Disparities in access to specialty care and emergency department use after hospital discharge to a skilled nursing facility

Abstract

Background: Patterns in access to specialists among patients in skilled nursing facilities (SNFs) have not been previously described.

Objective: To measure access to outpatient specialty follow-up and subsequent emergency department (ED) visits by patient characteristics, including race/ethnicity and those who received specialty care during the hospitalization that preceded the SNF stay.

Design, settings, and participants: This retrospective cohort study used the minimum data set and 100% Medicare fee-for-service claims for beneficiaries admitted to an SNF between 2012 and 2014. Hospital stays for surgical procedures were excluded.

Main outcome and measures: The associations between ED visits, follow-up, and race/ethnicity were measured using logistic and linear regression, adjusting for patient demographic and clinical characteristics.

Results: The sample included 1,117,632 hospitalizations by Medicare beneficiaries ≥65 with a consult by a medical subspecialist followed by discharge to SNF. Of the sample, 85.4% were non-Hispanic White (NHW) and 14.6% were Black, indigenous, and people of color (BIPOC), according to Medicare beneficiary records. During the SNF stay, BIPOC patients had lower odds of specialty follow-up compared to NHW patients (odds ratio [OR]: 0.96, 95% confidence intervals [CI]: 0.94-0.99, p = .004). BIPOC patients had higher rates of ED visits compared to NHW patients (with follow-up: 24.1% vs. 23.4%, and without follow-up: 27.4% vs. 25.9%, p < .001). Lack of follow-up was associated with a 0.8 percentage point difference in ED visits between BIPOC and NHW patients (95% CI: 0.3-1.3, p = .003).

Conclusions: There is a racial/ethnic disparity in subspecialty follow-up after hospital discharge to SNF that is associated with a higher rate of subsequent ED visits by BIPOC patients.

Figure 1:

Subspecialty Follow-up Rates after Hospital Discharge to SNF for the 10 Specialties by Race/Ethnicity Footnotes: Office visits to medical specialists after an inpatient consultation during the preceding hospitalization among Medicare fee-for-service beneficiaries admitted to a SNF 2012-2014 Footnotes. All statistically significant at p<0.001

Figure 2:

Adjusted Probability of an Emergency Department (ED) Visit by Subspecialty Follow-up by Race/Ethnicity Footnotes. *Statistically significant at p=0.003 Estimates adjusted for the clinical and other variables from the Minimum Data Set and Medicare claims used in nursing home measure risk adjustment by CMS, the Charlson Comorbidity Index, age, sex, and facility characteristics listed in Table 1. Models included facility fixed effects to account for differences in ED use between facilities.