M. A. Chaudhary1, A. Shah3, C. K. Zogg1, D. Metcalfe1, O. Olufajo1, E. J. Lilley1, A. Ranjit1, A. B. Chapital3, D. J. Johnson3, J. M. Havens2, A. Salim2, Z. Cooper1, A. H. Haider1 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Harvard Medical School, Harvard T H Chan School Of Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Trauma, Burns And Surgical Critical Care,BOSTON, MA, USA 3Mayo Clinic In Arizona,Department Of Surgery,Phoenix, AZ, USA
Introduction:
Post-acute rehabilitation is increasingly recognized as a vital component of surgical care, necessary to restore patients’ pre-disease functional status. Unequal receipt of such care may prevent full recovery in underprivileged patients. Disparities in utilization of Acute Care Surgery (ACS) have been documented, but little is known about disparities in post-discharge rehabilitation services. This study sought to determine whether disparities exist in the receipt of post-discharge rehabilitation in ACS patients.
Methods:
The Nationwide Inpatient Sample (2007-2011) was queried for adult patients (≥18y) with an ACS primary diagnosis, including trauma and emergency general surgery (EGS) conditions defined by the American Association for the Surgery of Trauma (AAST). Two trauma subgroups – traumatic brain injury (TBI) and spinal cord injury (SCI) – were analyzed separately, as evidence suggests that they have specific rehabilitation needs. Patients that died in hospital were excluded and inpatients who survived were assessed for differential receipt of post-discharge inpatient rehabilitation. Multivariable logistic regression models were used to determine independent predictors of discharge to rehabilitation, adjusting for influence of patient- (age, race, gender, insurance status, income, disease severity, complications) and hospital- (volume, teaching status, location, bed size, geographical region) level covariates and accounting for clustering of patients within hospitals. Trauma, TBI and SCI models were further adjusted for Injury Severity Score (ISS).
Results:
A total of 5,228,453 patient records were included, weighted to represent 26,353,162 patients nationwide. Among ACS patients, 27.4% (n=1,460,934) were admitted for trauma and 72.6% (n=3,872,622) for EGS. Of these 133,439 (2.6%) were discharged to rehabilitation facilities. In the sub-groups, 7.7% of trauma, 0.6% of EGS, 6.5% of SCI and 2.3% of TBI patients were discharged to rehabilitation facilities. Black and Hispanic patients had 15-43% lower risk-adjusted odds of rehabilitation discharge relative to White patients, for both trauma and EGS diagnosis. Similarly, Medicaid beneficiaries (OR: 0.90 [0.87-0.93]) and uninsured patients (OR: 0.38 [CI: 0.37-0.40]) were less likely to be discharged to inpatient rehabilitation after trauma. ACS Patients treated at teaching (OR: 1.44 [CI: 1.42-1.46]) and urban (OR: 1.80 [CI: 1.75-1.83]) hospitals were more likely to be discharged to rehabilitation facilities. These findings persisted in the SCI sub-group analysis but became non-significant for the TBI group.
Conclusion:
Historically disadvantaged minorities, Medicaid beneficiaries, and those treated at rural and non-teaching centers had disparate receipt of inpatient rehabilitation, which may limit recovery. Further work should investigate the implications of these findings on post-operative and post-injury functional and quality-of-life outcomes.