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Grabinski Z, Woo KM, Akindutire O, Dahn C, Nash L, Leybell I, Wang Y, Bayer D, Swartz J, Jamin C, Smith SW. Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission. Jt Comm J Qual Patient Saf 2024; 50:516-527. [PMID: 38653614 DOI: 10.1016/j.jcjq.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis. METHODS The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests. RESULTS The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education. CONCLUSION The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.
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Benny D, Giacobini M, Costa G, Gnavi R, Ricceri F. Multimorbidity in middle-aged women and COVID-19: binary data clustering for unsupervised binning of rare multimorbidity features and predictive modeling. BMC Med Res Methodol 2024; 24:95. [PMID: 38658821 PMCID: PMC11040796 DOI: 10.1186/s12874-024-02200-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 03/07/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Multimorbidity is typically associated with deficient health-related quality of life in mid-life, and the likelihood of developing multimorbidity in women is elevated. We address the issue of data sparsity in non-prevalent features by clustering the binary data of various rare medical conditions in a cohort of middle-aged women. This study aims to enhance understanding of how multimorbidity affects COVID-19 severity by clustering rare medical conditions and combining them with prevalent features for predictive modeling. The insights gained can guide the development of targeted interventions and improved management strategies for individuals with multiple health conditions. METHODS The study focuses on a cohort of 4477 female patients, (aged 45-60) in Piedmont, Italy, and utilizes their multimorbidity data prior to the COVID-19 pandemic from their medical history from 2015 to 2019. The COVID-19 severity is determined by the hospitalization status of the patients from February to May 2020. Each patient profile in the dataset is depicted as a binary vector, where each feature denotes the presence or absence of a specific multimorbidity condition. By clustering the sparse medical data, newly engineered features are generated as a bin of features, and they are combined with the prevalent features for COVID-19 severity predictive modeling. RESULTS From sparse data consisting of 174 input features, we have created a low-dimensional feature matrix of 17 features. Machine Learning algorithms are applied to the reduced sparsity-free data to predict the Covid-19 hospital admission outcome. The performance obtained for the corresponding models are as follows: Logistic Regression (accuracy 0.72, AUC 0.77, F1-score 0.69), Linear Discriminant Analysis (accuracy 0.7, AUC 0.77, F1-score 0.67), and Ada Boost (accuracy 0.7, AUC 0.77, F1-score 0.68). CONCLUSION Mapping higher-dimensional data to a low-dimensional space can result in information loss, but reducing sparsity can be beneficial for Machine Learning modeling due to improved predictive ability. In this study, we addressed the issue of data sparsity in electronic health records and created a model that incorporates both prevalent and rare medical conditions, leading to more accurate and effective predictive modeling. The identification of complex associations between multimorbidity and the severity of COVID-19 highlights potential areas of focus for future research, including long COVID and intervention efforts.
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Affiliation(s)
- Dayana Benny
- Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Turin, 10043, Piedmont, Italy.
- Modeling and Data Science, Department of Mathematics, University of Turin, Via Carlo Alberto 10, Turin, 10123, Piedmont, Italy.
| | - Mario Giacobini
- Data Analysis and Modeling Unit, Department of Veterinary Sciences, University of Turin, Turin, Italy
| | - Giuseppe Costa
- Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Turin, 10043, Piedmont, Italy
- Unit of Epidemiology, Regional Health Service, Local Health Unit Torino 3, Grugliasco, Turin, Italy
| | - Roberto Gnavi
- Unit of Epidemiology, Regional Health Service, Local Health Unit Torino 3, Grugliasco, Turin, Italy
| | - Fulvio Ricceri
- Centre for Biostatistics, Epidemiology, and Public Health, Department of Clinical and Biological Sciences, University of Turin, Orbassano, Turin, 10043, Piedmont, Italy
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Lee SS, French B, Balucan F, McCann MD, Vasilevskis EE. Characterizing hospitalization trajectories in the high-need, high-cost population using electronic health record data. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad077. [PMID: 38756367 PMCID: PMC10986247 DOI: 10.1093/haschl/qxad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/05/2023] [Accepted: 12/04/2023] [Indexed: 05/18/2024]
Abstract
High utilization by a minority of patients accounts for a large share of health care costs, but the dynamics of this utilization remain poorly understood. We sought to characterize longitudinal trajectories of hospitalization among adult patients at an academic medical center from 2017 to 2023. Among 3404 patients meeting eligibility criteria, following an initial "rising-risk" period of 3 hospitalizations in 6 months, growth mixture modeling discerned 4 clusters of subsequent hospitalization trajectories: no further utilization, low chronic utilization, persistently high utilization with a slow rate of increase, and persistently high utilization with a fast rate of increase. Baseline factors associated with higher-order hospitalization trajectories included admission to a nonsurgical service, full code status, intensive care unit-level care, opioid administration, discharge home, and comorbid cardiovascular disease, end-stage kidney or liver disease, or cancer. Characterizing hospitalization trajectories and their correlates in this manner lays groundwork for early identification of those most likely to become high-need, high-cost patients.
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Affiliation(s)
- Scott S Lee
- Section of Hospital Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Francis Balucan
- Section of Hospital Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Michael D McCann
- Section of Hospital Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Eduard E Vasilevskis
- Division of Hospital Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53726, United States
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Schoolmeester A, Keiser M. Use of Care Guides to Reduce Emergency Department Visits by High-Frequency Utilizers. J Emerg Nurs 2023; 49:863-869. [PMID: 37676184 DOI: 10.1016/j.jen.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND High-frequency utilizers are defined as patients who present 10 or more times to the emergency department in a rolling 12-month period. High-frequency utilizers contribute to emergency department overcrowding and misuse of resources, and reduce the efficiency of health care systems. Care guides have proven to be an effective tool in reducing high-frequency utilizers. OBJECTIVE The objective of this quality improvement project was to determine if implementing a care guide for high-frequency utilizers to address the core needs of the patient and facilitate resources through case management consultation decreases the number of visits and the cost of unreimbursed care to the emergency department from high-frequency utilizers. METHODS We implemented care guides for high-frequency utilizers in September 2014. Prior to initiating the care guides, we educated the physicians, nurses, case managers, and social workers in the emergency department. RESULTS Following the implementation of the care guides, there was a steady decline in the number of high-frequency utilizers (338 in 2013-68 in 2021), the number of total emergency department visits by high-frequency utilizers (6025 in 2013-1033 in 2021), and unreimbursed care ($2,068,063 in 2013-$589,298 in 2021). CONCLUSION The use of care guides was a successful strategy in reducing emergency department visits and the cost of unreimbursed care by high-frequency utilizers by providing them with the education and resources they require to receive health care services in appropriate settings.
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Nkemdirim Okere A, Moussa RK, Ali A, Diaby VK. Development and validation of a tool to predict high-need, high-cost patients hospitalised with ischaemic heart disease. BMJ Open 2023; 13:e073485. [PMID: 37751949 PMCID: PMC10533782 DOI: 10.1136/bmjopen-2023-073485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/25/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE To develop and validate a tool to predict patients with ischaemic heart disease (IHD) at risk of excessive healthcare resource utilisation. DESIGN A retrospective cohort study. SETTING We identified patients through the State of Florida Agency for Health Care Administration (N=586 518) inpatient dataset. PARTICIPANTS Adult patients (at least 40 years of age) admitted to the hospital with a diagnosis of IHD between 1 January 2007 and 31 December 2016. PRIMARY OUTCOME MEASURES We identified patients whose healthcare utilisation is higher than presumed (analysis of residuals) and used logistic regression (binary and multinomial) in estimating the predictive models to classify individual as high-need, high-care (HNHC) patients relative to inpatient visits (frequency of hospitalisation), cost and hospital length of stay. Discrimination power, prediction accuracy and model improvement for the binary logistic model were assessed using receiver operating characteristic statistic, the Brier score and the log-likelihood (LL)-based pseudo-R2, respectively. LL-based pseudo-R2 and Brier score were used for multinomial logistic models. RESULTS The binary logistic model had good discrimination power (c-statistic=0.6496), an accuracy of probabilistic predictions (Brier score) of 0.0621 and an LL-based pseudo-R2 of 0.0338 in the development cohort. The model performed similarly in the validation cohort (c-statistic=0.6480), an accuracy of probabilistic predictions (Brier score) of 0.0620 and an LL-based pseudo-R2 of 0.0380. A user-friendly Excel-based HNHC risk predictive tool was developed and readily available for clinicians and policy decision-makers. CONCLUSIONS The Excel-based HNHC risk predictive tool can accurately identify at-risk patients for HNHC based on three measures of healthcare expenditures.
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Affiliation(s)
- Arinze Nkemdirim Okere
- Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&M University, Tallahassee, Florida, USA
| | - Richard K Moussa
- Ecole Nationale Supérieure de Statistique et d'Économie Appliquée, Abidjan, Côte d'Ivoire
| | - Askal Ali
- Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&M University, Tallahassee, Florida, USA
| | - Vakaramoko K Diaby
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
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Yin Y. Prediction and analysis of time series data based on granular computing. Front Comput Neurosci 2023; 17:1192876. [PMID: 37576071 PMCID: PMC10413556 DOI: 10.3389/fncom.2023.1192876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/06/2023] [Indexed: 08/15/2023] Open
Abstract
The advent of the Big Data era and the rapid development of the Internet of Things have led to a dramatic increase in the amount of data from various time series. How to classify, correlation rule mining and prediction of these large-sample time series data has a crucial role. However, due to the characteristics of high dimensionality, large data volume and transmission lag of sensor data, large sample time series data are affected by multiple factors and have complex characteristics such as multi-scale, non-linearity and burstiness. Traditional time series prediction methods are no longer applicable to the study of large sample time series data. Granular computing has unique advantages in dealing with continuous and complex data, and can compensate for the limitations of traditional support vector machines in dealing with large sample data. Therefore, this paper proposes to combine granular computing theory with support vector machines to achieve large-sample time series data prediction. Firstly, the definition of time series is analyzed, and the basic principles of traditional time series forecasting methods and granular computing are investigated. Secondly, in terms of predicting the trend of data changes, it is proposed to apply the fuzzy granulation algorithm to first convert the sample data into coarser granules. Then, it is combined with a support vector machine to predict the range of change of continuous time series data over a period of time. The results of the simulation experiments show that the proposed model is able to make accurate predictions of the range of data changes in future time periods. Compared with other prediction models, the proposed model reduces the complexity of the samples and improves the prediction accuracy.
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Affiliation(s)
- Yushan Yin
- School of Electro-Mechanical Engineering, Xidian University, Xi’an, China
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LeBlanc M, McGaughey T, Peters PA. Characteristics of High-Resource Health System Users in Rural and Remote Regions: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5385. [PMID: 37047999 PMCID: PMC10094250 DOI: 10.3390/ijerph20075385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/15/2023] [Accepted: 03/29/2023] [Indexed: 06/19/2023]
Abstract
A small proportion of health care users are recognized to use a significantly higher proportion of health system resources, largely due to systemic, inequitable access and disproportionate health burdens. These high-resource health system users are routinely characterized as older, with multiple comorbidities, and reduced access to adequate health care. Geographic trends also emerge, with more rural and isolated regions demonstrating higher rates of high-resource use than others. Despite known geographical discrepancies in health care access and outcomes, health policy and research initiatives remain focused on urban population centers. To alleviate mounting health system pressure from high-resource users, their characteristics must be better understood within the context in which i arises. To examine this, a scoping review was conducted to provide an overview of characteristics of high-resource users in rural and remote communities in Canada and Australia. In total, 21 papers were included in the review. Using qualitative thematic coding, primary findings characterized rural high-resource users as those of an older age; with increased comorbid conditions and condition severity; lower socioeconomic status; and elevated risk behaviors.
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Affiliation(s)
- Michele LeBlanc
- School of Nursing, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Tomoko McGaughey
- Department of Health Sciences, Carleton University, Ottawa, ON K1S 5B6, Canada
| | - Paul A. Peters
- Department of Health Sciences, Carleton University, Ottawa, ON K1S 5B6, Canada
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Quinton JK, Jackson N, Mangione CM, Moin T, Vasilyev A, O'Shea DL, Duru OK. Differential Impact of a Plan-Led Standardized Complex Care Management Intervention on Subgroups of High-Cost High-Need Medicaid Patients. Popul Health Manag 2023; 26:100-106. [PMID: 37071688 PMCID: PMC10125392 DOI: 10.1089/pop.2022.0271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
Interventions to better coordinate care for high-need high-cost (HNHC) Medicaid patients frequently fail to demonstrate changes in hospitalizations or emergency department (ED) use. Many of these interventions are modeled after practice-level complex care management (CCM) programs. The authors hypothesized that a national CCM program may be effective for some subgroups of HNHC patients, and the overall null effect may obfuscate subgroup-level impact. They used a previously published typology defining 6 subgroups of high-cost Medicaid patients and evaluated program impact by subgroup. The analysis used an individual-level interrupted time series with a comparison group. Intervention subjects were high-cost adult Medicaid patients who enrolled in 1 of 2 national CCM programs implemented by UnitedHealthcare (UHC) (n = 39,687). The comparators were patients who met CCM program criteria but were ineligible due to current enrollment in another UHC/Optum led program (N = 26,359). The intervention was a CCM program developed by UHC/Optum to provide "whole person care" delivering standardized interventions to address medical, behavioral, and social needs for HNHC Medicaid patients, and the outcome was probability of hospitalization or ED use in a given month, estimated at 12 months postenrollment. A reduction in risk of ED utilization for 4 of 6 subgroups was found. A reduction in risk of hospitalization for 1 of 6 subgroups was also found. The authors conclude that standardized health plan led CCM programs demonstrate effectiveness for certain subgroups of HNHC patients in Medicaid. This effectiveness is principally in reducing ED risk and may extend to the risk of hospitalization for a small number of patients.
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Affiliation(s)
- Jacob K. Quinton
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, USA
- CMS Innovation Center, Centers for Medicare and Medicaid Services, Baltimore, Maryland, USA
| | - Nicholas Jackson
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, USA
| | - Carol M. Mangione
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, USA
| | - Tannaz Moin
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, USA
| | - Arseniy Vasilyev
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, USA
| | | | - O. Kenrik Duru
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, USA
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Ricket IM, Matheny ME, MacKenzie TA, Emond JA, Ailawadi KL, Brown JR. Novel integration of governmental data sources using machine learning to identify super-utilization among U.S. counties. INTELLIGENCE-BASED MEDICINE 2023; 7:100093. [PMID: 37476591 PMCID: PMC10358365 DOI: 10.1016/j.ibmed.2023.100093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
Background Super-utilizers consume the greatest share of resource intensive healthcare (RIHC) and reducing their utilization remains a crucial challenge to healthcare systems in the United States (U.S.). The objective of this study was to predict RIHC among U.S. counties, using routinely collected data from the U.S. government, including information on consumer spending, offering an alternative method for identifying super-utilization among population units rather than individuals. Methods Cross-sectional data from 5 governmental sources in 2017 were used in a machine learning pipeline, where target-prediction features were selected and used in 4 distinct algorithms. Outcome metrics of RIHC utilization came from the American Hospital Association and included yearly: (1) emergency rooms visit, (2) inpatient days, and (3) hospital expenditures. Target-prediction features included: 149 demographic characteristics from the U.S. Census Bureau, 151 adult and child health characteristics from the Centers for Disease Control and Prevention, 151 community characteristics from the American Community Survey, and 571 consumer expenditures from the Bureau of Labor Statistics. SHAP analysis identified important target-prediction features for 3 RIHC outcome metrics. Results 2475 counties with emergency rooms and 2491 counties with hospitals were included. The median yearly emergency room visits per capita was 0.450 [IQR:0.318, 0.618], the median inpatient days per capita was 0.368 [IQR: 0.176, 0.826], and the median hospital expenditures per capita was $2104 [IQR: $1299.93, 3362.97]. The coefficient of determination (R2), calculated on the test set, ranged between 0.267 and 0.447. Demographic and community characteristics were among the important predictors for all 3 RIHC outcome metrics. Conclusions Integrating diverse population characteristics from numerous governmental sources, we predicted 3-outcome metrics of RIHC among U.S. counties with good performance, offering a novel and actionable tool for identifying super-utilizer segments in the population. Wider integration of routinely collected data can be used to develop alternative methods for predicting RIHC among population units.
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Affiliation(s)
- Iben M. Ricket
- Department of Epidemiology, Dartmouth Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Michael E. Matheny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical Care Center, Tennessee Valley Healthcare System VA, Nashville, TN, USA
| | - Todd A. MacKenzie
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Jennifer A. Emond
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - Jeremiah R. Brown
- Department of Epidemiology, Dartmouth Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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Keeney T, Lee MK, Basford JR, Cheville A. Association of Function, Symptoms, and Social Support Reported in Standardized Outpatient Clinic Questionnaires With Subsequent Hospital Discharge Disposition and 30-Day Readmissions. Arch Phys Med Rehabil 2022; 103:2383-2390. [PMID: 35803330 DOI: 10.1016/j.apmr.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/23/2022] [Accepted: 06/02/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine whether patient-reported information, routinely collected in an outpatient setting, is associated with readmission within 30 days of discharge and/or the need for post-acute care after a subsequent hospital admission. DESIGN Retrospective cohort study. Six domains of patient-reported information collected in the outpatient setting (psychological distress, respiratory symptoms, musculoskeletal pain, family support, mobility, and activities of daily living [ADLs]) were linked to electronic health record hospitalization data. Mixed effects logistic regression models with random intercepts were used to identify the association between the 6 domains and outcomes. SETTING Outpatient clinics and hospitals in a Midwestern health system. PARTICIPANTS 7671 patients who were hospitalized 11,445 times between May 2004 and May 2014 (N=7671). INTERVENTION None. MAIN OUTCOME MEASURES 30-day hospital readmission and discharge home vs facility. RESULTS Domains were significantly associated with 30-day readmission and placement in a facility. Specifically, mobility (odds ratio [OR]=1.30; 95% confidence interval [CI], 1.16, 1.46), ADLs (OR=1.27; 95% CI, 1.13, 1.42), respiratory symptoms (OR=1.26; 95% CI, 1.12, 1.41), and psychological distress (OR=1.20; 95% CI, 1.07, 1.35) had the strongest associations with 30-day readmission. The ADL (OR=2.52; 95% CI, 2.26, 2.81), mobility (OR=2.35; 95% CI, 2.10, 2.63), family support (OR=2.28; 95% CI, 1.98, 2.62), and psychological distress (OR=1.38; 95% CI, 1.25, 1.52) domains had the strongest associations with discharge to an institution. CONCLUSIONS Patient-reported function, symptoms, and social support routinely collected in outpatient clinics are associated with future 30-day readmission and discharge to an institutional setting. Whether these data can be leveraged to guide interventions to address patient needs and improve outcomes requires further research.
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Affiliation(s)
- Tamra Keeney
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA; Center for Aging and Serious Illness, Mongan Institute, Massachusetts General Hospital, Boston, MA; Department of Health Services, Policy & Practice, Brown University, School of Public Health, Providence, RI.
| | - Minji K Lee
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Jeffrey R Basford
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | - Andrea Cheville
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
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Fan Q, Wang J, Nicholas S, Maitland E. High-cost users: drivers of inpatient healthcare expenditure concentration in urban China. BMC Health Serv Res 2022; 22:1348. [DOI: 10.1186/s12913-022-08775-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/02/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Total healthcare expenditures are concentrated among a small number of patients. To date, studies on the concentration of health care expenditures in developing countries are limited, mainly focusing on concentration measures and the demographic, clinical and socioeconomic characteristics of high-cost users (HCU). The drivers of the skewed overall distribution of health care expenditures are opaque. Using inpatient administrative claims data, this study provides new evidence on the concentration of healthcare expenditures in China; the demographic and clinical characteristics of high-cost users; and the drivers of the overall distribution of healthcare expenditures.
Methods
Utilizing administrative claims data for hospitalization in a prefecture-level city in China, we investigated the concentration of healthcare expenditure. We used recentered influence function (RIF) regression to examine the drivers of healthcare expenditure concentration, decomposing and estimating the effects of demographic and disease characteristics on the overall distribution of health care expenditures.
Results
Using a sample of 87,841 adults, we found extreme skewness in the distribution of inpatient medical expenditures in China, with approximately 49% of annual medical expenditures generated by the top 10% of inpatient groups. HCUs tend to be elderly and male, with high-frequency hospitalizations and long lengths of stay. In addition, healthcare expenditure concentration was related to diseases of the circulatory system, malignant neoplasms, diseases of the musculoskeletal system and connective tissue, diseases of the digestive system, injury and poisoning, and diseases of the respiratory system. Malignant and major diseases reinforced the concentration of healthcare spending, and a 10% increase in the prevalence of malignancy would result in a predicted Gini coefficient increase of 7.2%, heart disease of 0.92% and cerebrovascular disease of 1.5%. The above significant positive effects were not observed for hypertension and diabetes mellitus.
Conclusions
Our study provides new insights into the concentration of inpatient medical expenditures in China, including the precise picture of HCU expenditure concentration, the drivers of HCU expenditure concentration and the magnitude of their impact. With the aging of China's population and the profound shift in the disease spectrum, policymakers need to strengthen the early detection and intervention management of specific chronic diseases and high-risk populations, especially the early diagnosis and treatment of key cancers.
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Jiang L, Qiu Q, Zhu L, Wang Z. Identifying Characteristics Associated with the Concentration and Persistence of Medical Expenses among Middle-Aged and Elderly Adults: Findings from the China Health and Retirement Longitudinal Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12843. [PMID: 36232143 PMCID: PMC9564963 DOI: 10.3390/ijerph191912843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
Medical expenses, especially among middle-aged and elderly people, have increased in China over recent decades. However, few studies have analyzed the concentration or persistence of medical expenses among Chinese residents or vulnerable groups with longitudinal survey data. Based on the data of CHARLS (China Health and Retirement Longitudinal Study), this study sought to identify characteristics associated with the concentration and persistence of medical expenses among Chinese middle-aged and elderly adults and to help alleviate medical spending and the operational risk of social medical insurance. Concentration was measured using the cumulative percentages of ranked annual medical expenses and descriptive statistics were used to define the characteristics of individuals with high medical expenses. The persistence of medical expenses and associated factors were estimated using transfer rate calculations and Heckman selection modeling. The results show that total medical expenses were concentrated among a few adults and the concentration increased over time. People in the high medical expense group were more likely to be older, live in urban areas, be less wealthy, have chronic diseases, and attend higher-ranking medical institutions. Lagged medical expenses had a persistent positive effect on current medical expenses and the effect of a one-period lag was strongest. Individuals with chronic diseases during the lagged period had a higher likelihood of experiencing persistent medical expenses. Policy efforts should focus on preventive management, more efficient care systems, improvement of serious illness insurance level, and strengthening the persistent protection effect of social medical insurance to reduce the high medical financial risk and long-term financial healthcare burden in China.
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Affiliation(s)
- Luyan Jiang
- School of Health Policy & Management, Nanjing Medical University, Nanjing 211166, China
| | - Qianqian Qiu
- School of Health Policy & Management, Nanjing Medical University, Nanjing 211166, China
| | - Lin Zhu
- School of Health Policy & Management, Nanjing Medical University, Nanjing 211166, China
| | - Zhonghua Wang
- School of Health Policy & Management, Nanjing Medical University, Nanjing 211166, China
- Public Health Policy and Management Innovation Research Group, Nanjing Medical University, Nanjing 211166, China
- Center for Global Health, Nanjing Medical University, Nanjing 211166, China
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13
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Jadhakhan F, Romeu D, Lindner O, Blakemore A, Guthrie E. Prevalence of medically unexplained symptoms in adults who are high users of healthcare services and magnitude of associated costs: a systematic review. BMJ Open 2022; 12:e059971. [PMID: 36198445 PMCID: PMC9535167 DOI: 10.1136/bmjopen-2021-059971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Medically unexplained symptoms (MUS) is a common clinical syndrome in primary and secondary healthcare service. Outcomes for patients with persistent MUS include increased disability, poorer quality of life and higher healthcare costs. The aim of this systematic review was to determine the prevalence of MUS in patients who are high users of healthcare or high-cost patients in comparison with routine users and the magnitude of associated costs. DESIGN A systematic review of the available literature. DATA SOURCES AND ELIGIBILITY CRITERIA The following electronic databases were systematically searched without language restriction from inception to June 2018 and updated on 22 October 2021: MEDLINE, PsycINFO, EMBASE, CINAHL and PROSPERO. Inclusion criteria included studies investigating adults aged ≥18 years, who were high healthcare users or accrued high healthcare costs, in which the prevalence and/or associated costs of MUS was quantified. Two reviewers independently extracted information on study characteristics, exposure and outcomes. RESULTS From 5622 identified publications, 25 studies from 9 countries involving 31 650 patients were selected for inclusion. Due to high risk of bias in many studies and heterogeneity between studies, results are described narratively. There were wide variations in prevalence estimates for MUS in high users of healthcare (2.9%-76%), but MUS was more prevalent in high use groups compared with low use groups in all but one of the 12 studies that included a comparator group. Only three studies investigated healthcare costs associated with MUS, and all three reported greater healthcare costs associated with MUS. CONCLUSION MUS has been found to be more prevalent in high use healthcare populations than comparator groups, but the magnitude of difference is difficult to estimate due to considerable heterogeneity between studies and potential for bias. Future studies should prioritise a standardised approach to this research area, with agreed definitions of MUS and high healthcare use. PROSPERO REGISTRATION NUMBER CRD42018100388.
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Affiliation(s)
- Ferozkhan Jadhakhan
- Centre of Precision Rehabilitation for Spinal Pain School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Daniel Romeu
- Leeds and York Partnership NHS Foundation Trust, Leeds, UK
- Division of Psychological and Social Medicine, Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Oana Lindner
- Patient-Centred Outcomes Research Group, Leeds Institute of Medical Research at St. James's University Hospital, School of Medicine, University of Leeds, Leeds, UK
| | - Amy Blakemore
- Division of Nursing, Social Work and Midwifery, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Elspeth Guthrie
- School of Medicine, Leeds Institute of Health Sciences, University of Leeds, Room 10.39, Worsley Building, Clarendon Way, Leeds, UK
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14
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Liu L, Swearingen D, Simhon E, Kulkarni C, Noren D, Mans R. Interpretable Identification of Comorbidities Associated with Recurrent ED and Inpatient Visits. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:991-997. [PMID: 36086533 DOI: 10.1109/embc48229.2022.9871110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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15
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Ricket IM, MacKenzie TA, Emond JA, Ailawadi KL, Brown JR. Can diverse population characteristics be leveraged in a machine learning pipeline to predict resource intensive healthcare utilization among hospital service areas? BMC Health Serv Res 2022; 22:847. [PMID: 35773679 PMCID: PMC9248096 DOI: 10.1186/s12913-022-08154-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/03/2022] [Indexed: 06/02/2023] Open
Abstract
Background Super-utilizers represent approximately 5% of the population in the United States (U.S.) and yet they are responsible for over 50% of healthcare expenditures. Using characteristics of hospital service areas (HSAs) to predict utilization of resource intensive healthcare (RIHC) may offer a novel and actionable tool for identifying super-utilizer segments in the population. Consumer expenditures may offer additional value in predicting RIHC beyond typical population characteristics alone. Methods Cross-sectional data from 2017 was extracted from 5 unique sources. The outcome was RIHC and included emergency room (ER) visits, inpatient days, and hospital expenditures, all expressed as log per capita. Candidate predictors from 4 broad groups were used, including demographics, adults and child health characteristics, community characteristics, and consumer expenditures. Candidate predictors were expressed as per capita or per capita percent and were aggregated from zip-codes to HSAs using weighed means. Machine learning approaches (Random Forrest, LASSO) selected important features from nearly 1,000 available candidate predictors and used them to generate 4 distinct models, including non-regularized and LASSO regression, random forest, and gradient boosting. Candidate predictors from the best performing models, for each outcome, were used as independent variables in multiple linear regression models. Relative contribution of variables from each candidate predictor group to regression model fit were calculated. Results The median ER visits per capita was 0.482 [IQR:0.351–0.646], the median inpatient days per capita was 0.395 [IQR:0.214–0.806], and the median hospital expenditures per capita was $2,302 [1$,544.70-$3,469.80]. Using 1,106 variables, the test-set coefficient of determination (R2) from the best performing models ranged between 0.184–0.782. The adjusted R2 values from multiple linear regression models ranged from 0.311–0.8293. Relative contribution of consumer expenditures to model fit ranged from 23.4–33.6%. Discussion Machine learning models predicted RIHC among HSAs using diverse population data, including novel consumer expenditures and provides an innovative tool to predict population-based healthcare utilization and expenditures. Geographic variation in utilization and spending were identified.
Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08154-4.
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Affiliation(s)
- Iben M Ricket
- Department of Epidemiology, Geisel School of Medicine at Dartmouth College, NH, Hanover, USA.
| | - Todd A MacKenzie
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, NH, Hanover, USA
| | - Jennifer A Emond
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, NH, Hanover, USA.,Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth College, NH, Lebanon, USA
| | | | - Jeremiah R Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth College, NH, Hanover, USA
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16
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He X, Li D, Wang W, Liang H, Liang Y. Identifying patterns of clinical conditions among high-cost older adult health care users using claims data: a latent class approach. Int J Equity Health 2022; 21:86. [PMID: 35725607 PMCID: PMC9210624 DOI: 10.1186/s12939-022-01688-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/14/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives To identify patterns of clinical conditions among high-cost older adults health care users and explore the associations between characteristics of high-cost older adults and patterns of clinical conditions. Methods We analyzed data from the Shanghai Basic Social Medical Insurance Database, China. A total of 2927 older adults aged 60 years and over were included as the analysis sample. We used latent class analysis to identify patterns of clinical conditions among high-cost older adults health care users. Multinomial logistic regression models were also used to determine the associations between demographic characteristics, insurance types, and patterns of clinical conditions. Results Five clinically distinctive subgroups of high-cost older adults emerged. Classes included “cerebrovascular diseases” (10.6% of high-cost older adults), “malignant tumor” (9.1%), “arthrosis” (8.8%), “ischemic heart disease” (7.4%), and “other sporadic diseases” (64.1%). Age, sex, and type of medical insurance were predictors of high-cost older adult subgroups. Conclusions Profiling patterns of clinical conditions among high-cost older adults is potentially useful as a first step to inform the development of tailored management and intervention strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-022-01688-3.
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Affiliation(s)
- Xiaolin He
- Department of Social Policy, Shanghai Administration Institute, Shanghai, China
| | - Danjin Li
- School of Nursing, Fudan University, Shanghai, China
| | - Wenyi Wang
- School of Social Development and Public Policy, Fudan University, Shanghai, China
| | - Hong Liang
- School of Social Development and Public Policy, Fudan University, Shanghai, China
| | - Yan Liang
- School of Nursing, Fudan University, Shanghai, China.
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17
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Campwala Z, Davis G, Khazen O, Trowbridge R, Nabage M, Bagchi R, Argoff C, Pilitsis JG. The Impact of Multidisciplinary Conferences on Healthcare Utilization in Chronic Pain Patients. FRONTIERS IN PAIN RESEARCH 2022; 2:775210. [PMID: 35295478 PMCID: PMC8915707 DOI: 10.3389/fpain.2021.775210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/29/2021] [Indexed: 11/13/2022] Open
Abstract
Approximately 100 million adults in the United States have chronic pain, though only a subset utilizes the vast majority of healthcare resources. Multidisciplinary care has been shown to improve outcomes in a variety of clinical conditions. There is concern that multidisciplinary care of chronic pain patients may overwhelm existing resources and increase healthcare utilization due to the volume of patients and the complexity of care. We report our findings on the use of multidisciplinary conferences (MDC) to facilitate care for the most complex patients seen at our tertiary center. Thirty-two of nearly 2,000 patients seen per year were discussed at the MDC, making up the top 2% of complex patients in our practice. We evaluated patients' numeric rating score (NRS) of pain, medication use, hospitalizations, emergency department visits, and visits to pain specialists prior to their enrollment in MDC and 1 year later. Matched samples were compared using Wilcoxon's signed rank test. Patients' NRS scores significantly decreased from 7.64 to 5.54 after inclusion in MDC (p < 0.001). A significant decrease in clinic visits (p < 0.001) and healthcare utilization (p < 0.05) was also observed. Opioid and non-opioid prescriptions did not change significantly (p = 0.43). 83% of providers agreed that MDC improved patient care. While previous studies have shown the effect of multi-disciplinary care, we show notable improvements with a team established around a once-a-month MDC.
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Affiliation(s)
- Zahabiya Campwala
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Gregory Davis
- Department of Neurosurgery, Albany Medical Center, Albany, NY, United States
| | - Olga Khazen
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Rachel Trowbridge
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Melisande Nabage
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Rohan Bagchi
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Charles Argoff
- Department of Neurology, Albany Medical Center, Albany, NY, United States
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States.,Department of Neurosurgery, Albany Medical Center, Albany, NY, United States
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18
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Howson SN, McShea MJ, Ramachandran R, Burkom HS, Chang HY, Weiner JP, Kharrazi H. Improving the Prediction of Persistent High Healthcare Utilizers: Using an Ensemble Methodology. JMIR Med Inform 2022; 10:e33212. [PMID: 35275063 PMCID: PMC8990371 DOI: 10.2196/33212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 02/21/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background A small proportion of high-need patients persistently use the bulk of health care services and incur disproportionate costs. Population health management (PHM) programs often refer to these patients as persistent high utilizers (PHUs). Accurate PHU prediction enables PHM programs to better align scarce health care resources with high-need PHUs while generally improving outcomes. While prior research in PHU prediction has shown promise, traditional regression methods used in these studies have yielded limited accuracy. Objective We are seeking to improve PHU predictions with an ensemble approach in a retrospective observational study design using insurance claim records. Methods We defined a PHU as a patient with health care costs in the top 20% of all patients for 4 consecutive 6-month periods. We used 2013 claims data to predict PHU status in next 24 months. Our study population included 165,595 patients in the Johns Hopkins Health Care plan, with 8359 (5.1%) patients identified as PHUs in 2014 and 2015. We assessed the performance of several standalone machine learning methods and then an ensemble approach combining multiple models. Results The candidate ensemble with complement naïve Bayes and random forest layers produced increased sensitivity and positive predictive value (PPV; 49.0% and 50.3%, respectively) compared to logistic regression (46.8% and 46.1%, respectively). Conclusions Our results suggest that ensemble machine learning can improve prediction of care management needs. Improved PPV implies reduced incorrect referral of low-risk patients. With the improved sensitivity/PPV balance of this approach, resources may be directed more efficiently to patients needing them most.
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Affiliation(s)
| | - Michael J McShea
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, US
| | | | - Howard S Burkom
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, US
| | - Hsien-Yen Chang
- Center for Population Health IT, Johns Hopkins School of Public Health, 624 N BroadwayOffice 606, Baltimore, US
| | - Jonathan P Weiner
- Center for Population Health IT, Johns Hopkins School of Public Health, 624 N BroadwayOffice 606, Baltimore, US
| | - Hadi Kharrazi
- Center for Population Health IT, Johns Hopkins School of Public Health, 624 N BroadwayOffice 606, Baltimore, US
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19
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Ramachandran R, McShea MJ, Howson SN, Burkom HS, Chang HY, Weiner JP, Kharrazi H. Assessing the Value of Unsupervised Clustering in Predicting Persistent High Health Care Utilizers: Retrospective Analysis of Insurance Claims Data. JMIR Med Inform 2021; 9:e31442. [PMID: 34592712 PMCID: PMC8663459 DOI: 10.2196/31442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/26/2021] [Accepted: 09/30/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND A high proportion of health care services are persistently utilized by a small subpopulation of patients. To improve clinical outcomes while reducing costs and utilization, population health management programs often provide targeted interventions to patients who may become persistent high users/utilizers (PHUs). Enhanced prediction and management of PHUs can improve health care system efficiencies and improve the overall quality of patient care. OBJECTIVE The aim of this study was to detect key classes of diseases and medications among the study population and to assess the predictive value of these classes in identifying PHUs. METHODS This study was a retrospective analysis of insurance claims data of patients from the Johns Hopkins Health Care system. We defined a PHU as a patient incurring health care costs in the top 20% of all patients' costs for 4 consecutive 6-month periods. We used 2013 claims data to predict PHU status in 2014-2015. We applied latent class analysis (LCA), an unsupervised clustering approach, to identify patient subgroups with similar diagnostic and medication patterns to differentiate variations in health care utilization across PHUs. Logistic regression models were then built to predict PHUs in the full population and in select subpopulations. Predictors included LCA membership probabilities, demographic covariates, and health utilization covariates. Predictive powers of the regression models were assessed and compared using standard metrics. RESULTS We identified 164,221 patients with continuous enrollment between 2013 and 2015. The mean study population age was 19.7 years, 55.9% were women, 3.3% had ≥1 hospitalization, and 19.1% had 10+ outpatient visits in 2013. A total of 8359 (5.09%) patients were identified as PHUs in both 2014 and 2015. The LCA performed optimally when assigning patients to four probability disease/medication classes. Given the feedback provided by clinical experts, we further divided the population into four diagnostic groups for sensitivity analysis: acute upper respiratory infection (URI) (n=53,232; 4.6% PHUs), mental health (n=34,456; 12.8% PHUs), otitis media (n=24,992; 4.5% PHUs), and musculoskeletal (n=24,799; 15.5% PHUs). For the regression models predicting PHUs in the full population, the F1-score classification metric was lower using a parsimonious model that included LCA categories (F1=38.62%) compared to that of a complex risk stratification model with a full set of predictors (F1=48.20%). However, the LCA-enabled simple models were comparable to the complex model when predicting PHUs in the mental health and musculoskeletal subpopulations (F1-scores of 48.69% and 48.15%, respectively). F1-scores were lower than that of the complex model when the LCA-enabled models were limited to the otitis media and acute URI subpopulations (45.77% and 43.05%, respectively). CONCLUSIONS Our study illustrates the value of LCA in identifying subgroups of patients with similar patterns of diagnoses and medications. Our results show that LCA-derived classes can simplify predictive models of PHUs without compromising predictive accuracy. Future studies should investigate the value of LCA-derived classes for predicting PHUs in other health care settings.
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Affiliation(s)
- Raghav Ramachandran
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, MD, United States
| | - Michael J McShea
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, MD, United States
| | - Stephanie N Howson
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, MD, United States
| | - Howard S Burkom
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, MD, United States
| | - Hsien-Yen Chang
- Center for Population Health Information Technology, Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | - Jonathan P Weiner
- Center for Population Health Information Technology, Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | - Hadi Kharrazi
- Center for Population Health Information Technology, Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, United States
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20
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Scullen T, Mathkour M, Dumont AS. Commentary: Systematic Review and Meta-Analysis of the Dose-Response and Risk Factors for Obliteration of Arteriovenous Malformations Following Radiosurgery: An Update Based on the Last 20 Years of Published Clinical Evidence. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Kaltenborn Z, Paul K, Kirsch JD, Aylward M, Rogers EA, Rhodes MT, Usher MG. Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers. BMC Health Serv Res 2021; 21:338. [PMID: 33853590 PMCID: PMC8045386 DOI: 10.1186/s12913-021-06323-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Zach Kaltenborn
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Koushik Paul
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA
| | - Jonathan D Kirsch
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA
| | - Michael Aylward
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Elizabeth A Rogers
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Michael T Rhodes
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.
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22
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Guntuku SC, Klinger EV, McCalpin HJ, Ungar LH, Asch DA, Merchant RM. Social media language of healthcare super-utilizers. NPJ Digit Med 2021; 4:55. [PMID: 33767336 PMCID: PMC7994843 DOI: 10.1038/s41746-021-00419-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/16/2021] [Indexed: 12/02/2022] Open
Abstract
An understanding of healthcare super-utilizers' online behaviors could better identify experiences to inform interventions. In this retrospective case-control study, we analyzed patients' social media posts to better understand their day-to-day behaviors and emotions expressed online. Patients included those receiving care in an urban academic emergency department who consented to share access to their historical Facebook posts and electronic health records. Super-utilizers were defined as patients with more than six visits to the Emergency Department (ED) in a year. We compared posts by super-utilizers with a matched group using propensity scoring based on age, gender and Charlson comorbidity index. Super-utilizers were more likely to post about confusion and negativity (D = .65, 95% CI-[.38, .95]), self-reflection (D = .63 [.35, .91]), avoidance (D = .62 [.34, .90]), swearing (D = .52 [.24, .79]), sleep (D = .60 [.32, .88]), seeking help and attention (D = .61 [.33, .89]), psychosomatic symptoms, (D = .49 [.22, .77]), self-agency (D = .56 [.29, .85]), anger (D = .51, [.24, .79]), stress (D = .46, [.19, .73]), and lonely expressions (D = .44, [.17, .71]). Insights from this study can potentially supplement offline community care services with online social support interventions considering the high engagement of super-utilizers on social media.
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Affiliation(s)
- Sharath Chandra Guntuku
- Penn Medicine Center for Digital Health, Philadelphia, PA, USA.
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Elissa V Klinger
- Penn Medicine Center for Digital Health, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Haley J McCalpin
- Penn Medicine Center for Digital Health, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Lyle H Ungar
- Penn Medicine Center for Digital Health, Philadelphia, PA, USA
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA, USA
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
- Cpl Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Raina M Merchant
- Penn Medicine Center for Digital Health, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
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García-Arango V, Osorio-Ciro J, Aguirre-Acevedo D, Vanegas-Vargas C, Clavijo-Usuga C, Gallo-Villegas J. [Predictive validity of a functional classification method in older adultsValidação preditiva de método de classificação funcional em idosos]. Rev Panam Salud Publica 2021; 45:e15. [PMID: 33643398 PMCID: PMC7905750 DOI: 10.26633/rpsp.2021.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022] Open
Abstract
Objetivo. Evaluar la validez predictiva de un método de clasificación funcional (CF) sobre el uso de los servicios de urgencias y hospitalización, mortalidad y costos de la atención en salud en adultos mayores. Métodos. Estudio de cohorte retrospectivo que incluyó 2 168 adultos mayores en un programa de atención de las enfermedades crónicas no transmisibles (ECNT) en Medellín (Colombia). Los pacientes fueron estratificados según un método de CF con base en el estado funcional, presencia de factores de riesgo y control de la comorbilidad. Durante un año de seguimiento, se evaluó la validez predictiva de la CF sobre los desenlaces estudiados; se midieron la discriminación y la calibración con el estadístico-C y de Hosmer-Lemeshow (H-L), respectivamente. Resultados. El promedio de edad fue 74,6 ± 7,9 años; el 40,8% (n = 884) fueron hombres y 7,7% (n = 168) murieron. El riesgo de muerte (razón de posibilidades [OR, por su sigla en inglés]: 1,767; 3,411; 8,525), hospitalización (OR: 1,397; 2,172; 3,540) y un costo elevado de la atención en salud (OR: 1,703; 2,369; 5,073) aumentaron en la medida que hubo un deterioro en la CF, clases 2B, 3 y 4, respectivamente. El modelo predictivo para el desenlace muerte mostró una buena capacidad de discriminación (estadístico-C = 0,721) y calibración (estadístico de H-L = 10,200; P = 0,251). Conclusión. Existe una relación de dosis y respuesta entre el deterioro de la CF y un riesgo más elevado de muerte, hospitalización y costo elevado. La CF tiene validez predictiva para la tasa de mortalidad y podría utilizarse para la estratificación de adultos mayores en programas de atención de las ECNT con miras a dirigir las acciones de intervención.
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Affiliation(s)
- Víctor García-Arango
- Universidad de Antioquia Medellín Colombia Universidad de Antioquia, Medellín, Colombia
| | - Jorge Osorio-Ciro
- Universidad de Antioquia Medellín Colombia Universidad de Antioquia, Medellín, Colombia
| | | | - Catalina Vanegas-Vargas
- Institución Prestadora de Servicios de Salud Universitaria Medellín Colombia Institución Prestadora de Servicios de Salud Universitaria, Medellín, Colombia
| | - Carmen Clavijo-Usuga
- Institución Prestadora de Servicios de Salud Universitaria Medellín Colombia Institución Prestadora de Servicios de Salud Universitaria, Medellín, Colombia
| | - Jaime Gallo-Villegas
- Universidad de Antioquia Medellín Colombia Universidad de Antioquia, Medellín, Colombia
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Pino EC, Fontin F, James TL, Dugan E. Boston Violence Intervention Advocacy Program: Challenges and Opportunities for Client Engagement and Goal Achievement. Acad Emerg Med 2021; 28:281-291. [PMID: 33111373 DOI: 10.1111/acem.14162] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/13/2020] [Accepted: 10/22/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVES A better understanding of the factors affecting client engagement in hospital-based violence intervention programs (HVIPs), and which types of client needs prove most challenging to achieve, may be of key importance in developing novel, targeted strategies to violence intervention. In this study, we examined the demographics and injury characteristics of violently injured patients by their level of engagement with the Boston Violence Intervention Advocacy Program (VIAP) and determined the degree of client goal achievement through VIAP client services. METHODS This retrospective study was performed using a cohort of patients presenting to the Boston Medical Center emergency department for a violent penetrating injury due to community violence between 2013 and 2018. Data on client demographics, injury characteristics, and client needs were collected from the VIAP data repository. Cox proportional hazard regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals to assess the difference in hazards of client goal achievement by need type. RESULTS Of the 2,243 victims of violent injury, 839 (37.4%) patients engaged with VIAP. Significant predictors of client engagement include younger age, Black race, permanent home, existing mental health diagnosis, gunshot wound, and more severe injuries. Conversely, older age, homelessness, substance use, stab wound, and less severe injuries predicted refusal of VIAP services. For clients who chose to engage with VIAP, needs related to education (HR = 0.47, 95% CI = 0.38 to 0.58), employment (HR = 0.66, 95% CI = 0.57 to 0.77), and housing (HR = 0.76, 95% CI = 0.68 to 0.86) were significantly less likely to be achieved compared to basic needs. CONCLUSIONS This study demonstrates that VIAP is effectively engaging the client population that HVIPs have been designed to support. HVIPs should consider novel strategies to engage vulnerable populations not typically targeted by intervention programs. These results speak to the difficulties of program attrition and the complexities of altering the life course for victims of violence.
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Affiliation(s)
- Elizabeth C. Pino
- From the Department of Emergency Medicine Boston Violence Intervention Advocacy Program (VIAP) Boston Medical Center Boston MA USA
| | - Francesca Fontin
- From the Department of Emergency Medicine Boston Violence Intervention Advocacy Program (VIAP) Boston Medical Center Boston MA USA
| | - Thea L. James
- From the Department of Emergency Medicine Boston Violence Intervention Advocacy Program (VIAP) Boston Medical Center Boston MA USA
| | - Elizabeth Dugan
- From the Department of Emergency Medicine Boston Violence Intervention Advocacy Program (VIAP) Boston Medical Center Boston MA USA
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Eliacin J, Yang Z, Kean J, Dixon BE. Characterizing health care utilization following hospitalization for a traumatic brain injury: a retrospective cohort study. Brain Inj 2021; 35:119-129. [PMID: 33356602 DOI: 10.1080/02699052.2020.1861650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 08/31/2020] [Accepted: 12/05/2020] [Indexed: 10/22/2022]
Abstract
Objective: The purpose of this study was to characterize health services utilization among individuals hospitalized with a traumatic brain injury (TBI) 1-year post-injury.Methods: Using a retrospective cohort design, adult patients (n = 32, 042) hospitalized with a traumatic brain injury between 2005 and 2014 were selected from a statewide traumatic brain injury registry. Data on health services utilization for 1-year post-injury were extracted from electronic medical and administrative records. Descriptive statistics and logistic regression were used to characterize the cohort and a subgroup of superutilizers of health services.Results: One year after traumatic brain injury, 56% of participants used emergency department services, 80% received inpatient services, and 93% utilized outpatient health services. Superutilizers had ≥3 emergency department visits, ≥3 inpatient admissions, or ≥26 outpatient visits 1-year post-injury. Twenty-six percent of participants were superutilizers of emergency department services, 30% of inpatient services, and 26% of outpatient services. Superutilizers contributed to 81% of emergency department visits, 70% of inpatient visits, and 60% of outpatient visits. Factors associated with being a superutilizer included sex, race, residence, and insurance type.Conclusions: Several patient characteristics and demographic factors influenced patients' healthcare utilization post-TBI. Findings provide opportunities for developing targeted interventions to improve patients' health and traumatic brain injury-related healthcare delivery.
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Affiliation(s)
- Johanne Eliacin
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, USA
- Department of Psychology, Indiana University-Purdue University - Indianapolis, Indianapolis, USA
- Health Services Research, Regenstrief Institute, Inc., Indianapolis, USA
| | - Ziyi Yang
- Department of Biostatistics, Indiana University-Purdue University - Indianapolis, Indianapolis, USA
| | - Jacob Kean
- Informatics, Decision-Enhancement and Analytic Sciences Center, Health Services Research and Development, VA Salt Lake City Health Care System, Salt Lake City, USA
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, USA
- Department of Communication Sciences and Disorders, University of Utah School of Medicine, Salt Lake City, USA
| | - Brian E Dixon
- Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, USA
- Department of Epidemiology, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, USA
- Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, USA
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Young HW, Martin ET, Kwiatkowski E, Tyndall JA, Cottler LB. The Association between Emergency Department Super-Utilizer Status and Willingness to Participate in Research. Emerg Med Int 2020; 2020:9404293. [PMID: 32670641 PMCID: PMC7341402 DOI: 10.1155/2020/9404293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/09/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Research based on emergency departments (EDs) primarily focuses on medical conditions. There is limited research that investigates patients who willingly participate in research. This current study explored ED super-utilizers' (SUs') and nonsuper-utilizers' (NSUs') attitudes toward research. OBJECTIVE The study assesses the willingness of SUs to participate in research. We hypothesize that the SU population will be as interested as nonutilizers in participating in medical research. METHODS This prospective observational study stratified participants into SU and NSU cohorts based on their self-reported number of ED visits within 6 months. Surveys were captured in a secured database and analyzed using SAS 9.4. RESULTS 7,481 completed questionnaires. SUs were more interested in participating in all types of research compared to NSUs. Both groups were most willing to participate in surveys. Neither group was particularly interested in studies that required medications. SUs were not more willing to participate in studies without payment than NSUs. Both groups trusted researchers at the same rates. CONCLUSION Although rarely included in medical research, SUs were more willing to participate in nearly all types of research and expressed a similar trust in medical research when compared to nonsuper-utilizers.
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Affiliation(s)
- Henry W. Young
- Department of Emergency Medicine, University of Florida, 1329 SW 16th Street, Suite 5270, Gainesville, FL 32610, USA
| | - Emmett T. Martin
- Department of Emergency Medicine, University of Florida, 1329 SW 16th Street, Suite 5270, Gainesville, FL 32610, USA
| | - Evan Kwiatkowski
- Department of Biostatics, University of North Carolina, 135 Dauer Drive, Chapel Hill, N.C. 27599, USA
| | - J. Adrian Tyndall
- Department of Emergency Medicine, University of Florida, 1329 SW 16th Street, Suite 5270, Gainesville, FL 32610, USA
| | - Linda B. Cottler
- Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, 2004 Mowry Road, Room 4218, P.O. Box 100231, Gainesville, FL 32610, USA
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Gupta A, Meddings J, Houchens N. Quality & safety in the literature: May 2020. BMJ Qual Saf 2020; 29:436-440. [PMID: 32139399 DOI: 10.1136/bmjqs-2020-011059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Ashwin Gupta
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA .,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer Meddings
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Ang IYH, Ng SHX, Rahman N, Nurjono M, Tham TY, Toh SA, Wee HL. Right-Site Care Programme with a community-based family medicine clinic in Singapore: secondary data analysis of its impact on mortality and healthcare utilisation. BMJ Open 2019; 9:e030718. [PMID: 31892645 PMCID: PMC6955507 DOI: 10.1136/bmjopen-2019-030718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Stable patients with chronic conditions could be appropriately cared for at family medicine clinics (FMC) and discharged from hospital specialist outpatient clinics (SOCs). The Right-Site Care Programme with Frontier FMC emphasised care organised around patients in community rather than hospital-based providers, with one identifiable primary provider. This study evaluated impact of this programme on mortality and healthcare utilisation. DESIGN A retrospective study without randomisation using secondary data analysis of patients enrolled in the intervention matched 1:1 with unenrolled patients as controls. SETTING Programme was supported by the Ministry of Health in Singapore, a city-state nation in Southeast Asia with 5.6 million population. PARTICIPANTS Intervention group comprises patients enrolled from January to December 2014 (n=684) and control patients (n=684) with at least one SOC and no FMC attendance during same period. INTERVENTIONS Family physician in Frontier FMC managed patients in consultation with relevant specialist physicians or fully managed patients independently. Care teams in SOCs and FMC used a common electronic medical records system to facilitate care coordination and conducted regular multidisciplinary case conferences. PRIMARY OUTCOME MEASURES Deidentified linked healthcare administrative data for time period of January 2011 to December 2017 were extracted. Three-year postenrolment mortality rates and utilisation frequencies and charges for SOC, public primary care centres (polyclinic), emergency department attendances and emergency, non-day surgery inpatient and all-cause admissions were compared. RESULTS Intervention patients had lower mortality rate (HR=0.37, p<0.01). Among those with potential of postenrolment polyclinic attendance, intervention patients had lower frequencies (incidence rate ratio (IRR)=0.60, p<0.01) and charges (mean ratio (MR)=0.51, p<0.01). Among those with potential of postenrolment SOC attendance, intervention patients had higher frequencies (IRR=2.06, p<0.01) and charges (MR=1.86, p<0.01). CONCLUSIONS Intervention patients had better survival, probably because their chronic conditions were better managed with close monitoring, contributing to higher total outpatient attendance frequencies and charges.
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Affiliation(s)
- Ian Yi Han Ang
- Regional Health System Office, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Sheryl Hui-Xian Ng
- Regional Health System Office, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Nabilah Rahman
- Regional Health System Office, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Milawaty Nurjono
- Centre for Health Services and Policy Research (CHSPR), Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Tat Yean Tham
- Clinical Affairs Department, Frontier Healthcare Group, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sue-Anne Toh
- Regional Health System Office, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Singapore Population Health Improvement Centre (SPHERiC), National University Health System, Singapore, Singapore
| | - Hwee Lin Wee
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Faculty of Science, National University of Singapore, Singapore, Singapore
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