Patients with opioid use disorder twice as likely to get postacute care referral rejection
Inpatients with opioid use disorder were referred to more postacute care facilities but rejected significantly more often than other patients, even after researchers controlled for factors including homelessness and psychiatric disease, a Boston safety-net hospital found.
Hospitalized patients with opioid use disorder (OUD) who are referred to postacute care are more likely to be rejected by the facilities, a retrospective cohort study found.
Researchers linked all electronic referrals to private postacute care facilities from a Boston safety-net hospital in 2018 to clinical data and looked at the association between OUD diagnosis and the primary outcome, postacute care referral rejection. They defined OUD as the presence of ICD-10 codes for opioid use, abuse, or dependence or receipt of buprenorphine or liquid methadone during hospitalization or at discharge. Results were published in the March Health Affairs.
The final study cohort included 2,463 hospitalizations resulting in 16,503 referrals to 244 skilled nursing facilities or subacute care facilities, mostly located in Massachusetts but also in New Hampshire. There were 2,297 hospitalized patients without OUD and 166 with OUD, most of whom received medication to treat OUD. Patients with OUD were significantly younger and were significantly more likely to be male, to be insured by Medicaid, to have received an inpatient psychiatry or addiction consult, and to have experienced homelessness. While those with OUD were referred to more facilities than patients without OUD (8.2 vs. 6.6 per hospitalization), they were rejected a greater proportion of the time (83.3% vs. 65.5%) compared to those without. Patients with OUD also had greater odds of rejection from postacute care (adjusted odds ratio, 2.2 [95% CI, 1.7 to 2.8]; P<0.001) in analyses that controlled for other factors that may affect admissions decisions, such as experiencing homelessness, active psychiatric disease, or alcohol use disorder. Facilities that receive a higher proportion of OUD referrals were less likely to reject a referral for a person with OUD than facilities that receive a lower proportion of OUD referrals (adjusted odds ratio, 0.5 [95% CI, 0.4 to 0.6]; P<0.001).
Among other limitations, the results might not be generalizable to other locations or times, the study authors noted. They added that they could not fully account for decisions made by case managers or patients about which facilities receive referrals.
“These pervasive referral and rejection patterns provide further evidence of the inequities in postacute care access faced by people with OUD. … There are several possible explanations for these practices, including externalized stigma toward people with OUD, which may be formally or informally codified in admissions criteria; lack of comfort with or expertise in OUD treatment; and regulations that make provision of buprenorphine or methadone for OUD logistically challenging for postacute care facilities,” the authors wrote.