Evaluating the impact of social determinants of health on undertriage among trauma patients.
The journal of trauma and acute care surgery · 2025-11-12 · Observational study
Abstract
BACKGROUND: Rural America faces significant trauma outcome disparities, primarily driven by limited access to timely and appropriate care. Undertriage (UT) or the failure to transport severely injured patients to higher-level trauma centers further exacerbates these inequities. This study investigates the role of social determinants of health in influencing UT, hypothesizing that increased social deprivation correlates with higher UT rates. METHODS: Retrospective cohort study of injured patients transported by emergency medical services in Pennsylvania between 2000 and 2020 who met physiologic or anatomic National Field Triage Guidelines criteria for transport to a trauma center. Undertriage was defined as patients not initially transported to a level I or II trauma center. Logistic regression determined the association between the social deprivation index (SDI) and UT at both the patient and zip code levels. In addition, we applied Bayesian spatial models to explore regional patterns and influences on UT. RESULTS: The cohort included 166,632 trauma patients, with 29% experiencing UT. At the patient level, a 10-point increase in SDI (more deprivation) was associated with a 1.4% rise in the odds of UT (adjusted odds ratio, 1.014; 95% confidence interval, 1.002-1.026; p = 0.025). At the zip code level, SDI emerged as a significant predictor of UT rates (coefficient, 0.380; 95% CI, 0.0165-0.0595; p = 0.001), with spatial autocorrelation observed (Moran's I = 0.732, p < 0.0001). Bayesian spatial models revealed an association between regional SDI and UT, reinforcing the role of geographic and socioeconomic factors. Undertriage was linked to increased mortality, higher complication rates, and prolonged hospital stays ( p < 0.05). CONCLUSION: Undertriage is associated with more disadvantaged social determinants of health. This work highlights a critical opportunity to mitigate trauma disparities. Policy efforts should prioritize disseminating standardized triage guidelines, leveraging geospatial data for targeted interventions, and exploring air medical transport to improve access to care without overburdening ground emergency medical services systems. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.