Negative RCT of health care hotspotting in NEJM: What outcomes are important?

At the Upstream Lab, we’ve started up a regular journal club as part of our weekly meetings. We’ll be sharing a brief summary here on our blog. This week we looked at this study: Health care hotspotting – a randomized controlled trial (NEJM 2020; 382: 152-162). This was also the focus of discussion last week at MAP, the centre where we are based.

You may remember Atul Gawande‘s 2011 article on “The hot spotters”, profiling the work of the Camden Coalition of Healthcare Providers in Camden, New Jersey. This article got a lot of people interested in the idea that the solution to rising health costs was to focus on the people who were disproportionately using a huge amount of health services. Here in Ontario, we also started to focus on so-called “high-cost users”, leading to a new program called Health Links. I was involved in a study led by my colleague Dr. Laura Rosella that essentially found that social determinants played a big role in who would end up being a high-cost user. Maybe not surprising to visitors of this blog, but we thought it was really important to point this out. Most of the solutions being proposed were focused on just getting these folks more traditional health services.

Getting back to the article, this RCT focused on “superutilizers of the health care system — persons with medically and socially complex needs who have frequent hospital admissions”. These patients were identified during an admission and were connected to a multidisciplinary team with nurses, social workers, community health workers and health coaches. This team did a lot, including home visits, got people to appointments, helped with medications, measured BP and blood sugars, coached patients and helped patients apply for social services and behavioral health programs. That last part about social services sounds similar to some interventions we are studying.

The study found no difference in readmission to hospital after 6 months, between people who got the intervention compared to controls. Why not? Regression to the mean, is one explanation . Another is that people are on trajectories that are hard to change. A NYTimes article on the study made the case that it is really tough to make a difference in readmission to hospital, and mentions future work by the Camden Coalition will focus on housing. They are teaming up with lawyers to prevent evictions, something we’ve also been studying with the Health Justice Initiative.

For such studies, what outcomes are important to patients, families, providers and policymakers? I suspect that if outcomes included reduced stress, improved quality of life, and knowing where to go for help when in crisis, maybe the study would have been positive. Like so many studies of complex interventions, more work is required to really understand what is going on.

Published by Andrew Pinto

Dr. Andrew Pinto is the founder and director of The Upstream Lab. He is a Public Health and Preventive Medicine specialist and family physician at St. Michael’s Hospital. Dr. Pinto completed his residency at the University of Toronto and his Master’s in Health Policy, Planning and Financing at the London School of Economics and the London School of Hygiene and Tropical Medicine as a Commonwealth Scholar. Currently, he is a Scientist in the Centre for Urban Health Solutions at the Li Ka Shing Knowledge Institute at St. Michael’s Hospital and an Assistant Professor at the University of Toronto.

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