Characteristics of High-Need, High-Cost Patients : A "Best-Fit" Framework Synthesis.

Background: Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers.

Purpose: To identify characteristics and criteria to distinguish HNHC patients.

Data Sources: Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022.

Study Selection: English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost.

Data Extraction: Independent, dual-review extraction and quality assessment.

Data Synthesis: The review included 64 studies comprising multivariate exposure studies ( = 47), cluster analyses ( = 11), and qualitative studies ( = 6). A National Academy of Medicine (NAM) taxonomy was an initial "best-fit" framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC.

Limitation: Little evidence distinguished potentially preventable or modifiable health care use from overall use.

Conclusion: A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services.

Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179).