title: Clinical characteristics and preventable acute care spending among a high cost inpatient population.
abstract: A small proportion of patients account for the majority of health care spending. The objectives of this study were to explore the clinical characteristics, patterns of health care use, and the proportion of acute care spending deemed potentially preventable among high cost inpatients within a Canadian acute-care hospital.
  
  
  
  We identified all individuals within the Ottawa Hospital with one or more inpatient hospitalization between April 1, 2010 and March 31, 2011. Clinical characteristics and frequency of hospital encounters were captured in the information systems of the Ottawa Hospital Data Warehouse. Direct inpatient costs for each encounter were summed using case costing information and those in the upper first and fifth percentiles of the cumulative direct cost distribution were defined as extremely high cost and high cost respectively. We quantified preventable acute care spending as hospitalizations for ambulatory care sensitive conditions (ACSC) and spending attributable to difficulty discharging patients as measured by alternate level of care (ALC) status.
  
  
  
  During the study period, 36,892 patients had 44,066 hospitalizations. High cost patients (n = 1,844) accounted for 38 % of total inpatient spending ($122 million) and were older, more likely to be male, and had higher levels of co-morbidity compared to non-high cost patients. In over half of the high cost cohort (54 %), costs were accumulated from a single hospitalization. The majority of costs were related to nursing care and intensive care unit spending. High cost patients were more likely to have an encounter deemed to be ambulatory care sensitive compared to non-high cost inpatients (6.0 versus 2.8 %, p < 0.001). A greater proportion of inpatient spending was attributable to ALC days for high cost versus non-high cost patients (9.1 versus 4.9 %, p < 0.001).
  
  
  
  Within a population of high cost inpatients, the majority of costs are attributed to a single, non-preventable, acute care episode. However, there are likely opportunities to improve hospital efficiency by focusing on different approaches to community based care directed towards specific populations.
authors.affiliation: Department of Community Health Sciences, University of Calgary, 3330 Hospital Drive NW, Calgary, T2N 4N1, AB, Canada. peronksl@ucalgary.ca.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Ronksley
authors.affiliation: Department of Medicine, University of Ottawa, Ottawa, ON, Canada.|Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Kobewka
authors.affiliation: Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: McKay
authors.affiliation: Performance Measurement, The Ottawa Hospital, Ottawa, ON, Canada.
authors.forename: Deanna M
authors.initials: DM
authors.lastname: Rothwell
authors.affiliation: Department of Medicine, University of Ottawa, Ottawa, ON, Canada.|Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Sunita
authors.initials: S
authors.lastname: Mulpuru
authors.affiliation: Department of Medicine, University of Ottawa, Ottawa, ON, Canada.|Performance Measurement, The Ottawa Hospital, Ottawa, ON, Canada.|Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Forster
mesh_terms: D000208:Acute Disease / Q000191:economics* / Q000628:therapy; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000191:economics; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D017046:Cost Savings; D003365:Costs and Cost Analysis; D003422:Critical Care / Q000191:economics; D004180:Direct Service Costs / Q000706:statistics & numerical data; D017050:Episode of Care; D005260:Female; D005102:Health Expenditures; D006760:Hospitalization / Q000191:economics*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D009864:Ontario; D010351:Patient Discharge / Q000191:economics; D010359:Patient Readmission / Q000191:economics; D055815:Young Adult
keywords: Administrative data; Ambulatory care sensitive conditions; Healthcare cost; Hospitalization