Racial/Ethnic Disparities in Post‐Acute Care Discharge Patterns

Research Objective Americans who belong to racial/ethnic minorities, particularly those who are Black and/or Hispanic, face substantial inequities in access to care. To better understand the drivers of these inequities, it's important to quantify how care patterns differ between groups. There is limited research that describes patterns of post‐acute care (PAC) use of racial/ethnic minorities following hospitalizations. We used a national sample of hospitalized Medicare enrollees to compare first discharge location across racial/ethnic minority groups. Study Design We conducted a cohort study of Medicare enrollees admitted to the hospital for five conditions that often require post‐acute care (PAC): congestive heart failure (CHF), stroke, hip fracture, lower extremity joint replacement (LEJR), and chronic obstructive pulmonary disorder (COPD). We identified all traditional Medicare beneficiaries hospitalized for these conditions from 2007 through 2017 using the Medicare Provider Analysis and Review (MedPAR) file. We then used MDS, OASIS, and IRF‐PAI assessments and claims to identify which PAC locations patients were discharged to. Our multinomial outcome of interest was discharge to home without home health, home with home health (HH), skilled nursing facility (SNF), inpatient rehabilitation (IRF), other locations (long term care hospitals or other acute care), or death during hospitalization. Our primary explanatory variable was patient race/ethnicity. We first compared discharge locations by disease cohort and race ethnicity. We then used multinomial logit models to adjust for age, gender, Medicare disability entitlement, dual Medicare‐Medicaid eligibility, and zipcode and hospital fixed effects. We purposefully did not include chronic disease indicators as chronic disease coding may be endogenous with race/ethnicity, however in sensitivity analyses that included chronic disease flags, the results did not differ substantially. From these models, we calculated the adjusted percent discharged to each location and compared by race/ethnicity. Population Studied 2,782,117 Medicare beneficiaries who were admitted to a hospital for our target conditions from 2007 through 2017. Principal Findings The study included 313,735 patients admitted for CHF, 387,792 for stroke, 289,027 for hip fracture, 591,677 for LEJR and 1,199,886 for COPD. After adjustment, among patients with COPD, 26.9% of white patients were discharged to home without PAC, and 35.8% were discharged to SNF compared to 34.6% and 28.7% of Black and 33.9% and 27.5% of Hispanic patients. Among patients with CHF, 50.1% of white patients were discharged to home without PAC, and 19% were discharged to SNF compared to 57.1% and 11.4% of Asian and 55.3% and 11.9% of Hispanic patients. Among patients with stroke, 43.4% of white patients were discharged to home without PAC, and 19% were discharged to SNF compared to 31.3% and 19.0% of Black patients. Discharge patterns were similar for hip fracture and lower extremity joint replacement. Conclusions Even after accounting for a patient's discharging hospital and residential zipcode, there are important conditions with substantial differences in PAC utilization patterns across racial/ethnic minorities for stroke, CHF, and COPD, but not for hip fracture or LEJR. Implications for Policy or Practice As the proportion of patients requiring PAC continues to diversify over time, it will be imperative to understand the drivers of differences in PAC use and whether they lead to differential health outcomes. Primary Funding Source National Institutes of Health.