The fragmentation of hospital use among a cohort of high utilizers: implications for emerging care coordination strategies for patients with multiple chronic conditions

Med Care. 2014 Mar;52 Suppl 3:S67-74. doi: 10.1097/MLR.0000000000000049.


Background: Use of multiple hospitals by patients with multiple chronic conditions (MCC) may undermine emerging care coordination initiatives.

Objective: The aim of this study was to assess the prevalence and correlates of fragmented hospital use among high users with MCC and derive implications for care management.

Research design: Using all-payer hospital billing data, we follow a 2-year cohort of patients with at least 2 inpatient stays, identifying those with MCC and calculating the percentage using multiple hospitals and applying multivariate Poisson regression to predict correlates of multiple hospital use.

Subjects: The subjects included in our study were New Jersey adults with at least 2 inpatient stays during a 24-month period between 2007 and 2010.

Results: Nearly 80% of the study cohort had ≥2 chronic conditions and >30% had fragmented hospital use. The probability of visiting multiple hospitals was positively associated with the number of chronic conditions present at admission, total number of admissions, lower hospital market concentration, and injury or behavioral health diagnoses. Over 40% of patients with ≥4 stays had multiple hospital use.

Conclusions: Fragmentation of hospital care occurs frequently among high utilizers with MCC. Although multiple hospital use is not necessarily inappropriate, it may present barriers to effective care coordination for complex patients with MCC, leading to higher costs or worse outcomes. Leaders of innovative delivery reforms such as Accountable Care Organizations should monitor and coordinate care for multiple hospital users, especially those with MCC.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Chronic Disease / epidemiology*
  • Chronic Disease / therapy*
  • Cohort Studies
  • Comorbidity
  • Female
  • Hospitalization / statistics & numerical data*
  • Humans
  • Length of Stay / statistics & numerical data
  • Male
  • Middle Aged
  • New Jersey / epidemiology
  • Outcome Assessment, Health Care / statistics & numerical data*
  • Poisson Distribution
  • Quality Assurance, Health Care
  • Regression Analysis
  • Retrospective Studies
  • Young Adult