Super-utilization interventions - failing or evolving in complex systems? A scoping literature review

Introduction: Super-utilization (frequent acute hospital care use or frequent emergency department (ED) utilization and readmissions) describes high rates of emergency department visits and hospital admissions by some individuals. Reducing healthcare costs per capita has focused on reducing Super-utilization using system transformation and care management approaches. The empirical literature has not shown significant improvements due to these interventions over the past 12 years. The complex dynamics of human systems driving Super-utilization lack prominence.

Aims: The review aims to uncover essential frameworks and articles to investigate the mindset of super-utilization and its evolution and to illuminate current understandings and prevailing themes.

Methods: Utilizing primary articles, search terms were refined iteratively for searches on Super-utilization, Super-utilizer, and Care Management themes. Articles were intentionally chosen to illustrate primary themes. The review included the most recent and relevant articles to provide a narrative of the diverse set of taxonomies related to Super-utilization.

Findings: Utilization outcome measures were common to all four searches. Care Management was the second common theme. Needs were the lowest frequency in Super-utilization (8%) compared with Superutilizers (20%) and Care Management (24-25%) searches. Systematic reviews and key studies demonstrated limited success in care management, including system transformation from health into social care. Centralised policies such as the Triple Aim have inherent polarities. Health services must contain costs and meet the felt needs of under-resourced personal journeys and underserved communities.

Conclusion: Super-utilization is an expanding concern within academic literature. Efforts to reduce frequent and multi-dimensional acute care presentations using current care models appear ineffective. The predominant focus on utilization and costs wedded to a care management model, has diverted attention from taking both a more needs-centred and a broader complex systems perspective on Super-utilization. Distributive justice asks whether social funding should be increased in preference to expanding current health spending.