Disparity in Changes of Post-Acute Care Rehabilitation During the COVID-19 Pandemic

Objective To examine changes in access to post-acute care (PAC) across rehabilitation service areas (RSAs) before and during the COVID-19 pandemic, and to assess the effects of rurality, race/ethnicity, and dual eligibility on such changes. Design Retrospective cross-sectional study. Setting and Participants Medicare records for 736,663 beneficiaries aged ≥66 years hospitalized for stroke, hip fracture, or joint replacement from 2018 to 2021 linked to 1711 RSAs. Methods Multilevel generalized linear mixed models estimated PAC use, adjusting for patient and geographic factors. We examined interactions between the pandemic period (2018-2019 vs 2020-2021) and rurality, race/ethnicity, and dual eligibility for each diagnosis. Results As expected, PAC use declined during COVID-19 across all conditions. Minority [odds ratio (OR) = 0.93, P < .001] and dual-eligible (OR = 0.96, P = .003) stroke survivors had reduced PAC use during the pandemic. Dual-eligible patients with hip fractures had significantly decreased PAC use (OR = 0.84, P < .001). Unexpectedly, rural joint replacement patients showed increased PAC use (large rural OR = 1.08, P < .001; small town/rural OR = 1.05, P = .005). Conclusions and Implications We found variations of PAC use across conditions during the pandemic. Fewer stroke and hip fracture survivors—particularly those who were dual-eligible—received needed rehabilitation services, underscoring a gap in access during this critical period. In contrast, rural patients with joint replacements demonstrated increased PAC use during the pandemic. These findings highlight the importance of developing postpandemic policies that safeguard access to rehabilitation for traditionally vulnerable populations, such as dual-eligible patients.