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High Utilizers of Health Care

Key Questions Draft

Draft Key Questions

  1. What are the characteristics of patients who are "high utilizers"?
    1. How do definitions of "high utilizers" vary between studies?
    2. How much variation in utilization is considered "high utilization" and what are the rates and durations of high utilization?
    3. What patient characteristics, including clinical characteristics, social determinants of health, insurance status, or other are associated with high utilization?
    4. What methods have been developed to distinguish patients with potentially preventable high utilization vs. patients with conditions such as cancer where high utilization may be unavoidable?
    5. What characteristics distinguish the need for different types of interventions to address the high utilization?
  2. What are the effective interventions for adults identified as high utilizers of health care?
    1. Does effectiveness vary based on patient characteristics including underlying comorbidities, demographics and social determinants of health and wellness or other characteristics identified in question 1?
    2. Does effectiveness vary depending on who delivers the intervention (e.g. community health worker, social worker, nurse?
    3. Does effectiveness vary depending on the mode of intervention delivery (e.g., in-person, telehealth)?
    4. Does effectiveness vary depending on structural characteristics of the intervention (e.g., primary care-based versus health care system-based or partnership with non-health care entities [such as housing, or transportation] versus clinic-based?
    5. Does effectiveness vary depending on the characteristics of the health system?
  3. Overall, what is the evidence about which interventions targeting which patient groups lead to the highest overall improvement in health outcomes and cost savings for providers, patients and payers?

Background

A small proportion of patients, sometimes called high utilizers of health care, account for a large proportion of healthcare costs. In the US, 1% of patients incur more than 20% of health care costs, and 5% of patients incur approximately 50% of total costs.1 However, there is no consensus on the definition of patients who are high utilizers.2 Researchers characterize this population differently, including by the type of utilization (e.g., the number of emergency department [ED] visits or the number of hospital admissions), by costs, or by number of chronic conditions.3,4

Patients who are high utilizers of health care are a particularly heterogeneous population. High utilizers may be more likely to have multiple chronic conditions, mental health diagnoses, and risk factors for poor health including homelessness and history of recreational drug use.5 Patients may not remain high utilizers over time, as one study found only 6% of high utilizers met criteria consistently over a two-year period.4

Multiple interventions have been attempted to address high utilization, but it is not clear to health systems which interventions are most effective. Interventions for these patients are diverse in their design and delivery, including case management, intensive primary care (which may include expansion of primary care services, more frequent use of care, changes in the role of primary care providers, etc.), interventions addressing social determinants of health, hotspotting,6 and alerts in the ED.

To define the inclusion criteria for the key questions, we specify the population, interventions, comparators, outcomes, and setting (PICOS) of interest (Table 1).

Table 1. PICOS

Population Adults identified as high utilizers of health care*
Interventions
  • Intensive primary care support
  • Self-management
  • Home based care
  • Case management** (e.g., nurse, social worker)
  • Social interventions (e.g., transportation, housing)
  • Emergency department alerts
  • Hotspotting
  • Other
Comparators Any intervention above, usual care, no comparator
Outcomes Reduction in ED visits, hospitalizations or other healthcare utilization

All-cause mortality
Disease-specific outcomes (e.g., reductions in CHF exacerbation, HbA1c, BMI)
Quality of life
Cost

Setting All

Abbreviations: BMI: body-mass index; COPD: chronic obstructive pulmonary disease; CHF: congestive heart failure: ED: emergency department
*Exclude populations with single conditions (e.g., cancer, CHF, COPD)
**Case management is used to refer to both care or case management

 

Notes

  1. Cohen S. The Concentration of Health Care Expenditures and Related Expenses for Costly Medical Conditions, 2012. Statistical Brief #455 Agency for Healthcare Research and Quality, Rockville, MD. 2014.
  2. Hasselman D. Super-Utilizer Summit: Common Themes from Innovative Complex Care Management Programs. Center for Health Care Strategies, Inc. 2013.
  3. Hayes SL, Salzberg CA, McCarthy D, et al. High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? A Population-Based Comparison of Demographics, Health Care Use, and Expenditures. Issue Brief (Commonw Fund). 2016;26:1-14.
  4. Johnson TL, Rinehart DJ, Durfee J, et al. For many patients who use large amounts of health care services, the need is intense yet temporary. Health affairs (Project Hope). 2015;34(8):1312-1319.
  5. Bell J, Turbow S, George M, Ali MK. Factors associated with high-utilization in a safety net setting. BMC Health Services Research. 2017;17:1-9.
  6. Gawande A. The Hot Spotters. The New Yorker, 2011.