Effectiveness of multidisciplinary team case management: Direct and/or spill-over effects?
The primary method of integrating care at the service delivery level appears to rely on case management of ‘high-risk’ individuals in primary care. We aimed to evaluate a multidisciplinary team (MDT) case management intervention using a robust quasi-experimental study design, modelling effects at both the individual- (to capture direct effects of intervention) and practice-levels (to capture any potential spill-over effects of integrated care for the wider system).
We used a difference-in-differences design with multiple start dates.At the individual-level, we matched 2049 intervention patients using propensity scoring one-to-one with control patients. At the practice-level, we exploited the natural experiment of gradual roll-out of the intervention to 30 practices in a Clinical Commissioning Group.Primary measures, according to intervention aims were: A&E visits; inpatient non-elective admissions, 30-day re-admissions; inpatient elective admissions; 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).
At 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).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.
Here we show that MDT case management does not fulfil its primary aim, preventing emergency admissions for the high-risk patients it targets. However, we do show some indications of what may be small beneficial spill-over effects of MDT working at the practice-level, but these results do not withstand our robustness check and require further examination. An intervention which does not fulfil its primary aim may nevertheless be a poor substitute to alternatives for achieving professional integration and its potential system benefits. This study, however, indicates that these system benefits may be possible through multidisciplinary working. Case management alone may never be as effective as it needs to be to deliver major savings through a focus on high risk groups. This highlights the need for a variety of models to deal with system pressures, including integrated care at different levels of the health and care system, and with more of a focus on the wider population.