma Care Are Widespread

Two new studies from the Archives of Surgery point to significant inequalities in accessing trauma care. African Americans, the foreign-born, and the near-poor are more likely to encounter barriers to being treated at a trauma center, according to new research reports by UCSF emergency medicine physician and researcher Renee Hsia, MD, and her colleagues. Financial barriers to obtaining health care might receive more attention, but where one lives also matters. More than 38 million Americans do not have access to a certified trauma center within a one-hour drive from their homes, according to a study by Hsia and her research collaborators published in the January issue. Overall, the researchers found that, on average, people in rural areas were less likely to have easy access to trauma centers. In urban areas, 67 percent of people were an easy drive’s distance from a trauma center – less than 20 minutes away, compared to 24 percent in rural areas. In urban areas, 12 percent of people were more than a 60-minute drive from a trauma center, compared to 31 percent in rural areas. In addition, Hsia’s research team found that a trauma center was more likely to be more than one hour away for people living in communities with relatively higher proportions of people who are African American, foreign-born, or who have incomes well below the average.
Renee HsiaRenee Hsia
To conduct this study the research team used nationwide data from the 2000 US census and medical service data from the 2005 American Hospital Association annual survey. They focused on community demographics and hospital characteristics, and found that minorities, foreign born, elderly and the near-poor (income between $19,350 and $38,700 for a family of four) were at higher risk of difficult access to trauma centers. “If you live in a community that has a high proportion of near-poor people then you have a greater chance of having to go farther for emergency care,” Hsia says. “In our study, on average a near-poor family in either an urban or rural area was at least 1.5 times as likely to have difficult access to trauma centers compared to a family not in the near-poor category. “In addition, if you live in an area that has a high proportion of African Americans, then you are at higher risk of having more difficult access whether or not you live in an urban or rural setting.” People living in poverty did not appear to have more difficult access in the study. “That is a bit counterintuitive, because we found that the near-poor do have worse access,” Hsia says. “I would think this could be due to the fact that there are many more poor people in urban areas living near publicly funded trauma centers.” The researchers also did not find that poor in rural communities had worse access in comparison to the better off. This could be because rural access to trauma centers already is very limited, Hsia says. Hsia’s team also found that urban dwellers in communities with a high percentage of foreign born were less likely to have convenient access to a trauma center than those in communities with few foreign-born residents. The study did not take into account access to helicopter transport services to more distant trauma centers. There may be a motive for private hospitals and hospital networks to locate trauma centers in areas where most people are covered by better-paying private health insurance, Hsia says. By law, trauma centers cannot deny emergency care, regardless of insurance coverage. “We have a very market-based approach to health care in the United States,” she says. “In certain areas trauma centers are cost centers, rather than profit centers.”

Elderly Are Less Likely to Be Taken to a Trauma Center

In the second Archives of Surgery study, published online on January 17, Hsia and colleague Yu-Chu Shen, PhD, found that Californians age 65 and over who experience traumatic injuries are less likely to receive care at a trauma center in comparison to younger people with the same injuries. The study looked at the diagnosis of more than 430,000 patients hospitalized in California from 1999 through 2008. The researchers did not explore possible reasons for the disparity in this study. However, Hsia says one possible explanation is that elderly people may be less likely to exhibit the same outward signs of severe injury. Another consideration is that paramedic criteria for categorizing trauma – for instance, that a fall from a certain height should be treated at a trauma center – might not compensate for potentially greater harm to the elderly from such events, according to Hsia. Yet another possibility, Hsia says, is that elderly patients or their caregivers may be more likely to express a strong opinion about going to a hospital they are most familiar with, regardless of whether or not it is a specialized trauma center. Even individuals between the ages of 44 and 64 are less likely to receive care in a trauma center, the UCSF researchers found. “As we get older, the likelihood that we will be hospitalized at a trauma center goes down,” Hsia says. The studies were funded by the Robert Wood Johnson Foundation and the National Institutes of Health.
Possible Geographical Barriers to Trauma Center Access for Vulnerable Patients in the United States
Renee Hsia and Yu-Chu Shen
Archives of Surgery (January 2011)

Factors Associated with Trauma Center Use for Elderly Patients with Trauma
Renee Hsia, Ewen Wang, Olga Saynina and Paul Wise
Archives of Surgery (online January 17, 2011)