ABSTRACT

Objectives: To characterize patient-reported well being and assess the psychometric efficiency of health-related high quality of life (HRQOL) in high-cost, high-need (HCHN) populations.

Study Design: Retrospective longitudinal examine analyzing well being care utilization, expenditures, and patient-reported well being evaluating a baseline (yr 1) and follow-up yr (yr 2).

Methods: The pattern consists of adults (n = 46,934) collaborating within the Medical Expenditure Panel Survey between 2011 and 2016. We estimated HRQOL for every pattern member utilizing the bodily and psychological well being scales from the Medical Outcomes Study Short Form 12. We in contrast HRQOL stratified by HCHN, outlined as sufferers whose baseline (yr 1) demographics, utilization, and scientific traits predicted high decile well being spending in yr 2. Analyses assessed the validity, reliability, and responsiveness of bodily and, individually, psychological well being scales.

Results: Among HCHN adults, the bodily well being scale exhibited strong measure validity, reliability, and responsiveness throughout all age teams; the psychological well being scale didn’t. Mean bodily well being was 1.25 SDs decrease in HCHN vs different sufferers (37.9 vs 51.0 on a 0-100 scale growing in self-perceived well being; pooled SD, 10.5). Regressions indicated {that a} 0.5-SD enhance in yr 1 bodily well being amongst HCHN adults predicted a 5-percentage-point (10%) lower within the likelihood of high decile well being spending in yr 2. In distinction to well being care spending, HRQOL didn’t exhibit reversion to the imply in HCHN sufferers.

Conclusions: Patient-reported well being outcomes stay poor in HCHN populations, even after well being care utilization recedes. HRQOL is a promising final result measure for HCHN-focused fee and supply interventions.

Am J Manag Care. 2023;29(7):In Press

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Takeaway Points

We present the primary psychometric evaluation of health-related high quality of life (HRQOL) amongst high-cost, high-need (HCHN) populations. This is vital for the next causes:

• Health care utilization and expenditures revert to the imply amongst HCHN populations.
• In stark distinction, patient-reported well being outcomes don’t; poor self-rated well being persists.
• Outcome measurement for HCHN-focused interventions should transfer past narrowly centered well being care utilization and expenditures to appropriately seize affected person struggling.
• We display that HRQOL is a psychometrically sound candidate for patient-reported final result measurement in HCHN-focused interventions.

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When states purpose to enhance care amongst Medicaid “superutilizers,”¹ federal different fee fashions incorporate refinements concentrating on high-cost, high-need (HCHN) populations,² and novel HCHN-focused high quality enchancment interventions are developed and examined by payers and well being programs, the dominant measures of success are utilization and spending.³ Typical interventions increase customary care with enhanced care coordination and affected person engagement methods reminiscent of residence visits, entry to 24/7 nurse name strains, elevated monitoring throughout transitions throughout care settings, and by connecting sufferers with social service suppliers.^4,5 Associated affect evaluations rely closely on administrative knowledge on useful resource utilization as key final result measures.^6,7 Although elevated use of pricy well being care companies may be an unbiased marker of vulnerability in its personal proper,⁸ overreliance on utilization measures has a number of shortcomings. Common algorithms to establish HCHN sufferers for focused intervention in well being programs, as a result of reliance on well being care utilization, can reinforce racial and different biases in entry to care (eg, intercourse, geographic, financial).⁹ Furthermore, utilization measures ignore outcomes which can be most valued by sufferers.

Patient-reported final result measures provide one avenue to enhance measurement of affected person progress. These knowledge seize affected person perceptions of their underlying well being standing and functioning—elementary dimensions to total high quality of life.¹⁰ Although patient-reported final result measures have ample proof of validity, reliability, and responsiveness in broad populations,^11,12 one could fear that for HCHN sufferers, such measures will endure from flooring results (ie, everyone seems to be unwell) or could not add worth over extra broadly out there utilization measures reminiscent of emergency division (ED) visits and hospitalizations. In this text, we ask whether or not a well-validated patient-reported final result measure assemble—health-related high quality of life (HRQOL)—identifies significant variations inside HCHN sufferers and whether or not and the way HRQOL modifications over time for this inhabitants. In addition to characterizing ranges and developments in HRQOL amongst HCHN sufferers, we check the scientific appropriateness of adopting HRQOL for inhabitants and efficiency monitoring. Our overarching objective is to know whether or not the present utilization-centric concentrate on HCHN populations and initiatives that serve them may gain advantage from measuring and prioritizing patient-centric well being final result enchancment.

METHODS

Data

We used the Medical Expenditure Panel Survey (MEPS) to characterize patterns of self-reported bodily and psychological well being and to evaluate the efficiency of those measures amongst HCHN populations. The analytic pattern of 46,934 adults 18 years and older drew from 5 two-year panels of the Agency for Healthcare Research and Quality’s nationally consultant MEPS spanning 2011 to 2016. The MEPS consists of patient-reported well being measures and well being care utilization and value outcomes amongst HCHN populations.¹³ The eAppendix Figure (eAppendices available at ajmc.com) depicts the timing of information seize by spherical for every examine measure described under.

Measures

HRQOL. HRQOL displays a person’s well being and its affect on a number of domains, together with bodily, psychological, emotional, and social functioning. A big literature validates the usage of HRQOL throughout scientific and community-based settings (examples embody Moriarty et al,¹⁴ Slabaugh et al,¹⁵ Zack,¹⁶ and Vilagut et al¹⁷).¹⁸ The widespread, standardized assortment and dissemination of HRQOL knowledge allow stakeholders to benchmark well being throughout place, time, and inhabitants subgroups; this makes HRQOL a sexy measure in new settings and for brand new subgroups—reminiscent of HCHN populations—for whom no such benchmarks at the moment exist. In distinction to condition-specific patient-reported final result measures, the worldwide nature of HRQOL is probably invaluable within the context of HCHN populations, that are characterised by a excessive prevalence of multimorbidity.¹⁹ To date, HRQOL validation has not focused HCHN populations.

The MEPS captures HRQOL utilizing the Medical Outcomes Study Short Form 12 (SF-12, model 2), developed within the Nineteen Eighties.²⁰ The SF-12 is constructed of two subscales, the Physical Health Composite Scale and Mental Health Composite Scale, known as “physical health” and “mental health” all through this text. The bodily and psychological well being composites use 12 equivalent gadgets (eAppendix Table 1); nevertheless, the (proprietary) merchandise weighting differs throughout them. Both composites are scaled to have a imply (SD) of fifty (10). Higher scores characterize higher well being.²⁰ Numerous MEPS-specific research have demonstrated the reliability and validity of each scales in cohorts outlined by the presence of both particular signs (eg, a examine of people with noncancer ache),²¹ or particular situations (eg, a examine of people with diabetes).²²

Other measures. We used the MEPS abstract measures capturing annual whole ED visits and in a single day inpatient stays, in addition to whole annual well being care expenditures. We tailored the tactic developed by Fleishman and Cohen²³ to establish the next continual situations: anxiousness, arthritis, bronchial asthma, most cancers, cerebrovascular illness, diabetes, emphysema, coronary heart illness, hypertension, excessive ldl cholesterol, temper dysfunction (together with melancholy), schizophrenia, and substance use dysfunction. eAppendix A supplies additional element.

We used the next measures as covariates in adjusted analyses, or to stratify analyses as applicable: age, intercourse, schooling, marital standing, revenue, and geographic area. MEPS contributors who have been pregnant have been excluded from the analytic pattern. In retaining with associated work,²¹ we included 2 widespread measures of self-reported well being standing which can be conceptually associated to HRQOL for validity testing: self-reported basic well being and self-reported psychological well being.

Empirical Approach

HCHN cohort definition. Following associated literature^23,24 and customary implementation observe,²⁵ we recognized HCHN pattern members utilizing predicted spending. We estimated the likelihood that a person is within the high expenditure decile subsequent yr (yr 2) as a operate of baseline (yr 1) measures of well being care utilization, expenditures, continual situations, and sociodemographics. We then chosen pattern members within the high decile of predicted yr 2 spending for our analytic pattern. eAppendix B consists of methodological particulars and regression outcomes.

Psychometric evaluation. Following the CDC,²⁶ the scientific literature (eg, Aaronson et al²⁷), the National Quality Forum,²⁸ and CMS,²⁹ we designed empirical exams assessing the validity, reliability, and responsiveness of HRQOL amongst our HCHN cohort.

Validity. To assess validity, we requested the next questions:

1. Does HRQOL correlate with different well-established, conceptually associated patient-reported final result measures in a cross-section (assemble validity)?
2. Is there considerable regression to the imply in HRQOL, biasing longitudinal comparisons (inside validity)?
3. Does HRQOL predict future outcomes of curiosity (predictive validity)?

We assessed assemble validity by estimating the cross-sectional affiliation between yr 1 values of psychological well being and bodily well being and the yr 1 variety of continual situations amongst HCHN pattern members, adjusting for sociodemographic elements (age, intercourse, and schooling). This “sum-of-conditions” strategy proxies the Charlson and Elixhauser indices, each validated comorbidity measures.³⁰ A adverse correlation or gradient between the variety of continual situations and HRQOL means that the latter demonstrates applicable assemble validity.

We estimated 1-year modifications (yr 2 minus yr 1) to evaluate the extent of regression to the imply in HRQOL amongst HCHN pattern members, a key inside validity verify. Spending- and utilization-based measures exhibit appreciable regression to the imply amongst HCHN sufferers.^5,31 To our information, nevertheless, no analogous proof exams whether or not the sample holds true for HCHN sufferers’ HRQOL. We in contrast the sample of psychological well being and bodily well being scales over time with that of different patient-reported outcomes—particularly, single-item self-reported basic and psychological well being—in addition to with these exhibited by conventional resource-based measures capturing elevated total expenditures and ED and inpatient use. Additionally, we in contrast the longitudinal HRQOL patterns of HCHN vs non-HCHN sufferers, formalized utilizing a difference-in-differences framework (related mannequin specification detailed in eAppendix C).

We estimated the capability of HRQOL to foretell future expenditures and utilization—indicators of HCHN persistence—as our key predictive validity check. To our information, no analysis exists indicating whether or not HRQOL independently predicts expenditures and utilization amongst HCHN populations. Using logit fashions, we estimated whether or not a person is within the high decile of medical expenditures in yr 2 as a operate of yr 1 measures of HRQOL scales of psychological and bodily well being amongst HCHN sufferers, controlling for yr 1 sociodemographic traits (leads to eAppendix Table 2). A constructive coefficient exhibiting significant magnitude and statistical significance is indicative of predictive validity. We estimated comparable fashions for yr 2 high decile ED visits and for any inpatient hospitalization in yr 2.

Reliability

Our main reliability concern was making certain HRQOL’s robustness throughout the number of HCHN definitions employed by completely different stakeholders. The 2 essential approaches to HCHN cohort definition are potential project—the strategy we used—which employs predictive modeling to establish these sufferers who’re at elevated likelihood of HCHN standing within the upcoming yr, and rules-based project, using cutoffs primarily based on the prior yr’s utilization and/or expenditures. The key associated reliability concern for HRQOL is whether or not its values are comparable throughout the varied HCHN cohort classifications and whether or not these values differ meaningfully relative to non-HCHN sufferers. We examined this by computing psychological and bodily well being scales for our most popular cohort and 4 further (rules-based) cohorts: high decile expenditures in yr 1; 2 or extra ED visits in yr 1; any hospitalization in yr 1; and three or extra continual situations in yr 1. We computed unadjusted means total and stratified by age, evaluating values inside every of the 5 HCHN definitions and throughout the HCHN vs never-HCHN cohorts.

Responsiveness

We assessed the potential responsiveness of HRQOL by exploring whether or not HRQOL measures exhibit significant unfold throughout the HCHN cohort. Spread can point out unwarranted variation amenable to well being care intervention.³² We have been significantly aware of the potential presence of flooring results amongst HCHN sufferers, given their excessive ranges of morbidity. The extent of underlying unfold additionally has implications for statistical energy necessities, a key implementation consideration. We offered easy exploratory energy calculations assuming impact sizes of 0.3, 0.5, and 1 SD. Values of 0.3 and 0.5 SD mirror “minimally important differences” in HRQOL documented in scientific research of therapies concentrating on susceptible populations (eg, Jayadevappa et al,³³ Norman et al³⁴) and in population-based research (eg, Alghnam et al,³⁵ Baragaba et al,³⁶ Utah Department of Health³⁷). Finally, we estimated the marginal impact of accelerating yr 1 HRQOL by 0.3 and 0.5 SDs on the likelihood of yr 2 high decile expenditure, utilizing the related predictive validity mannequin mentioned above. This mannequin, though observational, demonstrates whether or not possible enhancements in psychological and bodily well being would possibly translate into future decreases in resource-intensive utilization.

RESULTS

Table 1 shows descriptive traits for all the pattern and individually throughout HCHN and non-HCHN pattern members (subsequently known as HCHNs and non-HCHNs for brevity). The sociodemographic composition throughout the two strata have been pretty comparable, with the notable exceptions of age and intercourse. The imply ages of HCHNs and non-HCHNs have been 64.2 and 45.5 years, respectively. A better proportion of HCHNs have been girls in contrast with non-HCHNs (58.2% vs 49.5%).

Our key measures of curiosity—HRQOL measures of psychological and bodily well being—have been decrease in HCHNs than in non-HCHNs. However, the relative distinction throughout the two measures was a lot bigger for bodily than for psychological well being. The imply bodily well being rating of 37.9 amongst HCHNs was 1.25 SDs decrease than the imply of 51.0 amongst non-HCHNs (utilizing the total pattern SD). In distinction, the imply psychological well being rating for the two teams differed by solely 3.4 factors (48.6 vs 52.0 amongst HCHNs vs non-HCHNs), or a 0.35-SD distinction (once more, utilizing the total pattern SD).

Figure 1 and Figure 2 show cross-sectional proof concerning reliability and concurrent validity. The panels comprising Figure 1 plot HRQOL distributions stratified by age and numerous definitions of HCHN standing. The age stratification helped us rule out the likelihood that the HCHN vs non-HCHN variations in HRQOL are pushed solely by variations in age distribution. Computing psychological and bodily well being throughout completely different HCHN definitions served as our main reliability check, assessing the robustness of HRQOL’s use throughout various however associated HCHN cohorts. Within every age group, the never-HCHN pattern—outlined as not assembly any of the HCHN definitions—exhibited significantly larger bodily well being scores relative to all HCHN populations (all variations statistically vital). Moreover, the distributions exhibited appreciable unfold inside HCHNs, offering reassurance concerning flooring and ceiling impact considerations. The psychological well being gradient throughout HCHN and never-HCHN populations, in distinction, differed markedly throughout age strata. In youthful age strata, psychological well being was a lot decrease amongst HCHN than never-HCHN adults. For older age strata, which comprised the vast majority of HCHN adults, there was little or no gradient in psychological well being. Small pattern sizes for the youthful age strata point out a necessity for warning when decoding these completely different age patterns; notably, solely 393 of the HCHN cohort members have been youthful than 45 years (age strata pattern sizes displayed in eAppendix Table 3).

Figure 2 demonstrates the outcomes from our concurrent validity evaluation, which assessed the affiliation between yr 1 HRQOL and continual situation rely amongst HCHN adults, adjusted for age, intercourse, and schooling. The estimates indicated that each psychological and bodily well being declined pretty monotonically because the situation rely will increase, demonstrating their validity as benchmarked in opposition to growing ranges of comorbidity. Here once more we noticed that the gradient is stronger for bodily than for psychological well being. For instance, shifting from 3 continual situations (the imply amongst HCHN adults) to five or extra continual situations (22.4% of the HCHN pattern) was related to an virtually 5-point lower in bodily well being, in contrast with an roughly 3.5-point lower in psychological well being.

Table 2 incorporates longitudinal analyses. Patterns for utilization- and resource-based measures amongst HCHNs evaluating years 1 and a couple of demonstrated imply reversion patterns comparable with these of the broader associated literature.^5,31 For instance, amongst folks within the high decile of predicted yr 2 spending, 83.7% had noticed high decile spending in yr 1, however solely 47.6% remained within the high decile of noticed spending in yr 2. In stark distinction, neither the psychological nor bodily well being scores among the many HCHN cohort exhibited qualitatively significant or statistically vital year-over-year regression to the imply. The measures of patient-reported truthful or poor well being exhibited comparable stability, offering further proof that decreases in resource-intensive utilization don’t translate to comparable enhancements in patient-reported final result measures in an observational context. The differences-in-differences outcomes, evaluating year-over-year modifications throughout HCHN and non-HCHN cohorts, demonstrated that though modifications in expenditures and useful resource utilization amongst HCHN adults diverse meaningfully from these amongst non-HCHN adults, modifications in patient-reported final result measures didn’t.

Estimates from the predictive validity regressions (Table 3) indicated that among the many HCHN cohort, yr 1 bodily well being reveals strong, unbiased predictive capability throughout all yr 2 useful resource utilization measures (odds ratios in eAppendix Table 4). In distinction, yr 1 psychological well being exhibited statistically vital predictive capability just for high decile expenditure membership. Moreover, the magnitude of the affiliation between yr 1 psychological well being and yr 2 useful resource utilization measures was uniformly smaller than that of bodily well being. Table 3 shows predicted chances derived from the highest decile expenditures regression. A 0.3-SD enchancment in yr 1 bodily well being was independently related to a 3-percentage-point (6%) lower within the likelihood of yr 2 high decile expenditure membership. A 0.5-SD enchancment in yr 1 bodily well being was related to a 5-percentage-point (10%) lower, and a 1-SD enchancment in yr 1 bodily well being was related to a 9-percentage-point (19%) lower.

Power calculations indicated that for each the psychological and bodily well being scores, fewer than 20 HCHNs are required in every remedy arm to realize 80% energy for anticipated impacts of 1 SD (eAppendix Table 5). Sample sizes of roughly 65 people per group have been wanted to realize 80% energy for anticipated impacts of 0.5 SD, and roughly 145 per group have been wanted for anticipated impacts of 0.3 SD. Assuming that 10% of the generally cited main care panel measurement of 2500 sufferers qualifies as HCHN means that initiatives on the observe stage—even these utilizing within-practice remedy and management arms—could also be suitably powered for anticipated impacts of 0.5 SD or larger.³⁸ Expected impacts on the order of 0.3 SD would doubtless require cross-practice remedy and comparability arms. Populations tracked by multipractice medical teams, even modestly sized built-in well being programs, payers, and coverage makers, simply exceed the entire minimal pattern measurement necessities.

DISCUSSION

We discovered that HCHN adults skilled decrease HRQOL relative to non-HCHN adults and that this gradient was appreciably stronger for bodily well being in contrast with psychological well being. Together, our empirical exams steered that bodily well being exhibited sturdy validity, reliability, and responsiveness as a measurement software for HCHN adults, whereas psychological well being—which, not like bodily well being, improves at older ages—was weaker alongside sure dimensions of validity and responsiveness. Unlike measures of useful resource utilization, HRQOL exhibited minimal regression to the imply amongst HCHN adults. Our findings suggest that HRQOL represents an vital, distinct assemble from the utilization-based metrics at the moment used to carry suppliers or payers accountable for care of HCHN populations.

Limitations

Several limitations of the present examine should be addressed previous to the usage of HRQOL for higher-stakes HCHN measurement contexts, reminiscent of these involving significant monetary or reputational impacts. First, our findings don’t deal with the inner validity risk arising from doubtless variations in affected person case combine, which might require threat adjustment. Moreover, tracing longer-term trajectories of the interaction between HRQOL and useful resource utilization amongst HCHNs may enhance predictive validity and yield clues on efficient intervention design. Further work ought to discover trade-offs related to utilizing a shorter HRQOL instrument amongst HCHNs—for instance, a single self-rated well being merchandise—to steadiness psychometric soundness vs measurement burden, as was performed for non-HCHN populations within the seminal HRQOL improvement work.³⁹

Our estimates additionally revealed a necessity for additional exploration of the divergent psychological well being patterns throughout completely different HCHN age strata. Statistical energy limitations precluded our capability to supply the related age-stratified validity assessments. Exploring the potential for utilizing psychological well being scores as measurement instruments in interventions concentrating on youthful ages is a probably promising path for future analysis. Additionally, additional work on the interaction amongst intercourse, HCHN standing, and HRQOL is vital, as girls appear to expertise the next prevalence of HCHN and have a unique set of things that drive HRQOL relative to males.⁴⁰

CONCLUSIONS

Our work contributes to the decision for capturing the affected person voice in measuring HCHN outcomes. We display that HCHN adults skilled vital well being burdens that persist after their well being care interactions recede. As such, an overemphasis on utilization when concentrating on care supply efforts to HCHN adults excludes many who’re nonetheless struggling and ignores the total burden of sickness, which extends far past its price.

Author Affiliations: Tuck School of Business, Dartmouth College (LJL), Hanover, NH; The Dartmouth Institute, Geisel School of Medicine, Dartmouth College (MT), Hanover, NH; Harvard School of Public Health, Harvard University (EM), Boston, MA.

Source of Funding: Agency for Healthcare Research and Quality’s Comparative Health System Performance Initiative underneath grant No. 1U19HS024075.

Author Disclosures: The authors report no relationship or monetary curiosity with any entity that will pose a battle of curiosity with the subject material of this text.

Authorship Information: Concept and design (LJL, EM); acquisition of information (LJL, MT); evaluation and interpretation of information (LJL, MT); drafting of the manuscript (LJL); vital revision of the manuscript for vital mental content material (LJL, MT); statistical evaluation (LJL, MT); acquiring funding (EM); administrative, technical, or logistic help (LJL, MT); and supervision (LJL, EM).

Address Correspondence to: Lindsey Jeanne Leininger, PhD, Tuck School of Business, Dartmouth College, 100 Tuck Hall, Hanover, NH 03755. Email: lindsey.j.leininger@tuck.dartmouth.edu.

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