A Clinical Trial Examines the Phenomenon of Healthcare “Hotspotting”—With Mixed Results

For what appears the first time, healthcare researchers have studied the phenomenon of “healthcare hotspotting,” through the vehicle of a randomized, controlled trial, with interesting, mixed results. In their article, “Health Care Hotspotting—A Randomized, Controlled Trial,” published on Jan. 9 in The New England Journal of Medicine, Amy Finkelstein, Ph.D., Annetta Zhou, Ph.D., Sarah Taubman, Sc.D., and Joseph Doyle, Ph.D., looked at the phenomenon, and found conflicting signals.

As they write, “Since being profiled in Atul Gawande’s seminal New Yorker article, ‘The Hot Spotters,’ the program created by the Camden Coalition of Healthcare Providers (hereafter, the Coalition) has been a flagship example of a promising superutilizer program. The Coalition’s Camden Core Model uses real-time data on hospital admissions to identify patients who are superutilizers, an approach referred to as ‘hotspotting.’ Focusing on patients with chronic conditions and complex needs, and starting with the premise that navigation of the standard system is difficult for these patients, the program uses an intensive, face-to-face care model to engage patients and connect them with appropriate medical care, government benefits, and community services, with the aim of improving their health and reducing unnecessary health care utilization.”

What’s more, the researchers note, “The program has been heralded as a promising, data-driven, relationship-based, intensive care management program for superutilizers, and federal funding has expanded versions of the model for use in cities other than Camden, New Jersey. To date, however, the only evidence of its effect is an analysis of the health care spending of 36 patients before and after the intervention and an evaluation of four expansion sites in which propensity-score matching was used to compare the outcomes for 149 program patients with outcomes for controls. More broadly, there are a number of promising observational studies of other superutilizer programs. However, regression to the mean — the tendency for patients selected for the exceptionally high cost of their care at a moment in time to move closer to average cost over time — may bias observational studies of superutilizer programs toward spurious results.”

And, they note, “Although there is limited rigorous evidence of the effectiveness of superutilizer programs, several randomized trials of care-transition programs — which, like the Camden Core Model, start with patients in the hospital and work with them after discharge — have shown substantially reduced readmissions. However, the Camden Core Model targets a much more heterogeneous population with greater social and medical complexity and substantially higher health care utilization. Therefore, the Coalition partnered with investigators to design a prospective, randomized evaluation of this nationally recognized program.”

As a result, these researchers wanted to look rigorously at how well the Camden Core Model might intervene with individuals with medically and socially complex needs and who are frequently admitted as inpatients, focusing on individuals with at least one hospital admission at any of four Camden-area hospital systems in the previous six months.

Essentially, they found, “[T]he Camden Core Model had no significant effect on participants’ 180-day readmission rate. The 95-percent confidence intervals rule out a decrease in readmission rates of more than 6 percentage points as compared with a control mean of 62 percent; this finding rules out the reductions in readmissions of 15 to 45 percent in the Medicare population reported in randomized evaluations of other care-transition programs. The Camden model targets a different population: one that was younger, with more diverse medical needs, greater social complexity, and much higher health care utilization; previous hospital use was nearly twice that in most previous successful programs involving care transition.”

In an interview with MIT News, Dr. Finkelstein said that “The reason it was so important we did a randomized, controlled trial, is that if you just look at the individuals in the intervention group, it would look like the program caused a huge reduction in readmissions. But when you look at the individuals in the control group—who were eligible for the program but were not randomly selected to get it — you see the exact same pattern.”

In short, the researchers conclude in the NEJM article, “Our results suggest that there are challenges for superutilizer programs aimed at medically and socially complex populations. They are consistent with the mixed results on hospital admissions from randomized evaluations of care-management programs for chronically ill populations, although those programs, unlike the Camden model, did not focus on the postdischarge transition. It is possible,” they add, “that approaches to care management that are designed to connect patients with existing resources are insufficient for these complex cases. The Coalition has continually worked to adapt the model to the needs of its patient population, and both the Coalition and others are exploring models that involve more complete redesigns of care provision.”