High-frequency hospital users: The tail that wags the readmissions dog

UMMS Affiliation

Meyers Primary Care Institute; Department of Population and Quantitative Health Sciences

Publication Date


Document Type



Health Services Administration | Health Services Research | Quality Improvement


OBJECTIVE: To describe the characteristics of high-frequency hospital users (four or more hospitalizations in a year) and the consequences of including or excluding their data from a readmission-based measure.

DATA SOURCES: 2015 and 2016 Massachusetts Medicaid data.

STUDY DESIGN: We compare demographics, morbidity burden, and social risk factors for high- and low-frequency hospital users, and membership in 17 accountable care organizations. We evaluate how excluding hospitalizations of high-frequency users from a 30-day readmission measure (with or without risk adjustment) changes its rate and variability and affects performance rankings of accountable care organizations. The outcome is readmission within 30 days; each live discharge from a hospital contributes one observation.

DATA COLLECTION/EXTRACTION METHODS: We studied 74 706 hospitalizations of 42 794 MassHealth members, 18-64 years old, managed-care-eligible, and ever hospitalized in 2016.

PRINCIPAL FINDINGS: Among adult managed-care-eligible MassHealth members with at least one acute hospitalization, 8.7% were high-frequency hospital users; they contributed 30.2% of hospitalizations and 69.4% of readmissions. High-frequency users were more often male (77.1% vs. 50.0%; P < 0.001) and sicker (mean medical morbidity score was 3.3 vs. 1.9; P < 0.001) than others. They also had significant social risks: 33.1% with housing problems, 44.1% disabled, 83.2% with serious mental illness, and 77.1% with substance abuse disorder (vs. 22.0%, 27.3%, 60.2%, and 50.0%, respectively, for other hospital users [all P values < 0.001]). Fully 50.7% of hospitalizations for high-frequency users led to 30-day readmissions (vs. 9.7%), contributing 72.0% of the variance in 30-day readmission, and substantially affecting judgments about the relative performance of accountable care organizations.

CONCLUSIONS: A small group of high-frequency hospital users have a disproportionate effect on 30-day readmission rates. This negatively affects some Medicaid ACOs, and more broadly is likely to adversely affect safety net hospitals. How these metrics are used should be reconsidered in this context.


Medicaid, accountable care organizations, health care, hospitalization, patient readmission, quality indicators

DOI of Published Version



Fouayzi H, Ash AS. High-frequency hospital users: The tail that wags the readmissions dog. Health Serv Res. 2021 Jun 1. doi: 10.1111/1475-6773.13677. Epub ahead of print. PMID: 34075581. Link to article on publisher's site

Journal/Book/Conference Title

Health services research

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Link to Article in PubMed