Should Regionalization Only Be in 1 Direction?

Abstract

The article by Matsushima et al1 gives a new perspective on regionalizationof care for trauma. Inelderlypatientswhohave been treated at level 1 and level 2 trauma centers in Pennsylvania, the authors noted a 25%decrease inmortality for those atcenters that treatmore than 100 geriatric patients annually. Thesehigh-volumegeriatric trauma centers have lower rates of major complications, even lower incidences of failure to rescue after a major complication when compared with centerswith fewer than 100 suchpatients annually. Conversely, at institutions that have larger numbers of nongeriatric traumapatients, therewasa significantlyhigher rateofmajor complications for elderly individuals. While theauthorscommentedthat thisobservationshould be used to “consider the needs of specific subgroups such as the elderly” and to drive the decision to allocate hospital resources to geriatric trauma, I look at it differently. Their data clearly show that large nongeriatric trauma volumesmay adversely affect the outcomes of geriatric trauma patients. Remember that trauma is a young person disease; so is it safer to divert elderly patients away from the large urban trauma centers and keep them in their community level 2 trauma hospitals? Regionalization of trauma care has increased survival throughout the United States. The rapid transport of critically injured patients to level 1 centers has been shown to improveoutcomes. So, is thismodel also true for the geriatric patients?While the authors did not analyze the age distribution of patients in their hospitals, tertiary, level 1 university hospitals typically have a younger age demographic than community hospitals, which are typically level 2 centers. Similarly, the trauma experienced by geriatric patients is much different than that experienced by younger patients. Most geriatric injuries are from falls, which yield orthopedic andneurosurgicalproblems;very fewarepenetrating fromviolence. They also havemore chronic problems than those seen in younger patients. I propose that thedatapresentedbyMatsushimaetal1 support the concept of regionalizing geriatric care to community hospital, level 2 trauma centers. Those are the ones that may verywell bebetter equipped tohandle the local geriatricpopulation than the tertiary, high-volume, level 1 trauma centers. There are benefits to this particular regionalization. First, elderly patients would be able to be cared for near their home and their families. Second, community doctorswould be able to participate in the care of their patients. Third, local rehabilitation centers—both long termand short term—wouldbenefit from close relationships to the patients at the local hospitals. Fourth, many community hospitals that are now experiencingdecreasing inpatientvolumesanddecreasing revenues would be able to make a new model for revenue generationand serving their local communitybydeveloping level 2 trauma services. Matsushima et al1 suggest that this is already happening. The Figure in their article shows a weak correlation between geriatric to nongeriatric volumes at trauma centers. Specifically, the 0.75 correlation noted, if significant, likely would be less so if the 2 outliers in the right upper portion of the graph were removed. That suggests that many geriatric patients are already being treated at local trauma centers. The article suggests that these patients are in fact being appropriately treated. The authors are well positioned to develop a model of regionalization of care to centers appropriate for age and injury and can establish the ratio of geriatric/nongeriatric trauma patients who will get these unique patients the best care.