Female patients admitted to the hospital with traumatic brain injury (TBI) are less likely than male patients to be admitted to specialized trauma centers, according to a new study.

The population-based cohort study, which analyzed data from health administrative databases in Ontario for more than 55,000 patients with TBI over an 11-year period, found that 26% of women with TBI were admitted to a specialized trauma center compared with 39% of men with TBI. Accounting for injury severity, comorbidities, and socioeconomic characteristics did not affect the results significantly.

The results suggest inequities and underscore the need for system-level strategies to ensure equitable triage and transfer practices, according to the authors.

The findings were published online on June 15 in CMAJ.

TBI Presentation May Differ

Access to healthcare differs by sex, and female patients face disadvantages in accessing care for traumatic injury, myocardial infarction, kidney transplant, and critical illness, the authors wrote. The study aimed to determine whether access to specialized care for TBI was similarly affected.

The investigators analyzed data of 55,606 patients who were admitted to the hospital for TBI in Ontario between April 2009 and March 2020. Of this group, 21,719 (39.0%) patients were female.

Overall, 18,650 patients were admitted to a lead trauma center, including 5666 (26.1%) of the female patients and 12,984, (38.3%) of the male patients. Female patients were older than male patients (median age, 78 vs 67 years) and were more likely to have comorbid conditions (84.6% vs 73.8%), including dementia (20.4% vs 11.8%) and hypertension (68.8% vs 54.8%).

Male patients were more likely to have severe trauma compared with females, as defined by an Injury Severity Score (ISS) score greater than 15. Severe trauma occurred in 32.6% of males vs 24.8% of females. The authors used the Abbreviated Injury Score (AIS) to assess the severity of a head injury and the ISS to assess major trauma.

Several factors may explain the observed disparities. “Unconscious bias, or mistakenly interpreting female patients as being less sick than they really are, could be an explanation,” first author Natalia Angeloni, MD, a PhD student at the University of Toronto in Toronto, told Medscape News Canada.

“There is not enough data on female patients to understand how a TBI might present differently in them than in men. We don’t know,” Angeloni said.

“The most important takeaway is that there is a difference, and we should take a closer look. I’m hoping my study is going to be hypothesis-generating and prompt different groups to study why this can happen. How does this affect outcome? That is something we are going to explore in further studies,” Angeloni said.

Good Data, Questionable Conclusion

Gender-based disparities in access to healthcare do not apply to referrals of patients with TBI to specialized trauma centers, Judith Marcoux, MD, assistant professor of neurology and neurosurgery at McGill University in Montreal, told Medscape News Canada.

“It has nothing to do with the sex of the patient, no mention of male or female. It’s a person whom we have assessed to have a severe brain injury that needs admittance to a specialized trauma center,” she added. Marcoux did not participate in the research. “It’s odd that they have used the ISS and AIS scales. We always use the Glasgow Coma Scale [GCS] to determine head injury severity,” Marcoux said.

Marcoux disagrees with the authors’ conclusion. “The data they present are good, but the conclusion drawn from it (that there is a disparity in the access to care for female patients with TBI) makes no sense.”

Quebec has clear guidelines for transferring patients with TBI. Published guidelines on when to do a CT of the head are everywhere in the province, Marcoux said. “Everyone with trauma gets a CT of the head. There is no difference between a man or a woman. If you’re unconscious, if you’re in a high-speed motorcycle accident, man or woman, you’ll get a scan. Sex doesn’t come into the equation at all.”

The CT findings influence whether the patient will be referred to a neurotrauma center. “The GCS is the standard for transfer, not the AIS, the sex is not there at all, so the conclusion is bizarre,” Marcoux added.

The older age and higher prevalence of comorbidities among the female patients in the current study may explain why women overall were less likely to be referred to specialized trauma centers. “Men required more intensive care unit admissions,” Marcoux added, because they tend to be involved in riskier occupations, types of work, and behavior than women are.

Men have more head trauma than women across all ages except the oldest ages, when rates are more equal, Marcoux continued. “A patient who is elderly and has dementia and is already in a nursing home won’t get transferred to a neurotrauma center because there’s no point. We have this written in our guidelines.”

“We have to limit the transfer to neurotrauma centers to patients needing neurosurgery, who also may need specialized rehabilitation and early intervention according to the severity of the trauma,” said Marcoux. “An elderly lady at 90 years old with dementia in a nursing home and a small bleed in the scan will never get a surgery and will never get to rehab because she is already in a nursing home. [The authors’] own data show that, so how can they conclude there is disparity in access to care?”

Studying Women’s Brain Health

Putting the question of inequities aside, it is important to study women’s brain health and women’s response to treatment for TBI, Paul van Donkelaar, PhD, professor of community engagement, social change, and equity at the University of British Columbia in Okanagan, British Columbia, told Medscape News Canada.

“That was my first thought when I saw these results. Maybe it’s because men have more severe injuries and therefore get admitted more. The authors did attempt to control for that and did an appropriate analysis with the data they had available to them,” van Donkelaar said. He also is scientific director of Supporting Survivors of Abuse and Brain Injury through Research.

Van Donkelaar agreed with Marcoux that the GCS should be used as the initial baseline measure. “That’s typically what is done. It may be that the male patients had higher GCS scores than the female patients for all sorts of reasons…. Women may be more likely to show up for healthcare even if their injury isn’t as severe, whereas men say they’ll be fine until it becomes clear that their injury is life-threatening.”

Van Donkelaar, who did not participate in the study, praised the authors for highlighting the lack of research on health among women compared with men. “It may not be surprising that that shows up in terms of the healthcare’s response to females vs males when they show up at the doors of the hospital or clinic. People providing care may not know as much, because there isn’t as much research being done. That is always a good thing to call out, and I hope that it leads to a better understanding.”

The study was funded by the Sunnybrook Research Institute Kimel-Schatzky Traumatic Brain Injury Research and Innovation Competition. Angeloni, Marcoux, and van Donkelaar reported having no relevant financial relationships.