Background: Hospital-associated disability (HAD) is the new loss of ability to complete one or more activities of daily living without assistance after hospital discharge and occurs in 31% of hospitalized patients. HAD and low mobility during hospitalization are associated with higher risk of readmission, permanent disability, new institutionalization, and death. Physical therapy (PT) is invaluable for preventing and treating HAD. However, Black patients have lower physical function, higher rates of mobility loss and functional decline, earlier and more progressive disability onset than White patients, but lower rates of referral to intensive and outpatient rehabilitation. Little is known about HAD and PT referrals for Black patients hospitalized for acute medical illness. We aimed to assess racial differences in HAD and PT referral in patients hospitalized for acute medical illness.
Methods: This was a cross-sectional study of patients admitted to medicine services 10/2018 – 3/2021. during the study period. Patients with missing data, who were discharged to hospice or a psychiatric facility, or died, were excluded. For remaining eligible patients, we obtained age, sex, race, length-of-stay, Activity Measure Post-Acute Care (AM-PAC) scores (functional mobility score) on admission and discharge, and presence or absence of PT referral during admission. HAD was defined as admission AMPAC score of > 18 with discharge AMPAC score ≤ 18. Change in mobility was calculated as discharge AM-PAC – admission AM-PAC. Functional impairment was defined as AMPAC < 18. Differences in HAD, functional impairment, and PT referral by race were analyzed by chi squared test. Difference in mobility change by race was assessed by two-sample T test. Logistic regression was used to analyze association of Black race with referral to PT, controlling for age, sex, baseline mobility, mobility change, and length-of-stay. Linear regression was used to analyze the association of Black race with mobility change controlling for age, gender, baseline mobility, and length-of-stay. Subgroup analyses were stratified by age (< 65 and 65+) and baseline mobility (AM-PAC >18 vs. ≤18).
Results: Of the 20,810 patients included in the study, 55% were female, 83% were Black, 42% were > 65 years old, and 55% received referral for PT. Black patients had more functional impairment on admission [48.1% vs 42.0% X2 (2, N = 20,810), = 34.1, p < 0.001]. Compared to White patients, Black patients with functional mobility impairment on admission had less mobility gain during hospitalization [-0.69 points t(9.349) = 2.5, p < 0.05]. Fewer Black patients with functional impairment on admission received PT referral [78.3% vs 81.4% X2 (2, N = 20,810), = 5.5, p < 0.05]. Black race was associated with a statistically significant negative effect on mobility change during hospitalization [F(20,810) = 471.8, p < 0.001, R2 = 0.15]. The negative effect was statistically significantly stronger for seniors and those with functional impairment on admission. There was no difference in PT referrals or HAD overall by race.
Conclusions: Our study suggests that Black patients with functional impairments have lower rates of PT referral and less mobility gain during hospitalization. Limitations included a single-center study in a population of mostly Black patients, affecting generalizability. Future studies will assess a broader patient population and control for social determinants of health. Hospitalists may consider Black race a risk factor when prescribing physical therapy.