Causal variation modelling identifies large inter- and intra-regional disparities in physical therapy offered to hip fracture patients in Estonia

Abstract

Purpose

An essential measure of hip fracture (HF) rehabilitation, the amount of physical therapy (PT) used per patient, has been severely understudied. This study (1) evaluates post-acute PT use after HF in Estonia, (2) presents causal variation modelling for examining inter- and intra-regional disparities, and (3) analyses its temporal trends.

Materials and methods

This retrospective cohort study used validated population-wide health data, including patients aged ≥50 years, with an index HF diagnosed between January 2009 and September 2017. Patients’ 6-month PT use was analysed and reported separately for acute and post-acute phases.

Results

While most of the included 11,461 patients received acute rehabilitation, only 40% of them received post-acute PT by a median of 6 h. Analyses based on measures of central tendency revealed 2.5 to 2.6-fold inter-regional differences in HF post-acute rehabilitation. Variation modelling additionally detected intra-regional disparities, showing imbalances in the fairness of allocating local rehabilitation resources between a county’s patients.

Conclusions

This study demonstrates the advantages of causal variation modelling for identifying inter- and intra-regional disparities in rehabilitation. The analyses revealed persisting large multi-level disparities and accompanying overall inaccessibility of PT in HF rehabilitation in Estonia, showing an urgent need for system-wide improvements.

Implications for rehabilitation

• This study demonstrates the advantages of causal variation modelling for identifying inter- and intra-regional disparities in rehabilitation, using an essential outcome measure – used physical therapy hours.

• The study revealed large multi-level disparities and overall inaccessibility of physical therapy in hip fracture rehabilitation in Estonia, showing an urgent need for system-wide improvements.

• This study expands our knowledge on unstudied topics – hip fracture post-acute care and long-term physical therapy use.

• This regional analysis provides the first evidence-based regional-level basis for improving the rehabilitation system in Estonia.

Keywords:

• Hip fracture
• rehabilitation
• research methodology
• causal directed acyclic graphs
• variation modelling
• zero-inflation

Acknowledgements

We acknowledge the EHIF for its assistance in providing the study data and Dr. Pirja Sarap, Dr. Toomas Saluse, Dr. Egon Puuorg, and Dr. Eiki Strauss for their help with data validation.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

R code and data used for modelling are accessible from the following link: https://doi.org/10.6084/m9.figshare.13374044

Additional information

Funding

This work was supported by the following research projects: Estonian Research Council projects [IUT20-46 and PRG335], and Interreg Baltic Sea Region Programme 2014-2020, Baltic Fracture Competence Centre [MMVCM16293I].