Beyond the tip of the iceberg: quantifying the odds of multidrug-resistance carriers for receiving post-acute follow-up rehabilitation after hospital stay - a real-world study using German data.

Introduction: Health equity means equal opportunities for all patients. While follow-up rehabilitation (German: Methods: We conducted a retrospective cohort study, including patients considered for transfer to ≥281 PAC providers (1 November 2015 to 31 October 2017) from a tertiary care teaching hospital. Breaking down the whole process to different stages, we modelled the odds of dropping out at every stage under the exposure to MDRO-carriage via multivariable logistic regression, adjusting for various covariates. Results: Based on 12 386 patient records, our data estimates that 45% (95% CI 36% to 54%) of MDRO-carriers considered for AHB do not receive AHB. This indicates that the proportion of carriers denied admission (13% (95% CI 7% to 19%)) is only the tip of the iceberg and that earlier dropouts exist. Provider decisions might have influenced earlier dropouts, since admission non-approvals increased the odds of proposal non-approvals (OR=4.85 (95% CI 4.24 to 5.54)) in multivariable regression. Thereby, strongest exposure signals were observed for carriers of vancomycin-resistant enterococci (VRE) compared with other MDRO-types. Conclusion: Given the long-standing debate on the necessity of VRE-screening and the hardships of VRE-eradication, VRE-carriers in need of AHB would thus be further disadvantaged in addition to their already poorer conditions. This would lead to prolonged hospital stays, increased disability and ultimately elevated burden of disease and health expenditures at societal level. The balancing act between rehabilitation goals and adherence to best possible infection prevention measures would thus increase chances of carriers to receive much needed rehabilitation courses and ease individual as well as societal burdens.