Abstract
BackgroundSenior high cost health care users (HCU) are a priority for many governments. Little research has addressed regional variation of HCU incidence and outcomes, especially among incident HCU. This study describes the regional variation in healthcare costs and mortality across Ontario’s health planning districts [Local Health Integration Networks (LHIN)] among senior incident HCU and non-HCU and explores the relationship between healthcare spending and mortality.MethodsWe conducted a retrospective population-based matched cohort study of incident senior HCU defined as Ontarians aged ≥66 years in the top 5% most costly healthcare users in fiscal year (FY) 2013. We matched HCU to non-HCU (1:3) based on age, sex and LHIN. Primary outcomes were LHIN-based variation in costs (total and 12 cost components) and mortality during FY2013 as measured by variance estimates derived from multi-level models. Outcomes were risk-adjusted for age, sex, ADGs, and low-income status. In a cost-mortality analysis by LHIN, risk-adjusted random effects for total costs and mortality were graphically presented together in a cost-mortality plane to identify low and high performers.ResultsWe studied 175,847 incident HCU and 527,541 matched non-HCU. On average, 94 out of 1000 seniors per LHIN were HCU (CV = 4.6%). The mean total costs for HCU in FY2013 were 12 times higher that of non-HCU ($29,779 vs. $2472 respectively), whereas all-cause mortality was 13.6 times greater (103.9 vs. 7.5 per 1000 seniors).Regional variation in costs and mortality was lower in senior HCU compared with non-HCU. We identified greater variability in accessing the healthcare system, but, once the patient entered the system, variation in costs was low. The traditional drivers of costs and mortality that we adjusted for played little role in driving the observed variation in HCUs’ outcomes. We identified LHINs that had high mortality rates despite elevated healthcare expenditures and those that achieved lower mortality at lower costs. Some LHINs achieved low mortality at excessively high costs.ConclusionsRisk-adjusted allocation of healthcare resources to seniors in Ontario is overall similar across health districts, more so for HCU than non-HCU. Identified important variation in the cost-mortality relationship across LHINs needs to be further explored.
Highlights
Senior high cost health care users (HCU) are a priority for many governments
This cohort was defined as consisting of seniors with annual total healthcare expenditures within the top 5% threshold of all Ontarians in the 2013 Ontario government fiscal year (FY2013), and not in the top 5% in the 2012 fiscal year (FY2012).The threshold of 5% to define HCU is aligned with previous Canadian studies of this population [3, 7, 37, 38].The incident HCU cohort was matched to a cohort of non-HCU using a 1:3 matching ratio, without replacement based on age at cohort entry (+/− 1 month), sex and residence
HCU were dispensed a higher number of prescription drugs, had more physicians involved in their circle of care, and were seen by a geriatrician more often
Summary
Senior high cost health care users (HCU) are a priority for many governments. Little research has addressed regional variation of HCU incidence and outcomes, especially among incident HCU. High-cost health care users (HCU), a minority of individuals who consume a large proportion of health care resources, are a diverse group [1] Due to their high burden on the healthcare system, a better understanding of various segments of the HCU population is needed to develop evidence-informed health care policy [1, 2]. In Canada, marked regional variation has been identified in key healthcare services such as hospitalization [10], surgical procedures [11, 12], and use of prescription drugs [13, 14] In contrast to this evidence of disparities in individual healthcare services, there is little information on variation in healthcare spending in the Canadian provincial context. Except for the total healthcare spending, the BC study did not provide information on variation among individual cost components such as hospitalization and physician costs which limits our understanding of the processes of care that contribute to higher or lower variation [21]
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