Abstract
Objective:
To determine if there were racial differences in discharge location among older adults treated for TBI at a level 1 trauma center.
Design:
Retrospective cohort study.
Setting:
R Adams Cowley Shock Trauma Center
Participants:
Black and white adults aged ≥65 years treated for TBI between 1998-2012 and discharged to home without services or inpatient rehabilitation (n=2,902).
Main Outcome Measures:
We assessed the association between race and discharge location via logistic regression. Covariates included age, gender, Abbreviated Injury Scale (AIS)-Head score, insurance type, Glasgow Coma Scale (GCS) score, and comorbidities.
Results:
There were 2,487 (86%) whites and 415 blacks (14%) in the sample. A total of 1,513 (52%) were discharged to inpatient rehabilitation and 1,389 (48%) were discharged home without services. In adjusted logistic regression, blacks were more likely to be discharged to inpatient rehabilitation than to home without services compared to whites (odds ratio 1.34, 95% confidence interval 1.06-1.70).
Conclusions:
In this group of Medicare-eligible older adults, blacks were more likely to be discharged to inpatient rehabilitation compared to whites.
Keywords: TBI, discharge disposition, race, older adults, rehabilitation
Traumatic brain injury (TBI) is one of the leading causes of injury-related disability and death in the United States. In 2013, 2.8 million people sustained a TBI and 282,000 resulted in hospitalization.1 TBI can result in significant impairment, with an estimated 3.2-5.3 million adults living with TBI-related disability.2 Older adults have the highest rates of TBI-related hospitalization and death, and worse functional outcomes following TBI compared to younger individuals with similar injuries, regardless of TBI severity.3,4 Rehabilitation following TBI improves cognitive, neuropsychological, and physical functioning among older adults,5–9 yet evidence suggests racial variation in discharge to rehabilitation.10–12
Several studies have reported that blacks and Hispanics are less likely to be discharged to rehabilitation following TBI compared to whites in mixed populations of older and younger adults.10, 12–14 One study of patients admitted to a Level I trauma center found that whites were more likely to be discharged to rehabilitation than to home compared to non-whites.14 Asemota et al. (2013) reported lower likelihood of receiving rehabilitation following moderate to severe TBI among blacks and Hispanics compared to whites, using hospital discharge records from the Nationwide Inpatient Sample (NIS).10 A limitation of these prior studies is that they did not analyze older adults separately. This is important because 94% of adults over 65 have government-administered health insurance, primarily through Medicare, improving their access to care and potentially minimizing differences in discharge location.15,16 One study addressed this limitation by conducting a sub-analysis among Medicare beneficiaries. In that study, Meagher at al. (2015) reported that blacks and Hispanics were less likely to be discharged to higher levels of rehabilitation compared to whites, suggesting that racial differences in discharge to rehabilitation post-TBI occur regardless of uniform insurance coverage.11
In addition to limited information on discharge differences among older adults with TBI, categorization of discharge location varied greatly in prior studies, hampering efforts to make comparisons across studies or replicate results.10,11,17 The objective of this study was to determine if there were racial differences in discharge location among older adults treated for TBI at a trauma center. Due to improved access to care through Medicare, we hypothesized that there would be no difference in discharge to rehabilitation by race. This information will help to promote favorable health outcomes for older adults following TBI.
Methods
Study Design and Source Population
We conducted a retrospective analysis of individuals ≥65 years old treated at the R Adams Cowley Shock Trauma Center (STC) of the University of Maryland for blunt or penetrating TBI between 1998-2012. The STC is Maryland’s Primary Adult Resource Center and treated thirty percent of all trauma cases in Maryland between June 2015 and May 2016.18 In addition, the STC is the state EMS system’s specialty referral center for neurotrauma, treating 2,258 patients with TBI over the same time period.19 Data for this study came from STC trauma registry (STR) which contains data on all STC admissions and includes demographic and clinical information, mechanism of injury, information regarding the nature and severity of the injury, procedures performed, and discharge location. The STC adheres to standard treatment protocols for all trauma including TBI that follow accepted best practices.
TBI was identified using International Classification of Diseases-9-CM diagnostic codes (ICD-9-CM) 800.xx, 801.xx, 803.xx, 804.xx, 850.xx- 854.1x, 950.1-950.3, and 959.01. To increase specificity, we required patients to have an Abbreviated Injury Scale (AIS)-Head score ≥ 1. Patients who were deceased at discharge were excluded. We categorized race as white or black. Individuals with other race (n=129, comprised of any other category of race: 29% American Indian/Alaska Native, 3% Asian, 11% Hispanic, 1% two or more races, and 56% other race) were excluded from analyses due to the heterogeneity of the group.
Outcome Measure
In the STR, there were nineteen codes for discharge location: outpatient therapy, home care, residential facility, inpatient rehabilitation, chronic care, acute care, home no services, University of Maryland Medical System (UMMS), psychiatric, military, shelter, home with services, inpatient out of state, inpatient in state, police custody, other, against medical advice, and hospice. We worked with experts at the STC to create categories. Our initial categorizations included home with services (home with services, home care, residential facility, outpatient therapy), home without services (discharge to home without services, shelter), inpatient rehabilitation (inpatient rehabilitation, inpatient out of state, inpatient in state), acute care (acute care, chronic care, UMMS), and other (psychiatric, military, police custody, against medical advice, hospice). Inpatient rehabilitation refers to rehabilitation within the same hospital, inpatient in state refers to rehabilitation at an external facility but within the same state, and inpatient out of state refers to rehabilitation at an external facility outside of the state. Due to the small numbers and heterogeneity of some of these categories, we restricted our analysis to the two largest groups, home without services and inpatient rehabilitation.
Covariates
Covariates included age, gender, primary insurance payer (Medicare, automobile (if this was the primary payer in motor vehicle collisions), commercial (includes military insurance, workman’s compensation, and self-pay)), intensive care unit (ICU) stay, and year of injury.
Measures of injury severity included the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS), and the Glasgow Coma Scale (GCS) score. The AIS is an anatomic measure of injury severity, classified by specific body regions (head, face, spine, thorax, extremities) ranging from 1 to 6, with 1 indicating mild injury and 6 indicating a fatal injury in each of the body regions.20 Here, we were specifically interested in the AIS-Head (AIS-H) score as a measure of TBI severity. For the purpose of this analysis, we have excluded anyone with an AIS-H score of 6 (unsurvivable injury) and have combined categories 1 and 2. The ISS is a score of severity assigned to those with multiple injuries, with higher scores indicating greater polytrauma.21 It is equal to the sum of the squares of the three highest AIS scores for different body regions. ISS was categorized as ≤9 (mild), 10-14 (moderate), 15-24 (severe), and ≥25 (critical).21 The Glasgow Coma Scale (GCS) score is a neurologic measure of TBI severity based on eye response, verbal response, and motor response.22 It measures the consciousness of a person following a brain injury and is scored on a 15-point scale with higher scores indicating better neurologic function. We categorized it as ≥13 (mild), 9-12 (moderate), and ≤8 (severe). Comorbidities were obtained via patient history and entered into the STR as ICD-9-CM codes, these included: Alzheimer’s dementia (331), alcohol dependence (303.9), arrhythmias (427.9), asthma (493.9, 493.91), chronic kidney disease (584.9, 585), chronic obstructive pulmonary disorder (COPD) (496), depression (311), diabetes (250, 250.01), heart failure (428), hypertension (401.9), ischemic heart disease (410.9, 412, 413.9), neurologic disorders (332, 345.9), overweight/obese (278), severe mental illness (295.9, 296.7), and stroke (436). We created a composite measure of comorbid illness by summing these comorbidities and dichotomizing that sum at 2.
Statistical Analysis
We assessed differences in clinical and demographic factors between races and discharge locations using Pearson’s chi square for categorical variables and Student’s t-test for continuous variables. Variables associated with race and discharge location at p<0.05 were considered for inclusion in our logistic regression model. We used logistic regression to model the adjusted association between race and discharge to inpatient rehabilitation compared to discharge to home without services. First, we modeled the association adjusting only for variables that were measured before the TBI and could not be in the causal pathway (age, sex, insurance type, and comorbidities) (Model 1). Next, we added post-TBI variables GCS and AIS-H to assess how much variation in the association between race and discharge location was explained by these severity measures (Model 2). We reported odds ratios (OR) and 95% confidence intervals (95% CI).
We conducted sensitivity analyses to test the effect of our assumptions on the results. To determine whether inclusion of individuals with mild TBI (AIS=1) might have biased results, we re-ran our models restricted to those with AIS-H ≥2. A second sensitivity analysis was performed by restricting the analysis to Medicare beneficiaries only in order to minimize differences in access to care. We also combined acute care with inpatient rehabilitation (considered higher level of care) and home with and without services (lower level care) to determine if our categorizations of discharge location may have affected results. Since other studies included ISS and ICU stay in their regression models, we added these variables to our models in sensitivity analysis.
All analyses were performed using SAS software version 9.3 (SAS Institute, Cary NC) and a p-value of <0.05 was considered statistically significant. This study was approved by the Institutional Review Board of the University of Maryland, Baltimore.
Results
We identified 4,551 patients aged 65 and older treated for TBI at the R Adams Cowley Shock Trauma Center (STC) between 1998-2012. Patients who were deceased at discharge (n=903), missing discharge disposition (n=6), missing insurance information (n=2), other race (n=129), and missing race (n=71) were excluded. Our analysis focused on the two most common discharge locations, representing 84% of discharges, hence individuals discharged to other locations (n=538) were excluded. However, characteristics of the total sample including all discharge locations are available in Table 1. Our final sample comprised 2,902 older adults with TBI of which 2,487 (86%) were white, 415 (14%) were black, and 2,198 (76%) had Medicare as the primary payer (Table 2). A total of 1,513 (52%) were discharged to inpatient rehabilitation and 1,389 (48%) were discharged home without services. Mean age of the sample was 77.3 (standard deviation (SD) 7.9) years and 53% were male.
Table 1.
Characteristics of adults age ≥65 treated for traumatic brain injury at the R Adams Cowley Shock Trauma Center (1998- 2012) by race including all discharge locations, N=3,440
| Total (N=3,440) |
White (N=2,952) |
Black (N=488) |
p-valuea | |
|---|---|---|---|---|
| Age in years (mean, SD) | 77.6 (7.9) | 77.9 (7.8) | 75.7 (7.8) | <0.001 |
| Age Categories (n,%) | <0.001 | |||
| 65-74 | 1,349 (39.2) | 1,107 (37.5) | 242 (49.6) | |
| 75-84 | 1,245 (36.2) | 1,075 (36.4) | 170 (34.8) | |
| ≥85 | 846 (24.6) | 770 (26.1) | 76 (15.6) | |
| Sex (n,%) | 0.02 | |||
| Female | 1,655 (48.1) | 1,445 (49.0) | 210 (43.0) | |
| Male | 1,785 (51.9) | 1,507 (51.0) | 278 (57.0) | |
| GCSb (n,%) | 0.03 | |||
| ≥13 | 2,978 (86.6) | 2,571 (87.1) | 407 (83.4) | |
| 9-12 | 254 (7.4) | 215 (7.3) | 39 (8.0) | |
| ≤8 | 207 (6.0) | 165 (5.6) | 42 (8.6) | |
| ISSc categories (n,%) | 0.82 | |||
| ≤9 | 883 (25.7) | 600 (24.1) | 132 (27.1) | |
| 10-14 | 456 (13.3) | 330 (13.2) | 66 (14.5) | |
| 15-24 | 1,300 (37.8) | 948 (38.1) | 183 (37.5) | |
| ≥25 | 801 (23.3) | 609 (24.5) | 107 (21.9) | |
| AIS Head Scored (n,%) | 0.02 | |||
| ≤2 | 1,064 (30.9) | 912 (30.9) | 152 (31.2) | |
| 3 | 631 (18.4) | 525 (17.8) | 106 (21.7) | |
| 4 | 1,356 (39.4) | 1,190 (40.3) | 166 (34.0) | |
| 5 | 389 (11.3) | 325 (11.9) | 64 (13.1) | |
| Insurance (n,%) | <0.001 | |||
| Medicare | 2,630 (76.4) | 2,274 (77.0) | 356 (73.0) | |
| Auto | 542 (15.8) | 472 (16.0) | 70 (14.3) | |
| Commercial | 268 (7.8) | 206 (7.0) | 62 (12.7) | |
| ICUe (n,%) | 0.50 | |||
| No | 2,570 (74.7) | 2,212 (74.9) | 358 (73.4) | |
| Yes | 870 (25.3) | 740 (25.1) | 130 (26.6) | |
| Discharge location (n,%) | 0.21 | |||
| Against medical advice | 3 (0.1) | 3 (0.1) | 0 (0.0) | |
| Acute care | 28 (0.8) | 25 (0.8) | 3 (0.6) | |
| Chronic care | 64 (1.9) | 57 (1.9) | 7 (1.4) | |
| Home without services | 1,389 (40.4) | 1,206 (40.8) | 183 (37.5) | |
| Home with services | 142 (4.1) | 123 (4.2) | 19 (3.9) | |
| Hospice | 6 (0.2) | 5 (0.2) | 1 (0.2) | |
| Inpatient in-state | 1,445 (42.0) | 1,225 (41.5) | 220 (45.1) | |
| Inpatient out-of-state | 67 (2.0) | 55 (1.9) | 12 (2.5) | |
| Inpatient rehabilitation | 1 (0.0) | 1 (0.0) | 0 (0.0) | |
| Military | 5 (0.2) | 3 (0.1) | 2 (0.4) | |
| Other | 24 (0.7) | 20 (0.7) | 4 (0.8) | |
| Outpatient therapy | 8 (0.2) | 5 (0.2) | 3 (0.6) | |
| Police custody | 3 (0.1) | 1 (0.0) | 2 (0.4) | |
| Psychiatric | 2 (0.1) | 2 (0.1) | 0 (0.0) | |
| Residential facility | 41 (1.2) | 37 (1.3) | 4 (0.8) | |
| UMMS | 212 (6.0) | 184 (6.2) | 28 (5.8) | |
| Comorbidities (n,%) | <0.001 | |||
| <2 | 2,038 (59.2) | 1,783 (60.4) | 255 (52.2) | |
| ≥2 | 1,402 (40.8) | 1,169 (39.6) | 233 (47.8) | |
| Injury Year (n,%) | 0.19 | |||
| 1998-2001 | 634 (18.4) | 534 (18.1) | 100 (20.5) | |
| 2002-2005 | 761 (22.1) | 669 (22.6) | 92 (18.8) | |
| 2006-2009 | 1,024 (29.8) | 882 (29.9) | 142 (29.1) | |
| 2010-2012 | 1,021 (29.7) | 867 (29.4) | 154 (31.6) | |
Table 2.
Characteristics of adults age ≥65 treated for traumatic brain injury at the R Adams Cowley Shock Trauma Center (1998- 2012) by race, restricted to home without without services vs. inpatient rehabilitation, N=2,902
| Total (N=2,902) |
White (N=2,487) |
Black (N=415) |
p-valuea | |
|---|---|---|---|---|
| Age in years (mean, SD) | 77.3 (7.9) | 77.7 (7.9) | 75.5 (7.8) | <0.001 |
| Age Categories (n,%) | <0.001 | |||
| 65-74 | 1,188 (41.2) | 975 (39.2) | 213 (51.3) | |
| 75-84 | 1,017 (34.8) | 881 (35.4) | 136 (32.8) | |
| ≥85 | 697 (24.0) | 631 (25.4) | 66 (15.9) | |
| Sex (n,%) | 0.01 | |||
| Female | 1,362 (46.9) | 1,191 (48.0) | 171 (41.2) | |
| Male | 1,540 (53.1) | 1,296 (52.0) | 244 (58.8) | |
| GCSb (n,%) | 0.06 | |||
| ≥13 | 2,522 (86.9) | 2,175 (87.5) | 347 (83.6) | |
| 9-12 | 202 (7.0) | 169 (6.8) | 33 (8.0) | |
| ≤8 | 177 (6.1) | 142 (5.7) | 35 (8.4) | |
| ISSc categories (n,%) | 0.52 | |||
| ≤9 | 708 (24.4) | 600 (24.1) | 108 (26.0) | |
| 10-14 | 391 (13.5) | 330 (13.3) | 61 (14.7) | |
| 15-24 | 1,104 (38.0) | 948 (38.1) | 156 (37.6) | |
| ≥25 | 699 (24.1) | 609 (24.5) | 90 (21.7) | |
| AIS Head Scored (n,%) | 0.005 | |||
| ≤2 | 897 (30.9) | 764 (30.7) | 133 (32.0) | |
| 3 | 520 (17.9) | 426 (17.1) | 94 (22.7) | |
| 4 | 1,146 (39.5) | 1,011 (40.7) | 135 (32.5) | |
| 5 | 339 (11.7) | 286 (11.5) | 53 (12.8) | |
| Insurance (n,%) | <0.001 | |||
| Medicare | 2,198 (75.7) | 1,898 (76.3) | 300 (72.3) | |
| Auto | 481 (16.6) | 418 (16.8) | 63 (15.2) | |
| Commercial | 223 (7.7) | 171 (6.9) | 52 (12.5) | |
| ICUe (n,%) | 0.52 | |||
| No | 2,135 (73.6) | 1,835 (73.8) | 300 (72.3) | |
| Yes | 767 (26.4) | 652 (26.2) | 115 (27.7) | |
| Discharge location (n,%) | 0.10 | |||
| Home without services | 1,389 (47.9) | 1,206 (48.5) | 183 (44.1) | |
| Inpatient rehabilitation | 1,513 (52.1) | 1,281 (51.5) | 232 (55.9) | |
| Comorbidities (n,%) | 0.002 | |||
| <2 | 1,747 (60.2) | 1,526 (61.4) | 221 (53.3) | |
| ≥2 | 1,155 (39.8) | 961 (38.6) | 194 (46.7) | |
| Injury Year (n,%) | 0.48 | |||
| 1998-2001 | 488 (16.8) | 420 (16.9) | 68 (16.4) | |
| 2002-2005 | 645 (22.2) | 564 (22.7) | 81 (19.5) | |
| 2006-2009 | 874 (30.1) | 744 (29.9) | 130 (31.3) | |
| 2010-2012 | 895 (30.9 | 759 (30.5) | 136 (32.8) | |
p-values were calculated using Student’s t test for continuous variables and Pearson’s chi-square test for categorical variables, significant at p<0.05.
GCS=Glasgow Coma Scale;
ISS=Injury Severity Score;
AIS-H=Abbreviated Injury Scale-Head;
ICU=Intensive Care Unit;
Blacks were younger than whites (75.5 (SD=7.80) years vs. 77.7 (SD=7.85 years, p<0.001) (Table 2). Age, sex, insurance status, comorbidities, AIS-H, and GCS differed significantly between races. In bivariate analysis, there was no significant difference in discharge location by race.
In unadjusted analysis, there was no significant difference in discharge location between blacks and whites (OR 1.19, 95% CI 0.97, 1.47) (Table 3). In model 1, adjusted for pre-TBI variables, blacks were significantly more likely to be discharged to inpatient rehabilitation than home compared to whites (OR 1.28, 95% CI 1.03-1.58). In model 2, adjusted for both pre and post-TBI variables, blacks were more likely to be discharged to inpatient rehabilitation compared to whites (OR 1.34, 95% CI 1.06-1.70).
Table 3.
Adjusted odds ratios (95% confidence intervals) of association between race and discharge to inpatient rehabilitation among older adults with TBI, N=2,902
| Unadjusted | Model 1 | Model 2 | |
|---|---|---|---|
| Race | |||
| White | Reference | Reference | Reference |
| Black | 1.19 (0.97, 1.47) | 1.28 (1.03, 1.58) | 1.34 (1.06, 1.70) |
| Age in years | 1.03 (1.02, 1.04) | 1.04 (1.03, 1.05) | |
| Female sex | 1.03 (0.89, 1.20) | 0.96 (0.82, 1.14) | |
| Insurance | |||
| Medicare | Reference | Reference | |
| Auto | 0.89 (0.73, 1.09) | 1.38 (1.10, 1.73) | |
| Commercial | 0.87 (0.66, 1.16) | 0.84 (0.61, 1.15) | |
| Comorbidities | |||
| <2 | Reference | Reference | |
| ≥2 | 1.13 (0.97, 1.31) | 1.13 (0.95, 1.33) | |
| GCSa | |||
| ≥13 | Reference | ||
| 9-12 | 4.53 (3.06, 6.69) | ||
| ≤8 | 8.72 (5.08, 14.96) | ||
| AIS-Hb | |||
| ≤2 | Reference | ||
| 3 | 2.26 (1.78, 2.85) | ||
| 4 | 4.07 (3.34, 4.96) | ||
| 5 | 9.76 (7.00, 13.62) |
GCS=Glasgow Coma Scale;
AIS-H=Abbreviated Injury Scale-Head
In sensitivity analyses, excluding those with mild injury (AIS-H <2) did not result in significant changes to our effect estimate. Similarly, restricting our analysis to those with Medicare coverage only did not change effect estimates significantly. Also, grouping discharge locations into higher and lower levels of care did not result in significant changes to effect estimates. Blacks were still more likely to be discharged to higher levels of care, which included inpatient rehabilitation, than whites. Finally, ISS and ICU stay were not significantly associated with race and did not significantly change the overall effect estimates when added into the model.
Discussion
In this study of older adults treated for TBI at a trauma center and primarily insured through Medicare, blacks were more likely to be discharged to inpatient rehabilitation, in contrast with our hypothesis and prior reports suggesting that whites were more likely to be discharged to higher levels of care following TBI.10,11 The observed association could be due to lower perceived or actual social support among blacks. Studies have shown that minorities with TBI report lower levels of social integration, such as interactions with family or friends.23,24 In a study of functional outcomes post-TBI among whites, African-Americans, and Hispanics, Arango-Lasprilla et al. reported worse outcomes for minorities compared to whites and indicted that blacks and Hispanics have lower social integration compared to whites.25 Thus, blacks may lack the social support necessary to provide care for them at home, resulting in selection of inpatient rehabilitation.
Another explanation for our findings may be underlying differences in disability between whites and blacks. There is evidence that blacks often have more disabilities later in life.26 A study by Kelley-Moore et al. suggested that there is a disability gap between whites and blacks, older blacks experience worse physical functioning compared to older whites.27 Lower socioeconomic status prior to receipt of Medicare coverage could result in greater disability in blacks compared to whites by limiting access procedures to improve functional status and reduce disability.26,28 Evidence suggests that there are differences in socioeconomic status between blacks and whites with blacks often having lower socioeconomic status and greater disability in mid-life and old age.29 Although we had information on a number of comorbidities, we were unable to assess severity of these comorbidities or any measure of disability.
In contrast with our findings, Asemota et al. (2013) reported that compared to insured whites, insured blacks had reduced odds of discharge to inpatient rehabilitation following TBI.10 However, that study restricted age to <65 years and had numerous categories of discharge disposition which may account for the contradictory findings. Our study focused specifically on individuals aged 65 and older to minimize the insurance differences present in younger populations. Meagher et al. (2015) reported that older blacks and Hispanics were less likely to be discharged to rehabilitation compared to whites following TBI; however, comparisons with our study are complicated by heterogeneity in discharge location categorization.11 A study by Schiraldi et al. (2015) reported that blacks were more likely to be discharged home following TBI compared to whites.12 However, the data source for that study did not contain injury related variables such as GCS or AIS, limiting ability to control for injury severity.
Study limitations
A limitation of the present study is that it was conducted over several years during which practice regarding discharge location may have changed, however, there was no evidence of a year effect in our analysis. We were unable to adjust for social and economic factors that may confound the observed association. Additionally, there may be functional differences between whites and blacks that were not captured in our data. Data on time between TBI occurrence and admission to the hospital were unavailable, but may explain some of the observed association. We restricted our analysis to the two largest categories of discharge location and did not examine discharge to other locations due to small numbers of individuals in those groups. However, when we grouped categories together in sensitivity analysis, we did not observe a difference in effect estimates. Another driver of discharge disposition is insurance status, however given that Medicare was the primary payer, differences in insurance coverage were minimized, which is a strength of the current study.30 This study was conducted at a single urban trauma center and the practices of this location may not reflect the practices of other facilities. Additionally, data on socioeconomic status, social support, and disability were not available and this may have impacted our findings. Future prospective studies in which this information could be obtained or linkages with datasets that may contain this information may further elucidate the relationships between discharge disposition and race. Although geographic location may affect the availability of inpatient rehabilitation facilities, we do not suspect that this is an issue in the current study as we are located in a large metropolitan area with many inpatient rehabilitation facilities.
Conclusions
In conclusion, among adults aged 65 and older treated for TBI at an urban trauma center and primarily insured through Medicare, blacks were more likely to be discharged to inpatient rehabilitation than home. Future analyses should examine the role that social support, as well as direct measures of function, play in decisions pertaining to discharge disposition.
Acknowledgments:
This research was supported by the National Institutes of Health grant T32AG000262.
Conflicts of Interest and Sources of Funding:
The authors have no conflicts of interest. Ms. Vadlamani is supported by the National Institutes of Health grant T32AG000262 (Magaziner, PI). Dr. Albrecht was supported by AHRQ grant K01HS024560.
Footnotes
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