title: Who Are the High-Cost Users? A Method for Person-Centred Attribution of Health Care Spending.
abstract: OBJECTIVE
  To develop person-centered episodes of care (PCE) for community-dwelling individuals in the top fifth percentile of Ontario health care expenditures in order to: (1) describe the main clinical groupings for spending; and (2) identify patterns of spending by health sector (e.g. acute care, home care, physician billings) within and across PCE.
  
  
  METHODS
  Data were drawn from population-based administrative databases for all publicly funded health care in Ontario, Canada in 2010/11.
  
  
  METHODS
  This study is a retrospective cohort study.
  
  
  METHODS
  A total of 587,982 community-dwelling individuals were identified among those accounting for the top 5% of provincial health care expenditures between April 1, 2010 and March 31, 2011. PCE were defined as starting with an acute care admission and persisting through subsequent care settings and providers until individuals were without health system contact for 30 days. PCE were classified according to the clinical grouping for the initial admission. PCE and non-PCE costs were calculated and compared to provide a comprehensive measurement of total health system costs for the year.
  
  
  RESULTS
  Among this community cohort, 697,059 PCE accounted for nearly 70% ($11,815.3 million (CAD)) of total annual publicly-funded expenditures on high-cost community-dwelling individuals. The most common clinical groupings to start a PCE were Acute Planned Surgical (35.2%), Acute Unplanned Medical (21.0%) and Post-Admission Events (10.8%). Median PCE costs ranged from $3,865 (IQR = $1,712-$10,919) for Acute Planned Surgical to $20,687 ($12,207-$39,579) for Post-Admission Events. Inpatient acute ($8,194.5 million) and inpatient rehabilitation ($434.6 million) health sectors accounted for the largest proportions of allocated PCE spending over the year.
  
  
  CONCLUSIONS
  Our study provides a novel methodological approach to categorize high-cost health system users into meaningful person-centered episodes. This approach helps to explain how costs are attributable within individuals across sectors and has applications in episode-based payment formulas and quality monitoring.
authors.affiliation: Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.|Health System Performance Research Network, Toronto, Ontario.|Centre for Research of Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.|Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Sara J T
authors.initials: SJ
authors.lastname: Guilcher
authors.affiliation: Health System Performance Research Network, Toronto, Ontario.|Institute for Clinical Evaluative Sciences, Toronto, Canada.|Institute of Health, Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Bronskill
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Jun
authors.initials: J
authors.lastname: Guan
authors.affiliation: Health System Performance Research Network, Toronto, Ontario.|Institute for Clinical Evaluative Sciences, Toronto, Canada.|Institute of Health, Policy, Management and Evaluation, University of Toronto, Toronto, Canada.|Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario.
authors.forename: Walter P
authors.initials: WP
authors.lastname: Wodchis
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000191:economics*; D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual; D017050:Episode of Care; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006699:Home Care Services / Q000191:economics*; D006760:Hospitalization / Q000191:economics*; D006801:Humans; D057187:Independent Living; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D009864:Ontario; D012189:Retrospective Studies