Rehabilitation after hip fracture--equal opportunity for all?

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.

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.

297 randomly selected hospitals from 5 states.

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

Observational study.

Initiation and intensity of PT/OT while in the acute hospital.

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.

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.