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“Hotspotting”
In 2011 Atul Gawande published an article in The New Yorker about the efforts of Dr. Jeffrey Brenner to collect and analyze health care data to identify areas with excess risk of injury and illness.[1] He used the term “hotspotters” talking about the use of “heat maps.” Now the concept is not new. Dr. John Snow used the same approach studying a cholera outbreak in London, which led to the famous removal of the pump handle 7 September 1854.[2] Gawande goes on to discuss development of a city-wide intervention program called The Camden Coalition of Healthcare Providers, which aimed to provide multidisciplinary interventions targeting the social determinants of health in Camden, New Jersey. Finkelstein and associates have now published a randomized, controlled trial of the interventions compared to usual care in three hospitals.[3] This study received broad media coverage, usually headlining that the intervention did not work. But the closer study is required as that is not a complete interpretation. The authors took patients with a hospital admission within the previous six months who had at least two chronic conditions and either use of five or more medications or social issues such as an active drug habit, homelessness, or a co-existing mental health condition. They excluded patients with cognitive impairment, cancer, or when the index hospitalization was for decompensation of a chronic disease for which limited treatments were available. So, the study included “difficult” patients, but excluded those likely to have “hospital-dependent” disease states, who constitute a significant percentage of all 30-day readmissions as counted by CMS. The study then attempted to randomize patients between the “core model” of the Coalition and compared it to “usual care.” The statistic of interest was 180 day readmission rates. They had secondary measures related to mortality and hospitalization. There primary finding was the readmission rate in the intervention group was 62.3% compared to 61.7% in the control group, which was not statistically significant. The authors concluded “Our results suggest that there are challenges for superutilizer programs aimed at medically and socially complex problems.” But what would have happened if nothing was done? Perhaps usual care in Camden includes a lot of coordinated effort between various social service and healthcare organizations that is lacking in other places. Perhaps getting a third of this difficult to manage population more stable is a reasonable goal. But it is expensive, so the issue of cost-benefit remains uncertain. Coincidentally, the same week Dodson and associates published a study predicting six-month mortality in older adults following an acute myocardial infarction.[4] [8.8% of the cohort died within six months.] Using a sophisticated modeling system, they identified items more common in patients who died than those who did not, including more co-morbidity, more frailty, and cognitive impairment. But no characteristic was definitive—trying to predict individual outcomes remains problematic. In the accompanying editorial the editorialists note frailty is becoming more recognized as an issue. [5] However, “routine use of risk prediction models is valuable only if they actually enhance clinical decision making in a way that improves outcomes for older adults at the highest risk.” They conclude that each intervention will need proof-testing before it is scaled up. Implicit in their opinion is the notion that interventions delaying death are appropriate. In the same issue, Vanstone and associates reported a multisite evaluation of the 3 Wishes Project.[6] The 3 Wishes Project seeks to engage patients and providers in conversations about end-of-life care and decide what the goals of care should be. It is cheap, mean of $5.19 per patient, and seems to be valuable to both patients and providers. So, what do all these articles have in common? They raise a question—what is the goal of the medical care process? Some patients have refractory issues, be they medical and/or psychiatric, and some have complicating social issues. Removing social barriers seems like a good idea but is expensive. Effective treatment for drug use in patients with major social barriers, for instance, is not widespread. Chronic diseases progress despite interventions. None of this means efforts aren’t worthwhile, but it is a matter of balancing costs and benefits. While it is possible to say no expenditure is cost-effective, that is not the real question. What we are really asking is can we do something better than highly expensive hospital care? Maybe we are part of the problem. I recall a conversation with an observant dialysis patient commenting on the recent death of another patient. She said, “When I first came back to dialysis, he was walking in. Then he was coming in using a walker. Then he was in a wheelchair and the last few times he came in by ambulance, so I wasn’t surprised he died.” Why are medical professionals? Of course, they really aren’t. One standard survey question is “would you be surprised if the patient died in the next six months.” The answer has reasonable predictive validity. The challenge is to “do something” when it makes sense, recognizing death is still inevitable, and knowing when it is time to switch from curing to caring. Perhaps we should be trying to develop methods to “hotspot” when the patient is in irreversible decline. 21 January 2020 [1] Gawande A. The Hotspotters. Can We Lower Medical Costs by Giving the Neediest Patients Better Care? The New Yorker. 16 January 2011. https://www.newyorker.com/magazine/2011/01/24/the-hot-spotters. Accessed 14 May 2019. [2] https://www.ph.ucla.edu/epi/snow/removal.html. [3] Finkelstein A, Zhou A, Taubman S, Doyle J. Health Care Hotspotting—A Randomized, Controlled Trial. N Engl J Med 2020;382(2):152-162,2020. doi:10.1057/NEJMsa1906848. [4] Dodson JA, Hadjuk A, Geda M, et. al. Predicting 6-Month Mortality for Older Adults Hospitalized With Acute Myocardial Infarction: A Cohort Study. Ann Intern Med 2020;172(1):12-21. doi:10.7326/M19-0974. [5] Kazi DS, Bibbins-Domingo K. Accurately Predicting Cardiovascular Risk—and Acting on It. Ann Intern Med 2020;172(1):61-62. doi.10.7326/M-19-3662. [6] Vanstone M, Nevill TH, Clarke FJ, et. al. Compassionate End-of-Life Care: Mixed-Methods Multisite Evaluation of the 3 Wishes Project. Ann Intern Med 2020;172(1):1-11. Doi:10/7326/M19-2438. |
Further Reading
Activating Patients - The Achilles Heel of Healthcare Reform? Studies show 25% of the population is not involved in their healthcare, but reform efforts assume wider application of evidence-based medicine is the key to better value. Perhaps it is the Achilles' Heel? On Dying in America The IOM report "On Dying in America" makes recommendations for change that physicians should embrace. On Failure Readmission Penalties CMS is in its third year of applying penalties to hospitals with excess readmissions, but almost 75% of hospitals were penalized this year. Is this a quality improvement or a surtax? The Limits of the Medical Model |