From the AGA Journals

Who are the 'high-need, high-cost' patients?

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Help these patients without hospitalization

Understanding the reasons underlying variations in health care utilization is central to any plan to reduce costs at the population level. To this end, Nguyen et al. provide crucial data for the patients for whom we care as gastroenterologists. Studying a longitudinal database of hospitalizations in 2013, the authors provide comprehensive demographic data for the top decile of inpatient health care utilizers (defined by hospital-days/month) with inflammatory bowel disease, chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, and pancreatic diseases. Although constrained by the limits of administrative data and the lack of outpatient/pharmaceutical data linkage, these findings are strengthened by their consistency across conditions. Indeed, despite the heterogeneous disorders surveyed, a remarkably consistent high-need/high-cost "phenotype" emerges: publicly insured, low-income, rural, obese but malnourished, and beset by infections and the complications of diabetes.

Dr. Elliot Tapper

What are the next steps?

When a minority of the patients are responsible for a substantial portion of the costs (i.e., the 80/20 rule), one strategy for cost containment is "hot-spotting." Hot-spotting is a two-step process: Identify high-need, high-cost patients, and then deploy interventions tailored to their needs. Nguyen and colleague's work is a landmark for the first step. However, before these findings may be translated into policy or intervention, we need granular data to explain these associations and suggest clear action items. Solutions will likely be multifactorial including early, intensified care for obesity and diabetes (before end-stage complications arise), novel care delivery methods for gastroenterology specialty care in rural hospitals, and intensified outpatient resources for high-need patients in order to coordinate alternatives to hospitalization.

Elliot B. Tapper, MD, is assistant professor, division of gastroenterology and hepatology, University of Michigan, Ann Arbor. He reports consulting for Novartis and receiving unrestricted research grants from Valeant and Gilead, all unrelated to this work.



Among patients hospitalized with gastrointestinal and liver diseases, a clearly identifiable subset uses significantly more health care resources, which incurs significantly greater costs, according to the results of a national database analysis published in the August issue of Clinical Gastroenterology and Hepatology.

Compared with otherwise similar inpatients, these “high-need, high-cost” individuals are significantly more likely to be enrolled in Medicare or Medicaid, to have lower income, to initially be admitted to a large, rural hospital, to have multiple comorbidities, to be obese, or to be hospitalized for infection, said Nghia Nguyen, MD, and his associates. “[A] small fraction of high-need, high-cost patients contribute disproportionately to hospitalization costs,” they wrote. “Population health management directed toward these patients would facilitate high-value care.”

Gastrointestinal and liver diseases incur more than $100 billion in health care expenses annually in the United States, of which more than 60% is related to inpatient care, the researchers noted. However, few studies have comprehensively evaluated the annual burden and costs of hospitalization in patients with chronic gastrointestinal and liver diseases. Therefore, using the Nationwide Readmissions Database, the investigators studied patients with inflammatory bowel disease (IBD), chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases who were hospitalized at least once during the first 6 months of 2013. All patients were diagnosed with IBD, chronic liver diseases, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases and followed for at least 6 months. The researchers stratified hospital days and costs and characterized the subset of patients who fell into the highest decile of days spent in the hospital per month.

The most common reason for hospitalization was chronic liver disease (nearly 377,000 patients), followed by functional gastrointestinal disorders (more than 351,000 patients), gastrointestinal hemorrhage (nearly 191,000 patients), pancreatic diseases (more than 98,000 patients), and IBD (more than 47,000 patients). Patients spent a median of 6-7 days in the hospital per year, with an interquartile range of 3-14 days. Compared with patients in the lowest decile for annual hospital stay (median, 0.13-0.14 days per month), patients in the highest decile spent a median of 3.7-5.1 days in the hospital per month. In this high-cost, high-need subset of patients, the costs of each hospitalization ranged from $7,438 per month to $11,425 per month, and they were typically hospitalized once every 2 months.

“Gastrointestinal diseases, infections, and cardiopulmonary causes were leading reasons for hospitalization of these patients,” the researchers wrote. “At a patient level, modifiable risk factors may include tackling the obesity epidemic and mental health issues and minimizing risk of iatrogenic or health care–associated infections, whereas at a health system level, interventions may include better access to care and connectivity between rural and specialty hospitals.”

Funders included the American College of Gastroenterology, the Crohn’s and Colitis Foundation, and the National Institutes of Health. Senior author Siddharth Singh disclosed unrelated grant funding from Pifzer and AbbVie. The other investigators reported having no conflicts of interest.

SOURCE: Nguyen NH et al. Clin Gastroenterol Hepatol. 2018 Feb 20. doi: 10.1016/j.cgh.2018.02.015.

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