Interventions to Improve Outcomes for High-Need, High-Cost Patients: A Systematic Review and Meta-Analysis

Abstract

BACKGROUND: Chronic disease patients who are the greatest users of healthcare services are often referred to as high-need, high-cost (HNHC). Payers, providers, and policymakers in the United States are interested in identifying interventions that can modify or reduce preventable healthcare use among these patients, without adversely impacting their quality of care and health. We systematically reviewed the evidence on the effectiveness of complex interventions designed to change the healthcare of HNHC patients, modifying cost and utilization, as well as clinical/functional, and social risk factor outcomes. METHODS: We searched 8 electronic databases (January 2000 to March 2021) and selected non-profit organization and government agency websites for randomized controlled trials and observational studies with comparison groups that targeted HNHC patients. Two investigators independently screened each study and abstracted data into structured forms. Study quality was assessed using standard risk of bias tools. Random-effects meta-analysis was conducted for outcomes reported by at least 3 comparable samples. RESULTS: Forty studies met our inclusion criteria. Interventions were heterogenous and classified into 7 categories, reflecting the predominant service location/modality (home, primary care, ambulatory intensive caring unit [aICU], emergency department [ED], community, telephonic/mail, and system-level). Home-, primary care-, and ED-based interventions resulted in reductions in high-cost healthcare services (ED and hospital use). ED-based interventions also resulted in greater use of primary care. Primary care-and ED-based interventions reduced costs. System-level transformation interventions did not reduce costs. DISCUSSION: We found limited evidence of intervention effectiveness in relation to cost and use, and additional evidence is needed to strengthen our confidence in the findings. Few studies reported patient clinical/ Prior Presentations Findings from an early draft of these results were presented at the 2020 AcademyHealth Annual Research Meeting. The results using all included studies can be found in the full AHRQ evidence report, available at https://doi.org/10.23970/AHRQEPCCER246.

Hospital Readmissions by Variation in Engagement in the Health Care Hotspotting Trial

“…While there are patients for whom reducing hospitalizations is an appropriate goal of complex care management, for others, frequent hospitalizations result from exceptional circumstances that are not resolved irrespective of intensive intervention . Other intervention outcomes such as care continuity and improved chronic disease management should be introduced into randomized evaluations along with patient-reported measures to advance a more holistic understanding of program value …”

“…1,2 These programs tend to focus on high-cost, high-needs populations, [3][4][5] and their value is often framed as cost savings achieved through reductions in avoidable hospitalizations and emergency department use. 6,7 Several randomized clinical trials have shown positive effects with complex care programs in reducing costs, 8,9 hospitalizations, 8,[10][11][12] or emergency department visits, 10 while others have produced null results for similar outcomes. [8][9][10][13][14][15][16] The Camden Coalition received support in 2012 from the US Centers for Medicare and Medicaid Services to refine, test, and scale their signature care management model: the Camden Core Model.…”

“…An approach to care for individuals with concurrent medical and social needs, complex care is distinct from other care management approaches for its interdisciplinary team-based models, prioritization of patients’ self-defined goals, and emphasis on cross-sector partnerships to improve care transitions across multiple settings . These programs tend to focus on high-cost, high-needs populations, and their value is often framed as cost savings achieved through reductions in avoidable hospitalizations and emergency department use . Several randomized clinical trials have shown positive effects with complex care programs in reducing costs, hospitalizations, or emergency department visits, while others have produced null results for similar outcomes …”

From theory to practice: The pragmatic value of applying systems thinking and complexity sciences in healthcare

“…32 Interventions based on linear input-output models do not reflect the actual complexities of the systems in which acute care operates and arec-ca-prioric-cdoomed to fail. 33 Rusoja and colleague's 22 case study of a learning health system provide a model to achieve learning systems 34 with the greatest possible potential to sustainably improve healthcare. Their approaches provide a practical example that synchronises well with the work of the Complexity Working Group of the North American Primary Health Care Research Group on Superutilization.…”

The intervening influence of the quality of health-care administrative process on the relationship between facilities management service quality and patients’ health-care experience in Ghana

“…Most health-care institutions do their very best to provide patients with quality health-care experience. Yet, most health-care institutions have not been able to achieve this due to the complexity of patients’ care (Chang et al , 2022). It is worth noting that patients’ health-care experience (PHcE) is reliant on a whole lot of issues comprising the effectiveness of the core health-care business as well as health-care facilities management (HcFM).…”