Identifying subgroups of adult high-cost health care users: a retrospective analysis

Wick, James; Campbell, David; McAlister, Finlay A.; Manns, Braden; Beall, Reed F.; Hemmelgarn, Brenda R.; Stewart, Andrew J.; Ronksley, Paul E.

doi:10.9778/cmajo.20210265

Cited by 6 publications

(4 citation statements)

References 31 publications

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“…12,13 Our intervention appears to be the first positive study of a SMES program that could be deployed at scale, with potential important contributions to public health if such interventions were available to people who are managing chronic medical conditions. Hospital admissions are a major driver of health care spending, 56,57 although cost saving was not demonstrated within the 3-year observation period of the study. This may be attributable to the fact that hospitalizations for ambulatory caresensitive conditions only account for a small portion of total hospitalizations, which there was no difference between intervention groups.…”

Section: Discussionmentioning

confidence: 78%

Self-Management Support Using Advertising Principles for Older Adults With Low Income at High Cardiovascular Risk: A Randomized Controlled Trial

et al. 2023

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Background: Self-management education and support (SMES) interventions have modest effects on intermediate outcomes for those at risk of cardiovascular disease, but few studies have measured or demonstrated an impact on clinical endpoints. Advertising for commercial products is known to influence behavior, but advertising principles are not typically incorporated into SMES design. Methods: This randomized trial studied the impact of a novel tailored SMES program designed by an advertising firm among a population of low-income older adults at high cardiovascular risk in Alberta, Canada. The intervention included health promotion messaging from a fictitious "peer" and facilitated relay of clinical information to patients' primary care provider and pharmacist. The primary outcome was the composite of death, myocardial infarction, stroke, coronary revascularization, and hospitalizations for cardiovascular-related ambulatory care-sensitive conditions. Rates of the primary outcome and its components were compared using negative binomial regression. Secondary outcomes included quality of life (EQ-5D index score), medication adherence, and overall healthcare costs. Results: We randomized 4,761 individuals, with a mean age of 74.4 years, of whom 46.8% were female. There was no evidence of statistical interaction (p=0.99) or of a synergistic effect between the two interventions in the factorial trial with respect to the primary outcome, which allowed us to evaluate the effect of each intervention separately. Over a median follow-up time of 36 months, the rate of the primary outcome was lower in the group that received SMES compared with the control group (incidence rate ratio (IRR): 0.78, 95% confidence interval (CI): 0.61-1.00, p=0.047). No significant between-group changes in quality of life over time were observed (mean difference 0.0001, 95%CI -0.018 to 0.018, p=0.99). The proportion of participants who were adherent to medications was not different between the two groups (p = 0.199 for statins, and p=0.754 for ACEi/ARBs). Overall adjusted health care costs did not differ between those receiving SMES and the control group ($2,015, 95%CI -1,953 to 5,985, p=0.320). Conclusions: In low-income older adults, a tailored SMES program using advertising principles reduced the rate of clinical outcomes compared with usual care, though the mechanisms of improvement are unclear and further studies are required.

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Section: Discussionmentioning

confidence: 78%

Self-Management Support Using Advertising Principles for Older Adults With Low Income at High Cardiovascular Risk: A Randomized Controlled Trial

et al. 2023

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“…Costs were increased for critically ill patients needing rehabilitation and complex continuing care, but conversely higher for long-term care in the non-ICU group. Patients with dementia become frailer after hospitalization, therefore requiring costly dispositioning for increased supports in their postdischarge recovery (37). As patients had more severe cognitive impairment in the non-ICU group, this may explain the need for institutionalization.…”

Section: Discussionmentioning

confidence: 99%

Outcomes and Cost Analysis of Patients with Dementia in the Intensive Care Unit: A Population-based Cohort Study

Dziegielewski

Fernando

Milani

et al. 2022

Preprint

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Background: Dementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia. Methods: We conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016-2019. We compared the characteristics and outcomes of these patients to those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs. Results: Among 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080). Conclusions: Patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. Future studies should investigate preventable costs and while optimizing quality of life in this high risk and vulnerable population.

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“…Finally, a "high-cost" patient cohort was created as a subset of the total patient population for the period of January 1 to December 31, 2017 (1 year cohort) to remove secular trends in patient demographics and health spending observed in prior work by our team. 21,22 Given the exploratory nature of this investigation, to facilitate comparison with existing highcost literature, 1,5,26,27 a "high-cost" patient with schizophrenia was defined as an individual with annual direct healthcare costs in the 95th percentile or greater. Independent variables.…”

Section: Methods Datamentioning

confidence: 99%

Identifying Unique Subgroups of High-Cost Patients With Schizophrenia: A Population-Based Study Using Latent Class Analysis

Stewart

Patten

Fiest

et al. 2023

Health�Serv�Insights

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Schizophrenia does not present uniformly among patients and as a result this patient population is characterized by a diversity in the type and amount of healthcare supports needed for daily functioning. Despite this, little work has been completed to understand the heterogeneity that exists among these patients. In this work we used a data-driven approach to identify subgroups of high-cost patients with schizophrenia to identify potentially actionable interventions for the improvement of outcomes and to inform conversations on how to most efficiently allocate resources in an already strained system. Administrative health data was used to conduct a retrospective analysis of “high-cost” adult patients with schizophrenia residing in Alberta, Canada in 2017. Costs were derived from inpatient encounters, outpatient primary care and specialist encounters, emergency department encounters, and drug costs. Latent class analysis was used to group patients based on their unique clinical profiles. Latent class analysis of 1659 patients revealed the following patient groups: (1) young, high-needs males early in their disease course; (2) actively managed middle-aged patients; (3) elderly patients with multiple chronic conditions and polypharmacy; (4) unstably housed males with low treatment rates; (5) unstably housed females with high acute care use and low treatment rates. This taxonomy may be used to inform policy, including the identification of interventions most likely to improve care and reduce health spending for each subgroup.

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Identifying subgroups of adult high-cost health care users: a retrospective analysis

Cited by 6 publications

References 31 publications

Self-Management Support Using Advertising Principles for Older Adults With Low Income at High Cardiovascular Risk: A Randomized Controlled Trial

Self-Management Support Using Advertising Principles for Older Adults With Low Income at High Cardiovascular Risk: A Randomized Controlled Trial

Outcomes and Cost Analysis of Patients with Dementia in the Intensive Care Unit: A Population-based Cohort Study

Identifying Unique Subgroups of High-Cost Patients With Schizophrenia: A Population-Based Study Using Latent Class Analysis

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