Auditing Access to Outpatient Rehabilitation Services for Children With Traumatic Brain Injury and Public Insurance in Washington State.

OBJECTIVE: To identify insurance-based disparities in access to outpatient pediatric neurorehabilitation services. DESIGN: Audit study with paired calls, where callers posed as a mother seeking services for a simulated child with history of severe traumatic brain injury and public or private insurance. SETTING: Outpatient rehabilitation clinics. PARTICIPANTS: Sample of rehabilitation clinics (N=287): 195 physical therapy (PT) clinics, 109 occupational therapy (OT) clinics, 102 speech therapy (ST) clinics, and 11 rehabilitation medicine clinics. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Acceptance of public insurance and the number of business days until the next available appointment. RESULTS: Therapy clinics were more likely to accept private insurance than public insurance (relative risk [RR] for PT clinics, 1.33; 95% confidence interval [CI], 1.22-1.44; RR for OT clinics, 1.40; 95% CI, 1.24-1.57; and RR for ST clinics, 1.42; 95% CI, 1.25-1.62), with no significant difference for rehabilitation medicine clinics (RR, 1.10; 95% CI, 0.90-1.34). The difference in median wait time between clinics that accepted public insurance and those accepting only private insurance was 4 business days for PT clinics and 15 days for ST clinics (P≤.001), but the median wait time was not significantly different for OT clinics or rehabilitation medicine clinics. When adjusting for urban and multidisciplinary clinic statuses, the wait time at clinics accepting public insurance was 59% longer for PT (95% CI, 39%-81%), 18% longer for OT (95% CI, 7%-30%), and 107% longer for ST (95% CI, 87%-130%) than that at clinics accepting only private insurance. Distance to clinics varied by discipline and area within the state. CONCLUSIONS: Therapy clinics were less likely to accept public insurance than private insurance. Therapy clinics accepting public insurance had longer wait times than did clinics that accepted only private insurance. Rehabilitation professionals should attempt to implement policy and practice changes to promote equitable access to care.

Association Between Facility Type During Pediatric Inpatient Rehabilitation and Functional Outcomes.

OBJECTIVE: To compare functional outcomes between children receiving inpatient rehabilitation at children's hospitals and those at other facilities. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Children (N=28,793) aged 6 months to 18 years who received initial inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Total, cognitive, and motor developmental functional quotients (DFQs; which is the WeeFIM score divided by age-adjusted norms and multiplied by 100) at discharge from inpatient rehabilitation and WeeFIM efficiency (the change in WeeFIM score from admission to discharge divided by the length of the rehabilitation stay), adjusting for age, sex, race, insurance, region, admission function, impairment type, discharge year, and length of stay. RESULTS: A total of 12,732 children received rehabilitation at 25 children's hospitals and 16,061 at 36 other facilities (general hospitals or freestanding rehabilitation hospitals). Adjusting for clustering by facility, patients at children's hospitals had a lower cognitive DFQ at admission (difference between children's hospitals and other facility types, -3.8; 95% confidence interval [CI], -7.7 to -0.1), a shorter length of stay (median, 16d vs 22d; P<.001), and a higher WeeFIM efficiency (difference, 0.63; 95% CI, 0.25-1.00) than did children at other facility types. Rehabilitation in a children's hospital was independently associated with a higher discharge cognitive DFQ (regression coefficient, 2.3; 95% CI, 0.3-4.2) and more efficient rehabilitation admissions (regression coefficient, 0.3; 95% CI, 0.1-0.6). CONCLUSIONS: Children who receive inpatient rehabilitation at children's hospitals have more efficient inpatient rehabilitation admissions, a shorter median length of stay, and a slight improvement in cognitive function than do children at other facility types.

Trends and Disparities in Inpatient Rehabilitation of Adolescents: The Effect of Demographics, Injury Characteristics, and Facility Type.

BACKGROUND: Intensive rehabilitation of adolescents occurs in general and pediatric inpatient rehabilitation facilities (IRFs), but differences in admission and outcomes by facility type have not been thoroughly investigated, particularly among persons with spinal cord injury (SCI). OBJECTIVES: To investigate factors related to admission to pediatric or adult IRFs among adolescents and compare the rehabilitation outcomes between facility types. METHODS: Using a single-center retrospective cohort study design, demographic information, medical data, and rehabilitation outcomes were obtained by chart review of patients aged 15 to 18 years who received a rehabilitation medicine consultation at an urban level 1 trauma center between 2017 and 2019 (N = 96). Analysis was performed using R statistical software. RESULTS: SCI was the second most common diagnosis (21% of patients) and accounted for 36% of inpatient rehabilitation admissions. SCI patients were more likely to undergo rehabilitation at the level 1 trauma versus pediatric facility (relative risk [RR] = 2.43; 95% confidence interval [CI] = 1.08-5.44) compared to traumatic brain injury patients. Admission to trauma versus pediatric IRF was also associated with Black compared to White race (RR = 2.5; CI = 1.12-5.56), violence compared to other etiologies of injury (RR = 2.0; CI = 1.10-3.77), and Medicaid compared to private insurance (RR = 2.15; CI = 1.01-4.59). Admission to pediatric IRF was associated with longer length of stay than admission to adult IRF when adjusted for diagnosis (30.86 ± 21.82 vs. 24.33 ± 18.17 days; p = .046), but Functional Independence Measures did not differ. CONCLUSION: Adolescents with SCI and those experiencing systemic disadvantages, including racism and poverty, were more likely to be admitted to trauma compared to pediatric IRF.

Caregiver and provider experiences of physical, occupational, and speech therapy for children with medical complexity.

PURPOSE: Children with medical complexity (CMC) often use rehabilitative services ("therapy") to achieve optimal health outcomes. The study aims were to characterize caregiver and provider experiences with: 1) determining the suitability of therapy and 2) obtaining therapy for CMC. METHODS: Primary caregivers of CMC (n = 20) and providers (n = 14) were interviewed using semi-structured questions to elicit experiences of therapy. Interviews were recorded, transcribed and coded to identify caregiver and provider reported themes. Applied thematic analysis was used to characterize themes related to study objectives. RESULTS: Participants endorsed challenges setting therapy goals amongst competing patient and family priorities. They also identified logistical challenges to obtaining therapy, including transition from early intervention services to school-based years. Participants raised concerns about variability in obtaining school-based therapy and insurance coverage of community-based therapy. Overall, funding, salary, credentialing requirements, and training impacts the pediatric therapy workforce's ability to meet the need of CMC. CONCLUSION: Setting the ideal "dose" of therapy within the individual and family context can be challenging for CMC. Sufficient government programming, insurance coverage, and workforce availability were barriers to obtaining services. This study adds a more detailed understanding of therapy for CMC that can be used to inform future research and policy work.

Caregiver and Provider Experiences of Home Healthcare Quality for Children With Medical Complexity.

Despite a growing population of children with medical complexity, little is known about the current quality of pediatric home healthcare. The objective of this study was to characterize the quality of pediatric home healthcare experienced by primary family caregivers (parents) and healthcare providers of children with medical complexity. Semistructured, in-depth key informant interviews of 20 caregivers and 20 providers were conducted and analyzed for factors affecting home healthcare quality using the Institute of Medicine's quality framework (effective, safe, patient-centered, timely, equitable, and efficient). System complexity, insurance denials, and workforce shortages affected patients' ability to establish and maintain access to home healthcare leading to hospital discharge delays and negative family impacts. When home healthcare was accessible, respondents experienced it as effective in improving patient and family daily life and minimizing use of emergency and hospital services. However, respondents identified a need for more pediatric-specific home healthcare training and increased efficiencies in care plan communication. Overall, home healthcare was not perceived as timely or equitable due to access barriers. This study provides a new conceptual framework representing the relationship between home healthcare quality and outcomes for children with medical complexity for future evaluations of quality improvement, research, and policy initiatives.

Differences in Injury Characteristics and Outcomes for American Indian/Alaska Native People Hospitalized with Traumatic Injuries: an Analysis of the National Trauma Data Bank.

OBJECTIVE: This study compares characteristics of American Indian/Alaska Natives (AI/AN) and non-Hispanic Whites (NHW) hospitalized for traumatic injury and examines the effect of race on hospital disposition. METHODS: Using 2007-2014 National Trauma Data Bank data, we described differences in demographic and injury characteristics between AI/AN (n = 39,656) and NHWs (n = 3,309,484) hospitalized with traumatic injuries. Multivariable regressions, adjusted for demographic and injury characteristics, compared in-hospital mortality and the risk of discharge to different dispositions (inpatient rehabilitation/long-term care facility, skilled nursing facility, home with home health services) rather than home between AI/AN and NHW patients. RESULTS: Compared to NHWs, a higher proportion of AI/ANs were age 19-44 (49% versus 27%) years and hospitalized with assault-related injuries (25% versus 5%). AI/ANs had lower odds of dying than NHWs during hospitalization (adjusted odds ratio (aOR) 0.72, 95% CI 0.63-0.84). However, AI/ANs also had lower odds than NHWs to discharge to locations with additional health services even after controlling for injury severity (inpatient rehabilitation/long-term care facilities aOR 0.79, 95% CI 0.67-0.93; skilled nursing facility aOR 0.70, 95% CI 0.49-0.98; home with home health services aOR 0.62, 95% CI 0.49-0.79). CONCLUSIONS: Injury patterns and acute hospitalization outcomes were significantly different for AI/ANs compared to NHWs. Injury prevention strategies targeting AI/ANs should reflect these differential injury patterns. Outcomes such as disability and access to rehabilitation services should be included when considering the burden of injury among AI/AN communities.

Unmet Rehabilitation Needs After Hospitalization for Traumatic Brain Injury.

OBJECTIVES: In this study, we describe unmet service needs of children hospitalized for traumatic brain injury (TBI) during the first 2 years after injury and examine associations between child, family, and injury-related characteristics and unmet needs in 6 domains (physical therapy, occupational therapy, speech therapy, mental health services, educational services, and physiatry). METHODS: Prospective cohort study of children age 8 to 18 years old admitted to 6 hospitals with complicated mild or moderate to severe TBI. Service need was based on dysfunction identified via parent-report compared with retrospective baseline at 6, 12, and 24 months. Needs were considered unmet if the child had no therapy services in the previous 4 weeks, no physiatry services since the previous assessment, or no educational services since injury. Analyses were used to compare met and unmet needs for each domain and time point. Generalized multinomial logit models with robust SEs were used to assess factors associated with change in need from pre-injury baseline to each study time point. RESULTS: Unmet need varied by injury severity, time since injury, and service domain. Unmet need was highest for physiatry, educational services, and speech therapy. Among children with service needs, increased time after TBI and complicated mild TBI were associated with a higher likelihood of unmet rather than met service needs. CONCLUSIONS: Children hospitalized for TBI have persistent dysfunction with unmet needs across multiple domains. After initial hospitalization, children with TBI should be monitored for functional impairments to improve identification and fulfillment of service needs.

Functional outcomes during inpatient rehabilitation for American Indian and Alaska Native children with traumatic brain injury.

PURPOSE: American Indian/Alaska Native (AI/AN) people have the highest traumatic brain injury (TBI)-related mortality in the United States, but little is known about AI/AN children who survive traumatic brain injury (TBI). This study compares function and factors associated with discharge function between AI/AN and White children with TBI during inpatient rehabilitation. METHODS: Retrospective national cohort study of 114 AI/AN and 7,267 White children aged 6 months-18 years who received inpatient TBI rehabilitation between 2002-2012 at facilities utilizing the Uniform Data System for Medical Rehabilitation\scriptsize®. The outcome measure was developmental functional quotients (DFQ is the FIM\scriptsize® or WeeFIM\scriptsize® score divided by age norms x 100) at discharge. RESULTS: AI/AN race was not associated with motor (regression coefficient (ß) 0.18, 95% confidence interval (CI) -2.39, 2.76) or cognitive (ß -1.54, 95% CI -3.75, 0.67) function. Among a subgroup with loss of consciousness > 24 hours (AI/AN n= 13, White n= 643), AI/AN race was associated with lower motor DFQ (ß -12.83, 95% CI -25.39, -0.34). CONCLUSIONS: Overall, AI/AN race was not associated with inpatient rehabilitation function for children with TBI, but providers should not assume AI/ANs with more severe injuries have equitable outcomes.

Disparities in Functional Outcomes during Inpatient Rehabilitation between American Indian/Alaska Native and White Children.

American Indian/Alaska Native (AI/AN) children have a high risk for poor health outcomes. Race/ethnicity and functional impairments are linked with health care disparities. While data exist for other race/ethnicity groups, little is known about outcomes for AI/AN children with functional impairments. In this study the Functional Independence Measure for Children (WeeFIM®) was used to determine differences in outcomes between AI/AN and White children receiving inpatient rehabilitation for functional impairments at one pediatric rehabilitation facility. American Indian/Alaska Native and White children had similar impairment types and functional levels at admission to inpatient rehabilitation. Both groups experienced functional improvement during rehabilitation. At discharge, AI/AN children had lower total functional scores and had less improvement in mobility scores compared with White children, with more impairment in physical mobility at discharge. This is one of the first studies to show a disparity in functional outcomes for AI/AN children compared with White children during inpatient rehabilitation.