How to Classify Super-Utilizers: A Methodological Review of Super-Utilizer Criteria Applied to the Utah Medicaid Population, 2016-2017

Outcomes of an integrated practice unit for vulnerable emergency department patients

BACKGROUND

An integrated practice unit (IPU) that provides a multidisciplinary approach to patient care, typically involving a primary care provider, registered nurse, social worker, and pharmacist has been shown to reduce healthcare utilization among high-cost super-utilizer (SU) patients or multi-visit patients (MVP). However, less is known about differences in the impact of these interventions on insured vs. uninsured SU patients and super high frequency SUs ([Formula: see text]8 ED visits per 6 months) vs. high frequency SUs (4-7 ED visits per 6 months).

METHODS

We assessed the percent reduction in ED visits, ED cost, hospitalizations, hospital days, and hospitalization costs following implementation of an IPU for SUs located in an academic tertiary care facility. We compared outcomes for publicly insured with uninsured patients, and super high frequency SUs with high frequency SUs 6 months before vs. 6 months after enrollment in the IPU.

RESULTS

There was an overall 25% reduction in hospitalizations (p < 0.001), and 23% reduction in hospital days (p = 0.0045), when comparing 6 months before vs. 6 months after enrollment in the program. There was a 26% reduction in average total direct hospitalization costs per patient (p = 0.002). Further analysis revealed a greater reduction in health care utilization for uninsured SU patients compared with publicly insured patients. The program reduced hospitalizations for super high frequency SUs. However, there was no statistically significant impact on overall health care utilization of super high frequency SUs when compared with high frequency SUs.

CONCLUSIONS

Our study supports existing evidence that dedicated IPUs for SUs can achieve significant reductions in acute care utilization, particularly for uninsured and high frequency SU patients.

TRIAL REGISTRATION

IRB201500212. Retrospectively registered.

Interpretable Identification of Comorbidities Associated with Recurrent ED and Inpatient Visits

In the hospital setting, a small percentage of recurrent frequent patients contribute to a disproportional amount of healthcare resource utilization. Moreover, in many of these cases, patient outcomes can be greatly improved by reducing re-occurring visits, especially when they are associated with substance abuse, mental health, and medical factors that could be improved by social-behavioral interventions, outpatient or preventative care. Additionally, health care costs can be reduced significantly with fewer preventable recurrent visits. To address this, we developed a novel, interpretable framework that both identifies recurrent patients with high utilization and determines which comorbidities contribute most to their recurrent visits. Specifically, we present a novel algorithm, called the minimum similarity association rules (MSAR), which balances the confidence-support trade-off, to determine the conditions most associated with re-occurring Emergency department and inpatient visits. We validate MSAR on a large Electronic Health Record dataset, demonstrating the effectiveness and consistency in ability to find low-support comorbidities with high likelihood of being associated with recurrent visits, which is challenging for other algorithms such as XGBoost. Clinical relevance- In the era of value-based care and population health management, the proposal could be used for decision making to help reduce future recurrent admissions, improve patient outcomes and reduce the cost of healthcare.

High-Frequency Utilization of the PICU

OBJECTIVES

To describe the demographic, clinical, outcome, and cost differences between children with high-frequency PICU admission and those without.

DESIGN

Retrospective, cross-sectional cohort study.

SETTING

United States.

PATIENTS

Children less than or equal to 18 years old admitted to PICUs participating in the Pediatric Health Information System database in 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed survivors of PICU admissions for repeat PICU admissions within a year of their index visit. Children with greater than or equal to 3 PICU admissions within a year were classified as high-frequency PICU utilization (HFPICU). We compared demographic, clinical, outcome, and cost characteristics between children with HFPICU and those with only an index or two admissions per year (nHFPICU). Of 95,465 children who survived an index admission, 5,880 (6.2%) met HFPICU criteria. HFPICU patients were more frequently younger, technology dependent, and publicly insured. HFPICU patients had longer lengths of stay and were more frequently discharged to a rehabilitation facility or with home nursing services. HFPICU patients accounted for 24.8% of annual hospital utilization costs among patients requiring PICU admission. Time to readmission for children with HFPICU was 58% sooner (95% CI, 56-59%) than in those with nHFPICU with two admissions using an accelerated failure time model. Among demographic and clinical factors that were associated with development of HFPICU status calculated from a multivariable analysis, the greatest effect size was for time to first readmission within 82 days.

CONCLUSIONS

Children identified as having HFPICU account for 6.2% of children surviving an index ICU admission. They are a high-risk patient population with increased medical resource utilization during index and subsequent ICU admissions. Patients readmitted within 82 days of discharge should be considered at higher risk of HFPICU status. Further research, including validation and exploration of interventions that may be of use in this patient population, are necessary.

Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah

In the United States, the top 1% and top 5% of health care spenders account for 23% and 50% of total health care spending, respectively. These high spenders have been coined the term super utilizers (SU). The aim of this study was to identify the characteristics associated with these patients to aid in developing public health interventions aimed at transitioning patients out of the SU category and thus ultimately helping to control health care costs. The authors utilized the Utah All-Payer Claims Database and Utah Population Database from 2013 to 2015 to identify demographics, comorbid conditions, health care utilization, and cost characteristics of persistent super utilizers (PSU) (≥3 hospitalizations per year for 3 years) of health care compared with persistent nonsuper utilizers (PNSU) (<3 hospitalizations per year for 3 years). Multivariable logistic regression was utilized to identify the characteristics associated with PSU versus PNSU. Higher outpatient/Emergency Department/noninpatient (eg, visits with imaging and Centers for Medicare & Medicaid Services preventive visits) health care utilization and spending, and prevalence of comorbid disease and psychosocial conditions were associated with PSU. In multivariable analysis, factors such as heart disease, chronic kidney disease (CKD), diabetes, alcohol abuse, and depression were statistically significantly associated with higher odds of PSU, with the most noteworthy being CKD (odds ratio [OR] 6.85, 95% confidence interval [95% CI] 5.84-8.02; P < 0.001), alcohol abuse (OR 5.90, 95% CI 4.49-7.69; P < 0.001), and heart diseases (OR 4.41, 95% CI 3.74-5.18; P < 0.001). The annual health care cost of a PSU is about 11.5 times greater than a PNSU ($54,776 vs. $4801; P < 0.001).

Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers

Background

Super-utilizers with 4 or more admissions per year frequently receive low-quality care and disproportionately contribute to healthcare costs. Inpatient care fragmentation (admission to multiple different hospitals) in this population has not been well described.

Objective

To determine the prevalence of super-utilizers who receive fragmented care across different hospitals and to describe associated risks, costs, and health outcomes.

Research design

We analyzed inpatient data from the Health Care Utilization Project’s State Inpatient and Emergency Department database from 6 states from 2013. After identifying hospital super-utilizers, we stratified by the number of different hospitals visited in a 1-year period. We determined how patient demographics, costs, and outcomes varied by degree of fragmentation. We then examined how fragmentation would influence a hospital’s ability to identify super-utilizers.

Subjects

Adult patients with 4 or more inpatient stays in 1 year.

Measures

Patient demographics, cost, 1-year hospital reported mortality, and probability that a single hospital could correctly identify a patient as a super-utilizer.

Results

Of the 167,515 hospital super-utilizers, 97,404 (58.1%) visited more than 1 hospital in a 1-year period. Fragmentation was more likely among younger, non-white, low-income, under-insured patients, in population-dense areas. Patients with fragmentation were more likely to be admitted for chronic disease management, psychiatric illness, and substance abuse. Inpatient fragmentation was associated with higher yearly costs and lower likelihood of being identified as a super-utilizer.

Conclusions

Inpatient care fragmentation is common among super-utilizers, disproportionately affects vulnerable populations. It is associated with high yearly costs and a decreased probability of correctly identifying super-utilizers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06323-5.