An article appearing in the August issue of Archives of Surgery reports on potential unconscious age bias among emergency medical services personnel: they are less likely to bring elderly trauma patients to a trauma center compared to younger patients.

David C. Chang, Ph.D., M.P.H., M.B.A. (Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore) and colleagues note that by 2050, some 39% of all trauma patients will be 65 years of age or older. They write: "Evidence-based clinical practice guidelines strongly recommend that elderly trauma patients be treated as aggressively as non-elderly patients...However, some studies have suggested that age bias may still exist in trauma care, even in the prehospital phase of that care."

With 10 years of data from the statewide Maryland Ambulance Information System, the researchers presented findings to emergency medical services (EMS) and trauma center personnel at EMS conferences and grand rounds between 2004 and 2006. They then surveyed the EMS personnel to further explore the issue. In the registry, there were 26,565 trauma patients (those who met criteria set by the American College of Surgeons (ACS) and were declared level I status - critically ill or injured and requiring immediate attention - by EMS personnel).

Chang and colleagues found that 49.9% of patients older than 65 were undertriaged - not taken to a state-designated trauma center - compared to just 17.8% of younger patients. Statistical adjustment for confounding factors revealed that being 65 years or older was linked to a 52% less likelihood of being taken to a trauma center. Further, the investigators note that the reduced likelihood begins at age 50 and decreases again at age 70.

Follow-up surveys were completed by 166 individuals - 127 EMS personnel and 32 medical personnel (14 attending physicians, four residents, six medical students and eight nurses). The researchers asked them to explain this observed disparity between younger and older patients: 25.3% of respondents cited inadequate training for managing elderly patients, 12% indicated unfamiliarity with protocol, and 13.4% suggested possible age bias.

The authors add that, "The problem of age bias raised in this study may negate efforts to improve clinical care for elderly trauma patients within trauma centers if the system as a whole does not function properly and deliver patients appropriately to needed resources."

"However, it may be difficult to change attitudes of age bias and may require a broad societal campaign. Nevertheless, it may be possible to address this problem without directly addressing age bias. A focus on retraining the providers about triage protocols may be sufficient," conclude the authors. "Additionally, it may be helpful to highlight the literature that now suggests that elderly trauma patients do, in fact, return to productive lives after their injury, which can eliminate the perception of futility of care that may be used consciously or subconsciously to justify age bias."

Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers
David C. Chang, PhD, MPH, MBA; Robert R. Bass, MD; Edward E. Cornwell, MD; Ellen J. MacKenzie, PhD
Archives of Surgery (2008). 143[8]: pp. 776-781.
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: Peter M Crosta