Mount Sinai Hospital in Toronto in February, 2024. The new study further highlights the pervasive gender disparities that exist in Canada’s health-care system.Fred Lum/The Globe and Mail
Female hospital patients in Ontario with traumatic brain injuries are significantly less likely than their male counterparts to be admitted to a specialized trauma centre, according to new research.
The study, published on Monday in the Canadian Medical Association Journal, concluded that females were 26 per cent less likely to be admitted, even after accounting for factors such as age, injury severity, comorbidities and socioeconomic status.
Lead author Natalia Angeloni, a PhD student at the University of Toronto, said in an interview that the study raises serious concerns about health care inequity. It can now serve as the foundation for additional research into TBI care, particularly for females, she said.
“This is the first step, to recognize that there’s a gap and that females are less likely to be admitted to a trauma centre,” Dr. Angeloni said. “Once we recognize that, we can start to hypothesize and test different components.”
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Already, she is part of a team analyzing additional data to determine the clinical outcomes for this population. This research will dig into what type of care male and female patients receive after being admitted to a trauma centre.
The new study further highlights the pervasive gender disparities that exist in Canada’s health care system. Previous research has already shown that female patients face disadvantages in accessing care for a range of conditions, such as heart attacks, kidney transplants and other critical illnesses.
It is now clear that access to specialized care for a TBI follows the same unfortunate trend, Dr. Angeloni said.
TBIs, which are any injury to the brain caused by an external force, are the leading cause of trauma-related death and disability worldwide. These injuries vary in severity, ranging from concussions to life-threatening emergencies.
The study was based on data from ICES, a non-profit Ontario research institute, covering 55,606 patients, 39 per cent of whom were female, who were admitted to an Ontario hospital for a TBI between April, 2009, and March, 2020. Twenty-six per cent of those female patients were then subsequently admitted to a trauma centre, compared to 38 per cent of males.
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Female patients skewed older, with a median age of 78, compared to 67 for males, and were more likely to have dementia and hypertension. Males, by contrast, had higher rates of severe head trauma.
The study’s authors pointed to several factors that help explain the difference in admissions to specialized trauma centres. This includes unconscious, sex-related bias and the under-representation of female patients with TBI in research studies.
“As a result, triage and transfer guidelines may not fully capture how TBI manifests in female patients, potentially leading to missed or delayed recognition of injury severity,” according to the study.
Additionally, the authors highlighted that females more often suffer TBIs after impact sustained from a low-velocity force or from falling from standing height or less. These circumstances “may attract less attention” and lessen the patient’s priority in hospital.
But Dr. Angeloni noted that there are many factors that influence triage decisions, some of which they were unable to measure, such as patient or family decisions to decline transfer to a specialized facility or advance directives.
The authors concluded that future research should more closely investigate how triage and interfacility transfer decisions are made, noting that triaging in Ontario hospitals is “suboptimal.” There are high rates of both overtriage (overestimating the severity of a patient’s condition) and undertriage (underestimating the severity), despite standardized guidelines.
“Understanding how this variability interacts with sex and gender is critical. The role, if any, of conscious and unconscious bias in clinical decision-making in care of patients with TBI should be explored, as has been done for other clinical conditions,” the researchers said.
Dr. Angeloni said this problem is not unique to Ontario and has been recognized in countries all over the world. She explained that emergency-care decisions have to be made quickly and health care workers are often working with limited or incomplete information, which can lead to gendered assumptions.
But she hopes this study can help to inform providers, giving them pause when TBI-related care decisions must be made. “That’s a take-away message from this study, that we need to pay attention,” Dr. Angeloni said.
Editor’s note: A previous version of this article was missing context in reference to statistics included in the study. Of 55,606 patients, 39 per cent of whom were female, who were admitted to an Ontario hospital for a TBI, 26 per cent of those female patients were then subsequently admitted to a trauma centre, compared to 38 per cent of males.