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Rehabilitation Practices

Race

Studies of the effects of race on rehabilitation outcomes have generally been limited to retrospective evaluations of the differences between whites and African Americans (Meade et al. 2004; Putzke et al. 2002). Similar to studies on gender, investigations on race have focused more on vocational issues and satisfaction with life (James et al. 1993; Krause 1998; Krause et al. 1998; Meade et al. 2004) than rehabilitation.

Author, Year Country Research Design PEDro-Score Total Sample Size

Measures Outcome

Krause et al. (2006); USA
Case Series
NInitial=1342, NFinal=1278

Population: Mean age=41.6yr; Gender & Race: 75% white, 74% male, 56% white male, 21% white female, 18% African American men, 5% African American females; Injury Duration: Mean=9.7yr; Injury level: Cervical=55%: Injury severity: No sensation or movement=29.4%, sensation but no movement=28.5%, movement but not ambulation=20.8%, useful function including ambulation=21.5%.
Intervention: No intervention. Cross-sectional survey to examine the effect of race and gender on health status and healthcare utilization and the mediating effects of education and income.
Outcome Measures: Three general health indicators from the Behavioural Risk Factor Surveillance (self-rated health, days of poor physical health, days of poor mental health) and three healthcare utilization measures (number of hospitalizations, days of hospitalizations, number of doctor visits).

  1. A significant difference was seen based on race in 3 of 6 outcomes: African Americans had more days in poor health, more hospitalizations in the past year and more days hospitalized.
  2. Inclusion of mediators in MANOVA analysis indicated that variables of income and education accounted for much more of the variance seen for these variables of general health and healthcare utilization than did race.

Meade et al. (2004); USA
Case Control NInitial=628, NFinal=628

Population: Traumatic SCI from United States Model Systems database; matched white versus African American subjects matched by level of function, ASIA Impairment Scale, age and primary care sponsor: Mean age=34.2yr; Gender: males=84.2%, females=14.7%; Level of injury: paraplegia, tetraplegia; Severity of injury: AIS: A-D.
Intervention: No intervention. Various outcomes associated with acute inpatient and rehabilitation care focusing on race effects by comparing outcomes of African Americans and whites.
Outcome Measures: AIS motor index scores, FIM motor score, Medical complications, discharge disposition, medical procedures and medical management. Collected at admission to acute care and admission to and discharge from rehabilitation.

  1. No significant differences between white versus African American races for AIS and FIM motor index scores.
  2. No significant differences for discharge disposition (p=0.622).
  3. African Americans were more likely to be injured as a result of violence and whites were more likely to be injured in MVCs.
  4. African Americans were significantly more likely to receive laparotomies (p<0.001) and be catheter free in comparison to Caucasians.
  5. Whites were more likely to receive spine surgeries (p<0.001) and have more suprapubic cystomies in comparison to African Americans.
  6. No significant differences between racial groups in the occurrence of medical complications during either acute care or rehabilitation.

Pollard & Apple, (2003); USA
Case Series NInitial=412, NFinal=95

Population: Mean age=not reported; Gender: not reported; Level and severity of injury: incomplete tetraplegia; Time since injury=not reported.
Intervention: No intervention. Retrospective review of patients with incomplete tetraplegia to determine what patient characteristics, injury variables and management strategies are associated with improved neurological outcomes.
Outcome Measures: Motor score, motor level sensory score, sensory level and ASIA grade.

  1. Neurological recovery was not significantly related to race (p>0.05).

Putzke et al. (2002); USA
Case Control Study 1: NInitial=2438, NFinal=374 Study 2: Ninitial=3301, NFinal=316

Population: Study 1: Mean age=34.8yr (white) & 35.3yr (African American); Gender (both groups): males=90%, females=10%.
Study 2: Mean age=37.7yr (white) & 37.8yr (African American): Gender (both groups): males=93%, females=7%.
Intervention: No intervention. Race effects on various outcomes associated with integrated acute and rehabilitation care (study 1) or long- term (study 2) studied by comparing results between whites and African Americans.
Outcome Measures:
Study 1: FIM motor and efficiency scores, length of stay, discharge destination, medical complications, charges.
Study 2: FIM motor and efficiency scores, CHART, Satisfaction with Life Scale (SWLS), SF-12 (measured the individual’s perception of his/her health status), medical complications and number of hospitalizations. All collected at admission, discharge or at annual follow-up (Study 2 only).

Study 1

  1. Significant differences between race were not found relating to any of the outcome measures including FIM, Length of Stay (acute or rehabilitation care), Discharge destination and charges (p>0.05).
  2. The 2 groups were significantly different (p<0.001) on numerous other demographic and injury- related factors including age, education, gender, race, marital and occupational status, lesion level, and injury duration.

Study 2

  1. No significant differences were seen with SWLS, SF-12 and CHART (p=0.25).
  2. None of the medical outcome variables differed significantly (p>0.05) with race, including days rehospitalized and number of rehospitalizations in the previous year, impairment level, and total medical complications.
  3. Despite non-significant results with multivariate analyses, univariate analyses were also conducted and were generally non-significant except that whites reported less handicap on the CHART mobility subscale (p=0.03).
  4. As with Study 1, both groups differed significantly on numerous demographic and injury-related factors (p<0.001).

Eastwood et al. (1999); USA
Case Series NInitial=5180, NFinal=3904

Population: Age: <21=882, 21-30=1182, 31- 40=803, 41-50=484, >50=552, unknown=1; Gender: males=3157, females=747; Level and severity of injury: paraplegia-incomplete=777, paraplegia-complete=1202, tetraplegia- incomplete=1065, tetraplegia-complete=782, unknown=78; Time since injury=not reported.
Intervention: No intervention. Retrospective chart review of patients discharged between 1990 and 1997 with traumatic SCI to determine predictors of acute rehabilitation length of stay and their association with medical and social outcomes. Outcomes were assessed at rehabilitation discharge and 1yr following injury.
Outcome Measures: Rehabilitation LOS, age, race, method of bladder management, tetraplegia, education, marital status, discharge disposition, 1yr presence of pressure ulcers, rehospitalization, place of residence, days per week out of residence.

  1. Caucasians experienced significantly longer rehabilitation LOS than African Americans (p<0.05).

Discussion

Similar case control designs employing matched groups of Caucasians versus African Americans from the United States 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 versus Caucasians but these were generally accounted for by socio-demographic and etiological differences associated with these groups (Meade et al. 2004; Putzke et al. 2002). 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 (Meade et al. 2004; Putzke et al. 2002). It is likely that these etiological and socio-demographic variations have far more to do with differences seen in rehabilitation outcomes than race. In support of this, Pollard and Apple (2003) found that neurological recovery was not affected by race.

Krause et al. (2006) observed that, post-discharge, African Americans in a Southeastern United States 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. In contrast, Eastwood and colleagues (1999) found that African Americans experienced shorter rehabilitation LOS than Caucasians. Although, this difference was not further explored in the study, it may be attributable to variation in injury severity.

Conclusions

There is level 3 (from two case control studies and three case series: Eastwood et al. 1999; Krause et al. 2006; Meade et al. 2004; Pollard & Apple 2003; Putzke et al. 2002) that there is no difference with respect to race (Caucasians versus African-American) on rehabilitation LOS and neurological or functional outcomes associated with rehabilitation that are not otherwise explained by socio-demographic or etiological differences.

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