Superutilization - a Position Statement from the CASFM Complexity Working Group

Context: Superutilization describes patterns of frequent use of acute hospital services for unmet nonemergency care needs by people with sub-acute or chronic conditions and reflects unmet health needs requiring longitudinal primary and social care. Superutilization creates unnecessary pressure on the acute care sector with sub-optimal service use.

Background: People experiencing socioeconomic disadvantage have greater disease burdens, less access to preventive primary care and fewer resources to self-manage their health. Aging populations experience more health conditions and associated disabilities. Multiple intersecting health dynamics (i.e., high chronicity and low access to prevention) and social determinants (e.g., poverty) drive Superutilization.

Objective: To develop a Consensus Statement on Improving Superutlization using Complex Adaptive Systems Frames based on a narrative review.

Findings: Published systematic reviews of clinical trials describe limited successes of case management diversionary activities on cohort trajectories at the time of Superutilization. Programs for heart failure and other specific conditions only improve condition focussed acute care. Enhanced primary care and other generic team-based interventions on individual patient journeys appear to have limited impact on longitudinal acute care use due to the systemic drivers of Superutilization in complex and changing contexts. Moreover, evaluation trials in these environments face unique statistical challenges, including matching complex risk in control selection with regression to the mean and nonnormal Pareto statical distributions. Traditional trials provide limited information on local context dynamics and sustainability beyond time-limited interventions. Complexity-informed modelling describes continuous and higher Superutilization rates driven by greater health and social disparities, but a feature of all systems..

Discussion: Moving beyond team-based trials would require systemic approaches, including the provision of cradle-to-grave primary care, improving population health, and community social resources. Conclusion The proposed Superutilization framework would involve local agents, including service users, providers, and the community collaborating in intersectoral tracking and adapting care across health and social systems. Participatory leadership, monitoring performance and improvement will be evaluated using longitudinal modelling and evaluation approaches.