Health Care Hotspotting - A Randomized, Controlled Trial

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.).

Figure 1:. Consort Diagram

Notes: Data are from the Health Information Exchange. “Declined” indicates the patient explicitly said no to the offer of randomization. “Soft Decline” indicates that the patient did not give consent when approached, but did not decline and could be reapproached during future hospitalizations if otherwise eligible. “Unable to Consent” indicates that the patient was discharged (or died) before they were reached or that they were unable to consent for reasons such as being asleep. “Consented but Excluded” includes five patients who consented and later asked to be removed and the last 4 patients enrolled in the study who were excluded to keep the study population at the 800 person target.

Figure 2:. Average Number of Inpatient Admissions per Quarter

Notes: All data are from the hospital discharge data and cover the analysis sample (N=782). Treatment data (N=393) and Control data (N=389) are shown separately. The horizontal axis shows quarters relative to the index admission; quarter 1 is thus the quarter that begins with the discharge date from the index admission, while quarter −1 is the quarter ending the day before the index admission. The index admission is excluded from the figure.