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Effect of Gender and Race on Rehabilitation Outcomes

Potentially, there are many additional factors that may affect rehabilitation outcomes following inpatient SCI rehabilitation. Two of these factors include gender and race, although neither has been examined comprehensively. With respect to gender effects, studies investigating rehabilitation outcomes associated with women have focused on long-term psychosocial outcomes associated with issues such as marriage or motherhood or issues associated with community and vocational reintegration (Westgren & Levi 1994; DeVivo et al. 1995; Shackelford et al. 1998; Krause et al. 1998). Studies of the effects of race on rehabilitation outcomes have been limited to evaluations of the differences between whites and African Americans using US Model Systems data (Meade et al. 2004a; Putzke et al. 2002), although as with studies of gender, investigations of the effects of race have focused more on vocational issues and satisfaction with life (James et al. 1993; Krause et al. 1998; Krause 1998; Meade et al. 2004b).

Table 8: Individual Studies – The Effect of Gender on Rehabilitation Outcomes

Table 9: Individual Studies – The Effect of Race on Rehabilitation Outcomes

Discussion

Gender

Greenwald et al. (2001) employed a mixed, block design, matching male and female subjects so as to control for covariant effects of injury characteristics (level and AIS) and age at injury. They retrospectively analyzed 1,074 subjects over a 10-year period from 1988-1998 by using US Model Systems data culled from 20 different SCI centers over a variety of geographic regions. In general, there were no significant differences between males and females for rehabilitation outcomes including discharge disposition, LOS, FIM motor scores (including change scores and efficiencies) or ASIA motor scores. There were also no reported gender-related differences for the incidence of most medical complications encountered during rehabilitation stay including pneumonia, autonomic dysreflexia, pulmonary embolism, cardiac arrest, kidney calculi or gastrointestinal hemorrhage. However, men did have significantly higher rates for pressure sores although the authors reported that these differences were not robust and did not result in increased stays, charges or lower functional outcomes.

Studies have found mixed evidence for gender-related differences in the incidence of DVT in the spinal cord injured population. Greenwald et al. (2001) demonstrated a significantly higher rate of DVT in men while Furlan et al. (2005) found a higher trend of DVT in women.

The prevalence of psychiatric complications was found to be higher in women than men in the spinal cord injured population (Furlan et al. 2005). After SCI, women in the chronic stage had more symptoms of depression than men in the chronic stage (Furlan et al. 2003) but Krause et al. (2006) did not report a gender difference with regard to number of days adversely impacted by poor mental health in women.

Sipski et al. (2004) demonstrated that as a whole no gender related differences were seen in ASIA score improvement 1 year after injury. However, in contrast to the Greenwald et al. (2001) and Furlan et al. (2005) studies, Sipski et al. (2004) found  women’s ASIA motor scores were significantly higher than men’s 1 year after injury. Also in contrast to Greenwald et al. (2001), Sipski et al. (2004) found men showed significantly more FIM motor improvement than women by discharge.

Overall, it appears there is only minimal evidence that suggests gender differences for most rehabilitation outcomes. Of note, the study with the strongest design (i.e., case control with matching to limit potential confounding) found few gender-related differences (Greenwald et al. (2001). Of note, Krause et al. (2006) found a significant difference between men and women in only one (i.e., nonroutine physician visits) of six measures addressing healthcare utilization and general health status. Upon analysis of the effect of the potential mediating variables of education and income it was found that these had substantially more impact on the likelihood of women having more nonroutine physician visit than did the role of gender differences.

Race

Similar case control designs employing matched groups of Caucasians vs. African Americans from the US Model Systems database have also been employed to examine race effects on rehabilitation outcomes. Putzke et al. (2002) matched race groups according to age, education, gender, occupational status, impairment level, etiology, primary sponsor of care and geographic region whereas Meade et al. (2004) matched according to level of injury, AIS, age and primary sponsor of care. By controlling for all these variables, these authors were able to establish that race acts more as a proxy variable than a predictor of outcomes (Putzke et al. 2002). For example, differences did exist in a wide variety of demographic, rehabilitation outcomes and medical complications for African Americans vs. Caucasians but these were generally accounted for by socio-demographic and etiological differences associated with these groups (Putzke et al. 2002; Meade et al. 2004). For example, African Americans were significantly more likely to be injured as the result of violence and have 11th grade education or less while Caucasians were more likely injured as a result of motor vehicle crashes and had high school education or more (Putzke et al. 2002; Meade et al. 2004). It is likely that these etiological and socio-demographic variations have far more to do with differences seen in rehabilitation outcomes than race.

Similarly, Krause et al (2006) observed that, post-discharge, African Americans in a Southeastern US SCI population reported a greater number of poor health days, more hospitalizations, and a greater number of days hospitalized. However, by conducting an analysis of the effect of the potential mediating variables of education and income it was found that these had substantially more impact on these findings than did the effect of race.

Conclusions

There is level 3 evidence from a single study that there is no difference with respect to gender on discharge destination, rehabilitation LOS and neurological or functional outcomes associated with rehabilitation, although there is conflicting level 4 evidence from individual studies that indicate gender differences for some of these outcomes.

There is level 3 evidence that there is no difference with respect to race (Caucasians vs African-American) on rehabilitation LOS and neurological or functional outcomes associated with rehabilitation that are not otherwise explained by socio-demographic or etiological differences.

  • Neither gender nor race effects have been demonstrated definitively for discharge destination, rehabilitation LOS and neurological or functional status in US Model Systems data.