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.

Tools for upstream thinkers: 5 tips for effective policy briefs

madeleine-bondy.jpgby Madeleine Bondy, 2019 summer student at the Upstream Lab

Too often researchers are not reaching out to those in government. As a young researcher and future physician, I’m curious about how to best influence the policies that impact the social determinants of health. Translating research into action is a key part of our work at the Upstream Lab.

Policy briefs are documents used to inform political action and influence public policies. They are usually short 3-4-page documents, but can be as longer. The briefs summarize an issue and include a synthesis of research evidence with the purpose of orienting policy action.

In writing a brief it is important to include the purpose of the brief as well as the problem and current status, the context, key considerations and existing evidence, an overview of the solutions including pros and cons and then your policy recommendation.

5 tips to make policy briefs effective

1. Know your audience

Who  the brief for and how will they use? Consider your audience’s needs and expectations. What is on their mind, what are the questions they need answered today? You may need different versions of a brief for different audiences. For example, one written for a specialist audience may need to be longer (6 pages) than for one for non-specialists (2-4 pages).

2. Context matters

Consider how the policy brief fits into the overall context of your knowledge and sharing strategy. A policy brief may not always be the most appropriate tool for your purposes. Rather, a phone or in-person chat may be best, followed by a brief. Avoid viewing the brief as an end to itself, but rather part of a wider strategy.

3. Power and interest are paramount

Policy is formed at multiple levels, so take time to select the right group to share your research. Your organization may not be the most appropriate one to disseminate the results so you may need to build relationships with other organizations that are better positioned to reach your intended audience. To reach the general public, for example, it is usually best to engage the media, using social media and online platforms. The graphic below shows how it is important to think about organizations that have the power to either support or oppose the issue, and may have potential interest in your subject.

4. Policy briefs are a dialogue

A policy brief doesn’t contain every detail about a topic, but sparks a dialogue. The most effective briefs draw attention to a specific problem, provide a clear interpretation of the results and describe a limited number of actions to be taken. The greater amount of trust in the authors of the policy brief, the higher the likelihood that its recommendations will be well received.

5. Understand the potential and the limitations of briefs

Researchers should produce policy briefs but should also be realistic about the outcomes. Policy briefs are only one part of your knowledge-sharing strategy. Continue to look for policy windows to re-disseminate the brief (i.e. when political circumstances change).

Short, medium-length and long examples of policy briefs focused on the social determinants of health:

  • The Wellesley Institute published this 2-page brief in 2017 on the need for supportive housing in Ontario.
  • The Hispanic Health Council published this 22-page brief on how community health workers can help address social determinants
  • Texas Children’s Hospital and Baylor College of Medicine published this 52-page brief on screening for social determinants in clinical settings.


Based in part on a webinar on how policy briefs can help bridge the research-to-policy gap, presented on June 19, 2019 by the National Collaborating Centre for Public Policy. Recording available here.

“Swimming upstream” in primary care to address health disparities

pinto-andrew-copyBy Andrew Pinto, director of The Upstream Lab
Recently, I hosted a medical student in my family medicine clinic in downtown Toronto. She had heard me speak about the social determinants of health (SDoH), and wanted to see how I put these ideas into practice. As we reviewed the patients we’d see that day, we talked about how poverty, precarious employment and poor housing conditions “get under our skin” and impact health outcomes.

We had a busy afternoon and saw many people dealing with complex social issues that affected their health. This included a man in his mid 20s who is homeless, making it challenging for him to stay on top of his HIV treatment or engage in services to help him manage his drug use. And a woman in her 50s, also living with HIV, but mostly concerned with precarious employment and her fluctuating income that impacts her ability to pay for medications. And a woman in her 40s who lives in a social housing building that is rife with violence, constantly triggering her anxiety and PTSD. We provided care, but also witnessed and listened to the strategies that these patients have come up with to support their own health in the face of societal and systemic inequities.

Not every patient was in crisis. Our catchment area has a mix of neighborhoods, and our waiting room is a cross-section of our diverse city. In Canada, we cherish the idea that all citizens, regardless of their income, deserve access to physicians and hospitals. But from person to person that day, we saw health disparities that exist at a population level. And we knew that access to the health system is only a small part of what determines who is healthy and who is not.

what-makes-canadians-sick-e.png                                                                Source: Canadian Medical Association.

At the end of clinic, I checked in with the student. We discussed how clinicians can feel like they are constantly “swimming upstream”, struggling against a strong current of health, social and political factors that limit us to temporary downstream solutions. This can lead to burnout, particularly if one faces these situations all alone. Our Family Health Team includes nurses, social workers, psychologists, dietitians and pharmacists. Everyone has a special role and set of skills, but also, we support one another as we swim in what colleagues in Scotland call the “deep end” of primary care – that is, those areas that face the worst health inequities.

We also need to support our patients by addressing the SDoH. At our Family Health Team, we developed a special committee and a series of new programs. First, we developed a unique income security health promotion service. Building on lessons from the United Kingdom, where several general practices partnered with charities that help people access government benefits, our program helps individuals and families access new sources of income, reduce expenses and build financial empowerment. We also looked to the United States, and obtained funding to start a medical-legal partnership. We began a Reach Out And Read program to improve child literacy and development. Finally, we have begun routinely collecting data about our patients and their SDoH.

I shared with the student how these initiatives get started and can be evaluated. To push the boundaries of what we can do, I started a research group called The Upstream Lab within the Centre for Urban Health Solutions at St. Michael’s Hospital. In our Lab we developed and tested an intervention on precarious employment, online tools to help with finances, community initiatives to boost economic resiliency, and even interventions that aim to influence policymakers by applying a SDoH lens to legislation. The priority is to ensure that patients can give feedback on whether these services are supporting them, and to study how these services impact their health and well-being.

Whenever we teach students about the SDoH, I think we are challenged to move beyond a “laundry list” of factors to new solutions that address the complex factors shaping patients’ health outcomes. Developing and evaluating evidence-based interventions requires an ongoing revolution in our thinking, including being constantly open to new approaches and the insights gained from working with and collecting feedback from patients. As the World Health Organization noted a decade ago, at the roots of the SDoH is the inequitable distribution of power.

The student and I ended our day by chatting about her pre-med experiences in community organizing. Her previous work included collaborating with food centers to build political power among people dealing with food insecurity. Now it was my opportunity to learn from her. With future colleagues like this, I feel optimistic about our collective work of going upstream of the health disparities we see in primary care.

This blog post was first published by the North American Primary Care Research Group (NAPCRG).

Can we learn financial resiliency from our peers?

Studying an innovative financial empowerment program that includes building advocacy skills

madeleine-bondy.jpgby Madeleine Bondy, MPH practicum student at The Upstream Lab

Many Canadians find it difficult to make ends meet with about half of us living from pay cheque to pay cheque. Although financial planning experts abound, services are often unavailable to those with low incomes. There are limited resources for average Canadians to learn how to advocate for themselves or to navigate their way through complex financial systems. Financial precariousness and income insecurity have serious implications for both individual and population health.

The Upstream Lab, at St. Michael’s Hospital’s Centre for Urban Health Solutions has studied the use of an online financial benefits tool and the impact of trained health promoters focused on income security. These services have resulted in several success stories around financial advocacy. One such story includes a patient in crisis with no income and mounting expenses, whose spouse had a heart attack and could no longer work. The income security health promoters helped the patient to advocate for themselves and complete an application to the Workers Safety and Insurance Board. This application resulted in 85% of their spouses’ salary as well as support from a PSW.

Now, The Upstream Lab is collaborating with Strive, a social enterprise focused on increasing financial resiliency for individuals and improved economic systems in our society, to study a pilot program to help Canadians build these same financial advocacy skills among peers.

Starting this week participants will attend a free pilot workshop series over 10 weeks on topics related to financial literacy (e.g. how to understand a credit report or build personal savings), capacity building (e.g. setting and meeting goals) and financial advocacy (e.g. how to access government benefits and avoid predatory lending).

The program focuses on three groups of people who face difference challenges: young people entering the workforce, people in precarious work situation, and older adults considering retirement but unsure whether they have enough savings.

The goal of the program is to build personal financial empowerment using a peer-to-peer engagement model in which participants share their own stories including both successes and challenges. Ultimately, each person must map out their own strategy for money management and financial advocacy. “There is no silver bullet and different people maneuver in different ways. Often the answers to challenges are found in everyday experience,” says Strive founder Monica Da Ponte.

The program is expected to help people develop a personalized plan to manage their money. Participants will provide feedback to the research team about which elements of the program are most helpful to them.

“We are hoping to see that this program reduces peoples stress, improves their quality of life and increases their knowledge and skills about finances so that folks are able to gain financial advocacy skills and, ultimately, improve their health.” says Dr. Andrew Pinto, director of The Upstream Lab.

If this approach works, Strive hopes to engage hospitals, universities and other organizations to offer this service for their patients, students and employees. In the future, individuals who have participated in the program could become peer facilitators, building ongoing peer groups that act as support for continued individual advancement.

Project funded by a seed grant from the Institute for Global Health, Equity and Innovation at Dalla Lana School of Public Health, University of Toronto.