Despite evidence showing that patients with preexisting mental illness tend to have worse outcomes and a more challenging hospitalization [4, 6], there is a scarcity of research on their perception of the care experience. To our knowledge, this is one of the first studies to examine satisfaction and characteristics of older trauma patients with preexisting mental illness. Across two level I trauma centers, of those who were PMI+, the most common diagnosis was depression and patients tended to be females who were between 55–64 years old, and had multiple comorbidities compared those who were PMI-. Only a small fraction of PMI + patients qualified for a behavioral health assessment; this was particularly true at hospital 1, where only two PMI + patients had an assessment, and reported significantly lower satisfaction with both delivery of information and physical care compared to PMI- patients.
Several of these patient characteristics have been substantiated in the published literature [4–6, 12–14]. Townsend and colleagues (2017) reported on characteristics of PMI + trauma patients using the Nationwide Inpatient Sample (2012) and found that 44% of trauma patients ≥ 18 years of age were PMI + across 36.5 million patients, and similarly, PMI + trauma patients were significantly more likely to be female, to be an average age of 61 years (vs. 56 years), and have a higher number of comorbidities compared to PMI- trauma patients . In a single center study, Weinberg et al. (2016) described the prevalence and characteristics of psychiatric illness among orthopedic polytrauma patients and also discovered a significantly higher percentage of PMI + patients (vs. PMI-) were female (38.5% vs. 23.7%) and had depression (22.3%) .
Interestingly, smoking status was identified as an independent predictor of lower patient satisfaction at both hospitals. There were several other characteristics associated with a history of smoking that may help explain this finding, including: they had had significantly more comorbidities, and significantly more had a history of alcoholism, compared to PMI- patients. Life satisfaction in older populations has been linked to activities that both temporarily alleviate and contribute to stress and pain, including smoking and alcohol consumption . Thus, a history of smoking has been associated with lower life satisfaction , as well as lower patient satisfaction .
Nonetheless, it remains essential for trauma centers to target unmet patient needs, in order to tailor care and improve satisfaction. The identification of the most common trigger for behavioral health assessments, “Coping concerns with acute changes in ADLs”, should serve as a starting point for both hospitals to best serve their older PMI + patient population. Because this was the most common trigger, it can be surmised that these concerns are insidious among the majority of older patients, both PMI + and PMI-. A decline in ADLs for older adults, but particularly those with dementia, has been shown to negatively affect their quality of life and perception of care  and furthermore, a diagnosis of depression or anxiety is associated with an increased risk of cognitive and physical decline over time for elderly patients [14, 17–22]. In this study, over half of PMI + patients had a diagnosis of depression. Depressed patients more frequently perceive events in their life as negative compared to those without depression [23, 24] and those with depressive symptoms have previously been found to be less satisfied with communication from their provider .
There is room for improvement across both hospitals. At hospital 2, although no difference in patient satisfaction across groups (PMI + vs. PMI-) was identified, overall satisfaction was significantly lower than at hospital 1. This finding may be due to several reasons, one being the older patient population at hospital 2; older patients generally have less mobility, translating to lower overall life and thus patient satisfaction [15, 16, 21]. Second, patients at hospital 2 also tended to be managed on the floor, whereas at hospital 1 with a younger population, patients had a slighter higher injury severity and typically went to critical care. At hospitals 1 and 2, communication of information on prognosis was significantly lower, which was identified as an area of lower patient satisfaction in another study on trauma patients , and in other studies [25–27]. Although these patients could in fact have been provided relevant information during their stay, perhaps the delivery of information could be slowed down or better refined for older PMI + patients, which may be rushed in the acute trauma setting.
At trauma centers injuries always take priority and PMI + patients may not be flagged for a behavioral health assessment, especially if their injury is critical; however, across both trauma centers, assessments only seemed to be triggered if the PMI + patient was clearly high-risk, potentially leaving many less obvious PMI + patients with unmet care needs. At hospital 1 specifically, communication and management surrounding pain, prognosis, procedures, and referrals to specialists, contributed to significantly lower satisfaction, suggesting that that providers may not be closing the loop on the continuity of care after managing the injury; closing the loop should include both rigorous screening and assessment, as well as appropriate referrals for counseling and other mental health support.
There are a number of limitations in the study. First, the patients responding to the satisfaction surveys may not have been representative of the general population seen across the facilities. Patients who were “very dissatisfied” or “undecided” may have withheld from taking the survey. Second, healthcare surveys administered in person can sometimes artificially inflate the results because patients might believe that their scores will negatively affect the care received; however, by capturing results soon before hospital discharge and without disclosing them to treating staff, a more accurate and unbiased description of patient satisfaction was obtained. Third, because this was a cross-sectional study of two trauma centers, other hospitals with different populations and behavioral health management strategies may not observe the same satisfaction scores; nonetheless, the inclusion of a general, older adult trauma population may help other centers hoping to understand satisfaction and characteristics of trauma patients who are PMI+. Fourth, because data was used from a larger ongoing study, the surveys used were not previously evaluated in a trauma population, or for those who are PMI + and additional work may be needed to verify the results using an instrument tailored for this population; however, Vogel and colleagues (2019) successfully measured patient and caregiver satisfaction using the FAMCARE surveys in a trauma population [10, 28]. Fifth, because the measurement of mental illness in this population was taken from patients who consented to take a survey, it is likely an underestimation of the true prevalence across these hospitals. Last, SBIRT components were not captured for PMI + patients and thus compliance with ACS guidelines was not able to be measured.