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Health Care Hotspotting — A Randomized, Controlled Trial

List of authors.
  • Amy Finkelstein, Ph.D.,
  • Annetta Zhou, Ph.D.,
  • Sarah Taubman, Sc.D.,
  • and Joseph Doyle, Ph.D.

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.)

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Funding and Disclosures

Supported by the National Institute on Aging of the National Institutes of Health under award number R01AG049897; the Health Care Delivery Initiative of J-PAL North America; and the Sloan School of Management of the Massachusetts Institute of Technology.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

The findings and conclusions expressed are solely those of the authors and do not represent the views of their funders.

A data sharing statement provided by the authors is available with the full text of this article at NEJM.org.

We thank Dr. Jeffrey Brenner for making this trial possible and for his input into the experimental protocol and pre-analysis plan; Martin Aragoneses, Rose Burnam, Bradley Clark, Grant Graziani, Erik James, Allyson Barnett Root, and John Tebes for research assistance and Adam Baybutt, Mary-Alice Doyle, Laura Feeney, and Jesse Gubb for project management; our partners at the Camden Coalition of Healthcare Providers — particularly Aaron Truchil, Stephen Singer, Kelly Craig, James Fisher, Alisha Patman, Itir Sonuparlak, Amadly Cruz, and Laura Buckley — for their patience, dedication, data expertise, and institutional knowledge; coalition recruiters Audrey Hendricks, Mary Pelak, Marisol Velazquez, Erica Foltz, Andrew Katz, Josie Martinez, Jason Turi, and Margarita Santiago, whose tireless work recruiting trial patients was essential to the success of this research; and persons who agreed to participate in this trial and who generously allowed us to analyze their health and social services data.

Author Affiliations

From the Massachusetts Institute of Technology (A.F., J.D.) and the National Bureau of Economic Research (A.Z., S.T.) — both in Cambridge.

Address reprint requests to Dr. Finkelstein at the Department of Economics, Massachusetts Institute of Technology, 50 Memorial Dr., Cambridge, MA 02142, or at .

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