title: Undertriage of older trauma patients: is this a national phenomenon?
abstract: BACKGROUND
  Older age is associated with high rates of morbidity and mortality after injury. Statewide studies suggest significantly injured patients aged ≥55 y are commonly undertriaged to lower level trauma centers (TCs) or nontrauma centers (NTCs). This study determines whether undertriage is a national phenomenon.
  
  
  METHODS
  Using the 2011 Nationwide Emergency Department Sample, significantly injured patients aged ≥55 y were identified by diagnosis and new injury severity score (NISS) ≥9. Undertriage was defined as definitive care anywhere other than level I or II TCs. Weighted descriptive analysis compared characteristics of patients by triage status. Multivariable logistic regression determined predictors of undertriage, controlling for hospital characteristics, injury severity, and comorbidities.
  
  
  RESULTS
  Of 4,152,541 emergency department (ED) visits meeting inclusion criteria, 74.0% were treated at lower level TCs or NTCs. Patients at level I and II TCs more commonly had NISS ≥9 (22.2% versus 12.3%, P < 0.001), but among all patients with NISS ≥9, 61.3% were undertriaged to a lower level TC or a NTC. On multivariable logistic regression, factors independently associated with higher odds of being undertriaged were increasing age, female gender, and fall-related injuries. A subgroup analysis examined urban and suburban areas only where access to a TC is more likely and found that 55.8% of patients' age were undertriaged.
  
  
  CONCLUSIONS
  There is substantial undertriage of patients aged ≥55 y nationwide. Over half of significantly injured older patients are not treated at level I or II TCs. The impact of undertriage should be determined to ensure older patients receive trauma care at the optimal site.
authors.affiliation: Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: lkodade1@jhmi.edu.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Kodadek
authors.affiliation: Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Shalini
authors.initials: S
authors.lastname: Selvarajah
authors.affiliation: Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Catherine G
authors.initials: CG
authors.lastname: Velopulos
authors.affiliation: Division of Trauma and Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.affiliation: Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012959:Socioeconomic Factors; D014193:Trauma Centers / Q000706:statistics & numerical data; D014218:Triage / Q000706:statistics & numerical data*; D014481:United States; D014947:Wounds and Injuries / Q000175:diagnosis*
keywords: Geriatric trauma; Nationwide Emergency Department Sample; Trauma centers; Trauma triage