Gold standard study casts doubt on utility of intensive interventions for superutilizers
With 5% of the population accounting for 50% of the United States's annual health care spending, there has been increasing interest in targeting patients with high health care use, also known as "superutilizers." This study examined a program in Camden, New Jersey, that targeted superutilizers using "hotspotting." This technique involves engaging patients and connecting them to appropriate medical and social services, which will hopefully lead to reducing inappropriate health care use.
The patients in this intervention needed at least 2 of the following traits:
- Use of at least 5 active outpatient medications
- Difficulty accessing services
- Lack of social support
- A coexisting mental health condition
- An active drug habit
Once discharged, patients were randomized to receive normal post-discharge care or to receive the hotspotting intervention which included a multidisciplinary team that did home visits, coordinated care, measured vitals, provided personal coaching, and assisted patients to apply for social services.
There was no significant difference in 180-day readmission between the treatment and control group. While studies of other care-transition programs have shown decreases in readmission, the authors suggest that their population was younger, more medically diverse, and socially complex with an increase in health care utilization. There was also the possibility that the current resources were not sufficient to cover the needs of this community. Barriers to quick follow-up care included a lack of housing, telephones, and available appointments.
This study showed that a care-transition program may not be effective in medically complex and socially complex communities. If that is the case, organizations and policies may need to restructure or focus on other targets to decrease inappropriate health care use. This may include targeting the barriers to quick follow-up as identified above. While hotspotting seems to make sense conceptually, it is important to have randomized controlled studies of interventions to evaluate whether these programs are actually effective.
Abstract: Finkelstein A, Zhou A, Taubman S, Doyle J. Health care hotspotting - a randomized, controlled trial. N Engl J Med. 2020;382(2):152-162.
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 caretransition 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. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, -5.97 to 7.61). In contrast, a comparison of the intervention-group admissions during the 6 months before and after enrollment misleadingly suggested a 38-percentage-point decline in admissions related to the intervention because the comparison did not account for the similar decline in the control group.
CONCLUSIONS: 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.
EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA
As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows, we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill. Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.