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The American Journal of Managed Care September 2019
VA Geriatric Scholars Program’s Impact on Prescribing Potentially Inappropriate Medications
Zachary Burningham, PhD; Wei Chen, PhD; Brian C. Sauer, PhD; Regina Richter Lagha, PhD; Jared Hansen, MStat; Tina Huynh, MPH, MHA; Shardool Patel, PharmD; Jianwei Leng, MStat; Ahmad Halwani, MD; and B. Josea Kramer, PhD
The Sociobehavioral Phenotype: Applying a Precision Medicine Framework to Social Determinants of Health
Ravi B. Parikh, MD, MPP; Sachin H. Jain, MD, MBA; and Amol S. Navathe, MD, PhD
From the Editorial Board: Jan E. Berger, MD, MJ
Jan E. Berger, MD, MJ
Medicaid Managed Care: Issues for Enrollees With Serious Mental Illness
Jean P. Hall, PhD; Tracey A. LaPierre, PhD; and Noelle K. Kurth, MS
Multi-Payer Advanced Primary Care Practice Demonstration on Quality of Care
Musetta Leung, PhD; Christopher Beadles, MD, PhD; Melissa Romaire, PhD; and Monika Gulledge, MPH; for the MAPCP Evaluation Team
Physician-Initiated Payment Reform: A New Path Toward Value
Suhas Gondi, BA; Timothy G. Ferris, MD, MPH; Kavita K. Patel, MD, MSHS; and Zirui Song, MD, PhD
Managed Care for Long-Stay Nursing Home Residents: An Evaluation of Institutional Special Needs Plans
Brian E. McGarry, PT, PhD; and David C. Grabowski, PhD
Changes in Ambulatory Utilization After Switching From Medicaid Fee-for-Service to Managed Care
Lisa M. Kern, MD, MPH; Mangala Rajan, MBA; Harold Alan Pincus, MD; Lawrence P. Casalino, MD, PhD; and Susan S. Stuard, MBA
Did Medicare Advantage Payment Cuts Affect Beneficiary Access and Affordability?
Laura Skopec, MS; Joshua Aarons, BA; and Stephen Zuckerman, PhD
Medicare Shared Savings Program ACO Network Comprehensiveness and Patient Panel Stability
Cassandra Leighton, MPH; Evan Cole, PhD; A. Everette James, JD, MBA; and Julia Driessen, PhD
Currently Reading
Which Patients Are Persistently High-Risk for Hospitalization?
Evelyn T. Chang, MD, MSHS; Rebecca Piegari, MS; Edwin S. Wong, PhD; Ann-Marie Rosland, MD, MS; Stephan D. Fihn, MD, MPH; Sandeep Vijan, MD; and Jean Yoon, PhD, MHS

Which Patients Are Persistently High-Risk for Hospitalization?

Evelyn T. Chang, MD, MSHS; Rebecca Piegari, MS; Edwin S. Wong, PhD; Ann-Marie Rosland, MD, MS; Stephan D. Fihn, MD, MPH; Sandeep Vijan, MD; and Jean Yoon, PhD, MHS
Most patients in a large integrated healthcare system who were high-risk for hospitalization were at substantially lower risk within 2 years.

Figure 2 shows the monthly risk status of the high-risk patient cohort over a 24-month period (quantitative results in eAppendix Table 6). After 1 year, 28.6% (n = 74,060) were persistently high-risk for hospitalization, 10.3% (n = 26,541) had died, 23.8% (n = 61,556) were initially high-risk for hospitalization, and 30.6% (n = 79,078) were intermittently high-risk for hospitalization. By the end of the 2-year period, just 13.8% (n = 35,770) remained persistently high-risk for hospitalization; 17.7% (n = 45,805) had died, 41.5% (n = 107,473) were initially high-risk, and 19.9% (n = 51,354) were intermittently high-risk, and the remaining 7.1% (n = 18,357) were hospitalized or left VHA care at study end.

Patients who were older than 45 years, male, unmarried, black, and living in an urban area had greater odds of being persistently high-risk for hospitalization (vs intermittently high-risk) and of being intermittently high-risk for hospitalization (vs initially high-risk) (Table 1 [part A and part B]). Patients with nearly all medical and mental comorbidities had greater odds of being persistently or intermittently high-risk for hospitalization. The largest differences between the risk categories were found with congestive heart failure (OR, 2.60; 95% CI, 2.55-2.65), chronic kidney disease (OR, 2.48; 95% CI, 2.39-2.58), and dementia (OR, 1.96; 95% CI, 1.90-2.00). Patients with social instability, such as discharges against medical advice, number of zip code changes, and diagnoses of nonadherence, had greater odds of being both persistently and intermittently high-risk for hospitalization. Median no-show rates in a given year were similar for all risk categories.

Patients who were persistently high-risk for hospitalization were more likely than those who were intermittently high-risk or initially high-risk to have a VHA hospitalization (89%, 75%, and 41%, respectively) or ED visit (93%, 86%, and 57%, respectively) during the follow-up period (Table 2). Also, persistently high-risk patients had more frequent VHA hospitalizations per year than the initially high-risk group, with a mean (SD) of 1.9 (3.5) hospitalizations per year; most (1.5 [3.1]) of these admissions were medical.

Patients who were persistently high-risk for hospitalization also had higher rates of outpatient utilization: They had a mean (SD) of 83.2 (81.2) total VHA outpatient encounters (telephone and in-person visits) per year, almost double the number of outpatient encounters per year among patients who were only initially high-risk for hospitalization (Table 2). Persistently high-risk patients had a mean (SD) of 10.6 (15.9) encounters in primary care, 18.1 (64.9) encounters in mental health, and 0.1 (1.9) encounters in palliative care per year. In contrast, patients who were only initially high-risk for hospitalization had, on average, 44.4 (58.4) outpatient encounters per year, 6.7 (11.0) in primary care, 9.5 (41.1) in mental health, and 0.02 (0.8) in palliative care. Intermittently high-risk patients had mean utilization in between the persistently high-risk and initially high-risk groups.

In multivariable analyses, we identified 20 statistically significant (P <.05) predictors of being persistently high-risk for hospitalization, including age, gender, urban residence, visual and hearing impairment, chronic pain (back and neck pain, arthritis, and headache), chronic medical comorbidities (chronic kidney disease, coronary artery disease, congestive heart failure, diabetes, hypertension, and nicotine use), number of visits to palliative care, cancer diagnosis, number of mental health visits, and all markers of social instability (Table 3).


In this study, we examined the patterns of risk status over time among a population of high-risk patients receiving continuous VHA care. Consistent with findings of prior research on costs and readmissions,3,24 the majority of these patients did not remain persistently high-risk during 2 years of follow-up; just 29% were persistently high-risk after 1 year, and 14% remained persistently high-risk after 2 years. Almost half (42%) were classified as being persistently low-risk by study end.

These findings may partly explain seemingly positive results from interventions that enroll patients who are high-risk at baseline but that report pre–post findings without a comparison group. The improvement in patient outcomes could, in fact, be due to naturally decreasing risk over time rather than due to the intervention itself. Several randomized studies of care management interventions for high-need, high-cost patients have found no differences in cost and utilization between intervention and usual-care groups.25-27

We found significant and meaningful differences in socio­demographics, clinical comorbidities, and utilization among the 3 trajectory groupings of high-risk patients. The presence of chronic medical or behavioral conditions (particularly heart failure and chronic kidney disease), a nonadherence diagnosis, and higher VHA utilization rates were associated with greater duration of remaining persistently high-risk for hospitalization, which indicates that programs for high-risk patients can focus efforts on patients with these characteristics. Persistently and intermittently high-risk patients used a remarkable amount of VHA services—as many as an average of 63 to 83 outpatient visits and 0.9 to 1.9 admissions per year—suggesting that they were actively engaged with ambulatory care providers. Some acute care may be unavoidable despite high utilization of outpatient services, especially for patients who rapidly decompensate or cannot be managed effectively with ambulatory care alone.28 Persistently high-risk patients were more likely to live in urban areas, but many (30%) lived in rural areas, indicating that smaller, rural community clinics or virtual care modalities may have an important role to play in mitigating risk for these patients.

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