This week’s blog is brought to you by: Professor Sir Muir Gray, Founding Director
Full reference and title from the journal:
Health Care Hotspotting — A Randomized, Controlled Trial, Finkelstein, A. et al (2020), N Engl J Med 2020;382:152-62.
Authors conclusion
Background
There is widespread interest in programs aiming to reduce spending and improve health care quality among “superutilizers,” patients with very high use of health care services. The “hotspotting” program created by the Camden Coalition of Healthcare Providers (hereafter, the Coalition) has received national attention as a promising superutilizer intervention and has been expanded to cities around the country. In the months after hospital discharge, a team of nurses, social workers, and community health workers visits enrolled patients to coordinate outpatient care and link them with social services.
Methods
We randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition’s care-transition program or to usual care. The primary outcome was hospital readmission within 180 days after discharge.
Results
The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group.
Conclusion
In this randomized, controlled trial involving patients with very high use of health care services, readmission rates were not lower among patients randomly assigned to the Coalition’s program than among those who received usual care.
3VH commentary on the Implications for Value Improvement
Population healthcare is now recognised as being of vital importance to complement and supplement the traditional focus of leadership and management on either the necessary bureaucracies, such as health boards or integrated care systems, and the different levels of care, generalist, specialist, and super specialist. Population healthcare is healthcare primarily focused on a segment of the population defined by need which may be
- a symptom such as backache, or
- a condition such as asthma or type II diabetes, or
- a characteristic such as being in the end stage of life
Population health management is one aspect of population healthcare in which the subgroup of the population who could become users of specialist services, for example through hospital admission as a result of an emergency, are identified and have their care organised in a way to reduce the risk of an emergency admission. The evidence in support of this approach is not strong and this week’s paper, published in the New England Journal of Medicine no less, produces no evidence to support this method.
As the health affairs blog summarised below points out the RCT is perhaps not the best method to evaluate a complex intervention
“So then, is hot-spotting with case management of no value? That conclusion seems unwise. First, RCTs do not prove that an
intervention does not work. They only show that in a specific setting with a specific group of people, the intervention did not alter the specified outcomes…. Second, RCTs can be compromised if people in the control group also begin to receive the intervention or something like it.” (1)
Other methods such as realistic evaluation are available for this type of evaluation however what we can say at present is that there is not strong evidence to invest resources and that further research is needed rather than seeing this as a method that should be adopted everywhere.
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Cold Water Or Rocket Fuel? Lessons From The Camden “Hot-Spotting” Randomized Controlled Trial, Eric C. Schneider, Tanya B. Shah HEALTH AFFAIRS BLOG,FEBRUARY 11, 2020 DOI: 10.1377/hblog20200210.863