Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers

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Background: Super-utilizers with 4 or more admissions per year frequently receive low-quality care and disproportionately contribute to healthcare costs. Inpatient care fragmentation (admission to multiple different hospitals) in this population has not been well described. Objective: To determine the prevalence of super-utilizers who receive fragmented care across different hospitals and to describe associated risks, costs, and health outcomes. Research design: We analyzed inpatient data from the Health Care Utilization Project’s State Inpatient and Emergency Department database from 6 states from 2013. After identifying hospital super-utilizers, we stratified by the number of different hospitals visited in a 1-year period. We determined how patient demographics, costs, and outcomes varied by degree of fragmentation. We then examined how fragmentation would influence a hospital’s ability to identify super-utilizers. Subjects: Adult patients with 4 or more inpatient stays in 1 year. Measures: Patient demographics, cost, 1-year hospital reported mortality, and probability that a single hospital could correctly identify a patient as a super-utilizer. Results: Of the 167,515 hospital super-utilizers, 97,404 (58.1%) visited more than 1 hospital in a 1-year period. Fragmentation was more likely among younger, non-white, low-income, under-insured patients, in population-dense areas. Patients with fragmentation were more likely to be admitted for chronic disease management, psychiatric illness, and substance abuse. Inpatient fragmentation was associated with higher yearly costs and lower likelihood of being identified as a super-utilizer. Conclusions: Inpatient care fragmentation is common among super-utilizers, disproportionately affects vulnerable populations. It is associated with high yearly costs and a decreased probability of correctly identifying super-utilizers.

Original languageEnglish (US)
Article number338
JournalBMC Health Services Research
Issue number1
StatePublished - Dec 2021

Bibliographical note

Funding Information:
We would additionally like to thank Genevieve Melton-Meaux, Anne Joseph for their thoughtful advice in conduct and translation of this project and Ann Marie Webber-Main for constructive criticism of an early draft of this manuscript.

Funding Information:
This project was supported by grant number R01HS026732 from the Agency for Healthcare Research and Quality. Dr. Rogers was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (NIH) under Award Number K23DK118207. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the NIH.

Publisher Copyright:
© 2021, The Author(s).


  • Fragmentation
  • Hospital super-utilizer
  • Socioeconomic health disparities


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