Health Care Practitioner Bias and Access to Inpatient Rehabilitation Services Among Survivors of Violence.

Abstract

Importance: Posthospital inpatient rehabilitation is essential for many patients with traumatic injuries. However, rehabilitation centers lack transparency and oversight in their admission practices and may be influenced by health care practitioner (HCP) use of stigmatizing language in patient medical records, leading to inequities in access to care.

Objectives: To examine differences in admission to inpatient rehabilitation centers for patients hospitalized for violent penetrating (VP) injuries compared with motor vehicle crash (MVC) injuries.

Design, setting, and participants: This mixed-methods retrospective qualitative study used data obtained from hospital records from 2015 to 2021. Data analysis occurred between July and December 2023. The study was performed at Boston Medical Center, an urban level I trauma center. The cohort included all patients hospitalized for VP or MVC injuries who were discharged to an inpatient rehabilitation center between 2015 and 2021.

Exposures: Injury type, categorized as VP or MVC.

Main outcomes and measures: The primary quantitative outcome was a denial for admission to an inpatient rehabilitation center. Qualitative content analysis identified similarities and differences across injury types in the manifestations of predetermined stigmatizing language categories in patients' medical records.

Results: Of 323 patients discharged to an inpatient rehabilitation center (median [IQR] age, 38 [25-59] years; 208 men [64.4%]; 29 Hispanic patients [9.0%], 118 non-Hispanic Black patients [36.5%], and 152 non-Hispanic White patients [47.1%]), 107 patients (33.1%) experienced at least 1 denial by a center before being placed (32 of 55 patients with VP injuries [58.2%] vs 75 of 268 patients with MVC injuries [28.0%]). Compared with patients with MVC injuries, patients with VP injuries had greater than 3 times the odds of experiencing a denial (odds ratio, 3.51; 95% CI, 1.93-6.48; P < .001). Medical records of patients with VP injuries had increased use of stigmatizing language that indicated culturally based or injury-related stereotyping, skepticism toward patient-reported symptoms, and heightened HCP-power dynamics contributing to unilateral decision-making.

Conclusions and relevance: In this mixed-methods qualitative study of hospital patients discharged to rehabilitation centers, significant disparities in denials for admission were observed among survivors of violence, who were disproportionally Black or Hispanic. Stigmatizing language found in medical records suggested that bias within the referral process may have contributed to these disparities. These findings underscore the need for reformed clinical documentation practices and enhanced oversight of rehabilitation referral processes to promote equitable access to care.