title: Using Merged Clinical and Claims Registry Data to Identify High Utilizers of Surgical Inpatient Care 1 Year after Colectomy.
abstract: BACKGROUND
  Under bundled payment initiatives, providers will be held financially responsible for patients' acute and post-acute care costs. Certain patients, termed high utilizers, use disproportionate shares of resources during 1 year. The aim of this study was to identify high utilizers, describe their costs, and determine whether preoperative characteristics predict high utilizer status.
  
  
  METHODS
  Colectomy patients with 1-year follow-up were identified in a linked clinical (American College of Surgeons NSQIP) and administrative (Medicare inpatient claims) dataset (2005 to 2008). Cost of inpatient care was calculated by multiplying patient Medicare charges in each cost center by cost-to-charge ratios from the Medicare cost reports. A mixed-effects logistic model quantified the association between preoperative characteristics and being a high utilizer after elective and emergent colectomies.
  
  
  RESULTS
  One thousand and fifty-five of 10,561 colectomy patients accounted for >50% of the inpatient care cost of the entire cohort during 1 year postoperatively. This top decile of patients were labeled high utilizers and had substantially greater costs in the following cost centers: intensive care ($36,322 vs $0), respiratory ($2,875 vs $22), radiology ($649 vs $29), and cardiology ($5,057 vs $166) (all p < 0.001). High utilizers more frequently had emergent index colectomies (43% vs 17%; p < 0.001). Patients with American Society of Anesthesiologists class IV and V had 2-fold increased odds of being high utilizers after both elective (odds ratio = 2.72; 95% CI, 1.89-3.90) and emergent colectomies (odds ratio = 2.09; 95% CI, 1.23-3.55).
  
  
  CONCLUSIONS
  Patients in the top cost decile account for the majority of costs in the year after colectomy, disproportionately accumulate those costs in particular cost centers, and can be identified preoperatively.
authors.affiliation: Icahn School of Medicine at Mount Sinai Medical Center, New York, NY; David Geffen School of Medicine, University of California, Los Angeles, CA. Electronic address: as013j@gmail.com.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Stey
authors.affiliation: David Geffen School of Medicine, University of California, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA.
authors.forename: Marcia M
authors.initials: MM
authors.lastname: Russell
authors.affiliation: David Geffen School of Medicine, University of California, Los Angeles, CA.
authors.forename: David S
authors.initials: DS
authors.lastname: Zingmond
authors.affiliation: David Geffen School of Medicine, University of California, Los Angeles, CA.
authors.forename: Melinda M
authors.initials: MM
authors.lastname: Gibbons
authors.affiliation: American College of Surgeons, Chicago, IL; Department of Surgery, Olin Business School, and Center for Health Policy, Washington University in Saint Louis, St Louis VA Medical Center, BJC Healthcare Saint Louis, St Louis, MO.
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Hall
authors.affiliation: Fielding School of Public Health, University of California, Los Angeles, CA.
authors.forename: Jack
authors.initials: J
authors.lastname: Needleman
authors.affiliation: David Geffen School of Medicine, University of California, Los Angeles, CA.
authors.forename: Elise H
authors.initials: EH
authors.lastname: Lawson
authors.affiliation: VA Greater Los Angeles Healthcare System, Los Angeles, CA.
authors.forename: Nancy
authors.initials: N
authors.lastname: Liu
authors.affiliation: David Geffen School of Medicine, University of California, Los Angeles, CA; American College of Surgeons, Chicago, IL.
authors.forename: Clifford Y
authors.initials: CY
authors.lastname: Ko
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003082:Colectomy / Q000191:economics*; D003625:Data Collection; D005260:Female; D005500:Follow-Up Studies; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006748:Hospital Departments / Q000191:economics / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000191:economics*; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare / Q000191:economics*; D008875:Middle Aged; D011183:Postoperative Complications / Q000191:economics*; D057234:Preoperative Period; D012042:Registries; D014481:United States