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Abstract: SA-PO713

Discharge Destination and Disparities in Dialysis Patients’ Post-Acute Care

Session Information

  • Geriatric Nephrology
    October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Geriatric Nephrology

  • 1100 Geriatric Nephrology

Authors

  • Kutner, Nancy G., Emory University School of Medicine, Atlanta, Georgia, United States
  • Zhang, Rebecca H., Emory University, Atlanta, Georgia, United States
  • Bowling, C. Barrett, Durham VA Medical Center, Durham, North Carolina, United States
Background

Post-acute care (PAC) goals emphasize functional recovery and reduced re-hospitalization, and PAC use has increased markedly since 2000. However, a recent concern is that lack of evidence-based guidelines for PAC decision-making creates opportunities for disparities in care, as in black/white disparities in PAC post-arthroplasty (JAMA 2018) and in PAC services among older community residents (JAGS 2017). Home health (HH) and skilled nursing facility (SNF) are most used but include substantially different levels of patient support (HH higher) and cost (HH lower). The inpatient rehabilitation facility (IRF) emphasizes physician involvement and care coordination, and IRF cost is higher. Outcomes following IRF may be superior to those following SNF for comparable patients with hip fracture and stroke diagnoses. Using Medicare claims data in USRDS files, we examined dialysis patient PAC patterns after lower-extremity amputation (LEA), fracture, and stroke, conditions for which kidney patients and blacks are at increased risk.

Methods

Prevalent dialysis patients with Medical Evidence data and Medicare Part A/B coverage, who were hospitalized at least once 11/2011-12/2012 followed by one or more PAC provider claims in 2012, were the study cohort (n=85,242). We identified IRF providers by matching CMS Certification Numbers with USRDS facility IDs in a provider crosswalk file. USRDS maintains HH and SNF analysis files. Dialysis patients’ receipt of HH, SNF and IRF following LEA (n=10,290), fracture (n=10,119), and stroke (n=5,537) was observed in claims data.

Results

Median (IQR) age was 66 (58, 75) for HH users, 72 (63, 80) for SNF users, and 69 (60, 77) for IRF users. Women were 50% of HH and SNF users and 45% of IRF users; blacks were 32% (HH), 29% (SNF), and 30% (IRF). The percentage of dialysis patients with LEA, fracture and stroke was larger among IRF users than among SNF users, but SNF use far exceeded IRF use. Among those who received IRF services, blacks accounted for 39% of those with LEA and 31% of those with stroke, but only 17% of all IRF patients with fracture.

Conclusion

Equity is needed in PAC choices, and the challenge of “who belongs where” when multiple PAC options are available calls for well-designed studies of patients’ rehabilitation needs and outcomes during an extended window of patient experience.

Funding

  • NIDDK Support