How Not to Handle Frequent Flyers

Written by Clay Smith

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Deploying a team of healthcare professionals to assist patients with complex medical and social needs at hospital discharge did not reduce readmission rate.

Why does this matter?
Some patients are heavy utilizers of healthcare resources. Would surrounding these patients with a team of nurses, social workers, and community health workers reduce future healthcare utilization, namely readmission?

Frequent flyer fail
This was a RCT with 800 “superutilizer” patients with complex medical and social needs and frequent admission who were randomized to the Camden Coalition of Healthcare Providers “hotspotting” program (team described above) vs usual care upon hospital discharge. Camden is an economically challenged area in New Jersey. Patients in the program received a median of 7.6 home visits, 8.8 phone calls, and 2.5 primary visits. Yet, for the primary outcome of 180-day readmission, there was no difference: 62.3% hotspotting vs 61.7% control. The program also had no significant impact on downstream benefit participation in supplemental nutrition, temporary assistance for needy families, or general assistance. Clearly, this program is not the magic bullet for frequent flyers. A team of people doesn’t reduce the complex needs of such patients. It also shows that “usual care” is doing a good job connecting patients with resources. It may not be possible to reduce costs by reducing repeat hospitalization. This study shows why RCTs to evaluate such programs targeting “superutilizers” are important. Just because a patient is consuming vast resources today does not mean this will persist at such a high level. In fact, there was a regression to the mean, with both groups of superutilizers seeing a reduction in subsequent healthcare costs. An observational model would have appeared to show benefit which was not, in fact, real.

Source
Health Care Hotspotting – A Randomized, Controlled Trial. N Engl J Med. 2020 Jan 9;382(2):152-162. doi: 10.1056/NEJMsa1906848.

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