title: The fragmentation of hospital use among a cohort of high utilizers: implications for emerging care coordination strategies for patients with multiple chronic conditions.
abstract: 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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: *The Robert Wood Johnson Foundation, Princeton †Rutgers University Center for State Health Policy, New Brunswick ‡Rutgers University Department of Statistics, Piscataway §Department of Mathematics, University of Southern California, California CA ∥Camden Coalition of Healthcare Providers, Camden, NJ.
authors.forename: Katherine
authors.initials: K
authors.lastname: Hempstead
authors.forename: Derek
authors.initials: D
authors.lastname: Delia
authors.forename: Joel C
authors.initials: JC
authors.lastname: Cantor
authors.forename: Tuan
authors.initials: T
authors.lastname: Nguyen
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Brenner
mesh_terms: D000328:Adult; D002908:Chronic Disease / Q000453:epidemiology* / Q000628:therapy*; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009515:New Jersey / Q000453:epidemiology; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D016012:Poisson Distribution; D011785:Quality Assurance, Health Care; D012044:Regression Analysis; D012189:Retrospective Studies; D055815:Young Adult