Characterization, Categorization, and 5-Year Mortality of Medicine High Utilizer Inpatients

Abstract

Background: Patients who are frequently admitted to Medicine inpatient services comprise a distinct subset of readmitted patients about whom not much is known. Objective: We sought to characterize this group including mortality rates, with the goal of better understanding this population. Design: Observational study of frequently hospitalized patients defined as 4 or more admissions over a 6-month period, with hospitalization defined as nonelective admission to the hospital. Setting: Single large academic medical center. Patients: Adult inpatients on general medicine and medicine subspecialty services. Measurements: The number of nonelective medicine hospitalizations, age, clinical conditions and comorbidities, calculation of an age-adjusted Charlson Comorbidity Index (CCI), outpatient and emergency department visits, length of stay, costs of hospitalization, and mortality over a 5-year period. Descriptive statistics were used to characterize variables of interest. Results: We identified 153 patients with a total of 781 nonelective hospitalizations, totaling greater than 4000 hospital days and with charges of approximately US$9 million during the 6 months. Nearly all had insurance coverage and good outpatient follow-up (median of 7 appointments over the 6-month study period). Only 14% of those admissions qualified for observation status. Over 40% of patients had comorbid mental health disease or chronic narcotic dependence. Twenty-nine percent of patients died within 1 year; 50% were dead within 5 years. Age-adjusted CCI scores ranged annually from 3.00 to 3.58 among surviving patients versus 4.31 to 6.60 among deceased patients. Conclusions: These findings point to distinct groups of patients who are frequently hospitalized, and therefore would benefit from tailored management strategies: Those with progression of end-stage disease comprised one-third of the group and targeting that subset with palliative care referrals could help decrease readmission rates. Those with recurrent exacerbations of a chronic medical condition could be managed through telemanagement programs. Those with exacerbations of chronic pain could be addressed through collaboration with pain management specialists. Individualized care management plans may be useful for all, especially the latter two groups. Based on differences between survivors and deceased patients, an age-adjusted CCI score of 4 or 5 could be valuable sensitive or specific cutoffs, respectively, for predicting those who would benefit most from palliative care consultation regarding end-of-life goals and management.