Who Becomes a High Utilizer? A Case-Control Study of Older Adults in the USA

A novel pharmacy liaison program to address health-related social needs at an urban safety-net hospital

PURPOSE

Patients with unmet health-related social needs (HRSNs) often experience poor health outcomes and have high levels of healthcare utilization. We describe a program where dually trained pharmacy liaison-patient navigators (PL-PNs) screen for and address HRSNs while providing medication management services to patients with high levels of acute care utilization in a Medicaid Accountable Care Organization. We are unaware of prior studies that have described this PL-PN role.

METHODS

We analyzed case management spreadsheets for the 2 PL-PNs who staffed the program to identify the HRSNs that patients faced and the ways PL-PNs addressed them. We administered surveys, including an 8-item client satisfaction questionnaire (CSQ-8), to characterize patient perceptions of the program.

RESULTS

Initially, 182 patients (86.6% English speaking, 80.2% from a marginalized racial or ethnic group, and 63.2% with a significant medical comorbidity) were enrolled in the program. Non-English-speaking patients were more likely to receive the minimum intervention dose (completion of an HRSN screener). Case management spreadsheet data (available for 160 patients who engaged with the program) indicated that 71% of participants faced at least one HRSN, most often food insecurity (30%), lack of transportation (21%), difficulty paying for utilities (19%), and housing insecurity (19%). Forty-three participants (27%) completed the survey with an average CSQ-8 score of 27.9, indicating high levels of satisfaction with the program. Survey participants reported receiving medication management services, social needs referrals, health-system navigation assistance, and social support.

CONCLUSION

Integration of pharmacy medication adherence and patient navigation services is a promising approach to streamline the HRSN screening and referral process at an urban safety-net hospital.

High-Frequency Utilization of the PICU

OBJECTIVES

To describe the demographic, clinical, outcome, and cost differences between children with high-frequency PICU admission and those without.

DESIGN

Retrospective, cross-sectional cohort study.

SETTING

United States.

PATIENTS

Children less than or equal to 18 years old admitted to PICUs participating in the Pediatric Health Information System database in 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed survivors of PICU admissions for repeat PICU admissions within a year of their index visit. Children with greater than or equal to 3 PICU admissions within a year were classified as high-frequency PICU utilization (HFPICU). We compared demographic, clinical, outcome, and cost characteristics between children with HFPICU and those with only an index or two admissions per year (nHFPICU). Of 95,465 children who survived an index admission, 5,880 (6.2%) met HFPICU criteria. HFPICU patients were more frequently younger, technology dependent, and publicly insured. HFPICU patients had longer lengths of stay and were more frequently discharged to a rehabilitation facility or with home nursing services. HFPICU patients accounted for 24.8% of annual hospital utilization costs among patients requiring PICU admission. Time to readmission for children with HFPICU was 58% sooner (95% CI, 56-59%) than in those with nHFPICU with two admissions using an accelerated failure time model. Among demographic and clinical factors that were associated with development of HFPICU status calculated from a multivariable analysis, the greatest effect size was for time to first readmission within 82 days.

CONCLUSIONS

Children identified as having HFPICU account for 6.2% of children surviving an index ICU admission. They are a high-risk patient population with increased medical resource utilization during index and subsequent ICU admissions. Patients readmitted within 82 days of discharge should be considered at higher risk of HFPICU status. Further research, including validation and exploration of interventions that may be of use in this patient population, are necessary.

Multimorbidity and Inpatient Utilization Among Older Adults with Opioid Use Disorder in New York City

BACKGROUND

Nationally, there is a sharp increase in older adults with opioid use disorder (OUD). However, we know little of the acute healthcare utilization patterns and medical comorbidities among this population.

OBJECTIVE

This study describes the prevalence of chronic conditions, patterns of inpatient utilization, and correlates of high inpatient utilization among older adults with OUD in New York City (NYC).

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

Patients aged ≥55 with OUD hospitalized in NYC in 2012 identified using data from New York State's Statewide Planning and Research Cooperative System (SPARCS).

MAIN MEASURES

The prevalence of comorbid substance use diagnoses, chronic medical disease, and mental illness was measured using admission diagnoses from the index hospitalization. We calculated the ICD-Coded Multimorbidity-Weighted Index (MWI-ICD) for each patient to measure multimorbidity. We followed the cohort through September 30, 2015 and the outcome was the number of rehospitalizations for inpatient services in NYC. We compared patient-level factors between patients with the highest use of inpatient services (≥7 rehospitalizations) during the study period to low utilizers. We used multiple logistic regression to examine possible correlates of high inpatient utilization.

KEY RESULTS

Of 3669 adults aged ≥55 with OUD with a hospitalization in 2012, 76.4% (n=2803) had a subsequent hospitalization and accounted for a total of 22,801 rehospitalizations during the study period. A total of 24.7% of the cohort (n=906) were considered high utilizers and had a higher prevalence of alcohol and cocaine-related diagnoses, congestive heart failure, diabetes, schizophrenia, and chronic obstructive pulmonary disease. Multivariable predictors of high utilization included being a Medicaid beneficiary (adjusted odds ratio [aOR]=1.70, 95% confidence interval [CI]=1.37-2.11), alcohol-related diagnoses (aOR=1.43, 95% CI: 1.21-1.69), and increasing comorbidity measured by MWI-ICD (highest MWI-ICD quartile: aOR=1.98, 95% CI=1.59-2.48).

CONCLUSIONS

Among older adults with OUD admitted to the hospital, multimorbidity is strongly associated with high inpatient utilization.