What Happens When I am Proven Wrong?

By | March 3, 2020

“Hot-spotting” is a method in healthcare to identify areas for intervention. The premise suggests, if I can identify a segment that is responsible for most of a situation and change its trajectory, a positive outcome will occur. This premise is the basis for disease management, and now value-based care concerning social determinants of health.

However, a recent randomized controlled study from the Commonwealth Fund of the Camden Project revealed that there was no difference in outcomes and cost when “hot-spotting” occurred. This result is causing people to question the intervention, and others challenging the study to argue that intuition says it works, as well as other corollary studies that show benefit.

In truth, I believe we need to step back and ask a bigger question, how do we think about an issue when the evidence does not support our thinking? The first necessary step is to contemplate the reason for the results: is the premise incorrect? Is the assumption correct, but the intervention was implemented improperly, or was the data collected incorrectly? And, it’s critical to examine each of these premises.

Concerning these results, it is difficult to argue with the design of a randomized controlled trial, as it is excepted as the gold standard from a study design perspective. The intervention and implementation are well designed. So, let us examine the possibility that the premise is wrong. It is tough to argue that social determinants do not have a substantial influence on health and wellness. Our public health data proves this time and again. Where we have struggled is how to make a difference. Currently, our present reasoning is that if I fix the underlying issue for you by just identifying it and giving you the solution, your situation will ultimately improve.

Unfortunately, this is an extremely physiologic approach, let me diagnose a situation and treat it. However, the “human condition” does not work this way. The psychosocial axis, which encompasses activation, engagement, and habits, is a powerful influencer on change. Furthermore, our present models do not consider these issues. Sure, we think about them, but as secondary characteristics at best. Additionally, we begin with a disease or situation (ED visits and hospitalizations specifically in this study), then identify possible reasons, and then ‘perhaps’ contemplate the physiologic makeup of the individuals identified.

A completely different paradigm would be to find those that are poorly activated who have situations that need interventions that are high cost. This model comes at it from a completely different direction. This approach would lead us first, to increase one’s activation and engagement, give them resources if needed, and then monitor the results it has on overall cost.

When we approach a tenuous situation, let us step back and critically address the possible causes instead of saying something did not work as intended. I view the results of this one particular study as incredibly informative and gives me tremendous hope that we can solve the issues at hand. The key is how do I utilize these findings. Sure, “Hot-Spotting” might make sense, but there is usually a bigger picture to consider so we need to learn where to place our focus.