Effects of Intensive Outpatient Integrative Medicine on Health Care Utilization on High Utilizer Patients at a Major Academic Health System

Introduction

The United States has the greatest per-capita spending on health care among 11 high-income nations while having the highest chronic-disease burden and lowest life expectancy. ¹ Much of this cost comes from a subset of patients with disproportionately high rates of hospitalizations and emergency department (ED) visits. Public and private institutions are increasingly developing novel programs to improve outcomes and control costs for this population. ^{2 –4}

The complex care-management program at CareMore Health System, a California-based Medicare Advantage and Medicaid provider, invested heavily in coordinated services for chronically ill patients at high risk of developing complications. ⁵ According to a randomized quality-improvement trial comparing enrollment in this program with routine care, this investment paradoxically saved costs through fewer inpatient days, patient admissions, and specialist visits. ⁶ This provider-led model was coined the “Extensivist” approach for the comprehensive (extensive) continuity of care provided to these high-utilizer patients.

This and other successes have inspired many institutions to create similar programs; however, integrative medicine (IM) is not commonly included among them. Yet the integrative approach to health care—which focuses on prevention, personalized care, multidisciplinary collaboration, and holistic health—would be well suited to address the dual problems of escalating costs and poor health outcomes. The authors hypothesized that an IM approach to caring for these patients would improve outcomes when integrated into the growing number of complex care-management programs designed to care for this population.

Existing economic studies support the cost-savings impact of IM modalities on a wide variety of conditions such as low back pain, headaches, chronic pain, pain in hospitalized patients, and cancer-related symptoms in inpatient oncology patients. ^{7 –11,19} These studies targeted specific diagnoses, so there is little published data on the cost-effectiveness of IM in managing a heterogenous population of high-complexity and high-utilizer patients. This article describes one such pilot model of treating this population with IM modalities and measures its effect on acute care utilization, which strongly correlates with costs.

The University of California, Los Angeles (UCLA) Extensivist Program is a complex primary-care-based complex care program designed to provide coordinated services to high-utilizing UCLA patients, defined as two or more hospitalizations or four or more ED visits in the prior 12 months. Launched in July 2017, the program provides comprehensive care management from a multidisciplinary team comprising an internal medicine trained Extensivist physician, nurse, social worker, pharmacist, and care coordinator. Patients cared for by the Extensivist Program are the most medically and socially complex patients in UCLA's Health System, often presenting with complex chronic conditions that benefit from a biopsychosocial interdisciplinary approach.

The UCLA Center for East-West Medicine (CEWM) was established in 1993 as an IM specialty service, which combines principles of Traditional Chinese Medicine (TCM) with modern IM principles to treat a variety of different conditions and improve health and well-being. It has grown to include four clinics around greater Los Angeles, seeing roughly 30,000 patients per visits per year, and employing 9 full-time faculty, 8 licensed acupuncturists, and additional support staff. CEWM was brought into the Extensivist Program in July of 2018 to incorporate IM consultation, treatments, and longitudinal care into managing this high-risk population.

A pilot cohort of 29 Extensivist patients received East-West care between June 2018 and March 2019. This study evaluates observed health-utilization outcomes for these patients, including hospitalization rates, hospitalization days, and emergency room visits.

Materials and Methods

Twenty-nine patients with high health care utilization were referred to the UCLA East-West Extensivist program as individuals who may benefit from IM care as a part of their Extensivist management plan. These patients were evaluated by an East-West physician embedded into the multidisciplinary team and provided with comprehensive integrative assessments and longitudinal East-West care for a 6-month trial period.

At each visit, they were treated with a combination of acupuncture, trigger point injections, dietary counseling, myofascial self-care, stress management, psychosocial support, and health coaching. Myofascial self-care includes diaphragmatic breathing, stretching, self-massage, and acupressure. This was done in addition to the intensive medical management and care coordination they received as an enrollee in the Extensivist program.

The electronic medical record was used to identify the total number of hospitalizations, hospitalization days, and ED visits for the 12 months preceding their initial visit, as well as for 6 months postenrollment. This study was approved by the UCLA Institutional Review Board no. IRB 19-000208. Each patient's trial period began on the date of their first East-West appointment.

One-tailed paired t-tests were used for statistical analyses. Further subgroup analysis was completed comparing those with 6+ East-West visits to those with 5 or fewer. To facilitate interpretation, the 6-month follow-up data were normalized to 1 year.

Results

Table 1 lists the baseline characteristics of the study sample set, including reason for referral. Three patients were removed from the analysis as the authors could not verify their baseline hospitalization data. One patient was removed as an extreme outlier outside of the 1.5 times interquartile range rule. The average age at initial enrollment of the 25 patients analyzed was 52.1 years. Eight patients were male and 17 female. The majority were referred for pain-related complaints, and many had mental-health concerns as a main complaint or major comorbidity.

Table 2 lists the results of this trial on hospitalizations, hospitalization days, and ED visits. In the year before enrollment, patients averaged 3.68 hospitalizations (standard deviation [SD] 1.89), 26.56 hospitalization days (SD 18.3), and 3.96 ED visits (SD 4.18). Patients attended an average of 7.96 (range 1–50, median 5) CEWM clinic appointments for the 6-month pilot period. During the 6-month intervention of CEWM and Extensivist involvement, patients averaged 1.12 fewer hospitalizations per year (31% decrease, p = 0.021), 10.08 fewer hospitalization days per year (38% decrease, p = 0.038), and 0.84 fewer ED visits per year (21% decrease, p = 0.189) compared with the preceding year.

Eleven patients had six or more appointments, and 14 patients had five or fewer. Those who received 6+ CEWM appointments had 14.45 fewer hospitalization days per year (55% decrease, p = 0.035) compared with 6.64 fewer hospitalization days per year (p = 0.212) for those with 5 or fewer CEWM appointments. There was no statistically significant difference in subgroup analysis for number of hospitalizations or ED visits.

Discussion

Enrollment into the CEWM intervention in the Extensivist program significantly decreased the number of hospitalizations and hospitalization days for the initial patient cohort, with a still-greater decrease in hospitalization days for those with a higher number of East-West visits (six or greater). A full cost-effectiveness study is outside of the scope of this brief report, but for context the average costs paid by health plans at UCLA is $2,500 per ED visit, $9,000 per hospital day, and $56,000 per hospitalization (unpublished data). Accordingly, this study suggests that IM care should be considered as a part of complex care-management programs designed to reduce costs and acute care utilization among high-utilizer patients.

These observed effects may be due to low-cost outpatient therapies utilized by CEWM that partially take the place of high-technology and more invasive interventions typically found in the acute care setting. In treating the whole person, CEWM care may also increase health-promoting behaviors such as healthy lifestyle change, improved stress management, and increased patient engagement, contributing to global improvements in health that decrease acute care needs. The trust and relationship that develops between CEWM providers and patients may also lead to patients seeking out CEWM solutions early on in the course of their symptoms and potentially preventing exacerbations that require more invasive and costly care.

There are a number of limitations to this study. The sample size is small, and patients were not randomly chosen; instead they were referred for enrollment due to perceived high likelihood of response. These represent potential biases commonly seen among pilot programs and require further study.

The comparison group is another area of potential bias. The study team used each patients' pre-enrollment data as the comparison group rather than case-matching, given the complexity of medical and psychosocial comorbidities in the study population. These “non-codable” variables made case-matching unreliable. A subgroup analysis was performed to help distinguish this bias from true signal. That treatment visits and health care utilization were inversely correlated argues in favor of treatment-related effect and against regression to the mean. These limitations warrant additional studies, ideally with a greater number of patients, which are prospectively randomized to the East-West intervention.

Other issues to consider include whether these findings are broadly generalizable. The UCLA Extensivist program is unique and was rapidly expanding during the study period. And while CEWM shares many similarities to other IM programs as defined by the American Board of Integrative Medicine, the basis of practice is rooted in the principles of TCM, and all practitioners are trained in providing acupuncture as part of their treatment. While the authors believe that much of the value observed will also be seen with other IM subdisciplines, further investigation should be done before implementation at other institutions. In addition, CEWM benefits from being well-established and fully integrated into the existing care infrastructure, with wide acceptance and referral base among UCLA physicians. This may be difficult to replicate at other institutions lacking a robust existing IM program.

Finally, the study was unable to differentiate between the effects of the Extensivist program standing alone or the effects of IM management. This said, it may be misguided to artificially separate the two. Each component of the Extensivist program, from care coordinator to social worker to the Extensivist primary care physician and IM physician, works synergistically to improve patient care. Future studies comparing Extensivist versus Extensivist+IM care are warranted. When individual services work in a unified coordinated program, the sum of the whole is greater than its parts. Based on the results of these findings, IM should be considered a component of future programs designed to bring coordinated care for high utilizer patients.

Conclusion

For high-risk high-utilizer patients, adding East-West medicine services to the complex care management program correlates with reductions in hospitalizations and hospitalization days. This pilot program supports incorporating IM into complex care-management programs.