Does prevention-focused integration lead to the triple aim? An evaluation of two new care models in England.

Jonathan Stokes,Leontine Goldzahl,Matt Sutton,Søren Rud Kristensen,Vishalie Shah

doi:10.1177/1355819620963500

Abstract

ObjectivesTo examine the effectiveness of two integrated care models (‘vanguards’) in Salford and South Somerset in England, United Kingdom, in relation to patient experience, health outcomes and costs of care (the ‘triple aim’).MethodsWe used difference-in-differences analysis combined with propensity score weighting to compare the two care model sites with control (‘usual care’) areas in the rest of England. We estimated combined and separate annual effects in the three years following introduction of the new care model, using the national General Practice Patient Survey (GPPS) to measure patient experience (inter-organisational support with chronic condition management) and generic health status (EQ-5D); and hospital episode statistics (HES) data to measure total costs of secondary care. As secondary outcomes we measured proxies for improved prevention: cost per user of secondary care (severity); avoidable emergency admissions; and primary care utilisation.ResultsBoth intervention sites showed an increase in total costs of secondary care (approximately £74 per registered patient per year in Salford, £45 in South Somerset) and cost per user of secondary care (£130–138 per person per year). There were no statistically significant effects on health status or patient experience of care. There was a more apparent short-term negative effect on measured outcomes in South Somerset, in terms of increased costs and avoidable emergency admissions, but these reduced over time.ConclusionNew care models such as those implemented within the Vanguard programme in England might lead to unintended secondary care cost increases in the short to medium term. Cost increases appeared to be driven by average patient severity increases in hospital. Prevention-focused population health management models of integrated care, like previous more targeted models, do not immediately improve the health system’s triple aim.

Highlights

Health systems globally are attempting to integrate care in response to demographic changes and economic challenges,[1] with an increasing emphasis on what has been referred to as the ‘triple aim’,2 that is the simultaneous improvement of patient experience and health status while reducing the cost of health care
There were no statistically significant differences in intervention sites compared to controls in terms of patient experience or health status as measured by EQ5D
We found that South Somerset had consistently higher total cost of secondary care for multimorbid patients, whereas Salford did not

Summary

Introduction

Health systems globally are attempting to integrate care in response to demographic changes and economic challenges,[1] with an increasing emphasis on what has been referred to as the ‘triple aim’,2 that is the simultaneous improvement of patient experience and health status while reducing the cost of health care. More recently there has been greater focus on what has been described as population health management, with integrated care models seeking to take a (geographically defined) whole-systems approach and to improve outcomes for the local population.[6] This approach targets ‘place’ rather than a specific patient group and tends to place greater emphasis on disease prevention (in the relatively healthy general population) rather than high-risk patient management. This study examined two novel models of integrated care that were implemented in England and that sought to take a more population health management approach We evaluated their effectiveness in terms of patient experience, health outcomes and costs of care (‘triple aim’), with a particular focus on the prevention-centred aspects of the care model

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