Drivers Of Healthcare Resource Utilization

Abstract

MANUSCRIPT 1: BACKGROUND: Hot spotting is a population management method for identifying high utilizers and enabling them to receive intensive case management services. However, since this method is retrospective, the benefit from hot spotting is reaped only after patients have become high utilizers. Studies looking at prospective hot spotting offer a promising alternative, as patients at high risk of becoming high utilizers can be identified, and interventions can be implemented. OBJECTIVES: The aim of this review is to summarize literature that examines how investigators identify high utilizers, describes characteristics of high utilizers, evaluates the effects of interventions aimed at reducing unnecessary utilization, and compare and contrast methods of hot spotting. METHODS: PUBMED and Scopus were with keywords “patient”, retention”, “patient disenrollment”, “healthcare system”, “frequent users”, “patient centered medical home”, and “primary care”. The following MeSH terms were also used: “patient centered care”, “primary care”. Abstracts were screened, and then selected by the author. Systematic reviews, retrospective cohort, randomized controlled trials that described characteristics of high utilizers or patients of a similar nature were ultimately chosen. Studies with were also selected if interventions were tested with outcomes of cost and/or frequencies of visits were used. RESULTS: Definitions of high utilization varied. Most were in the setting of the emergency department. High utilizers had multiple chronic diseases, were mostly women, had Medicare or Medicaid, impoverished, have mental health issues, and substance abuse problems. Models for identifying high utilizers used prior visit history and various clinical data points to generate an algorithm for patient identifications. Targeted case management interventions seem to decrease the frequency of emergency department visits. CONCLUSION: The literature shows evidence of effective models for identifying high utilizers. However, current models do not adequately capture a transformation of a patient to a high utilizer. MANUSCRIPT 2: BACKGROUND: Reducing healthcare utilization is a critical national focus. Though patients with a high burden of chronic disease measured by the Charlson Comorbidity Index accounts for a disproportionate amount of healthcare costs, as a result of emergency department (ED) and inpatient visits, reasons for high utilization are complex and incompletely understood. OBJECTIVES: Within a managed care Medicaid population, identify characteristics among patients with a Comorbidity Index score of ? 4 who visit the ED. A secondary objective is to identify characteristics of patients who are hospitalized that are associated with ED visits. METHODS: This study assessed 43 MetroPlus Medicaid patients in the South Bronx with comorbidity scores of ? 4, older than 18 years old, and able to speak English or Spanish. Patients were interviewed to assess demographic, psychological, clinical, social, and economic domains. The primary outcome was number of emergency room visits within 1 year prior to enrollment and up to 6 months after. The secondary outcome was non-elective inpatient hospitalizations during the same time frame. RESULTS: 43 patients completed enrollment. 45% of patients had ED visits; those who had ED visits usually had more than one. Patients with and without ED visits did not differ according to: age (61 years old), gender (88% were women), ethnicity (88% Latino, employment status (86% unemployed), acculturation (both groups were poorly acculturated). The major difference between high comorbid patients who did and did not have ED visits was social support. The major finding was that 71% of patients with low social support had an ED visit, while 27% of patients with high social support had an ED visit. CONCLUSION: While sample size limits restricts more conclusive statements to be made, the finding of patients with low social support having more ED visits deserves further investigation.