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

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.

Factors associated with high health care spending among patients with schizophrenia. / Facteurs associés aux dépenses élevées en soins de santé chez les patients atteints de schizophrénie.

INTRODUCTION: Understanding the reasons for the wide variation in health care spending among patients with schizophrenia may benefit the development of interventions aimed at improving patient outcomes and health care spending efficiency. The aim of our study was to determine factors associated with high health care spending in the patient population. METHODS: A serial cross-sectional study used the administrative health records of residents of Alberta, Canada between 1 January 2008 and 31 December 2017 and provincial costing methodologies to calculate total health care spending and sector-specific costs. Factors that modified the odds of being a high cost (i.e. 95th percentile or higher) patient with schizophrenia were estimated using generalized estimating equations. RESULTS: This study captured 242 818 person-years of observations among 38 177 unique patients with schizophrenia. Increased odds of being a high-cost patient were associated with younger age (18-29 years), male sex, unstable housing status and requiring care from multiple medical specialties. The strongest estimated associations between high cost status and comorbidity were for metastatic cancer (OR = 2.26) and cirrhosis (OR = 2.07). In contrast, polypharmacy was associated with a decreased odds of being high cost compared with untreated patients. CONCLUSION: Factors associated with being a high-cost patient are the result of complex interactions between individual, structural and treatment-related factors. Efforts to improve patient outcomes and address rising health care costs must consider the value of allocating resources towards early detection and support of patients with schizophrenia along with the prevention/management of comorbidity.

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

BACKGROUND: Few studies have categorized high-cost patients (defined by accumulated health care spending above a predetermined percentile) into distinctive groups for which potentially actionable interventions may improve outcomes and reduce costs. We sought to identify homogeneous groups within the persistently high-cost population to develop a taxonomy of subgroups that may be targetable with specific interventions. METHODS: We conducted a retrospective analysis in which we identified adults (≥ 18 yr) who lived in Alberta between April 2014 and March 2019. We defined "persistently high-cost users" as those in the top 1% of health care spending across 4 data sources (the Discharge Abstract Database for inpatient encounters; Practitioner Claims for outpatient primary care and specialist encounters; the Ambulatory Care Classification System for emergency department encounters; and the Pharmaceutical Information Network for medication use) in at least 2 consecutive fiscal years. We used latent class analysis and expert clinical opinion in tandem to separate the persistently high-cost population into subgroups that may be targeted by specific interventions based on their distinctive clinical profiles and the drivers of their health system use and costs. RESULTS: Of the 3 919 388 adults who lived in Alberta for at least 2 consecutive fiscal years during the study period, 21 115 (0.5%) were persistently high-cost users. We identified 9 subgroups in this population: people with cardiovascular disease (n = 4537; 21.5%); people receiving rehabilitation after surgery or recovering from complications of surgery (n = 3380; 16.0%); people with severe mental health conditions (n = 3060; 14.5%); people with advanced chronic kidney disease (n = 2689; 12.7%); people receiving biologic therapies for autoimmune conditions (n = 2538; 12.0%); people with dementia and awaiting community placement (n = 2520; 11.9%); people with chronic obstructive pulmonary disease or other respiratory conditions (n = 984; 4.7%); people receiving treatment for cancer (n = 832; 3.9%); and people with unstable housing situations or substance use disorders (n = 575; 2.7%). INTERPRETATION: Using latent class analysis supplemented with expert clinical review, we identified 9 policy-relevant subgroups among persistently high-cost health care users. This taxonomy may be used to inform policy, including identifying interventions that are most likely to improve care and reduce cost for each subgroup.

10-Year Trends in Healthcare Spending among Patients with Schizophrenia in Alberta, Canada.

OBJECTIVES: Schizophrenia is characterized by high levels of disability often resulting in increased healthcare utilization and spending. With expanding healthcare costs across all healthcare sectors, there is a need to understand how healthcare spending has changed over time. We conducted a population-based study using administrative health data from Alberta, Canada, to describe changes in medical complexity and direct healthcare spending among patients with schizophrenia over a 10-year period. METHODS: A serial cross-sectional study from January 1, 2008, to December 31, 2017, was conducted to determine changes in demographic characteristics, medical complexity, and costs among all adults (18 years or older) with schizophrenia. Total healthcare spending and sector-specific costs attributable to hospitalizations, emergency department visits, practitioner billings, and prescriptions were calculated and compared over time. RESULTS: Over the 10-year period the contact prevalence of patients with schizophrenia increased from 0.6% (n = 16,183) to 1.0% (n = 33,176) within the province. There was a marked change in medical complexity with the number of patients living with 3 or more comorbidities increasing from 33.0% to 47.3%. Direct annual healthcare costs increased 2-fold from 321 to 639 million CAD (493 million USD) with a 7-fold increase in medication expenditures over the 10-year time frame. As of 2017, spending on pharmaceutical treatment surpassed hospitalizations as the leading spending category in this population. CONCLUSIONS: Healthcare spending among patients with schizophrenia continues to increase and may be partially attributable to growing rates of multimorbidity within this population. Although promising second-generation antipsychotic medications have entered the market, this has resulted in considerable changes in the distribution of healthcare spending over time. These findings will inform policy discussions around resource allocation and efforts to curb health spending while also improving care for patients with schizophrenia.

Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol.

Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.

First-line pharmacotherapy for incident type 2 diabetes: Prescription patterns, adherence and associated costs.

AIMS: To use real-world prescription data from Alberta, Canada to: (a) describe the prescribing patterns for initial pharmacotherapy for those with newly diagnosed uncomplicated type 2 diabetes; (b) describe medication-taking behaviours (adherence and persistence) in the first year after initiating pharmacotherapy; and (c) explore healthcare system costs associated with prescribing patterns. METHODS: We employed a retrospective cohort design using linked administrative datasets from 2012 to 2017 to define a cohort of those with uncomplicated incident diabetes. We summarized the initial prescription patterns, adherence and costs (healthcare and pharmaceutical) over the first year after initiation of pharmacotherapy. Using multivariable regression, we determined the association of these outcomes with various sociodemographic characteristics. RESULTS: The majority of individuals for whom metformin was indicated as first-line therapy received a prescription for metformin monotherapy (89%). Older individuals, those with higher baseline A1C and those with no comorbidities, were most likely to be started on non-metformin agents. Adherence with the initially prescribed regimen was suboptimal overall, with nearly half (48%) being non-adherent over the first year. One-third of those who started metformin discontinued it in the first 3 months. Those started on non-metformin agents had roughly twice the healthcare costs, and five to seven times higher medication costs, compared to those started on metformin, in the first year after starting therapy. CONCLUSIONS: With the addition of new classes of medications, healthcare providers who look after those with type 2 diabetes have more pharmaceutical options than ever. Most individuals continue to be prescribed metformin monotherapy. However, adherence is suboptimal, and drops off considerably within the first 3 months.

Antihypertensive Prescribing for Uncomplicated, Incident Hypertension: Opportunities for Cost Savings.

BACKGROUND: A range of first-line similarly effective medications ranging in price are recommended for treating uncomplicated hypertension. Considering drug costs alone, thiazides and thiazide-like diuretics are the most cost-efficient option. We determined incident prescribing of thiazides for newly diagnosed hypertension as first-line treatment in Alberta, factors that predicted receiving thiazides vs more costly medications, and how much could be saved if more patients were prescribed thiazides. METHODS: Using a retrospective cohort design, factors predicting receiving thiazides vs other agents were determined using mixed effects logistic regression. Cost savings were simulated by shifting patients from other antihypertensive medications to thiazides and calculating the difference. RESULTS: Within our cohort of 89,548 adults, only 12% received thiazides as first-line treatment whereas 44% received angiotensin converting enzyme inhibitors, 17% received angiotensin receptor blockers, 16% received calcium channel blockers, and 10% received ß-blockers. Antihypertensive medications were typically prescribed by office-based, general practitioners (88%). Being male and receiving a prescription from a physician with ≥ 20 years of practice and a high clinical workload were associated with increased odds of receiving nonthiazides. In the extreme case that all patients received thiazides as their first prescription, spending would have been reduced by a maximum of 95% (CAD$1.8 million). CONCLUSIONS: Only 12% of Albertan adults with incident, uncomplicated hypertension were prescribed thiazides as first-line treatment. With the opportunity for drug cost savings, future research should evaluate the risk of adverse events and side effects across the drug classes and whether the costs associated with managing those risks could offset the savings achieved through increased thiazide use.

CONTEXTE: De nombreux médicaments tous aussi efficaces les uns que les autres, mais de prix variable, sont recommandés pour le traitement de première intention de l'hypertension non compliquée. Si l'on tient compte du coût du médicament seulement, les thiazides et les diurétiques apparentés aux thiazides sont les options les plus économiques. Nous avons évalué le taux de prescription d'un thiazide pour le traitement de première intention de l'hypertension nouvellement diagnostiquée en Alberta, les facteurs de prédiction de la prescription d'un thiazide plutôt que d'un autre médicament plus coûteux, ainsi que les économies qui pourraient être réalisées si on prescrivait un thiazide à un plus grand nombre de patients. MÉTHODOLOGIE: Dans le cadre de notre étude de cohorte rétrospective, nous avons déterminé les facteurs de prédiction de la prescription d'un thiazide plutôt que d'un autre agent à l'aide d'une régression logistique à effets mixtes. Nous avons simulé les économies qui pourraient être réalisées en faisant passer à un thiazide les patients à qui un autre médicament antihypertenseur a été prescrit et en calculant la différence. RÉSULTATS: Dans notre cohorte de 89 548 adultes, seulement 12 % des patients ont reçu un thiazide en première intention; 44 % ont reçu un inhibiteur de l'enzyme de conversion de l'angiotensine; 17 %, un antagoniste des récepteurs de l'angiotensine; 16 %, un inhibiteur calcique; et 10 %, des bêtabloquants. Les agents antihypertenseurs sont généralement prescrits par des omnipraticiens en cabinet (88 %). Le fait d'être un homme et le fait d'obtenir une prescription auprès d'un médecin exerçant depuis au moins 20 ans et ayant une lourde charge de travail clinique étaient associés à une probabilité supérieure de recevoir un agent autre qu'un thiazide. Dans le cas extrême où tous les patients se verraient prescrire un thiazide en première intention, la réduction des dépenses pourrait atteindre 95 % (soit 1,8 million de dollars canadiens). CONCLUSIONS: En Alberta, un thiazide a été prescrit en première intention à seulement 12 % des adultes venant de recevoir un diagnostic d'hypertension non compliquée. Compte tenu des économies qui pourraient être réalisées si un thiazide était prescrit dans ce contexte, il conviendrait d'effectuer des recherches plus poussées pour évaluer le risque de manifestations indésirables et d'effets secondaires associé aux différentes classes de médicaments, et pour déterminer si les coûts liés à la prise en charge de ce risque annuleraient les économies réalisées en augmentant le recours aux thiazides.

Associations between the built environment and physical activity among adults with low socio-economic status in Canada: a systematic review.

OBJECTIVE: To synthesize literature on the associations between the built environment and physical activity among adults with low socio-economic status (SES) in Canada. METHODS: Using a pre-specified study protocol (PROSPERO ID: CRD42019117894), we searched seven databases from inception to November 2018, for peer-reviewed quantitative studies that (1) included adults with low SES living in Canada and (2) estimated the association between self-reported or objectively measured built characteristics and self-reported or objectively measured physical activity. Study quality was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Findings were synthesized using a narrative approach. SYNTHESIS: Of the 8338 citations identified by our search, seven studies met the inclusion criteria. Most studies included adults living in one province (Alberta, British Columbia, Ontario, or Quebec), with one study including a national sample. All studies were cross-sectional, and none controlled for residential self-selection. Sampling designs and data collection strategies were heterogeneous. Sample sizes ranged between 78 and 37,241 participants. Most studies measured SES using household income. Street connectivity, greenness, destination density, and walkability were positively associated with physical activity. Relative to the objectively measured built environment, associations between the self-reported built environment and physical activity were less consistent. Studies were of fair to good quality. CONCLUSION: Findings suggest that the neighbourhood built environment is associated with physical activity among adults with low SES in Canada. More rigorous study designs are needed to determine whether or not the built environment and physical activity are causally related within this vulnerable population.

RéSUMé: OBJECTIF: Faire une synthèse de la littérature scientifique sur les associations entre l'environnement bâti et l'activité physique chez les adultes de faible statut socioéconomique (SSE) au Canada. MéTHODE: À l'aide d'un protocole d'étude préétabli (numéro d'identification PROSPERO : CRD42019117894), nous avons interrogé sept bases de données, entre l'inception de chacune et novembre 2018, pour repérer les études quantitatives évaluées par les pairs qui : 1) incluaient des adultes de faible SSE vivant au Canada; et 2) estimaient l'association entre les caractéristiques autodéclarées ou objectivement mesurées de l'environnement bâti et l'activité physique autodéclarée ou objectivement mesurée. La qualité des études a été évaluée à l'aide de l'outil Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Nous avons fait la synthèse des constatations selon une démarche narrative. SYNTHèSE: Sur les 8 338 citations repérées dans notre recherche, sept études répondaient aux critères d'inclusion. La plupart incluaient des adultes vivant dans une province (Alberta, Colombie-Britannique, Ontario ou Québec), et une étude comportait un échantillon national. Toutes les études étaient transversales, et aucune ne tenait compte de l'auto-sélection de la résidence. Les modes d'échantillonnage et les stratégies de collecte de données étaient hétérogènes. La taille des échantillons variait de 78 à 37 241 participants. La plupart des études mesuraient le SSE à l'aide du revenu des ménages. La connectivité des rues, la verdure, la densité des destinations et la marchabilité étaient associées positivement à l'activité physique. Par rapport à l'environnement bâti objectivement mesuré, les associations entre l'environnement bâti autodéclaré et l'activité physique étaient moins constantes. La qualité des études était de moyenne à bonne. CONCLUSION: Nos constatations indiquent que l'environnement bâti du quartier est associé à l'activité physique chez les adultes de faible SSE au Canada. Des protocoles d'étude plus rigoureux sont nécessaires pour déterminer s'il existe ou non une relation causale entre l'environnement bâti et l'activité physique dans cette population vulnérable.

Derivation and Internal Validation of a Clinical Risk Prediction Tool for Hyperkalemia-Related Emergency Department Encounters Among Hemodialysis Patients.

BACKGROUND: Approximately 10% of emergency department (ED) visits among dialysis patients are for conditions that could potentially be managed in outpatient settings, such as hyperkalemia. OBJECTIVE: Using population-based data, we derived and internally validated a risk score to identify hemodialysis patients at increased risk of hyperkalemia-related ED events. DESIGN: Retrospective cohort study. SETTING: Ten in-center hemodialysis sites in southern Alberta, Canada. PATIENTS: All maintenance hemodialysis patients (≥18 years) between March 2009 and March 2017. MEASUREMENTS: Predictors of hyperkalemia-related ED events included patient demographics, comorbidities, health-system use, laboratory measurements, and dialysis information. The outcome of interest (hyperkalemia-related ED events) was defined by International Classification of Diseases (10th Revision; ICD-10) codes and/or serum potassium [K+] ≥6 mmol/L. METHODS: Bootstrapped logistic regression was used to derive and internally validate a model of important predictors of hyperkalemia-related ED events. A point system was created based on regression coefficients. Model discrimination was assessed by an optimism-adjusted C-statistic and calibration by deciles of risk and calibration slope. RESULTS: Of the 1533 maintenance hemodialysis patients in our cohort, 331 (21.6%) presented to the ED with 615 hyperkalemia-related ED events. A 9-point scale for risk of a hyperkalemia-related ED event was created with points assigned to 5 strong predictors based on their regression coefficients: ≥1 laboratory measurement of serum K+ ≥6 mmol/L in the prior 6 months (3 points); ≥1 Hemoglobin A1C [HbA1C] measurement ≥8% in the prior 12 months (1 point); mean ultrafiltration of ≥10 mL/kg/h over the preceding 2 weeks (2 points); ≥25 hours of cumulative time dialyzing over the preceding 2 weeks (1 point); and dialysis vintage of ≥2 years (2 points). Model discrimination (C-statistic: 0.75) and calibration were good. LIMITATIONS: Measures related to health behaviors, social determinants of health, and residual kidney function were not available for inclusion as potential predictors. CONCLUSIONS: While this tool requires external validation, it may help identify high-risk patients and allow for preventative strategies to avoid unnecessary ED visits and improve patient quality of life. TRIAL REGISTRATION: Not applicable-observational study design.

CONTEXTE: Environ 10 % des visites aux urgences des patients hémodialysés concernent des affections qui pourraient être prises en charge en ambulatoire, notamment l'hyperkaliémie. OBJECTIF: À l'aide de données populationnelles, nous avons dérivé et validé en interne une cote de risque pour dépister les patients hémodialysés présentant un risque accru de visites aux urgences liées à l'hyperkaliémie. TYPE D'ÉTUDE: Étude de cohorte rétrospective. CADRE: Dix sites d'hémodialyse en center du sud de l'Alberta (Canada). SUJETS: Tous les adultes sous hémodialyse chronique entre mars 2009 et mars 2017. MESURES: Les prédicteurs d'une visite aux urgences liée à l'hyperkaliémie incluaient les données démographiques du patient, les maladies concomitantes, l'utilization du système de santé, les mesures de laboratoire et les informations sur la dialyze. Le résultat d'intérêt (nombre de visites aux urgences liées à l'hyperkaliémie) a été défini par les codes CIM-10 et/ou une kaliémie [K+] égale ou supérieure à 6 mmol/L. MÉTHODOLOGIE: La régression logistique de type « bootstrap ¼ a été utilisée pour dériver et valider en interne un modèle des principaux prédicteurs d'une visites aux urgences liée à l'hyperkaliémie. Un système de pointage a été créé à partir des coefficients de régression. La discrimination du modèle a été évaluée par une statistique C corrigée selon l'optimisme, et l'étalonnage par des déciles de risque et une courbe d'étalonnage. RÉSULTATS: Des 1 533 patients de notre cohorte, 331 (21,6 %) se sont présentés aux urgences pour un total de 615 événements liés à l'hyperkaliémie. Une échelle à neuf points mesurant le risque a été créée, où un pointage a été attribué à cinq puissants prédicteurs en fonction du coefficient de régression: i) au moins une mesure de K+ égale ou supérieure à 6 mmol/L dans les six mois précédents (3 points); ii) au moins une mesure de l'hémoglobine A1C [HbA1C] égale ou supérieure à 8 % dans les 12 mois précédents (1 point); iii) une ultrafiltration moyenne d'au moins 10 mL/kg/heure dans les deux semaines précédentes (2 points); iv) un cumulatif d'au moins 25 heures de dialyze dans les deux semaines précédentes (1 point); et v) le fait d'être en dialyze depuis au moins 2 ans (2 points). La discrimination du modèle (statistique C: 0,75) et l'étalonnage ont été jugés bons. LIMITES: Les mesures relatives aux comportements en matière de santé, aux déterminants sociaux de la santé et à la fonction rénale résiduelle n'étaient pas disponibles pour leur inclusion comme prédicteurs potentiels. CONCLUSION: Bien que cet outil doive être validé en externe, il peut aider à dépister les patients présentant un risque élevé de visiter les urgences pour une hyperkaliémie. Il pourrait également favoriser l'élaboration de stratégies préventives visant à réduire les visites inutiles et à améliorer la qualité de vie des patients. ENREGISTREMENT DE L'ESSAI: Sans objet ­ essai observationnel.

Comparing Onset of Biosimilar Versus Generic Competition in the United States.

We sought to compare expected and observed biosimilar and generic entry dates among new drugs approved by the US Food and Drug Administration (FDA) between 2000 and 2012. We defined expected biosimilar and generic entry dates as the later of the expiration of the key patent term or statutory exclusivity (12 years for biologics, 5 years for small molecule drugs not indicated for a rare disease, and 7 years for small molecule drugs indicated for a rare disease; plus 6 months if a pediatric extension had been granted). For drugs with expected entry prior to 2019, we calculated the proportion with observed biosimilar or generic entry. The expected biosimilar entry dates were estimated to be a median of 12.3 years (interquartile range (IQR) 12.0-14.0, n = 60) after FDA approval. The 12-year biologic statutory exclusivity period comprised 98% of the median expected protection period. By contrast, expected generic entry was estimated to be a median of 12.2 years (IQR 8.4-14.0, n=268), or 7.2 years after the 5-year small molecule statutory exclusivity (59% of the total expected market protection period). By 2019, observed biosimilar entry occurred in 12% of cases (3/25) and observed generic entry in 65% (101/155). We concluded that expected US market exclusivity periods are similar for biologic and small molecule drugs. Statutory exclusivity plays a more substantial role in market exclusivity protection for biologics. Biosimilar competition, currently lagging behind generic competition, will likely increase as the biosimilar market becomes established.

Clinical factors contributing to high cost hospitalizations in a Canadian tertiary care centre.

BACKGROUND: Like much of the developed world, healthcare costs in Canada are rising. A small proportion of patients account for a large proportion of healthcare spending and much of this spending occurs in acute care settings. The purpose of our study was to determine potentially modifiable factors related to care processes that contribute to high-cost admissions. METHODS: Using a mixed-methods study design, factors contributing to high-cost admissions were identified from literature and case review. We defined pre- and post-admission factors contributing to high-cost admissions. Pre-admission factors included reason for admission (e.g. complex medical, elective surgery, trauma, etc.). Post-admission factors included medical complications, disposition delays, clinical services delays, and inefficient clinical decision-making. We selected a random sample of admissions in the top decile of inpatient cost from the Ottawa Hospital between January 1 and December 31, 2010. A single reviewer classified cases based on the pre- and post-admission factors. We combined this information with data derived from the Ottawa Hospital Data Warehouse to describe patient-level clinical and demographic characteristics and costs incurred. RESULTS: We reviewed 200 charts which represents ~5% of all high cost admissions within the Ottawa Hospital in 2010. Post-admission factors contributing to high-cost admissions were: complications (60%), disposition delays (53%), clinical service delays (39%), and inefficient clinical decision-making (13%). Further, these factors varied substantially across service delivery lines. The mean (standard deviation (SD)) cost per admission was $49,923 CDN ($45,773). The most common reason for admission was "complex medical" (49%) and the overall median (IQR) length of stay was 27 (18-48) days. Approximately 1 in 3 high cost admissions (29%) included time in the intensive care unit (ICU). CONCLUSIONS: While high cost admissions often include time in ICU and have long lengths of stay, a substantial proportion of costs were attributable to complications and potentially preventable delays in care processes. These findings suggest opportunities exist to improve outcomes and reduce costs for this diverse patient population.

Factors contributing to high-cost hospital care for patients with COPD.

Chronic obstructive pulmonary disease (COPD) is a leading cause of hospital admission, the fifth leading cause of death in North America, and is estimated to cost $49 billion annually in North America by 2020. The majority of COPD care costs are attributed to hospitalizations; yet, there are limited data to understand the drivers of high costs among hospitalized patients with COPD. In this study, we aimed to determine the patient and hospital-level factors associated with high-cost hospital care, in order to identify potential targets for the reorganization and planning of health services. We conducted a retrospective cohort study at a Canadian academic hospital between September 2010 and 2014, including adult patients with a first-time admission for COPD exacerbation. We calculated total costs, ranked patients by cost quintiles, and collected data on patient characteristics and health service utilization. We used multivariable regression to determine factors associated with highest hospital costs. Among 1,894 patients included in the study, the mean age was 73±12.6 years, median length of stay was 5 (interquartile range 3-9) days, mortality rate was 7.8% (n=147), and 9% (n=170) required intensive care. Hospital spending totaled $19.8 million, with 63% ($12.5 million) spent on 20% of patients. Factors associated with highest costs for COPD care included intensive care unit admission (odds ratio [OR] 32.4; 95% confidence interval [CI] 20.3, 51.7), death in hospital (OR 2.6; 95% CI 1.3, 5.2), discharge to long-term care facility (OR 5.7; 95% CI 3.5, 9.2), and use of the alternate level of care designation during hospitalization (OR 23.5; 95% CI 14.1, 39.2). High hospital costs are driven by two distinct groups: patients who require acute medical treatment for severe illness and patients with functional limitation who require assisted living facilities upon discharge. Improving quality of care and reducing cost in this high-needs population require a strong focus on early recognition and management of functional impairment for patients living with chronic disease.

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.

Self-reported financial barriers to care among patients with cardiovascular-related chronic conditions.

BACKGROUND: People with chronic conditions who do not achieve therapeutic targets have a higher risk of adverse health outcomes. Failure to meet these targets may be due to a variety of barriers. This article examines self-reported financial barriers to health care among people with cardiovascular-related chronic conditions. DATA AND METHODS: A population-based survey was administered to western Canadians with cardiovascular-related chronic conditions (n = 1,849). Associations between self-reported financial barriers and statin use, the likelihood of stopping use of prescribed medications, and emergency department visits or hospitalizations were assessed. RESULTS: More than 10% respondents reported general financial barriers (12%) and lack of drug insurance (14%); 4% reported financial barriers to accessing medications. Emergency department visits or hospitalizations were 70% more likely among those reporting a general financial barrier. Those reporting a financial barrier to medications were 50% less likely to take statins and three times more likely to stop using prescribed medications. Individuals without drug insurance were nearly 30% less likely to take statins. INTERPRETATION: In this population, self-reported financial barriers were associated with lower medication use and increased likelihood of emergency department visits or hospitalization.

Perceived barriers to primary care among western Canadians with chronic conditions.

BACKGROUND: This analysis explores barriers to the receipt of health care from a primary care physician for management of chronic conditions. DATA AND METHODS: A population-based survey was administered to adults in Manitoba, Saskatchewan, Alberta and British Columbia who had hypertension, diabetes, heart disease or stroke (n=1,849). Associations between socio-demographic factors and barriers to receipt of primary care were identified. RESULTS: Most respondents with chronic conditions required care from a primary care physician in the past year and had no difficulty receiving it; about 10% reported a barrier. Barriers were most commonly reported by respondents with diabetes (16%) and were related to initiation of care or waiting too long to get care. INTERPRETATION: A small percentage of adults with chronic conditions report barriers to receiving care from a primary care physician.

The association of income with health behavior change and disease monitoring among patients with chronic disease.

BACKGROUND: Management of chronic diseases requires patients to adhere to recommended health behavior change and complete tests for monitoring. While studies have shown an association between low income and lack of adherence, the reasons why people with low income may be less likely to adhere are unclear. We sought to determine the association between household income and receipt of health behavior change advice, adherence to advice, receipt of recommended monitoring tests, and self-reported reasons for non-adherence/non-receipt. METHODS: We conducted a population-weighted survey, with 1849 respondents with cardiovascular-related chronic diseases (heart disease, hypertension, diabetes, stroke) from Western Canada (n = 1849). We used log-binomial regression to examine the association between household income and the outcome variables of interest: receipt of advice for and adherence to health behavior change (sodium reduction, dietary improvement, increased physical activity, smoking cessation, weight loss), reasons for non-adherence, receipt of recommended monitoring tests (cholesterol, blood glucose, blood pressure), and reasons for non-receipt of tests. RESULTS: Behavior change advice was received equally by both low and high income respondents. Low income respondents were more likely than those with high income to not adhere to recommendations regarding smoking cessation (adjusted prevalence rate ratio (PRR): 1.55, 95%CI: 1.09-2.20), and more likely to not receive measurements of blood cholesterol (PRR: 1.72, 95%CI 1.24-2.40) or glucose (PRR: 1.80, 95%CI: 1.26-2.58). Those with low income were less likely to state that non-adherence/non-receipt was due to personal choice, and more likely to state that it was due to an extrinsic factor, such as cost or lack of accessibility. CONCLUSIONS: There are important income-related differences in the patterns of health behavior change and disease monitoring, as well as reasons for non-adherence or non-receipt. Among those with low income, adherence to health behavior change and monitoring may be improved by addressing modifiable barriers such as cost and access.

Association between perceived unmet health care needs and risk of adverse health outcomes among patients with chronic medical conditions.

BACKGROUND: Adults with chronic medical conditions are more likely to report unmet health care needs. Whether unmet health care needs are associated with an increased risk of adverse health outcomes is unclear. METHODS: Adults with at least one self-reported chronic condition (arthritis, chronic obstructive pulmonary disease, diabetes mellitus, heart disease, hypertension, mood disorder, stroke) from the 2001 and 2003 cycles of the Canadian Community Health Survey were linked to national hospitalization data. Participants were followed from the date of their survey until March 31, 2005, for the primary outcomes of all-cause and cause-specific admission to hospital. Secondary outcomes included length of stay, 30-day and 1-year all-cause readmission to hospital, and in-hospital death. Negative binomial regression models were used to estimate the association between unmet health care needs, admission to hospital, and length of stay, with adjustment for socio-demographic variables, health behaviours, and health status. Logistic regression was used to estimate the association between unmet needs, readmission, and in-hospital death. Further analyses were conducted by type of unmet need. RESULTS: Of the 51 932 adults with self-reported chronic disease, 15.5% reported an unmet health care need. Participants with unmet health care needs had a risk of all-cause admission to hospital similar to that of patients with no unmet needs (adjusted rate ratio [RR] 1.04, 95% confidence interval [CI] 0.94-1.15). When stratified by type of need, participants who reported issues of limited resource availability had a slightly higher risk of hospital admission (RR 1.18, 95% CI 1.09-1.28). There was no association between unmet needs and length of stay, readmission, or in-hospital death. INTERPRETATION: Overall, unmet health care needs were not associated with an increased risk of admission to hospital among those with chronic conditions. However, certain types of unmet needs may be associated with higher or lower risk. Whether unmet needs are associated with other measures of resource use remains to be determined.