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 languageEnglish
    Article numbere030110
    Pages (from-to)1-10
    Number of pages10
    JournalBMJ Open
    Volume10
    Issue number1
    Early online date19 Jan 2020
    DOIs
    Publication statusPublished - 19 Jan 2020

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    Keywords

    • economic evaluation
    • multimorbidity
    • patient-centred care
    • primary care

    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), 1-10. [e030110]. https://doi.org/10.1136/bmjopen-2019-030110