Effectiveness of multidisciplinary team case management: difference-in-differences analysis

Abstract

ObjectivesTo evaluate a multidisciplinary team (MDT) case management intervention, at the individual (direct effects of intervention) and practice levels (potential spillover effects).DesignDifference-in-differences design with multiple intervention start dates, analysing hospital admissions data. In secondary analyses, we stratified individual-level results by risk score.SettingSingle clinical commissioning group (CCG) in the UK's National Health Service (NHS).ParticipantsAt the individual level, we matched 2049 intervention patients using propensity scoring one-to-one with control patients. At the practice level, 30 practices were compared using a natural experiment through staged implementation.InterventionPractice Integrated Care Teams (PICTs), using MDT case management of high-risk patients together with a summary record of care versus usual care.Direct and indirect outcome measuresPrimary measures of intervention effects were accident and emergency (A&E) visits; inpatient non-elective stays, 30-day re-admissions; inpatient elective stays; outpatient visits; and admissions for ambulatory care sensitive conditions. Secondary measures included inpatient length of stay; total cost of secondary care services; and patient satisfaction (at the practice level only).ResultsAt the individual level, we found slight, clinically trivial increases in inpatient non-elective admissions (+0.01 admissions per patient per month; 95% CI 0.00 to 0.01. Effect size (ES): 0.02) and 30-day re-admissions (+0.00; 0.00 to 0.01. ES: 0.03). We found no indication that highest risk patients benefitted more from the intervention. At the practice level, we found a small decrease in inpatient non-elective admissions (−0.63 admissions per 1000 patients per month; −1.17 to −0.09. ES: −0.24). However, this result did not withstand a robustness check; the estimate may have absorbed some differences in underlying practice trends.ConclusionsThe intervention does not meet its primary aim, and the clinical significance and cost-effectiveness of these small practice-level effects is debatable. There is an ongoing need to develop effective ways to reduce unnecessary attendances in secondary care for the high-risk population.

Use of hospital-related health care among Health Links enrollees in the Central Ontario health region: a propensity-matched difference-in-differences study

“…Our findings are consistent with a recent quasi-experimental study from the United Kingdom that showed modest increases in hospital admissions and readmissions among at-risk patients who received multidisciplinary team case management. 25 A randomized controlled trial of guided care teams for multimorbid older adults in the United States showed no reductions in hospital or emergency department use during the 20 months after initial care. 26 In the province of Quebec, use of health care services was comparable between older frail adults assigned to the Program of Research to Integrate Services for the Maintenance of Autonomy community-based care model relative to comparator patients 1 year after intervention; rates of emergency department visits were lower in the experimental group only after 4 years of follow-up.…”

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

“…72 In recent years, UK initiatives have focused on multidisciplinary team (MDT)-led case management but have demonstrated little or no reduction in use of secondary care. 73 Increasingly, attention has focused on the 'added value' of benefits for patients and professionals. 74 Interest in case management has been revived by the new models of care initiatives, with their focus being on integrated care.…”

“…78 The mapping review identified two further quantitative UK studies (three papers) of case management for cardiovascular or respiratory conditions published since 2010. One study examined a COPD population in a single general practice 79 and the other study 73,80 presented data on 20 ACSCs. The six conditions of relevance to this review were asthma, atrial fibrillation, CHD, COPD, heart failure and hypertension.…”

“…80 These tools generate a heterogeneous group of patients, and it may be that there are subgroups for which the direct effects of the intervention are more effective. However, as papers by Stokes et al 73,80 reveal, it can be extremely challenging to identify so-called 'super utilisers' both in terms of the 'safe' margin of those who can be appropriately managed in primary care and, equally, in terms of those for whom the complexity of their comorbidities renders secondary care an appropriate option.…”

The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity

“…26 Similarly the evidence for case management suggests that patient satisfaction can be improved, but cost and self-assessed health are not significantly affected, 34 particularly for the most complex patients and even when conducted by a multidisciplinary team. 35 Finally, although several models were based on reorganization of services using telehealth, evidence suggests this approach may not be cost-effective for managing chronic conditions. 36 Health systems have only recently begun to implement new models of care for multimorbidity, with limited evidence of success.…”