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Systematic review of high-cost patients’ characteristics and healthcare utilisation
  1. Joost Johan Godert Wammes1,
  2. Philip J van der Wees1,
  3. Marit A C Tanke1,
  4. Gert P Westert2,
  5. Patrick P T Jeurissen1
  1. 1 Radboud University Medical Center, Scientific Center for Quality of Healthcare/Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
  2. 2 Radboud University Medical Center, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
  1. Correspondence to Mr. Joost Johan Godert Wammes; Joost.Wammes{at}radboudumc.nl

Abstract

Objectives To investigate the characteristics and healthcare utilisation of high-cost patients and to compare high-cost patients across payers and countries.

Design Systematic review.

Data sources PubMed and Embase databases were searched until 30 October 2017.

Eligibility criteria and outcomes Our final search was built on three themes: ‘high-cost’, ‘patients’, and ‘cost’ and ‘cost analysis’. We included articles that reported characteristics and utilisation of the top-X% (eg, top-5% and top-10%) patients of costs of a given population. Analyses were limited to studies that covered a broad range of services, across the continuum of care. Andersen’s behavioural model was used to categorise characteristics and determinants into predisposing, enabling and need characteristics.

Results The studies pointed to a high prevalence of multiple (chronic) conditions to explain high-cost patients’ utilisation. Besides, we found a high prevalence of mental illness across all studies and a prevalence higher than 30% in US Medicaid and total population studies. Furthermore, we found that high costs were associated with increasing age but that still more than halve of high-cost patients were younger than 65 years. High costs were associated with higher incomes in the USA but with lower incomes elsewhere. Preventable spending was estimated at maximally 10% of spending. The top-10%, top-5% and top-1% high-cost patients accounted for respectively 68%, 55% and 24% of costs within a given year. Spending persistency varied between 24% and 48%. Finally, we found that no more than 30% of high-cost patients are in their last year of life.

Conclusions High-cost patients make up the sickest and most complex populations, and their high utilisation is primarily explained by high levels of chronic and mental illness. High-cost patients are diverse populations and vary across payer types and countries. Tailored interventions are needed to meet the needs of high-cost patients and to avoid waste of scarce resources.

  • high-need high-cost
  • integrated delivery of health care
  • health care utilization
  • health care costs

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Footnotes

  • Contributors JJGW drafted the first manuscript and conducted the analyses. JJGW and PJvdW selected eligible studies. JJGW, PJvdW and MACT conceptualised the study and interpreted the data. GPW and PPTJ made a substantial contribution to the development of the research question and interpretation and presentation of the findings. All authors provided feedback to and approved the final manuscript.

  • Funding The study was conducted as part of a research program funded through the Dutch Ministry of Health.

  • Disclaimer The funding source had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the manuscript for publication.

  • Competing interests None declared.

  • Patient consent None required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Detailed forms with extracted data are available from the authors upon request.

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