Cost-effectiveness of a patient-centred approach to managing multimorbidity in primary care: a pragmatic cluster randomised controlled trial

Joanna Thorn; Mei-See Man; Katherine Chaplin; Peter Bower; Sara Brookes; Daisy Gaunt; Bridie Fitzpatrick; Caroline Gardner; Bruce Guthrie; Sandra Hollinghurst; Victoria Lee; Stewart W. Mercer; Chris Salisbury

doi:10.1136/bmjopen-2019-030110

Cost-effectiveness of a patient-centred approach to managing multimorbidity in primary care: a pragmatic cluster randomised controlled trial

Joanna Thorn (Lead / Corresponding author), Mei-See Man, Katherine Chaplin, Peter Bower, Sara Brookes, Daisy Gaunt, Bridie Fitzpatrick, Caroline Gardner, Bruce Guthrie, Sandra Hollinghurst, Victoria Lee, Stewart W. Mercer, Chris Salisbury

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Abstract

Objective: Patients with multiple chronic health conditions are often managed in a disjointed fashion in primary care, with annual review clinic appointments offered separately for each condition. This study aimed to determine the cost-effectiveness of the 3D intervention, which was developed to improve the system of care.

Design: Economic evaluation conducted alongside a pragmatic cluster-randomised trial.

Setting: General practices in three centres in England and Scotland.

Participants: 797 adults with three or more chronic conditions were randomised to the 3D intervention, while 749 participants were randomised to receive usual care.

Intervention: The 3D approach: comprehensive 6-monthly general practitioner consultations, supported by medication reviews and nurse appointments.

Primary and secondary outcome measures: The primary economic evaluation assessed the cost per quality-adjusted life year (QALY) gained from the perspective of the National Health Service (NHS) and personal social services (PSS). Costs were related to changes in a range of secondary outcomes (QALYs accrued by both participants and carers, and deaths) in a cost-consequences analysis from the perspectives of the NHS/PSS, patients/carers and productivity losses.

Results: Very small increases were found in both QALYs (adjusted mean difference 0.007 (-0.009 to 0.023)) and costs (adjusted mean difference £126 (£-739 to £991)) in the intervention arm compared with usual care after 15 months. The incremental cost-effectiveness ratio was £18 499, with a 50.8% chance of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY (55.8% at £30 000 per QALY).

Conclusions: The small differences in costs and outcomes were consistent with chance, and the uncertainty was substantial; therefore, the evidence for the cost-effectiveness of the 3D approach from the NHS/PSS perspective should be considered equivocal.

Trial registration number: ISCRTN06180958.

Original language	English
Article number	e030110
Number of pages	10
Journal	BMJ Open
Volume	10
Issue number	1
Early online date	19 Jan 2020
DOIs	https://doi.org/10.1136/bmjopen-2019-030110
Publication status	Published - Jan 2020

Keywords

economic evaluation
multimorbidity
patient-centred care
primary care

ASJC Scopus subject areas

General Medicine

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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Final Published VersionFinal published version, 614 KBLicence: CC BY

Cite this

Thorn, J., Man, M.-S., Chaplin, K., Bower, P., Brookes, S., Gaunt, D., Fitzpatrick, B., Gardner, C., Guthrie, B., Hollinghurst, S., Lee, V., Mercer, S. W., & Salisbury, C. (2020). Cost-effectiveness of a patient-centred approach to managing multimorbidity in primary care: a pragmatic cluster randomised controlled trial. BMJ Open, 10(1), Article e030110. https://doi.org/10.1136/bmjopen-2019-030110

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abstract = "Objective: Patients with multiple chronic health conditions are often managed in a disjointed fashion in primary care, with annual review clinic appointments offered separately for each condition. This study aimed to determine the cost-effectiveness of the 3D intervention, which was developed to improve the system of care.Design: Economic evaluation conducted alongside a pragmatic cluster-randomised trial.Setting: General practices in three centres in England and Scotland.Participants: 797 adults with three or more chronic conditions were randomised to the 3D intervention, while 749 participants were randomised to receive usual care.Intervention: The 3D approach: comprehensive 6-monthly general practitioner consultations, supported by medication reviews and nurse appointments.Primary and secondary outcome measures: The primary economic evaluation assessed the cost per quality-adjusted life year (QALY) gained from the perspective of the National Health Service (NHS) and personal social services (PSS). Costs were related to changes in a range of secondary outcomes (QALYs accrued by both participants and carers, and deaths) in a cost-consequences analysis from the perspectives of the NHS/PSS, patients/carers and productivity losses.Results: Very small increases were found in both QALYs (adjusted mean difference 0.007 (-0.009 to 0.023)) and costs (adjusted mean difference £126 (£-739 to £991)) in the intervention arm compared with usual care after 15 months. The incremental cost-effectiveness ratio was £18 499, with a 50.8% chance of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY (55.8% at £30 000 per QALY).Conclusions: The small differences in costs and outcomes were consistent with chance, and the uncertainty was substantial; therefore, the evidence for the cost-effectiveness of the 3D approach from the NHS/PSS perspective should be considered equivocal.Trial registration number: ISCRTN06180958.",

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author = "Joanna Thorn and Mei-See Man and Katherine Chaplin and Peter Bower and Sara Brookes and Daisy Gaunt and Bridie Fitzpatrick and Caroline Gardner and Bruce Guthrie and Sandra Hollinghurst and Victoria Lee and Mercer, {Stewart W.} and Chris Salisbury",

note = "{\textcopyright} Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.",

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Thorn, J, Man, M-S, Chaplin, K, Bower, P, Brookes, S, Gaunt, D, Fitzpatrick, B, Gardner, C, Guthrie, B, Hollinghurst, S, Lee, V, Mercer, SW & Salisbury, C 2020, 'Cost-effectiveness of a patient-centred approach to managing multimorbidity in primary care: a pragmatic cluster randomised controlled trial', BMJ Open, vol. 10, no. 1, e030110. https://doi.org/10.1136/bmjopen-2019-030110

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T1 - Cost-effectiveness of a patient-centred approach to managing multimorbidity in primary care

T2 - a pragmatic cluster randomised controlled trial

AU - Thorn, Joanna

AU - Man, Mei-See

AU - Chaplin, Katherine

AU - Bower, Peter

AU - Brookes, Sara

AU - Gaunt, Daisy

AU - Fitzpatrick, Bridie

AU - Gardner, Caroline

AU - Guthrie, Bruce

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AU - Mercer, Stewart W.

AU - Salisbury, Chris

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AB - Objective: Patients with multiple chronic health conditions are often managed in a disjointed fashion in primary care, with annual review clinic appointments offered separately for each condition. This study aimed to determine the cost-effectiveness of the 3D intervention, which was developed to improve the system of care.Design: Economic evaluation conducted alongside a pragmatic cluster-randomised trial.Setting: General practices in three centres in England and Scotland.Participants: 797 adults with three or more chronic conditions were randomised to the 3D intervention, while 749 participants were randomised to receive usual care.Intervention: The 3D approach: comprehensive 6-monthly general practitioner consultations, supported by medication reviews and nurse appointments.Primary and secondary outcome measures: The primary economic evaluation assessed the cost per quality-adjusted life year (QALY) gained from the perspective of the National Health Service (NHS) and personal social services (PSS). Costs were related to changes in a range of secondary outcomes (QALYs accrued by both participants and carers, and deaths) in a cost-consequences analysis from the perspectives of the NHS/PSS, patients/carers and productivity losses.Results: Very small increases were found in both QALYs (adjusted mean difference 0.007 (-0.009 to 0.023)) and costs (adjusted mean difference £126 (£-739 to £991)) in the intervention arm compared with usual care after 15 months. The incremental cost-effectiveness ratio was £18 499, with a 50.8% chance of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY (55.8% at £30 000 per QALY).Conclusions: The small differences in costs and outcomes were consistent with chance, and the uncertainty was substantial; therefore, the evidence for the cost-effectiveness of the 3D approach from the NHS/PSS perspective should be considered equivocal.Trial registration number: ISCRTN06180958.

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Cost-effectiveness of a patient-centred approach to managing multimorbidity in primary care: a pragmatic cluster randomised controlled trial

Abstract

Keywords

ASJC Scopus subject areas

UN SDGs

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