The influence of socioeconomic status on pre-hospital triage in the Netherlands; a multi-center cohort study

Purpose: Optimizing pre-hospital triage is essential to improve outcomes after severe injury. Sociodemographic factors may influence triage decision, but the role of neighborhood socioeconomic status (SES) at the scene of injury remains unclear. This study evaluated the association between neighborhood SES and the accuracy of pre-hospital trauma triage. Methods: This multicenter cohort study included all trauma patients transported by eight ambulance regions in the Netherlands between January 2015 and December 2017. Neighborhood SES was defined using income, education, and employment indicators. Outcomes were undertriage and overtriage, based on Injury Severity Score (ISS) ≥ 16. Associations between SES and triage accuracy were analyzed with generalized linear models using inverse probability weighting, adjusted for age, trauma mechanism, injury severity, and trauma center proximity. Results: A total of 160,109 patients were included, of whom 32,466 (20.2%) were injured in low-SES neighborhoods. Compared with higher-SES areas, these patients were younger (median 55.7 vs. 58.3 years), more often sustained penetrating injuries (1.3% vs. 0.7%), and were injured closer to higher-level centers (median 7.5 vs. 20.3 km). Unadjusted undertriage was lower (14.9% vs. 25.9%) and overtriage higher (27.8% vs. 19.4%). After adjustment, low-SES neighborhoods were associated with increased undertriage risk (aOR 1.30; 95% CI 1.03–1.63) and decreased overtriage risk (aOR 0.65; 95% CI 0.62–0.67). Conclusion: Neighborhood SES is significantly associated with pre-hospital trauma triage. Severely injured patients in low-SES neighborhoods are at increased risk of undertriage, underscoring the need for targeted strategies to ensure equitable access to specialized trauma care.