Hospital effects drive variation in access to inpatient rehabilitation after trauma.

Background Post-acute care rehabilitation is critically important to recover after trauma but many patients do not have access. A better understanding of the drivers behind inpatient rehabilitation facility (IRF) use has the potential for major cost-savings as well as higher quality, and more equitable patient care. We sought to quantify the variation in hospital rates of trauma patient discharge to inpatient rehabilitation and understand which factors (patient- vs injury- vs hospital-level) contribute the most. Methods We performed a retrospective cohort study of 668,305 adult trauma patients admitted to 900 Level I-IV trauma centers between 2011 and 2015 using the National Trauma Data Bank (NTBD). Participants were included if they met the following criteria: age >18, injury severity score (ISS) >9, identifiable injury type, and who had one of the Centers for Medicare & Medicaid Services (CMS) preferred diagnoses for inpatient rehabilitation under the "60% rule". Results The overall risk- and reliability-adjusted hospital rates of discharge to IRF averaged 18.8% in the non-elderly adult cohort (18-64 years old) and 23.4% in the older adult cohort (65 years or older). Despite controlling for all patient, injury and hospital-level factors, hospital discharge of patients to IRF varied substantially between hospital quintiles and ranged from 9-30% in the non-elderly adult cohort and from 7-46% in the older adult cohort. Proportions of total variance ranged from 2.4% (patient insurance) to 12.1% (injury-level factors) in the non-elderly adult cohort and from 0.3% (patient-level factors) to 26.0% (unmeasured hospital-level factors) in the older adult cohort. Conclusion Among a cohort of injured patients with diagnoses that are associated with significant rehabilitation needs, the hospital at which a patient receives their care may drive a patient's likelihood of recovering at an IRF just as much, if not more, than their clinical attributes. Level of evidence Level III. Epidemiological.