Racial Disparities in Ambulatory Care Settings After Inpatient Admission

• In Event: Racialized Bias in Health, Education, and Employment

Abstract

Background: There are various and complex factors that influence where and when patients seek outpatient care. There are clearer mechanisms that separate individuals by racial identity into facilities for inpatient care. Examination of ambulatory care follow-up after an inpatient admission may model facility referral patterns that lead to racially segregated systems of care. 

Purpose/Research Question: This study aims to evaluate the extent of race-based sorting of Medicaid beneficiaries into specific ambulatory care settings following an index admission into an inpatient facility.  

Methods: We analyze TAF claims data from 51,614 Medicaid beneficiaries with an inpatient admission in 2018 or 2019 with regular ambulatory care usage before being admitted. To identify race-based sorting, we model post-index settings of ambulatory care utilization within 180 days of discharge as a function of race/ethnicity, adjusted for index admission characteristics, including inpatient severity, beneficiary characteristics, prior regular care setting, as well as admission hospital and month fixed effects. Fixed effects for hospital and time allow us to control for all time-invariant unobserved confounders, and also for broader shocks and seasonality across years and months of observations, respectively. Controlling for pre-index regular care setting further isolates within-beneficiary variation in post-index care setting outcomes, net of stable between-beneficiary differences.  We confirm findings with robustness checks examining subsets of the sample. 

Results/Findings: Black NH and Hispanic beneficiaries are more likely to visit a safety-net facility following an inpatient admission (3.6 and 2.6 percentage points, respectively) compared to White NH beneficiaries. Conversely, Asian PI NH beneficiaries are less likely to visit safety-net facilities (-2.4 percentage points). These patterns are independent of prior utilization, health status and clinical need at index admission, as well as hospital and provider characteristics. The higher likelihood of visiting safety-net facilities appears to be driven by the utilization of hospital outpatient clinics and emergency departments among Black NH (1.4 and 1.9 percentage points) and Hispanic beneficiaries (1.0 and 0.9 percentage points).  

Conclusion/Implications:  Our findings show racial patterns in care settings following an inpatient admission, specifically that beneficiaries from racialized groups are more likely to be sorted into safety-net ambulatory settings compared to White NH counterparts.  Black NH and Hispanics are modestly more likely to utilize safety-net facilities within 180 days of being discharged from an inpatient admission. These findings suggest nontrivial racialized sorting into certain care settings following inpatient admission events, and further support broader findings about overall racial disparities in care settings.

Authors

• Jacqueline Chiofalo, CUNY Graduate Center
  Presenting Author

• Mustafa Hussein, CUNY School of Public Health
  Non-Presenting Co-Author