EvidenceAlerts

Finkelstein A, Zhou A, Taubman S, et al. Health Care Hotspotting - A Randomized, Controlled Trial. N Engl J Med. 2020 Jan 9;382(2):152-162. doi: 10.1056/NEJMsa1906848. (Original study)
Abstract

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. 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. (Funded by the National Institute on Aging and others; ClinicalTrials.gov number, NCT02090426; American Economic Association registry number, AEARCTR-0000329.).

Ratings
Discipline Area Score
Public Health 7 / 7
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Hospital Doctor/Hospitalists 5 / 7
Internal Medicine 5 / 7
Comments from MORE raters

Hospital Doctor/Hospitalists rater

This is probably not a surprise to those of us on the hospital medicine clinical front line.

Public Health rater

Another intensive home intervention after discharge fails to impact readmissions. This is one of several interventions where clinicians unfamiliar with the patient’s ‘drop in’ to the patients home. None of these types of interventions have succeeded. As the authors state, they failed with the key ingredient; connecting the patient to their longitudinal provider. The only intervention which has been shown to be effective. ACO held promise in making an impact but there are no incentives yet to get PCP’s and specialists like cardiologists to prioritize these folks in their schedules. Until then...

Public Health rater

All who work with integrated delivery systems should read this study closely. There is a great example of how we can combine good intentions with regression to the mean to come to a likely false conclusion. However, interventions regarding social determinants of health remain important and promising. The main audience here should be leadership and medical directors of large practices, community health clinics and integrated delivery systems.
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