NEJM Highlights for June 2016: Improving care delivery is just plain #%^*! hard


Disappointing interim results from two ACA experiments

Two papers reporting results from ACA experiments – the Comprehensive Primary Care (CPC) Initiative in which primary practices were incentivized with fairly generous payments to strengthen care management activities such as management of chronic conditions, or coordination of care – and the ACO initiatives (2012 cohort) described elsewhere in many reviews. Both papers provide a view on the early impact of these initiatives (2 years out) on costs and outcomes by using well controlled no-intervention comparison groups. The upshot is that so far, the CPC and ACO (v. 2012) initiatives do not show significant change in most measures compared to controls, and when changes are statistically significant, they tend to be small.   This represents an interesting conundrum given that anyone who seriously looks at the US healthcare system cannot help but be struck by a tremendous level of inefficiency and under-performance.  Is the problem that we have yet to figure out the secret sauce of effective population health and care management? Or is it that any given secret sauce is only applicable to a specific setting? Or is it that we know what to do, but that legacy mindsets and systems are so ingrained that we are unable to deploy new solutions? I suspect a bit of each, but probably more of the latter. Two-Year Costs and Quality in the Comprehensive Primary Care Initiative; Early Performance of Accountable Care Organizations in Medicare (subscriber access)


Increasing productivity in research to improve care delivery productivity

Why is it so hard to improve the effectiveness of care delivery? One of the reasons is that clinical experiments in care delivery are expensive when done at scale.  There have been attempts to get around this by embedding research in routine patient care – this is feasible when the standard of care includes a range of possible approaches and one essentially asks the treating physicians to make choices between accepted practices based on an external randomization process. In a review of four such clinical trials the main conclusion is this: whenever the full apparatus of clinical research has to be invoked (patient consent, data safety monitoring board, etc.) the complexity increases exponentially, often beyond what is justified given that there are no departures from the standard of care. Fortunately, an attempt is on-going to streamline the rules governing this type or research.

Another reason is that many institutions or even individuals are reinventing the wheel – every other hospital is trying to figure out a better process to manage patients with CHF, COPD, and other common conditions. This work is conducted in individual settings and the results are never truly disseminated.  One approach being explored is the Vivli platform which aims to create a standardized clinical trial data sharing environment that can be broadly accessed.  Integrating Randomized Comparative Effectiveness Research with Patient Care (subscriber access); A Global, Neutral Platform for Sharing Trial Data (free access)


The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer a brief overview of highlights that might be of interest to our clients and others.