Rural/urban differences in discharge from rehabilitation in older adults with traumatic brain injury

Abstract

Background/objectives: Rates of traumatic brain injury (TBI) among older adults and treatment of this population in nursing homes are increasing. The objective of this study is to examine differences in the quality of care and outcomes of older adults with TBI in rural and urban settings by (1) comparing the rates of successful community discharge; and (2) reasons for not achieving successful discharge among patients in rural and urban environments.

Design: Retrospective national cohort study of skilled nursing facility (SNF) patients using Medicare inpatient claims linked with Minimum Data Set assessments. Demographic, health, and facility characteristics were compared between rural and urban settings using descriptive statistics. Logistic regression with state random effects was used to identify characteristics that predicted successful discharge.

Setting: U.S. skilled nursing facilities (n = 11,771).

Participants: Medicare beneficiaries aged 66 and older discharged to a SNF following hospitalization for TBI between 2011 and 2015 (n = 61,021).

Measurements: Successful community discharge defined as discharge from SNF within 100 days of admission and remaining in the community for ≥30 days without dying or admission to an inpatient healthcare facility.

Results: Unadjusted rates of successful discharge were significantly lower for patients in rural settings compared with patients in urban settings (52.1% vs 58.5%, p < 0.01). Patients in rural settings had lower adjusted odds (odds ratio 0.84, 95% confidence interval = 0.80-0.89) of successful discharge. Reasons for not discharging successfully differed between rural and urban settings with rural patients less likely to discharge from SNF within 100 days though also less likely to be rehospitalized within 30 days of SNF discharge.

Conclusion: Given the low overall rate of successful community discharge and worse outcomes among rural patients, further research to explore interventions to improve SNF care and discharge planning in this population is warranted.

Keywords: brain injuries; rural health service; skilled nursing facilities; urban health service.