Playing it Safe?
Many health care organizations have become frightened—so much change is being forced upon them it seems insane to voluntarily try something different. Thus, it is of interest to read about two different organizations who are experimenting—one by choice and one by necessity. Both give insights into ways forward.
Horowitz and associates have reported their experience at NYU Langone Medical Center with what they call “rapid-cycle randomized testing.” They began by noting that last year they had spent more than $1 million using best-practice alerts in the EHR, recalling hundred of patients overdue for a visit, contacting 19,000 people following hospital discharge and sent thousands of reminders for preventive health exams without any idea if it was working.
“At best, a hospital may track outcomes over time in the hope of seeing a benefit. However, such before-and-after analyses are typically limited by secular trends, selection biases, regression to the mean…and a host of other real-world problems.”
They received seed money from a hospital trustee and set up a process where they could set up cluster analysis of interventions with both an active and a control group, with quick assessment of impact. In one year, they completed 10 such projects. So, what did they find? First, they found calling patients after discharge had no impact on readmission rates. Using community health workers in the ED to do “case management” for social determinants of health had no impact on likelihood of seeking acute care at 30 or 60 days. Preventive care reminders produced no response. (Not mailing reminders would save $25,000.) On the other hand, tweaking the phone call designed to get patients in for annual wellness visits produced an increase in appointments. Smoking cessation efforts were a mixed bag and influenza vaccination rates were not changed.
They report on the lessons learned, which include that it is hard to decide on the appropriate level of analysis—patient or unit—and staff turnover was such that true randomization was difficult to achieve. They used methods such as odd or even terminal digit medical record numbers to allocate persons to intervention or no intervention, for example. But they note it is important to NOT disrupt front-line staff routines to do the study, or results are likely to get worse. Although the results are for only one year, they are planning to implement different trial designs and take on more complex issues in an effort to define what works, what doesn’t, and what, if anything, can be done to make ineffective efforts effective. I applaud the authors and their institution for they boldness and candor. I wish them success and look forward to future reports.
The other instance of successful innovation comes from the opposite end of the health care organizational spectrum—rural health clinics. Deborah and James Fallows have reported on efforts by one such clinic in Eastport, ME. The article was part of a series which previously examined clinics in Brownsville, TX, and Ajo, AZ.
“The community health centers, like Eastport’s, strike similar chords: The centers are built in underserved communities; they require majority local representation in their governing and decisions; and they are committed to serving everyone, regardless of ability to pay.”
The clinic, located in Washington County, Maine, has three locations: Eastport, Machias and Calais. The county ranks 15 out of 16 for health-related behaviors and 16/16 for health outcomes. Not surprisingly, then, the board of the clinic decided its priorities needed to be controlling the opioid epidemic, diabetes, hypertension, obesity, food and heat insecurity, and mental health. One of the first barriers was getting the 32,000 residents to one of the clinics, as many are more than an hour’s drive away. The clinic responded by using patient navigators to coordinate visits to minimize trips, arranging for overnight stays, providing food, and so forth. A second barrier was recruiting staff to a poor county with lots of needs and little in the way of resources. They decided to work on embedding cultural knowledge in the students who come to their organization for training, which they call cultural immersion. So far, they have had two professionals agree to hire on. Given that there are few jobs for their young people, the clinic has funded scholarships for students in hopes of getting them into the healthcare field and having them come back home. So far, they have funded 58 students. They are also working to make exercise facilities more available.
Have they solved their problems? No, of course not. But they have been creative in using their limited resources to try multiple prongs of attack to achieve their primary goal of better health for their residents. They recognize that for many, this means tending to those social determinants of health listed previously. Maybe it is a case of necessity being the mother of invention, but it is good to see an organization that isn’t whining about the drawbacks or being envious of those in a better position.
Is there a common theme with ramifications for the rest of us? I believe most of our medical organizations have become fearful in a way that is new. Sure, there were always challenges and the tug between those who wanted to try something new and those who opposed change as a reflex have been present during my career, and probably from time immemorial, but in the “olden days” nobody really thought the outcome would determine survival of the organization. Now, almost everyone who is paying any attention is aware there are existential threats to organizational survival. Hospitals have been closing, particularly in rural areas, and many of those still open are not really breaking even. Big hospitals desperately seek to become bigger in hopes of hanging on to more of the money, usually unsuccessfully. And everyone is afraid to experiment—not because what we are doing now is working so well, but because we afraid the experiment might make it worse. But what if the only way to ensure survival is to experiment—with measurement of desired outcomes and strict budget limits, of course—but throwing ideas at the wall and seeing what sticks? Something worth thinking about.
7 October 2019
 Horowitz LI, Kuznetsova M, Jones SA. Creating a Learning Health System Through Rapid-Cycle Randomized Testing. N Engl J Med 2019;381(12):1175-1179. doi. 10.1056/NEJMsb1900856.
 Fallows D, Fallows J. Our Towns: Eastport Grapples with Rural Health Care. Accessed 4 September 2019 at https://www.theatlantic.com/notes/2019/09/rural-health-care-surprising-legacy-sixties/597259/.
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