Abstract
BACKGROUND: Older adults with socioeconomic disadvantage experience greater decline in function and cognition after critical illness, an adverse outcome potentially preventable through mobilization. Whether safety-net hospitals (SNHs) that serve the highest proportions of patients with socioeconomic disadvantage are less likely to deliver rehabilitation during hospitalization with stay in the ICU is unknown. RESEARCH QUESTION: Are SNHs less likely to provide rehabilitation (physical or occupational therapy or both) services to older adults hospitalized with acute respiratory failure (ARF) who receive invasive mechanical ventilation (IMV) than non-SNHs? STUDY DESIGN AND METHODS: A retrospective cohort study of older adults (age ≥ 65 years) hospitalized with ARF, an ICU stay of ≥ 1 day, and receipt of IMV between 2016 and 2019 using Medicare Provider Analysis and Review files. The primary outcome was delivery of rehabilitation during hospitalization. The exposure was SNH status, defined as hospitals in the top quartile of the Disproportionate Share Hospital index. We constructed hierarchical multivariable logistic regression models with hospitals as the random effect, adjusting for patient and hospital characteristics, to evaluate the association between SNH status and rehabilitation delivery. We calculated hospital-level risk-standardized rehabilitation delivery rate and characterized variation using a median OR (MOR). RESULTS: We identified 868,735 ICU hospitalizations across 1,859 US hospitals; one-half were adults between 65 and 74 years of age, 48% were female, and 77% were White. Rehabilitation was delivered in 59.1% of all hospitalizations. In the adjusted model, SNHs showed 20% lower odds of delivering rehabilitation compared with non-SNHs (adjusted OR, 0.80; 95% CI, 0.75-0.86). Hospitals varied widely in delivering rehabilitation services with a median risk-standardized rehabilitation rate of 59.4% (interquartile range, 51.7%-67.3%) and an MOR of 1.69. INTERPRETATION: SNHs showed a 20% lower odds of delivering rehabilitation to older adults hospitalized with ARF. Differences in rehabilitation delivery could be a potential mechanism for socioeconomic disparities in functional and cognitive decline after critical illness.