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Small Fraction of GI Patients Drive More than 50% of Hospital Costs.

Targeting populations at highest need could improve outcomes, save money.

As in other medical conditions, a small fraction of high-need, high-cost patients with gastrointestinal (GI) and liver diseases contribute disproportionately to hospitalization costs, according to a nationwide database analysis published in Clinical Gastroenterology and Hepatology.

The study found that across five common diseases, patients in the top two deciles of hospital utilization accounted for well over half of hospital costs and those in the top decile accounted for more than a third of costs, and in one case, reached almost 40% of costs.

“Population health management strategies directed toward identifying this high-need, high-cost patients and implementing multi-component chronic care models may improve the quality of care and reduce costs of care,” the study’s senior author, Siddarth B. Singh, MD, MS, of the University of California San Diego, told MedPage Today.

He and his colleagues noted that research on the annual burden of hospitalization costs for chronic GI diseases has been limited.

For the study, the team used discharge information from the all-payer National Readmission Database (NRD) 2013 and identified 10,931,271 records of 8,214,048 unique adult patients with at least one hospitalization in the following disease categories:

  • * Inflammatory bowel disease (IBD; 47,402 patients)
  • * Chronic liver disease (376,810 patients)
  • * Functional GI disorders (351,583 patients)
  • * GI hemorrhage (190,881 patients)
  • * Pancreatic diseases (98,432 patients)

The patients were followed for a median of 10 months after the index hospitalization.

The highest resource users represented only relatively small numbers of the five disease cohorts, as follows:

  • * 4,717 in IBD
  • * 37,293 in chronic liver disease
  • * 34,910 in functional disorders
  • * 18,864 in GI hemorrhage
  • * 9,648 in pancreatic diseases

Multivariate logistic regression revealed that this high-need, high-cost patients were overall more likely to have the following characteristics: to be slightly older (age 55 versus 51), to have Medicare/Medicaid, to have lower income status, to have index admission to a large rural hospital, to have a high comorbidity burden, to be obese, and to have hospitalization for infection-related reasons.

These patients more frequently underwent GI procedures and received blood transfusions and enteral or parenteral nutrition at their index admission and subsequent hospitalizations. Younger age and male sex were risk factors in the chronic liver disease cohort.

Patients with these five GI conditions spent a median total of 6 or 7 days (interquartile range [IQR] 3-14) in hospital each year. Across all five, patients in the highest-need decile by the total number of hospital days spent a median of 3.7 to 5.1 days a month in hospital versus the median of 0.13 to 0.14 days a month spent by those in the lowest decile.

Total median costs across hospitalizations were highest for those with functional and motility disorders, at $23,298; and lowest for patients with IBD, at $12,716.



In the IBD cohort, patients spent a median of 6 days (IQR, 3-12) in hospital annually (median per month 0.6 days). Cumulatively, IBD patients in the highest decile contributed 38% of hospitalization costs, while patients in the top two deciles contributed 55%.

Six days of hospitalization was also the annual median for those with GI hemorrhage and pancreatic disease, while the median was 7 days for chronic liver disease and functional bowel disorders.

In the liver disease cohort, patients in the highest decile spent 4.14 days per month in hospital (IQR 3.42-5.63), with hospitalization costs of $8,925 per month. Within the highest decile, patients at the 99th centile spent 9.89 days per month in the hospital, with one hospitalization per month, at a cost of $28,473 per month. Cumulatively, patients in the highest decile contributed 36% of total hospitalization costs, and patients in the top two deciles contributed 55%.

Cost proportions were similar for the highest decile of hospital stay in the other three diseases, ranging from 34% in functional disorders and 38% in GI hemorrhaging to 39% in pancreatic disease. The cost proportions for the top two deciles varied from 52% in functional disorders to 57% in pancreatic diseases.

Asked for her perspective, Anne Peery, MD, of the University of North Carolina, Chapel Hill, who was not involved in the study, told MedPage Today: “The importance of identifying high-need, high-cost patients is established in the medical literature, but it is novel and important to know this applies to our patients with chronic gastrointestinal and liver diseases who are admitted to the hospital.”

She said she agreed with the authors’ conclusion that identifying these potentially high resource users has the potential to improve outcomes and reduce expenditures.

Singh and colleagues explained that at a patient level, modifiable risk factors may include tackling the obesity epidemic and mental health issues and minimizing the risk of iatrogenic or healthcare-associated infections, whereas at a health system level interventions may include better access to care and connectivity between rural and specialty hospitals.

At the healthcare system level, understanding utilization commonalities across these GI diseases might lead to the adaptation of interventions proven successful in other diseases to gastroenterological care, the researchers said.

In addition to the study’s retrospective nature, limitations included the focus on inpatient use without details of outpatient clinic visits, medication use, and laboratory variables, the team noted. In addition, readmission causes were identified using primary discharge diagnoses, and because the NRD uses data from state inpatient databases, patients were not tracked across state boundaries. There was also some potential overlap in patients between different GI disease categories since approximately 20% had two or more candidate conditions at the index hospitalization. Furthermore, the researchers said, since the NRD does not capture out-of-hospital mortality, there was a potential for bias in the at-risk-for-hospitalization time period.

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