Socioeconomic disparities and access to care: Fragmentation of care after older adult trauma

BACKGROUND: Fragmentation of care (FOC) describes unplanned readmission to a nonindex hospital and is associated with poorer clinical outcomes, particularly in older adults. The aim of this study was to evaluate the impact of socioeconomic disparities, particularly patient income and region of residence, on FOC in older adult trauma patients. METHODS: In this retrospective study, we analyzed the 2019 Nationwide Readmissions Database to identify patients 65 years of age or above who were readmitted within 90 days following an index admission for trauma. FOC was defined as an unplanned readmission to a nonindex hospital, and patients were stratified by the presence or absence of FOC. Multivariable logistic regression was used to study the effect of median patient household income (stratified into quartiles) and patient location (urban vs. rural) on FOC. RESULTS: A total of 142,584 patients were included: 73% nonfragmented and 27% fragmented. The median age was 80 years. On univariate analysis, patients residing in rural regions were much more likely to be fragmented (15% vs. 11%, p <0.001). After adjusting for clinically relevant factors, higher income quartiles were associated with a stepwise decrease in the odds of FOC (adjusted odds ratio: 0.96 for second quartile, 0.90 for third quartile, and 0.82 for fourth quartile, first quartile as reference; p <0.001). Rural residence was associated with higher odds of FOC compared with urban residence (adjusted odds ratio: 1.86, 95% CI: 1.77–1.95). These results were unchanged after stratifying patients by index hospital teaching status, with higher income associated with a greater decrease in risk of FOC in the cohort of patients initially admitted to nonteaching hospitals. CONCLUSIONS: Lower income and rural residence were independently associated with higher FOC in the older adult trauma population. These findings highlight the importance of accounting for the impact of socioeconomic disparities on access to care in older adult trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.