Effect of an integrated care pathway on use of primary and secondary healthcare by patients at high risk of emergency inpatient admission: a matched control cohort study in Tower Hamlets

Abstract

ObjectivesTo assess the effects of an integrated care pathway on the use of primary and secondary healthcare by patients at high risk of emergency inpatient admission.DesignObservational study of a real-life deployment of integrated care, using patient-level administrative data. Regression analysis was used to compare integrated care patients with matched controls.SettingA deprived, inner city London borough (Tower Hamlets).Participants1720 patients aged 50+ years registered with a general practitioner in Tower Hamlets and at high risk of emergency inpatient admission enrolled onto integrated care during 2014. These patients were matched to control patients, also selected from Tower Hamlets, with respect to demographics, diagnoses of health conditions, previous hospital use and risk score.InterventionsEnrolled patients were eligible for a range of interventions, such as case management, support with self-care and enhanced care coordination. Control patients received usual care.Primary and secondary endpointsNumber of emergency inpatient admissions in the year after enrolment onto integrated care. Secondary endpoints included numbers of elective inpatient admissions, inpatient bed days, accident and emergency attendances, outpatient attendances and general practitioner contacts in the year after enrolment.ResultsThere was no evidence that the integrated care pathway reduced patients’ healthcare utilisation in the first year post-enrolment. Matched controls and integrated care patients were similar at baseline. Following enrolment, integrated care patients were more likely than matched controls to experience elective inpatient admissions (adjusted incidence rate ratio (IRR)=1.27, 95% CI 1.08 to 1.49, p=0.004). They were also more likely to experience general practitioner contacts (adjusted IRR=1.11, 95% CI 1.06 to 1.16, p<0.001), but other endpoints were not significantly different between the groups.ConclusionsThe integrated care pathway was not associated with a reduction in healthcare utilisation in the first year, but appeared to have increased elective inpatient admissions and general practitioner workload.

Why do evaluations of integrated care not produce the results we expect?

“…Within our own work and elsewhere, we have found a number of curious cases in which the data suggest that people receiving integrated care were using some hospital services more than a carefully selected group of matched controls. [1][2][3] Studies like these stick out, even in an equivocal evidence base that cannot agree whether integrated care initiatives can reduce the use or cost of services in the community and in hospitals. [4][5][6][7] The curious studies we highlight raise questions about why such unexpected results are still being found decades into the integrated care journey in England, and whether the aims of integration, specifically surrounding reducing hospital admissions and improving system efficiency, will ever be consistently achieved.…”

What could prevent chronic condition admissions assessed as preventable in rural and metropolitan contexts? An analysis of clinicians’ perspectives from the DaPPHne study

“…Our understanding of which interventions work to reduce PPH is evolving over time and many interventions, whilst demonstrating improvements in quality of life measures and patient satisfaction do not report improvements in hospital admissions [ 6 , 33 , 34 , 40 , 41 ]. Indeed some studies have reported interventions which have led to increased admissions [ 6 , 42 ].…”

Evidence of integrated primary-secondary health care in low-and middle-income countries: protocol for a scoping review

“…Within the hierarchical structure of the health system, IPSCS can bring "closer-to-community services" within broader management (organizational integration) or provide the opportunity for functional, clinical, or service level integration (4). It opens the prospect for organized service delivery between primary care provider and specialist, leading to early detection of disease, improved quality of care, better follow-up, and patient outcome (6-10)-howevereffectiveness of the integration varies by context and interventions (11).…”