Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers

Abstract

Background: Super-utilizers with 4 or more admissions per year frequently receive low-quality care and disproportionately contribute to healthcare costs. Inpatient care fragmentation (admission to multiple different hospitals) in this population has not been well described.

Objective: To determine the prevalence of super-utilizers who receive fragmented care across different hospitals and to describe associated risks, costs, and health outcomes.

Research design: We analyzed inpatient data from the Health Care Utilization Project's State Inpatient and Emergency Department database from 6 states from 2013. After identifying hospital super-utilizers, we stratified by the number of different hospitals visited in a 1-year period. We determined how patient demographics, costs, and outcomes varied by degree of fragmentation. We then examined how fragmentation would influence a hospital's ability to identify super-utilizers.

Subjects: Adult patients with 4 or more inpatient stays in 1 year.

Measures: Patient demographics, cost, 1-year hospital reported mortality, and probability that a single hospital could correctly identify a patient as a super-utilizer.

Results: Of the 167,515 hospital super-utilizers, 97,404 (58.1%) visited more than 1 hospital in a 1-year period. Fragmentation was more likely among younger, non-white, low-income, under-insured patients, in population-dense areas. Patients with fragmentation were more likely to be admitted for chronic disease management, psychiatric illness, and substance abuse. Inpatient fragmentation was associated with higher yearly costs and lower likelihood of being identified as a super-utilizer.

Conclusions: Inpatient care fragmentation is common among super-utilizers, disproportionately affects vulnerable populations. It is associated with high yearly costs and a decreased probability of correctly identifying super-utilizers.

Keywords: Fragmentation; Hospital super-utilizer; Socioeconomic health disparities.

Fig. 1

Proportion of patients identified as super-utilizers using single hospital data: Comparing 4 different single hospital methods to detect super-utilizers: 3 and 4 or more inpatient encounters, and top 5th percentile for either inpatient days and inpatient cost. We determined the likelihood that a single hospital would correctly identify a patient as a super-utilizer in the absence of data sharing