A Prominent Hotspotting Program Didn't Show Benefit for High Need Patients. What's Next?
In a recent article in the New England Journal of Medicine, a team of researchers reported results from a prospectively designed "hotspotting" intervention designed by the Camden Coalition of Healthcare Providers to improve outcomes among superutilizers, patients with very high use of health care services. The intervention involves a team of nurses, social workers, and community health workers working with superutilizers after hospital discharge to coordinate ambulatory care and connect them with needed social services.
Hotspotting-related interventions were the focus of a previous #VSSLviews post (read that here). As noted in that entry:
Health care "hotspotting" -- defined by some as "the strategic use of data to reallocate resources to a small subset of high-needs, high-cost patients" -- has become widely popular among physician groups, hospitals, and health systems as a way to manage health care spending. Hotspotting is directed at "super utilizers", patients who are outliers with respect to high health care utilization and spending.
Many super utilizers are individuals with chronic conditions and complex care needs that can be challenging to manage with processes and strategies that are prevalent in the current US health system. Therefore, the intuition for using hotspotting in primary is straightforward: identify high utilization/cost outliers, implement tailored (and often intensive) primary care interventions to manage their care, improve outcomes, and drive down spending.
As the New England Journal of Medicine authors note, the Camden program "has received national attention as a promising superutilizer intervention and has been expanded to cities around the country." Given this context and broad enthusiasm and uptake of 'superutilizer' programs across the nation, the study findings -- that in an intervention "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" -- have set off a robust discussion about the implications for high-risk care management.
VSSL members Drs. Leah Marcotte and Joshua Liao -- no strangers to these issues given their health system leadership roles and published peer-reviewed work highlighting the potential limits of hotspotting-driven interventions in primary care -- have weighed in. Dr. Liao described some key take-aways on Twitter for ongoing and future work:
VSSL member Dr. Leah Marcotte was interviewed in an article by Medscape discussing the New England Journal of Medicine paper. In discussing the challenges that may underlie the study results, Dr. Marcotte notes:
"Managing medical complexity, even when patients have good social support and are well resourced, is very hard to do. Managing complex medical conditions when patients do not have stable housing or a reliable way to communicate with the health care team, two barriers specifically called out by the authors in this study, is exceedingly more difficult."
Collectively, these points highlight the need to differentiate between social and clinical complexity, to recognize the distinction between health care and health interventions, and to simultaneously explore interventions targeted at high-risk and normal- or low-risk individuals.