why women with brain injuries may not be getting to the right hospital
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a hard fall. a car crash. a blow to the head.
when someone suffers a traumatic brain injury (tbi), every decision that follows can affect their recovery. which hospital do they go to? do they see a neurosurgeon quickly? are they transferred to a specialized trauma centre?
a new canadian study suggests those decisions may not be the same for everyone.
what did they find?
researchers analyzed more than 55,000 adults hospitalized with tbis in ontario and found women were significantly less likely than men to be admitted to a level i or ii trauma centre — hospitals specially equipped to treat severe injuries.
published in the canadian medical association journal, the findings remained even after researchers accounted for age, injury severity, existing health conditions, income, and whether patients lived in rural or urban areas.
overall, just over one in four women (26.1%) were admitted to a lead trauma centre, compared with nearly four in 10 men (38.3%). after adjusting for other factors, the gap narrowed to about 4.7 percentage points, but researchers say that’s still meaningful across thousands of patients.
dr. tatyana mollayeva, scientist at uhn’s kite research institute.
tim fraser & kite studio
‘lifelong consequences’
dr. tatyana mollayeva, a scientist at uhn’s kite research institute, says the findings deserve attention because tbis can have lasting effects.
“traumatic brain injury is a serious condition that can have lifelong consequences,” she said. “… across a large population, even small differences in referral and admission patterns can translate into a substantial number of patients who may not receive specialized trauma care.”
she also cautions against jumping to conclusions.
the study found a sex-based difference in referral patterns, but it does not prove women received inappropriate care or that discrimination played a role.
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“there are many patient-level, clinical and health-system factors” that influence referral decisions, she explained.
why might this be happening?
women and men in the study also looked quite different medically. women were generally older, had more chronic health conditions and were less likely to have severe brain injuries. men were more likely to have major trauma, require intensive care and have substance abuse issues — all factors that can point to greater instability when first assessed by emergency responders.
researchers also lacked important information that can influence transfer decisions, including glasgow coma scale scores, neurological exams, vital signs, hospital capacity, transfer suitability and patients’ wishes about their care. without those details, the study can’t explain exactly why the gap exists.
one possible explanation raised by the authors is unconscious bias, but dr. mollayeva says it should be considered alongside other factors.
“unconscious bias is one possible explanation, but it should be considered alongside other clinical and knowledge system-level factors,” she said.
she says another challenge is that women with brain injuries don’t always fit the profile clinicians have traditionally associated with severe trauma.
research has historically focused more on men
historically, much of the research on tbis has focused on men, especially those injured in car crashes, military settings or workplace accidents.
older women are more likely to suffer brain injuries after ground-level falls and may also have frailty, dementia, multiple chronic illnesses or take medications that make their injuries harder to assess. their symptoms can overlap with other conditions, making serious brain injuries easier to miss.
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“if the presentation does not match our existing knowledge of the ‘average’ severe trauma patient,” dr. mollayeva said, “tbi in females can be overlooked or underestimated.”
she stresses that doesn’t necessarily mean clinicians are making the wrong decisions. instead, it points to gaps in what researchers know.
“(it raises) a reasonable concern that some female patients with tbi may be managed differently in decisions regarding transfer to specialized trauma centres,” she said.
the study also found the difference persisted across several groups, including younger and older patients, people with more and less severe injuries, rural and urban residents, and patients with dementia.
questions researchers need to answer next
for dr. mollayeva, the biggest takeaway is that researchers still don’t know exactly why the gap exists.
future studies, she says, should combine hospital records with ambulance reports, emergency department data and trauma registry information to better understand how transfer decisions are made.
researchers should also examine whether referral patterns changed between 2009 and 2020, when ontario introduced new trauma network guidance.
“if the difference narrowed … that may suggest improvement in referral pathways,” dr. mollayeva said. “if it remained stable, it may indicate a persistent pattern. and if it widened, it would raise new questions about the quality of evidence, system changes or access to trauma care.”
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