Research Article: A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions

Date Published: June 19, 2019

Publisher: Public Library of Science

Author(s): Brent M. Egan, Susan E. Sutherland, Peter L. Tilkemeier, Robert A. Davis, Valinda Rutledge, Angelo Sinopoli, Kees Ahaus.


Approximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress.

To determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, ‘other’). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R2 = 0.36) in claims paid/beneficiary.

Identifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.

Partial Text

In 2014, 42% of adults in the U.S. had multiple chronic conditions (CCs), defined as two or more comorbidities lasting at least a year, requiring recurrent medical attention and care, or limiting activities of daily living [1,2]. The prevalence of multiple CCs increases sharply with age, rising from 18% at ages 18–44 years to 81% in those 65 years and older [1]. Healthcare utilization and costs also rise rapidly as a function of the number of CCs. In 2014, hospital admissions increased from 6% of those with 1 or 2 CCs to 24% in those with five or more CCs, the number of prescriptions filled from 9 to 51 and the number of medical outpatient visits from 6 to 20. Twenty-eight percent of U.S. adults with ≥3 CCs accounted for two-thirds of healthcare costs, whereas the 72% with 0–2 CCs accounted for one-third [1].

In this Medicare beneficiary cohort, 85% were ≥65 years, 88% White and 58% female with an average of 6.3 CCs and 4 healthcare visits annually (Table 1). Beneficiaries who were < 65 years of age were more likely to be Black and Male, had higher BMI values, and were much more likely to be current smokers. Both age groups had the same number of CCs. Blacks were younger than Whites, and they had a higher BMI and a slightly greater number of CCs. Women were approximately two years older than men, and they were less likely to report smoking. Multiple CCs are common in the U.S. population, especially in older groups including Medicare beneficiaries [1,2]. Among 44,645 Medicare beneficiaries who were continuously enrolled in one accountable care organization during 2015, 95% had two or more CCs (Table 2). A prior report indicated that 68% of Medicare beneficiaries had two or more CCs from diagnoses on paid claims [30]. The prevalence of CCs in this group of Medicaid beneficiaries based on EHRS information is greater than in a prior report, which used CMS paid data. Our finding is consistent with studies that documented a higher prevalence of chronic conditions from EHRS than claims data [31]. The difference may also reflect the greater burden of CCs in the Southeast than other U.S. regions [32]. The prevalence of chronic conditions reflected diagnoses contained in the EHRS, since reliable data were available and evidence indicates that estimates of chronic condition prevalence are more accurate when several years of data are used rather than a single year [14].   Source: