Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury

Abstract

OBJECT Disparities in access to inpatient rehabilitation services after traumatic brain injury (TBI) have been identified, but less well described is the likelihood of discharge to a higher level of rehabilitation for Hispanic or black patients compared with non-Hispanic white patients. The authors investigate racial disparities in discharge destination (inpatient rehabilitation vs skilled nursing facility vs home health vs home) following TBI by using a nationwide database and methods to address racial differences in prehospital characteristics. METHODS Analysis of discharge destination for adults with moderate to severe TBI was performed using National Trauma Data Bank data for the years 2007–2010. The authors performed propensity score weighting followed by ordered logistic regression in their analytical sample and in a subgroup analysis of older adults with Medicare. Likelihood of discharge to a higher level of rehabilitation based on race/ethnicity accounting for prehospital and in-hospital variables was determined. RESULTS The authors identified 299,205 TBI incidents: 232,392 non-Hispanic white, 29,611 Hispanic, and 37,202 black. Propensity weighting resulted in covariate balance among racial groups. Hispanic (adjusted OR 0.71, 95% CI 0.68–0.75) and black (adjusted OR 0.94, 95% CI 0.91–0.97) populations were less likely to be discharged to a higher level of rehabilitation than were non-Hispanic whites. The subgroup analysis indicated that Hispanic (adjusted OR 0.79, 95% CI 0.71–0.86) and black (OR 0.87, 95% CI 0.81–0.94) populations were still less likely to receive a higher level of rehabilitation, despite uniform insurance coverage (Medicare). CONCLUSIONS Adult Hispanic and black patients with TBI are significantly less likely to receive intensive rehabilitation than their non-Hispanic white counterparts; notably, this difference persists in the Medicare population (age ≥ 65 years), indicating that uniform insurance coverage alone does not account for the disparity. Given that insurance coverage and a wide range of prehospital characteristics do not eliminate racial disparities in discharge destination, it is crucial that additional unmeasured patient, physician, and institutional factors be explored to eliminate them.