A small proportion of high-need, high-cost (HNHC) patients with chronic gastrointestinal (GI) and liver disease account for a disproportionate share of hospital costs, according to a new study in Clinical Gastroenterology and Hepatology.
“A detailed understanding of variability in hospitalization-related burden and health care costs of chronic gastrointestinal diseases will allow identification and characterization of HNHC patients of hospitalization-related care and facilitate population health management targeting at-risk populations to decrease costs,” wrote the authors, led by Nghia H. Nguyen, MD, Department of Internal Medicine, University of California San Diego, La Jolla, CA.
Currently, limited data are available regarding the annual cost burden of hospitalization in patients with chronic GI and liver diseases. Recent estimates have pegged the annual cost of management of chronic liver and GI disease at > $103 billion, of which 62% is accounted for by inpatient spending and 20% is accounted for by ambulatory spending.
Metrics in other studies reflecting 30-day readmissions do not capture the burden of hospitalization costs from the vantage point of both the patient and the health-care institution for the following reasons:
- Some HNHC patients are not readmitted to the hospital within a period of 30 days.
- Some patients who are readmitted within 30 days may just be readmitted once.
- Patients who are readmitted within 30 days pose variable costs and stay in the hospital for various lengths of time.
One useful alternative measure when assessing high-value care can be total days spent in the hospital. This outcome measure was developed in studies of terminally ill patients.
In the current study, investigators mined the Nationwide Readmissions Database (NRD) 2013 for patients with inflammatory bowel diseases (n=47,402), chronic liver diseases (n=376,810), functional GI disorders (n=351,583), GI hemorrhage (n=190,881), or pancreatic diseases (n=98,432). Approximately 20% of patients had ≥ 2 of these conditions.
NRD 2013 was used to gauge the annual burden and patterns of hospitalization in patients with these five conditions, and represented > 85% of inpatient discharges from 21 state inpatient databases. The primary outcome for this study was number of days spent in the hospital per month, and the secondary outcomes were the number of all-cause hospitalizations per month and the costs of hospitalizations per month.
The team utilized multivariate logistic regression based on patient, hospital, and index hospitalization-related factors to identify HNHC patients spanning the five conditions.
Overall, the researchers found that costs and length of hospital stay were highest for patients with chronic liver diseases and functional GI disorders.
They also found that the highest decile of hospitalization burden for each condition spent a median of 3.7 to 5.1 days per month in the hospital. In this top decile, hospitalization costs averaged $7,438 to $11,425 per month.
Characteristics of HNHC patients were fairly uniform across all conditions and included the following:
- Medicare/Medicaid insurance
- Lower income status
- Index hospitalization in a large rural hospital
- Heightened comorbidity burden
- Obesity and infection-related hospitalization
The researchers suggested that—similar to the findings of their study—a small number of patients comprise HNHC in other chronic non-GI conditions.
“HNHC patients include 2 sets of patients: first, chronically high utilizers, who have established disease-related complications at very high risk of repeated decompensation (eg, patients with decompensated cirrhosis), and, second, compensated patients who are not chronically ill, but at high risk of complications (eg, patients with controlled IBD who develop a severe flare),” wrote the authors.
One limitation of this study was that causes for patient readmission were determined using primary discharge diagnoses, which were grouped by disease system for interpretation.
“Population health management strategies directed toward identifying HNHC patients and implementing multicomponent chronic care models may improve the quality of care and reduce costs of care,” concluded the authors.
This study was funded by the American College of Gastroenterology, Crohn’s and Colitis Foundation , Patient-Centered Outcomes Research Institute: Clinical Data Research Network, and the National Heart, Lung, and Blood Institute.