Trauma Care: Why Are Females Waiting Longer Than Males?

Female trauma patients waited longer for care and had longer average emergency department lengths of stay (ED LOS) compared to male patients, and were also more likely to be discharged to a long-term care facility instead of to their own homes, according to findings from a retrospective cohort study published in JAMA Surgery.

Sex-based disparities in acute care are well established, with differences in timeliness of diagnostic and therapeutic care known to occur in acute myocardial infarction care, stroke care, and intensive care unit triage, Martha-Conley E. Ingram, MD, MPH, of Feinberg School of Medicine at Northwestern University, Chicago, and colleagues explained. However, sex-based differences in trauma care, and particularly timeliness of care, are less well understood.

To help fill this knowledge gap, Ingram and colleagues set out to assess sex-based differences in the timeliness of trauma care, "from the prehospital phase through to definitive surgical treatment phases, in injured patients across U.S. trauma centers," as well as to determine whether timeliness of care was associated with differences in discharge disposition between male and female patients.

Their retrospective analysis "identified sex-based disparities in 1 of 9 efficiency measures associated with timeliness of care and in discharge disposition between male and female patients after severe injury," they reported. "Results suggest that female patients experienced a significantly longer ED LOS, were more likely to have delays with femur or pelvic fracture repairs, and when matching for age, ISS, injury types, and mechanism, were more likely to be discharged to long-term care facility than to home compared with male patients."

Ingram and colleagues concluded that their findings "suggest potential gaps of care that may be excellent targets for quality improvement of existing processes of assessment and triage and discharge planning."

Writing in an invited commentary, Rachel L. Warner, DO, and Marie Crandall, MD, MPH, both of the University of Florida College of Medicine Jacksonville, said that Ingram et al "are to be congratulated for this thought-provoking work that serves at a catalyst to further evaluate and continue to discuss sex and gender disparities in trauma care."

Notably, Warner and Crandall pointed out that while women experienced significantly longer ED LOS compared to men in this analysis, "time to definitive intervention, including angiography, intracranial pressure monitor placement, and spine, femur, and pelvic fixation, was not significantly different. This finding suggests that the delay in care occurs at injury identification. This is in line with previous literature that has found longer ED LOS for female patients experiencing myocardial infarctions, drug overdoses, and strokes. This begs the question, why are the women waiting?"

Ingram and colleagues conducted their analysis from July 2020-2021 using data from the 2013-2016 Trauma Quality Improvement Program (TQIP) databases for level I-III trauma centers in the U.S. The TQIP database includes data on all patients 16 years or older with at least one severe injury (with the exception of severe burns or isolated geriatric hip fractures) with an Abbreviated Injury Scale (AIS) score ≥3 in one or more regions of the body, who were not dead on arrival, and who do not have preexisting advanced directives, they explained.

For this analysis, the study authors included adult patients with Injury Severity Scores (ISS) ≥15 who presented to a TQIP hospital with time-sensitive injuries—including traumatic brain injury, intra-abdominal injury, pelvic fracture, spinal cord injury, and femur fracture—from Jan. 1, 2013-Dec. 31, 2016.

The study’s primary predictor of interest was patient sex, but they also included covariates such as "age, race and ethnicity, ISS, Revised Trauma Score… injury type… injury intent (unintentional, self-inflicted, assault, undetermined), mechanism of injury, hospital trauma ICU bed size, hospital teaching status, ACS level verification, and measures related to timeliness of care (i.e., efficiency measures)," they explained.

The nine efficiency measures considered included "prehospital emergency medical services (EMS) time (minutes), ED LOS (hours), time to venous thromboembolism (VTE) chemoprophylaxis (hours), time to invasive cerebral monitor placement (hours), time to angiography (hours), and time to operative procedure (days) (e.g., time to pelvic fracture fixation, time to femur fracture fixation, time to anterior or posterior spinal fixation, and time to exploratory laparotomy) as indicated by injury type(s)."

The primary outcome of interest was discharge disposition, including inpatient mortality, discharge to postacute care facility (home, inpatient psychiatry, law enforcement, or acute rehabilitation), or discharge to a long-term care facility.

The study included 28,332 trauma patients (70.6% male; mean age 43.3 years for men, 48.5 years for women) with ISS scores of 15 or more (ISS score 16-24, 53.1% for males versus 56.2% for females; ISS score 41-74, 10.3% for males versus 10.2% for females).

Ingram and colleagues found that men were more likely to have abdominal (4,257 [21.3%] versus 1,268 [15.2%]) and spinal cord injuries (3,989 [20.0%] versus 1,274 [15.3%]). Female patients were more likely to have femur (3,670 [44.0%] versus 8422 [42.1%]) and pelvic fractures (3,970 [47.6%] versus 6,963 [34.8%]).

They found that "[f]emale patients experienced significantly longer emergency department length of stay (median [IQR], 184 [92-314] minutes versus 172 [86-289] minutes; P<0.001), longer time in pretriage (median [IQR], 52 [36-80] minutes versus 49 [34-77] minutes; P<0.001), and increased likelihood of discharge to nursing or long-term care facilities instead of home after matching by age, ISS, mechanism, and injury type (male patient:female patient, odds ratio, 0.72; 95% CI, 0.67-0.78)."

Overall, odds of mortality did not differ by sex, Ingram and colleagues noted, though patients whose injury was classified as intentional or other intent (e.g., assault, undetermined, self-inflicted) "presented with 2.74 times higher odds of mortality than discharge to an LTF compared with patients who experienced unintentional injury (OR, 2.74; 95% CI, 2.07-3.64). ACS verification level, number of ICU trauma beds, and teaching hospital status were not found to be significantly associated with discharge disposition."

The study authors noted that their findings are consistent with previous literature suggesting that female injury burden is more frequently underestimated, "both in the field and in-hospital," compared to men, and women are more likely to be undertriaged and less likely to receive trauma care, EMS transportation, or transfer to trauma centers.

They also posited possible reasons for the sex-based disparities in discharge disposition; for example, "as traditional primary caretakers of households, female patients are susceptible to decreased social support or have family members who are more likely to request long-term care facility discharge than permitting continued recovery at home." Studies also suggest "a lack of appropriate psychological support and/or early referral to physical therapy services while admitted after trauma may contribute to decreased functional outcomes reported among female patients older than 16 years after major multiple traumas, compared with age- and ISS-comparable male counterparts."

In their commentary, Warner and Crandall also pointed to recent literature demonstrating "that female patients have higher functional impairment, take more pain medications, and have higher rates of posttraumatic stress disorder after injury, all of which likely contribute to increased rates of discharge to long-term care facilities as this study found."

As for the increased ED LOS seen in the study, Warner and Crandall pointed to known delays in radiographic imaging for women compared to men as a potential cause, as well as the biased perception that women are more "sensitive and emotional" when experiencing pain, leading to female patients "having to work to have symptoms taken seriously.

"Although the reason for the sex disparity in ED LOS is unclear and likely multifactorial, implicit bias cannot be fully ruled out; thus, a closer look at our trauma triage protocols and practices is warranted," they wrote.

Study limitations cited by the study authors included that TQIP data were not collected specifically to facilitate this analysis; the TQIP database does not differentiate between sex and gender, and the sex variable is defined based on external anatomy rather than self-reported, identity-based differences, which may have led to a lack of data on further disparities experienced by non-binary individuals and an overestimation of risk for individuals with varying sex; the acuity of injury encounters represented in the study may be susceptible to selection bias; and that the findings may not be generalizable beyond ACS-verified level I and II trauma centers, which formed the majority of centers included in the analysis.

Study coauthor Thomas reported receiving the American College of Surgeons Firearm Clinical Scholar Fellowship, which was funded by the American Foundation for Firearm Injury Reduction in Medicine, the Eastern Association for the Surgery of Trauma, the American College of Surgeons Committee on Trauma, the Pediatric Trauma Society, the Western Trauma Association, and the American Association for the Surgery of Trauma. Coauthor Reddy reported receiving grants from the National Institutes of Health during the conduct of the study. Coauthor Stey reported receiving the American College of Surgeons James Carrico Faculty Research Fellowship and the American Association for the Surgery of Trauma Research and Education Fund Scholarship Award.

Warner and Crandall had no relationships to disclose.

Ingram MCE, et al "Sex-based disparities in timelines of trauma care and discharge disposition" JAMA Surg 2022; DOI: 10.1001/jamasurg.2022.1550.

Warner RL, Crandall M "Sex disparities in trauma care—why are the women waiting?" JAMA Surg 2022; DOI: 10.1001/jamasurg.2022.1551.