The Cost-Saving Potential of Trauma-Informed Primary Care
Anita Ravi Interviews Jeffrey Brenner on The Impact of Adverse Childhood Experiences and Adult Health
When Jeffery Brenner, MD, was in medical school and serving his residency he never learned about the emerging science of “trauma-informed” primary care that takes into account patients’ adverse childhood experiences (ACEs) as well as their immediate physical symptoms.
It wasn’t until 2003 when he founded his now-nationally famous “hot spotting” program of health care delivery innovation in Camden, N.J., that Brenner began to immerse himself in the medical literature of a research collaboration of the Centers for Disease Control and the Kaiser Permanente Health Maintenance Organization.
That collaboration’s original ACE Study in the late 1990s has given rise to more than 50 additional scientific articles and 100 conferences and workshops. All focus on the clinical and health economics implications of the finding that there is “a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.”
In 2013 Brenner, the Founder and Executive Director of the Camden Coalition of Healthcare Providers, was awarded a MacArthur Foundation “Genius” grant for his work in one of the country’s poorest cities. His coalition coaxed all hospitals serving Camden’s population to stream daily patient data into its computers, identified the highest-risk, highest-cost patients that were leaving the hospitals, and then dispatched teams of clinicians, health coaches and social workers to comprehensively support those patients in their homes. The end result was significantly reduced ER visits, re-hospitalizations and costs in a multi-morbidity population that has traditionally driven the highest level of health care spending.
Driving health care utilization
“In the beginning,” Brenner said, “as we got deeper and deeper into taking care of outlier, high-cost patients, we spent a lot of time trying to uncover the root cause of that. When we came across the literature of adverse childhood experiences it really opened a whole new window into what’s driving utilization for these patients.”
“There’s a scientific basis to connect health outcomes, healthcare spending, healthcare utilization, and adverse childhood experiences,” Brenner emphasized in a video interview that was part of a gathering of University of Pennsylvania Robert Wood Johnson Clinical Scholars.
Brenner, who is also the Medical Director of the Urban Health Institute at the Cooper University Healthcare system was interviewed by Anita Ravi, MD, MPH. Along with being a Penn/VA RWJF Clinical Scholar and LDI Fellow, Ravi is also the Founder and Attending Physician of New York City’s Institute For Family Health’s new PurpLE Clinic that provides trauma-informed primary care for people who have experienced sexual violence or exploitation. The capitalized “LE” in the clinic’s name stands for “Listen and Engage.”
“In the original ACE study,” said Brenner, “a survey was mailed to 13,000 middle class patients asking them about the horrible things that happened to them as a kid and 70% of them returned it — that’s an incredible response in this kind of work. Then, they agreed to have the survey results connected to their medical records at Kaiser-Permanente. And to date, this same study has been repeated many times. The best predictor we’ve found for health care spending, health care utilization, poorly controlled chronic illness, obesity, substance abuse, smoking, and out-of-wedlock teen birth is the number of bad things that happen to you as a kid.”
“That’s a pretty stunning correlation,” Brenner continued. “We get obsessed with very small correlations all the time in healthcare. We run around and say that hormone replacement therapy is bad for you. Well statistically, adverse childhood experiences is far worse and we’re not talking about that. We get very focused on very small relationships between things and generate huge headlines about them, but here’s a huge relationship that has good, solid scientific evidence for it and we’re not doing anything about it.”
“When I’m speaking to large audiences,” he continued, “I often ask for a show of hands of those familiar with the ACE literature and there will be, like, one lonely social worker in the back who raises his or her hand.”
“It’s not a new idea that a patient who might have had physical or sexual abuse or a variety of other things happen to them might have consequences later in life,” he said. “That’s not a new idea. But we now understand at a much better level the biology of that, the neurobiology, the genetics, the sociology, and the psychology.”
Ravi asked Brenner if he expects medical educational institutions to integrate ACE concepts into their curriculum any time soon.
“We’re pretty far away from that,” said Brenner, “because the medical community is afraid of anything above the neck. There’s a history of us being very focused on cells, pathways and biochemicals and really being overwhelmed by non-linear complex systems. Our patients’ emotional states and their life histories are things that we struggle to understand and then struggle to put into like a nice, neat scientific framework.”
He pointed out that it took a hundred years for doctors to start washing their hands after the germ theory was scientifically established and an equal amount of time for the practice of blood letting to cease.
“So,” Brenner said, “it may take a while for us to actually take a holistic view that there’s no way you can deliver better care at lower cost without coming to grips with patients’ life history.”