Clinical characteristics and preventable acute care spending among a high cost inpatient population.

BACKGROUND: A small proportion of patients account for the majority of health care spending. The objectives of this study were to explore the clinical characteristics, patterns of health care use, and the proportion of acute care spending deemed potentially preventable among high cost inpatients within a Canadian acute-care hospital. METHODS: We identified all individuals within the Ottawa Hospital with one or more inpatient hospitalization between April 1, 2010 and March 31, 2011. Clinical characteristics and frequency of hospital encounters were captured in the information systems of the Ottawa Hospital Data Warehouse. Direct inpatient costs for each encounter were summed using case costing information and those in the upper first and fifth percentiles of the cumulative direct cost distribution were defined as extremely high cost and high cost respectively. We quantified preventable acute care spending as hospitalizations for ambulatory care sensitive conditions (ACSC) and spending attributable to difficulty discharging patients as measured by alternate level of care (ALC) status. RESULTS: During the study period, 36,892 patients had 44,066 hospitalizations. High cost patients (n = 1,844) accounted for 38 % of total inpatient spending ($122 million) and were older, more likely to be male, and had higher levels of co-morbidity compared to non-high cost patients. In over half of the high cost cohort (54 %), costs were accumulated from a single hospitalization. The majority of costs were related to nursing care and intensive care unit spending. High cost patients were more likely to have an encounter deemed to be ambulatory care sensitive compared to non-high cost inpatients (6.0 versus 2.8 %, p < 0.001). A greater proportion of inpatient spending was attributable to ALC days for high cost versus non-high cost patients (9.1 versus 4.9 %, p < 0.001). CONCLUSIONS: Within a population of high cost inpatients, the majority of costs are attributed to a single, non-preventable, acute care episode. However, there are likely opportunities to improve hospital efficiency by focusing on different approaches to community based care directed towards specific populations.

Variations in Resource Intensity and Cost Among High Users of the Emergency Department.

OBJECTIVES: High users of emergency department (ED) services are often identified by number of visits per year, with little exploration of the distribution/pattern of visits over time. The purpose of this study was to examine patient- and encounter-level factors and costs related to periods of short-term resource intensity among high users of the ED within a tertiary care teaching facility. METHODS: We identified all adults with at least three visits to the Ottawa Hospital ED within a 1-year period from April 1, 2012, to March 31, 2013. Within this high-user cohort, we then measured intensity of use by calculating average daily visit rates to identify individuals with a cluster of ED visits. Those with at least three ED visits/7 days at any point during follow-up were considered patients with clustered ED use (i.e., a period of short-term resource intensity). Detailed clinical and administrative data were used to compare patient- and encounter-level characteristics and cost profiles between the clustered and nonclustered groups. Analyses were repeated using varying cut points to define high users (at least five and at least eight visits per year). RESULTS: Of the 16,153 patients identified as high ED users during the study period, 13.5% had their visits clustered within a short period of time. These clustered users were more likely to be homeless, to require psychiatric services, and to leave without being seen by a physician and less likely to be admitted to the hospital. Approximately one in three (31.2%) high ED users with clustered visits returned for the same medical problem (namely pain-related disorders, shortness of breath, and cellulitis) within a 1-week period. Similar trends were observed when the high-user cohort was restricted to those with at least five and at least eight ED visits/year. Finally, patients with short-term intensity periods had lower direct and indirect costs per encounter than those without. CONCLUSIONS: Using a novel methodology that accounts for both number and intensity of ED encounters over time, we were able to identify specific subpopulations of high ED users. Further work is required to determine if this methodology has utility for targeting care pathways within this heterogeneous and high-risk patient group.

Patterns of health care use in a high-cost inpatient population in Ottawa, Ontario: a retrospective observational study.

BACKGROUND: A small proportion of patients account for the majority of health care spending. We used detailed clinical and administrative data to explore clinical characteristics, patterns of health care use and changes in cost profiles over time among high-cost inpatients in an acute tertiary care hospital in Ottawa, Ontario. METHODS: We identified all people who had 1 or more inpatient admissions to The Ottawa Hospital between Apr. 1, 2009, and Mar. 31, 2012. We calculated the direct inpatient costs using case-costing information to categorize patients into persistently high-cost, episodic high-cost and non-high-cost groups. Within each group, we used discharge abstracts to measure encounter-level characteristics and patterns of inpatient health care use over time. We also developed transition matrices to explore how inpatient costing states changed over time. RESULTS: During the study period, 100 178 patients had 132 996 hospital admissions. Hospital spending was often limited to a single year for most of the patients (90.2%), with only a small proportion (7.4%) of patients remaining in the high-cost group in the subsequent year. Patients in the persistently (n = 236) and episodic (n = 5062) high-cost groups were often older, had medically complex conditions and generated most of the costs from nursing care and intensive care. Compared with patients in the other cost groups, those in the persistently high-cost group were more likely to have multiple readmissions (43.4%) and multiple placements in an alternate level of care (19.0%) and were high users of health care services outside of the hospital setting. INTERPRETATION: Hospital spending was often limited to a single year for most patients, and only a small proportion of patients remained in the high-cost group in the subsequent year. These persistently high-cost patients had medically complex conditions and often required expensive care. A greater understanding of the circumstances that result in persistent hospital spending remains an area for future work, including an exploration of the potential barriers impeding efficient transition out of acute care for high-risk patients.

Influence of educational, audit and feedback, system based, and incentive and penalty interventions to reduce laboratory test utilization: a systematic review.

Laboratory and radiographic tests are often ordered unnecessarily. This excess testing has financial costs and is a burden on patients. We performed a systematic review to determine the effectiveness interventions to reduce test utilization by physicians. The MEDLINE and EMBASE databases were searched for the years 1946 through to September 2013 for English articles that had themes of test utilization and cost containment or optimization. Bibliographies of included papers were scanned to identify other potentially relevant studies. Our search resulted in 3236 articles of which 109 met the inclusion criteria of having an intervention aimed at reducing test utilization with results that could be expressed as a percent reduction in test use relative to the comparator. Each intervention was categorized into one or more non-exclusive category of education, audit and feedback, system based, or incentive or penalty. A rating of study quality was also performed. The percent reductions in test use ranged from a 99.7% reduction to a 27.7% increase in test use. Each category of intervention was effective in reducing test utilization. Heterogeneity between interventions, poor study quality, and limited time horizons makes generalizations difficult and calls into question the validity of results. Very few studies measure any patient safety or quality of care outcomes affected by reduced test use. There are numerous studies that use low investment strategies to reduce test utilization with one time changes in the ordering system. These low investment strategies are the most promising for achievable and durable reductions in inappropriate test use.