International Comparisons of High-Need, High-Cost Patient Care Trajectories: Upcoming Webinar and Health Services Research Special Issue

Ciara Duggan is a Research Assistant in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health

Register here for a November 11th webinar on International Comparisons of High-Need Patient Care Trajectories.

Across health systems, high-need, high-cost (HNHC) patients tend to constitute a relatively small segment of the population while accounting for a disproportionately large share of healthcare expenditures. Understanding how international differences in care delivery correspond to differences in the cost and quality of care received by HNHC patients is therefore an important step toward improving high-need patients’ lives and optimizing health system performance. Previously, however, little was known about how patterns of healthcare spending, utilization, and outcomes vary across health systems for this complex and costly group of patients.

Founded in 2018 and led by researchers at the Harvard School of Public Health and the London School of Economics, the International Collaborative on Costs, Outcomes and Needs in Care (ICCONIC) sought to fill this gap by comparing patterns of care delivery among HNHC patients across 11 OECD countries: The United States, Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, and Switzerland. The results of this research will be featured in an upcoming special issue of Health Services Research (expected to be released November 12th, 2021).


Using regional and national administrative data, ICCONIC employed a case-vignette methodology to compare two specific HNHC personas across countries and care settings: (1) a frail older adult recovering from a hip fracture, and (2) an older person with complex multimorbidity (i.e., hospitalized with congestive heart failure and a comorbid diagnosis of diabetes). To best capture patterns of spending, utilization, and outcomes among these patients, ICCONIC examined the entire patient care trajectory, encompassing seven domains of care—hospital care, primary care, outpatient specialty care, outpatient drugs, post-acute rehabilitative care, home health care, and long-term care.

Key Findings

Results from the ICCONIC project indicate that average utilization and spending vary substantially across the 11 countries for an older person with complex multimorbidity and a frail older person who sustains a hip fracture, with the US spending far more than comparison countries for both personas. High levels of spending in the US are driven by both (a) higher prices per unit of care across most settings and (b) above-average utilization of post-acute rehab and outpatient specialty care.

The ICCONIC project also revealed substantial variation in mortality rates for both personas across countries at different time intervals, with the exception of England, which consistently reports the highest mortality rates across all time intervals. While the US reports relatively low 30-day mortality rates, it reports the second highest mortality rates at 365-days post-hospitalization. Higher spending thus does not correspond to better long-term outcomes for HNHC patients in the US, suggesting inefficiencies in how the US cares for these patients (such as possible under-utilization of long-term care services and over-utilization of post-acute and specialty care).

Additional analyses of frail patients who sustained a hip fracture also unveiled notable cross-country differences in long-term care trajectories and end-of-life care.

Finally, using Gini coefficients to compare within-country variation in the care consumption of complex multimorbid patients, ICCONIC found significant within-country differences in care consumption patterns, as well as common differences by sex across countries, with women using less specialty care and more rehabilitative and home nursing care than men do on average.

Looking Forward: Implications for Research and Policy

The results of the ICCONIC project have important implications for those in the research community interested in conducting international healthcare comparisons as well as national policymakers interested in understanding how their country performs relative to peers when it comes to caring for high-need, high-cost patients.

These implications will be discussed in greater detail at an upcoming webinar on “International Comparisons of High-Need Patient Care Trajectories,” to take place November 11th, 2021 from 12-1pm EST. The webinar will be moderated by Dr. John E. McDonough of the Harvard School of Public Health and will feature presentations by Dr. Jose F. Figueroa and Dr. Irene Papanicolas, Co-Directors of ICCONIC. Dr. David Blumenthal, President of the Commonwealth Fund, and Dr. Jennifer Dixon, Chief Executive of the Health Foundation will join to discuss the results and their policy implications for the US and the UK. Register here to join the webinar.

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