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Characteristics of High-Need, High-Cost Patients : A "Best-Fit" Framework Synthesis
Nancy D Berkman1, Eva Chang2, Julie Seibert3
1RTI-University of North Carolina Evidence-based Practice Center and RTI International, Research Triangle Park, North Carolina (N.D.B., R.A.).
Insights
Identifying high-need, high-cost (HNHC) patients is crucial for healthcare. Key characteristics include multiple severe chronic conditions, behavioral health issues, and social risks, alongside prior high healthcare utilization.
Area of Science:
- Health Services Research
- Population Health Management
- Healthcare Policy
Background:
- Identifying high-need, high-cost (HNHC) patients is a significant challenge for U.S. policymakers and healthcare systems.
- Reducing preventable healthcare use among HNHC patients with chronic conditions is a key priority.
Purpose of the Study:
- To identify key characteristics and criteria for accurately distinguishing HNHC patients.
- To inform strategies for better targeting interventions and resources.
Main Methods:
- Systematic literature review of 64 studies published between 2000 and 2022.
- Included multivariate exposure, cluster, and qualitative studies on adult HNHC patients.
- Utilized dual-review extraction and quality assessment, adapting a National Academy of Medicine taxonomy.
Main Results:
- HNHC patients often present with numerous and severe comorbid chronic conditions (e.g., heart disease, diabetes, cancer).
- Behavioral health conditions and social risk factors significantly amplify HNHC risk.
- The revised framework identified chronic pain and past high healthcare use as critical risk indicators.
Conclusions:
- A combination of patient characteristics effectively identifies HNHC individuals.
- Addressing the complex needs of HNHC patients requires individualized assessments of care requirements and support services.
- Future efforts should focus on distinguishing modifiable healthcare use for improved outcomes.
Background:
Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers.
Purpose:
To identify characteristics and criteria to distinguish HNHC patients.
Data Sources:
Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022.
Study Selection:
English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost.
Data Extraction:
Independent, dual-review extraction and quality assessment.
Data Synthesis:
The review included 64 studies comprising multivariate exposure studies (n = 47), cluster analyses (n = 11), and qualitative studies (n = 6). A National Academy of Medicine (NAM) taxonomy was an initial "best-fit" framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC.
Limitation:
Little evidence distinguished potentially preventable or modifiable health care use from overall use.
Conclusion:
A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services.
Primary Funding Source:
Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179).
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