Associations between Social Determinants of Health and Post-Hospitalization Rehabilitation among Critically Ill Older Adults.

Abstract

Rationale: Older adults who survive hospitalization with a stay in the intensive care unit (ICU) often develop new or worsened disability; those with social vulnerabilities suffer a greater burden of disability. It is unknown whether social determinants of health (SDOH) are associated with disparities in delivery of post-hospitalization rehabilitation.

Objective: To evaluate whether SDOH are associated with disparities in delivery of post-discharge rehabilitation services to older adults in skilled nursing facilities (SNFs), in home health, and in outpatient rehabilitation facilities in the 100 days after an ICU hospitalization.

Methods: In this observational cohort study, we used data from the National Health and Aging Trends Study (NHATS) with links to Medicare inpatient claims (2011-19), the Minimum Data Set for SNFs, the Outcomes and Assessment Information Set for home health, and outpatient claims files. We identified older adults with an ICU hospitalization who survived to discharge. The main outcome was rehabilitation delivery in the first 100 days after discharge ascertained as minutes of physical and/or occupational therapy (PT/OT) in SNFs and receipt of any PT/OT in home health and outpatient settings. We constructed multivariable regression models to evaluate the association between SDOH (socioeconomic disadvantage, race and ethnicity, education, and limited English proficiency), and rehabilitation delivery, adjusting for demographics, hospitalization, and post-hospitalization characteristics.

Results: We identified 295 ICU hospitalizations with SNF stays, 205 with home health assessments, and 784 where patients were alive for ≥7 days after discharge, thereby eligible for outpatient rehabilitation. Socioeconomic disadvantage, non-White race or Hispanic ethnicity, and lower level of education were associated with reduced delivery of in-home rehabilitation [adjusted odds ratio (95% CI):0.43 (0.23, 0.81); 0.39 (0.16, 0.93); and 0.42 (0.18, 0.99)]. Although the sample sizes in their respective cohorts were small, SDOH were not associated with rehabilitation delivery in either SNFs or outpatient settings.

Conclusions: We found socioeconomic disadvantage, minoritized race and ethnicity, and lower education were associated with reduced delivery of rehabilitation at home among older ICU survivors. Given its important role in promoting functional recovery, our findings warrant interventions to mitigate inequities in rehabilitation delivery at home following hospital discharge.