New study highlights urgent need to improve equity in trauma care.
Injured women are half as likely as men to receive the life-saving drug tranexamic acid (TXA) even though the treatment is equally effective regardless of sex, according to new research in the British Journal of Anaesthesia.
The study was conducted by a team from the London School of Hygiene & Tropical Medicine and University Hospitals Plymouth NHS Trust, which included Critical Care Doctors Tim Nutbeam and Lauren Weekes. Devon Air Ambulance clinicians often collaborate with many others in the field, which is beneficial not only to the broader clinical community, but also to the collective knowledge and awareness of the crew, ultimately supporting patients.
In this two-part investigation, the team initially re-analysed data from two large randomised trials involving over 20,000 adult trauma victims, whose original findings showed that TXA can save the lives of tens of thousands of accident victims worldwide. They found the drug is equally effective in male and female patients and reduces the risk of death by up to 30%.
They next looked at data from 216,000 injured patients included on the Trauma Audit Research Network (TARN) database for England and Wales to see if injured women were being treated to the same extent. The researchers found that compared with men, injured women were half as likely to get TXA, both in and outside of the hospital setting. The discrepancy in treatment occurred even where women have the same risk of death from bleeding as men. The gap in administration was greatest in older patients and those with a lower risk of death from blood loss.
Professor Ian Roberts from the London School of Hygiene & Tropical Medicine and study author, said:
“These results are very concerning. TXA is the only proven lifesaving treatment for traumatic bleeding. Women were treated less frequently than men regardless of their risk of death from bleeding or the severity of their injuries. This looks like sex discrimination, and there is an urgent need to reduce this disparity in TXA treatment so all patients who need the drug have the chance to receive it.”
Tranexamic acid is a safe and established treatment for bleeding. Current UK guidance for its administration states it should be given where there is “known or suspected severe traumatic haemorrhage” and the injury has occurred within the previous three hours. It is also administered to patients with certain types of head injury.
Professor Tim Nutbeam from University Hospitals Plymouth NHS Trust and study author, said:
“These results are striking but sadly not surprising. It is already known that women with chest pain are less likely to receive aspirin, less likely to be resuscitated for out of hospital cardiac arrest, and less likely to be taken to hospital by an ambulance using lights and sirens.
“Although we have shown large sex differences in TXA treatment, we can only speculate about the underlying causes. Clinicians in the UK must be provided with clearer treatment guidance so that we can help reduce this bias. If all patients were treated according to need, we could save 160 lives per year in the UK.”
Dr Lauren Weekes from University Hospitals Plymouth NHS Trust and study author, said:
“There is a vast data gap in the medical literature when it comes to health outcomes for women. By sex-disaggregating data from the CRASH trials and the TARN database our study has contributed to a body of knowledge concerning women’s health. The next step is to work towards redressing the inequitable administration of this lifesaving medication.”
The authors acknowledge limitations of the study include missing data for some of the variables used to calculate the risk of death due to bleeding, although the percentage of missing data was similar for men and women. There is also potential for inaccuracy in predictions of the risk of death from bleeding, despite studies showing the method used has high reliability.
The next steps are for further research to establish awareness of this specific issue in critical care and encourage other analysis of gender/sex bias in access to and delivery of health care to ensure evidence-based delivery of treatments, and that policies and triage tools do not discriminate. It will also be necessary to investigate the specific bias.
Darren Goodwin, Operations Manager at Devon Air Ambulance said:
“We very much value the work clinicians like Tim and Lauren undertake in partnership with University Hospitals Plymouth NHS Trust. An important aspect of our work as clinicians is to drive change and innovation in the sector, not only at a local level, but globally and for the benefit of all patients. We always seek to enhance our culture of learning, training, and the sharing of insights that ultimately influence practice and help to save more lives.”