Geriatric Consultation in Trauma Care: A Marker of System‐Level Quality

The rapid growth of the older adult population has fundamentally altered the case mix of U.S. trauma centers. Adults aged 65 years and older experience higher mortality and increased vulnerability to geriatric syndromes following injury [1]. In response, national organizations have promoted geriatric-focused trauma care for more than a decade, most recently through updated American College of Surgeons (ACS) Geriatric Trauma Management Best Practices Guidelines [2]. Yet despite widespread endorsement, the field has lacked hospital-level evidence identifying which recommended structures or processes are most closely associated with better outcomes. In this issue, Ordoobadi and colleagues address that gap by examining the relationship between geriatric consult services, other geriatric-focused processes of care, and hospital-level mortality among injured older adults [3]. The study's design is notable both for its national scope and for its unit of analysis. Using linked survey data from trauma centers and outcomes from the Trauma Quality Improvement Program (TQIP), the authors examine whether geriatric-focused processes of care are associated with hospital-level mortality among injured older adults. Among the 145 surveyed centers, only 34% reported availability of a geriatric consult service, consistent with prior work demonstrating wide variability in geriatric trauma care models across institutions [4]. The central finding is that geriatric consultation was the only evaluated geriatric-focused process associated with lower odds of being in the highest quartile of observed-to-expected mortality at the hospital level. After adjustment for patient case mix, hospital characteristics, trauma verification level, and the presence of other geriatric processes of care, the availability of a geriatric consult service was associated with an 80% reduction in the odds of being among the worst-performing hospitals with respect to mortality (odds ratio 0.20; 95% confidence interval 0.05–0.73) [3]. Importantly, the nature of this association warrants careful interpretation. Geriatric consultation was not associated with an increased likelihood of hospitals achieving lower-than-expected mortality. Rather, its presence distinguished hospitals that avoided the highest mortality quartile. As illustrated in the authors' mortality distribution outcomes were largely similar across much of the continuum, with the notable exception that none of the hospitals with the worst observed-to-expected mortality had a geriatric consult service. This pattern suggests a threshold effect, in which the absence of geriatrics integration characterizes the poorest performing institutions, rather than a dose-response relationship in which consultation progressively improves outcomes. Two aspects of these results deserve emphasis. First, the finding contrasts with the mixed effects of geriatric consultation on mortality in trauma populations [5] and suggests that geriatric integration may exert its influence at the level of institutional practice and organizational capacity, rather than solely through individual patient encounters. Second, the absence of independent mortality associations for other commonly recommended processes should not be interpreted as lacking in effectiveness, particularly when looking at outcomes that matter most to older adults, including functional status, delirium, discharge destination, and goal-concordant care [1]. Rather, the observed association reflects broader institutional influences of geriatrics integration, including interdisciplinary collaboration, protocol development, and reinforcement of geriatric priorities across care teams, rather than the direct effect of consultation on individual patients alone [2, 5]. The authors appropriately note several limitations. The retrospective design and center-level exposure measurement preclude causal inference. Centers able to sustain geriatric consult services may differ in unmeasured ways, such as staffing stability, leadership engagement, or financial resources. Mortality, while important, is an incomplete outcome for older adults, potentially overlooking gains in function, cognition, or quality of life [1]. In addition, geriatric-focused practices were measured as binary variables, limiting insight into the quality or consistency of implementation. Finally, the modest survey response rate of 23% raises the possibility of selection bias, although responding and nonresponding centers appeared similar on key characteristics. Despite these limitations, the study provides some of the strongest national-level evidence to date that geriatric consultation may be a defining component of high-quality trauma care for older adults. The findings arrive at a time when trauma centers face persistent barriers to implementation, including shortages of geriatricians and limited reimbursement for consultative care. Notably, the 2023 ACS guidelines acknowledge these constraints and suggest hospitalist-led alternatives, but comparative outcome data for such models remain limited [2, 6]. From a policy and implementation perspective, this work reframes geriatric consultation not as a discretionary enhancement, but as a potential marker of institutional capacity to deliver effective geriatric trauma care [2, 6]. Future studies should focus on prospective evaluation, alternative consultation models, and outcomes beyond mortality, including function, cognition, discharge destination, and patient-centered goals [4-6]. Until such data are available, the findings by Ordoobadi and colleagues provide the strongest evidence that meaningful integration of geriatrics into trauma systems may be necessary to improve outcomes beyond mortality that matter to older adults [1, 2]. The author was solely responsible for the conception, drafting, revision, and final approval of the manuscript. The author has nothing to report. The author declares no conflicts of interest. This publication is linked to a research article by Ordoobadi et al. To view this article, visit https://doi.org/10.1111/jgs.70320.