Contextual Determinants of Health Disparities in Utilization of Community-Based Rehabilitation Services Among Medicare Fee-for-Service Beneficiaries With Traumatic Brain Injury

OBJECTIVE: To examine the association between contextual social determinants of health (SDoH) and receipt of first outpatient or home health (HH) rehabilitation visit after hospital discharge among older adults with traumatic brain injury (TBI) in Texas. SETTING: Community following hospital discharge. PARTICIPANTS: 19 117 patients aged 66 and older hospitalized for a TBI from January 1, 2014, and discharged up to December 31, 2018, who returned home within 90 days from discharge. DESIGN: Retrospective cohort study using 100% Texas Medicare claims data. MAIN MEASURES: Contextual-level SDoH (eg, neighborhood ethno-racial identity make-up, socioeconomic position, and residential context) from the 2022 American Community Survey (zip-code level) and the 2023 County Health Rankings; HH and Outpatient Rehabilitation Services (eg, physical therapy, occupational therapy, speech/language therapy, and behavioral health [eg, psychology, neuropsychology, social work]). Fine-Gray competing risk models were conducted. RESULTS: Patients living in areas with higher median household incomes (Hazard ratio, HR = 0.92; 95% Confidence Interval, 95% CI: 0.87-0.97) and higher unemployment rate (HR = 0.98; 95% CI: 0.97-0.99) had decreased likelihood of having a HH visit upon return to community; those with higher uninsured rates (HR = 0.78; 95% CI: 0.70-0.87) and in rural areas (HR = 0.83; 95% CI: 0.76-0.92) had decreased likelihood of having an outpatient visit. In contrast, Food Environment Index (HR = 1.08; 95% CI: 1.05-1.11) increased the likelihood of having a HH visit while a higher percentage with severe housing problems (HR = 1.34; 95% CI: 1.22-1.46) increased the likelihood of an outpatient visit. When treating either outpatient or HH visits as a competing event, contextual-level SDoH was associated with a decreased likelihood of an outpatient visit but an increased likelihood of a HH visit. CONCLUSIONS: Disparities exist in access to rehabilitation following community discharge, based on contextual-level SDoH, indicating the need to improve access to rehabilitation services for persons with TBI living in communities with greater social needs.