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.

Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions

“…Furthermore, health care provider characteristics, racial myths about pain sensitization, and assumed criminality all impact provider treatment decision making and the receipt of pain treatment by Black patients 26 . Black populations have been documented to have more limited access to specialty and follow‐up care, 27 so our finding that these groups are significantly more likely to receive prescriptions of shorter duration may further compound inequities in access to adequate treatment. Finally, disparities in opioid prescribing may vary by indication, from traumatic conditions such as injuries or fractures to nontraumatic conditions such as migraine or back pain.…”

Specialty care in skilled nursing facilities: Tackling a hidden disparity

“…1 Unnecessary readmissions and emergency department (ED) visits disrupt patients' clinical care progression, are costly to the healthcare system, and unfortunately are borne unequally across racial lines. 2,3 In this issue of Journal of Hospital Medicine, Krickus et al 4 unearth a previously unidentified driver of ED visits among patients discharged to SNFs: lack of access to specialty follow-up-a type of healthcare resource with disparate access across racial and socioeconomic strata. In their study of Medicare fee-for-service beneficiaries admitted to a SNF between 2012 and 2014 who had received an inpatient consult, they found that Black, Indigenous, and people of color (BIPOC) patients had lower odds of outpatient specialty care follow-up during their SNF stay compared to non-Hispanic White (NHW) patients.…”