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

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

doi:10.9778/cmajo.20210265

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Figure 1:
Identification of persistently high-cost individuals across at least 2 consecutive fiscal years. Persistently high-cost users were those in the top 1% of health care spending in at least 2 consecutive fiscal years. Episodic high-cost users were those who were in the top 1% of health care spending for 1 year only, or for nonconsecutive years.
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Figure 2:
Standardized difference of classifying characteristics for each group relative to the overall population. Note: CAD = coronary artery disease, CKD = chronic kidney disease, COPD = chronic obstructive pulmonary disease, ED = emergency department, PCP = primary care provider.
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Figure 3:
Breakdown of health care spending for each high-cost subgroup, by encounter type. Note: CKD = chronic kidney disease, comm. = community, COPD = chronic obstructive pulmonary disease, ED = emergency department.

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Table 1:

Characteristics of persistently high-cost subgroups

Characteristic	Subgroup, %^*
Characteristic	Overall, n (%) n = 21 115	CVD n = 4537	Rehab. or care after surgery n = 3380	Severe mental health conditions n = 3060	Advanced CKD n = 2689	Biologic therapies for autoimmune conditions n = 2538	Dementia and awaiting comm. placement n = 2520	COPD or other respiratory conditions n = 984	Treatment for cancers n = 832	Unstable housing or substance use n = 575
Age, yr
Mean ± SD	60.2 ± 18.4	73.5 ± 11.6	56.5 ± 15.5	47.4 ± 15.7	59.0 ± 14.5	41.8 ± 13.4	81.1 ± 7.6	61.2 ± 9.7	59.1 ± 12.1	41.2 ± 11.5
18–49	5810 (27.5)	2.6	28.1	50.5	26.0	72.7	0.2	6.5	16.5	77.6
50–64	6182 (29.3)	20.5	39.4	37.1	38.2	22.1	1.1	63.2	51.1	21.2
65–74	4008 (19.0)	26.7	25.4	11.3	23.1	4.6	16.0	23.8	25.8	1.0
75+	5115 (24.2)	50.2	7.2	1.1	12.8	0.5	82.7	6.5	6.6	0.2
Male	11 371 (53.9)	58.4	62.1	53.8	61.7	47.3	34.6	59.5	43.4	52.3
Urban residence	18130 (86.2^†)	81.1	71.1	94.1	90.5	91.0	93.4	92.7	90.8	81.3
History of homelessness	486 (2.3)	0.2	0.4	7.9	0.0	0.0	0.0	0.2	0.0	38.3
Continuing care	5957 (28.2)	37.2	20.3	50.5	5.5	0.1	65.2	10.4	6.5	15.5
≥ 1 hospitalizations in the previous 12 mo	7570 (35.9)	57.8	6.8	44.2	26.6	21.7	29.6	84.3	4.0	85.7
Emergency department visits in the previous 12 months
0	8933 (42.3)	21.9	69.6	31.8	51.7	50.6	46.2	14.2	76.7	0.0
1–4	9122 (43.2)	57.6	21.1	47.8	40.9	40.1	50.1	70.7	23.2	10.3
5–15	2575 (12.2)	18.5	7.8	16.6	6.8	8.0	3.4	14.8	0.0	60.5
16+	485 (2.3)	2.0	1.6	3.8	0.5	1.3	0.3	0.2	0.1	29.2
Primary care provider attachment in the previous 2 years
< 50%	14 037 (66.5)	71.2	69.3	77.8	45.3	47.2	84.4	58.0	49.3	96.3
50%–74.9%	4908 (23.2)	21.8	22.5	16.7	31.4	31.9	14.4	31.3	35.8	3.7
> 75%	2084 (9.9)	6.7	7.8	5.4	22.5	19.3	1.1	10.7	14.9	0.0
Few visits	86 (0.4)	0.3	0.4	0.1^*	0.8	1.5	0.0	0.0	0.0	0.0
Number of specialist types visited at least twice in the previous year
0	4089 (19.4)	9.5	72.5	10.4	4.1	8.0	22.1	0.0	1.0	2.1
1	4470 (21.2)	13.9	19.6	24.0	20.2	36.2	20.6	0.0	49.8	8.2
2–3	7673 (36.3)	36.6	7.8	42.5	48.6	42.8	37.7	43.8	44.5	53.0
4+	4883 (23.1)	40.1	0.0	23.1	27.1	13.0	19.6	56.2	4.8	36.7
Underlying medical diagnoses
Alcohol misuse	3364 (15.9)	10.3	13.8	46.7	7.0	3.2	1.7	20.7	1.3	82.1
Depression	5001 (23.7)	16.9	6.2	70.4	10.0	18.5	16.3	20.9	14.1	68.9
Schizophrenia	1987 (9.4)	1.4	0.8	55.1	0.7	1.2	1.5	1.8	0.0	17.9
COPD	6702 (31.7)	59.3	23.3	32.2	18.7	11.6	28.8	41.1	13.7	33.9
Dementia	1510 (7.2)	12.3	0.5	13.2	0.0	0.2	19.5	2.0	0.0	2.6
Diabetes	7439 (35.2)	65.8	24.8	29.4	60.0	7.7	26.0	8.7	4.8	22.4
CAD	7289 (34.5)	88.8	12.5	20.2	31.0	6.7	34.3	24.1	6.0	11.3
Heart failure	4398 (20.8)	70.3	2.9	8.3	18.1	1.3	8.9	8.5	0.0	4.7
Hypertension	13 264 (62.8)	99.3	45.5	43.8	95.8	16.4	85.2	43.6	19.0	28.0
CKD	6771 (32.1)	64.7	8.8	18.9	70.9	12.3	14.4	17.0	9.1	24.3
Autoimmune condition	1552 (7.4)	1.2	0.5	0.3	0.3	56.0	1.3	0.2	0.0	0.7
Stroke	4055 (19.2)	41.2	8.5	14.2	13.1	4.6	28.7	15.7	3.4	15.7
Cancer	3318 (15.7)	20.5	8.6	7.3	14.6	4.1	19.2	52.1	38.6	10.1
Mean per person cost, $	136 735	121 454	133 880	178 946	143 291	112 200	119 263	150 302	178 920	119 407
Outpatient	13 542	13 953	14 028	18 227	14 149	6808	11 905	14 119	11 937	17 909
Emergency department	19 912	27 582	15 018	12 448	46 423	8447	9297	16 225	14 041	15 815
Hospital	64 076	70 520	77 355	75 948	49 156	22 181	81 439	61 269	54 776	68 866
Medication	39 205	9398	27 479	72 323	33 563	74765	16 623	58 689	98 167	16 817
Median per person cost, $	76 915	86 544	83 924	86 207	82 093	61 927	88 990	77 745	68 940	85 440
Outpatient	12 033	12 550	12 255	16 085	12 488	3052	10 803	12 413	10 245	16 320
Emergency department	7418	9386	7260	6055	29 292	3396	4688	8840	6725	12 222
Hospital	52 593	60 229	61 299	58 846	34 643	2789	70 641	49 738	42 351	52 624
Medication	4871	4379	3111	5221	5670	52 689	2858	6754	9620	4274

Note: CKD = chronic kidney disease, comm. = community, COPD = chronic obstructive pulmonary disease, CVD = cardiovascular disease, ED = emergency department, rehab. = rehabilitation, SD = standard deviation.
Light grey shading indicates that the ratio of the characteristic relative to the overall persistent high-cost population was less than 0.5. Dark grey shading indicates that the ratio of the characteristic relative to the overall persistent high-cost population was 2.0 or greater, or had a prevalence of 90% or higher.
↵* Except where indicated otherwise.
↵† Data were available for n = 21 032 individuals.