Dataset Information

Identifying subgroups of adult high-cost health care users: a retrospective analysis.

ABSTRACT:

Background

Few studies have categorized high-cost patients (defined by accumulated health care spending above a predetermined percentile) into distinctive groups for which potentially actionable interventions may improve outcomes and reduce costs. We sought to identify homogeneous groups within the persistently high-cost population to develop a taxonomy of subgroups that may be targetable with specific interventions.

Methods

We conducted a retrospective analysis in which we identified adults (≥ 18 yr) who lived in Alberta between April 2014 and March 2019. We defined "persistently high-cost users" as those in the top 1% of health care spending across 4 data sources (the Discharge Abstract Database for inpatient encounters; Practitioner Claims for outpatient primary care and specialist encounters; the Ambulatory Care Classification System for emergency department encounters; and the Pharmaceutical Information Network for medication use) in at least 2 consecutive fiscal years. We used latent class analysis and expert clinical opinion in tandem to separate the persistently high-cost population into subgroups that may be targeted by specific interventions based on their distinctive clinical profiles and the drivers of their health system use and costs.

Results

Of the 3 919 388 adults who lived in Alberta for at least 2 consecutive fiscal years during the study period, 21 115 (0.5%) were persistently high-cost users. We identified 9 subgroups in this population: people with cardiovascular disease (n = 4537; 21.5%); people receiving rehabilitation after surgery or recovering from complications of surgery (n = 3380; 16.0%); people with severe mental health conditions (n = 3060; 14.5%); people with advanced chronic kidney disease (n = 2689; 12.7%); people receiving biologic therapies for autoimmune conditions (n = 2538; 12.0%); people with dementia and awaiting community placement (n = 2520; 11.9%); people with chronic obstructive pulmonary disease or other respiratory conditions (n = 984; 4.7%); people receiving treatment for cancer (n = 832; 3.9%); and people with unstable housing situations or substance use disorders (n = 575; 2.7%).

Interpretation

Using latent class analysis supplemented with expert clinical review, we identified 9 policy-relevant subgroups among persistently high-cost health care users. This taxonomy may be used to inform policy, including identifying interventions that are most likely to improve care and reduce cost for each subgroup.

SUBMITTER: Wick J

PROVIDER: S-EPMC9022936 | biostudies-literature | 2022 Apr-Jun

REPOSITORIES: biostudies-literature

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Publications

Identifying subgroups of adult high-cost health care users: a retrospective analysis.

Wick James J Campbell David J T DJT McAlister Finlay A FA Manns Braden J BJ Tonelli Marcello M Beall Reed F RF Hemmelgarn Brenda R BR Stewart Andrew A Ronksley Paul E PE

CMAJ open 20220419 2

<h4>Background</h4>Few studies have categorized high-cost patients (defined by accumulated health care spending above a predetermined percentile) into distinctive groups for which potentially actionable interventions may improve outcomes and reduce costs. We sought to identify homogeneous groups within the persistently high-cost population to develop a taxonomy of subgroups that may be targetable with specific interventions.<h4>Methods</h4>We conducted a retrospective analysis in which we identi ...[more]

PMID: 35440486

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Project description:INTRODUCTION:Segmentation of the high-need, high-cost (HNHC) population is required for reorganizing care to accommodate person-centered, integrated care delivery. Therefore, we aimed to identify and characterize relevant subgroups of the HNHC population in primary care by using demographic, biomedical, and socioeconomic patient characteristics. METHODS:This was a retrospective cohort study within a Dutch primary care group, with a follow-up period from September 1, 2014 to August 31, 2017. Chronically ill patients were included in the HNHC population if they belonged to the top 10% of care utilizers and/or suffered from multimorbidity and had an above-average care utilization. In a latent class analysis, forty-one patient characteristics were initially used as potential indicators of heterogeneity in HNHC patients' needs. RESULTS:Patient data from 12 602 HNHC patients was used. A 4-class model was considered statistically and clinically superior. The classes were named according to the characteristics that were most dominantly present and distinctive between the classes (i.e. mainly age, household position, and source of income). Class 1 ('older adults living with partner') included 39.3% of patients, class 2 ('older adults living alone') included 25.5% of patients, class 3 ('middle-aged, employed adults with family') included 23.3% of patients, and class 4 ('middle-aged adults with social welfare dependency') included 11.9% of patients. Diabetes was the most common condition in all classes; the second most prevalent condition differed between osteoarthritis in class 1 (21.7%) and 2 (23.8%), asthma in class 3 (25.3%), and mood disorders in class 4 (23.1%). Furthermore, while general practitioner (GP) care utilization increased during the follow-up period in the classes of older adults, it remained relatively stable in the middle-aged classes. CONCLUSIONS:Although the HNHC population is heterogeneous, distinct subgroups with relatively homogeneous patterns of mainly demographic and socioeconomic characteristics can be identified. This calls for tailoring care and increased attention for social determinants of health.

Project description:ObjectiveTo develop person-centered episodes of care (PCE) for community-dwelling individuals in the top fifth percentile of Ontario health care expenditures in order to: (1) describe the main clinical groupings for spending; and (2) identify patterns of spending by health sector (e.g. acute care, home care, physician billings) within and across PCE.Data sourcesData were drawn from population-based administrative databases for all publicly funded health care in Ontario, Canada in 2010/11.Study designThis study is a retrospective cohort study.Data collection/extraction methodsA total of 587,982 community-dwelling individuals were identified among those accounting for the top 5% of provincial health care expenditures between April 1, 2010 and March 31, 2011. PCE were defined as starting with an acute care admission and persisting through subsequent care settings and providers until individuals were without health system contact for 30 days. PCE were classified according to the clinical grouping for the initial admission. PCE and non-PCE costs were calculated and compared to provide a comprehensive measurement of total health system costs for the year.Principal findingsAmong this community cohort, 697,059 PCE accounted for nearly 70% ($11,815.3 million (CAD)) of total annual publicly-funded expenditures on high-cost community-dwelling individuals. The most common clinical groupings to start a PCE were Acute Planned Surgical (35.2%), Acute Unplanned Medical (21.0%) and Post-Admission Events (10.8%). Median PCE costs ranged from $3,865 (IQR = $1,712-$10,919) for Acute Planned Surgical to $20,687 ($12,207-$39,579) for Post-Admission Events. Inpatient acute ($8,194.5 million) and inpatient rehabilitation ($434.6 million) health sectors accounted for the largest proportions of allocated PCE spending over the year.ConclusionsOur study provides a novel methodological approach to categorize high-cost health system users into meaningful person-centered episodes. This approach helps to explain how costs are attributable within individuals across sectors and has applications in episode-based payment formulas and quality monitoring.

Project description:BackgroundMost health care spending is concentrated within a small group of high-cost health care users. To inform health policies, we examined the characteristics of index hospital admissions and their predictors among incident older high-cost users compared to older non-high-cost users in Ontario.MethodsUsing Ontario administrative data, we identified incident high-cost users aged 66 years or more and matched them 1:3 on age, gender and Local Health Integration Network with non-high-cost users aged 66 years or more. We defined high-cost users as patients within the top 5% most costly high-cost users during fiscal year 2013/14 but not during 2012/13. An index hospital admission, the main outcome, was defined as the first unplanned hospital admission during 2013/14, with no hospital admissions in the preceding 12 months. Descriptively, we analyzed the attributes of index hospital admissions, including costs. We identified predictors of index hospital admissions using stratified logistic regression.ResultsOver half (95 375/175 847 [54.2%]) of all high-cost users had an unplanned index hospital admission, compared to 8838/527 541 (1.7%) of non-high-cost users. High-cost users had a poorer health status, longer acute length of stay (mean 7.5 d v. 2.9 d) and more frequent designation as alternate level of care before discharge (20.8% v. 1.7%) than did non-high-cost users. Ten diagnosis codes accounted for roughly one-third of the index hospital admission costs in both cohorts. Although many predictors were similar between the cohorts, a lower risk of an index hospital admission was associated with residence in long-term care, attachment to a primary care provider and recent consultation by a geriatrician among high-cost users.InterpretationThe high prevalence of index hospital admissions and the corresponding costs are a distinctive feature of incident older high-cost users. Improved access to specialist outpatient care, home-based social care and long-term care when required are worth further investigation.

Dataset Information

Identifying subgroups of adult high-cost health care users: a retrospective analysis.

Background

Methods

Results

Interpretation

Publications

Identifying subgroups of adult high-cost health care users: a retrospective analysis.

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