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.