Women with traumatic brain injury 26 per cent less likely to receive trauma care than men, Ontario study finds

young Ontario explore shows women with traumatic wit injuries ar far to a lesser extent likely than men to be admitted for trauma care, raising questions about why patients with similar, life-altering injuries may be receiving less-specialized treatment.

Published Monday in the Canadian Medical Association Journal, the study analyzed a decade of data from more than 55,000 adult patients admitted to hospital for traumatic brain injury (TBI) across Ontario. From 2009 to 2020, roughly a quarter of women in the study were admitted to specialized trauma centres, compared to nearly 40 per cent of men.

Overall, women were 26 per cent less likely to receive trauma care, even after the researchers accounted for factors such as age, underlying health conditions, and the severity of the brain injury.

"[The trend] is consistent, and strong enough, that we actually have to pay attention to it," said study co-author Dr. Natalia Angeloni, a critical care physician who is currently completing her doctorate at the University of Toronto.

TBIs include any injury to the brain caused by an external force, such as a fall, car crash or blow to the head.

"It goes from as mild as a concussion, to something so severe that it can cause death in the moment," said Angeloni. "Our study covers the whole definition of a traumatic brain injury, from the mildest to the most severe."

An average of more than 21,000 Canadians are hospitalized for TBIs each year, federal data shows, and nine in 10 of those involve injuries more serious than a concussion.

While milder TBIs may not require trauma care, more serious injuries can benefit from that higher level of treatment. 

In Ontario, trauma centres are hospital facilities that include dedicated trauma bays, state-of-the-art diagnostic capabilities and specialized surgeons available to manage complex, life-threatening injuries.

Accessing trauma care quickly after a TBI "really can be life-changing," said trauma surgeon Dr. Najma Ahmed, head of surgery at the Unity Health Network's St. Michael's Hospital in downtown Toronto. Ahmed was not involved in the study.

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Something as simple as a fall can lead to serious injuries involving dangerous blood buildup around the brain, requiring surgery to alleviate the pressure, Ahmed said. Early access to specialized care can also link patients with rehabilitation teams and other long-term supports, she added, which can help patients navigate what may be a challenging, lengthy recovery.

Yet even when the researchers compared men and women with the most severe TBIs, men were still more likely to end up receiving trauma care than women.

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There were also other key trends among the TBI patients. Women in the study were older, on average, than men, while men were more likely to have a severe brain injury than women. Women also had more baseline disease, such as hypertension or dementia.

Even though older women may be severely injured, Ahmed said their symptoms can be distinct and under-appreciated in triage settings, such as feelings of confusion, nausea, or trouble finding the right words. 

"We should all be quite alert to even minor-seeming injuries, particularly in older women, but in all women," Ahmed added. "We need to take women's symptoms seriously."

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Angeloni agreed there could be "unconscious bias" among health-care professionals working in fast-paced emergency departments.

"Female patients usually have falls from standing, and that [may be] interpreted as a less severe injury than a motor vehicle crash that's seen more in male patients," she said, adding that her study didn't compare what caused individual patients' injuries.

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Fully understanding what's at play here will require more research, said Dr. Shannon Scratch, a clinician-scientist and neuropsychologist at Holland Bloorview Kids Rehabilitation Hospital. 

Still, she praised the research team for investigating sex-based differences in TBI care.

"We know that brain injury research has been heavily skewed towards boys, towards men, for decades … so it's possible that [health-care teams] are actually employing the triage criteria correctly, but the triage criteria itself could be biased."

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Francene Gillis knows all too well that a lack of access to care after a brain injury can have a ripple effect on someone's long-term recovery. 

The resident of Port Hood in Cape Breton, N.S. Was on her way to work as a high school English teacher in the winter of 2016 when she slipped and fell on black ice.

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When Gillis went to her local hospital for an assessment, she was diagnosed with a concussion and whiplash and sent home to rest. But a week later, after symptoms of nausea and vomiting set in, Gillis went back to hospital and was admitted for more than a week. She wasn't sent to a trauma centre, however — partly because of her location in a rural area — and didn't end up seeing a specialist for months after her injury.

Gillis struggled with long-lasting symptoms, including severe balance issues, speech impairment, and intense brain fog that cut short her dual careers as a teacher and regular columnist for her local paper. 

The new CMAJ research didn't actually show whether women with TBI had worse outcomes from being less likely to access trauma care, "as mortality and functional recovery were not examined," noted Dr. Louis Hugo Francescutti, an adjunct professor in the department of emergency medicine at the University of Alberta.

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Francescutti stressed that while the paper's ultimate findings are "concerning and warrant further investigation," they merely show an association, not a cause. 

"The key message for me is that the study identifies a disparity that deserves attention," he said. 

"The next step is understanding why that disparity exists and whether changes to trauma system processes are needed to ensure equitable access to specialized trauma care."

Senior Health & Medical Reporter

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