Rehabilitation after hip fracture--equal opportunity for all?

Objectives: To determine whether factors unrelated to clinical appropriateness affect use of physical and occupational therapy (PT/OT) in elderly Medicare patients with acute hip fracture.

Design: Bivariate and multivariate analysis of detailed clinical data retrospectively gathered from medical records and of nonclinical variables obtained through linkage with the American Hospital Association data base.

Setting: 297 randomly selected hospitals from 5 states.

Patients: 2,762 elderly Medicare patients hospitalized with a primary diagnosis of acute hip fracture who were hospitalized during 1981-1982 or 1985-1986.

Intervention: Observational study.

Main Outcome Measures: Initiation and intensity of PT/OT while in the acute hospital.

Results: We found evidence that factors not relevant to clinical appropriateness, such as race, hospital size, and state, significantly affect whether patients receive any PT/OT after acute fracture, as well as the intensity of PT/OT. For example, after controlling for patient clinical characteristics, we found that 63% of African-American patients received low-intensity PT/OT in comparison to 43% among non-African-American, and we found threefold differences among states both in initiation of PT/OT and in the intensity of its use. Overall, clinical characteristics had relatively greater influence on whether patients started PT/OT, whereas factors not relevant to clinical appropriateness had relatively greater influence on how much rehabilitation was provided.

Conclusion: There are significant disparities in use of rehabilitation after hip fracture, only partially explained by patient clinical characteristics. Factors without obvious relevance to the clinical appropriateness of PT/OT exert a significant influence on use of rehabilitation services, particularly on the intensity of their use.