Making Sense of Health Care Transformation as Adaptive-Renewal Cycles

A growing literature sees medicine as a complex enterprise that is best understood from a sociological and ecological as well as an economic perspective (1). Developing this model is no mere academic exercise. As we struggle to reform the health care system, grasping how medicine works is critical if our reforms are to have the desired effects.

The article by Stange, Ferrer, and Miller (2) adds an important historical dimension to our understanding, suggesting there is a cyclic pattern of innovation and consolidation which may collapse under external pressures, stimulating reorganization. Recognizing where contemporary institutions fit in such a scheme may help clarify how to resolve the current crisis.

Distracting and unnecessary jargon aside -- "revolt connections" and "remember connections" add little to the theoretical construct -- the paper is also important in emphasizing that health systems are made up of inter-dependent parts and are endlessly adaptive. For example, when the diagnosis-related-group system of hospital reimbursement was introduced in 1983, skilled nursing facilities developed as a way to care for elderly patients who had not regained their baseline level of functioning when hospital care was no longer profitable.

"Resilience" and "connectedness" of health care systems are critical to our understanding of the way hospitals, doctors, drug companies, device manufacturers and others develop ingenious means of preserving their interests. But it is not clear that the goal of reform is to foster more connections and stimulate enhanced resilience. Far from having "rigid interconnections" that make "the overall system brittle and vulnerable to catastrophic collapse," modern health care systems are diabolically inter-connected and remarkably resilient -- we do not need to make them more so, but rather to understand that because of these properties, reform attempts often have extensive ripple effects and unanticipated consequences. For instance, when determination-of-need legislation constrained hospital construction in the 1990s, health care institutions created ambulatory surgical centers, which only now are becoming extensively regulated.

The model of health care as an interactive, adaptive system has implications for research. Rather than concluding that we need to try multiple different approaches to see what flourishes, as proposed by Stange et al, it might make sense to study the numerous pilot projects undertaken in recent years -- the Johns Hopkins hospital-at-home to decrease hospitalization (3), the Penn transitional care program to prevent readmission of frail elders (4), the Aetna case management for patients with advanced illness (5) -- not merely to determine whether they achieved their goals, but also to look for other consequences throughout the complex health care system of which they are a part.

1. Gillick MR. Medicine as ecoculture. Ann Intern Med 2009; 151: 577-580.
2. Stange K, Ferrer L, Miller W. Making sense of health care transformation as adaptive-renewal cycles, Ann Fam Med 2009; 7: 484-487.
3. Leff B, Burton S, Mader S et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med 2005; 143: 798-808.
4. Naylor M, Brooten D, Campbell R et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA 1999; 281: 613-620.
5. Spettell C, Rawlins W, Krakauer R et al. A omprehensive case management program to improve palliative care. Journal of Palliative Medicine 2009; 12: 827-832.

Competing interests:   None declared