Effectiveness and cost-effectiveness of an integrated primary care approach to improve well-being of frail community-dwelling older persons

Abstract

Introduction: Care for older persons is one of the greatest challenges in healthcare. Integrated care approaches are increasingly advocated as means to redesign primary healthcare. The aim of our study was to evaluate the effectiveness and cost-effectiveness of a proactive, integrated care approach to improve well-being of frail community-living older people, which is called ‘Finding and Follow-up of Frail older persons’ (FFF). Methods: FFF approach: The aim of the FFF approach is to redesign primary care for frail older persons in order to improve their well-being. An integrated primary care system is established in which frail older people receive a continuum of (healthcare) services according to their needs and through different professionals. The FFF approach consists of multiple interrelated elements, such as proactive case finding, case management, medication review, self-management support, and working in multidisciplinary teams. Evaluation study: The study had a matched quasi-experimental design and was conducted in the Netherlands between September 2014 and July 2016. The study included an intervention group (11 GP practices that implemented the FFF approach) and a control group (4 GP practices delivering care as usual). The target population consisted of frail community-dwelling older persons (≥ 75 years). Primary outcomes were well-being and health-related quality of life. Several secondary outcomes were measured, like quality of care. We assessed intervention costs, healthcare costs, and patient-related costs. Data were collected at baseline and 12 months after and were analyzed by intention-to-treat using univariate, multivariate, and multilevel methods. Results: Frailty was assessed among 2956 older persons registered at the 15 GP practices. In total 42.2% of these older people were identified as frail. At baseline, 464 frail older persons were included in the evaluation study (n=232 in each group). Follow-up rates were 78.4% (n=182) in the intervention group and 75.9% (n=176) in the control group at 12 months. The groups were comparable in baseline characteristics except for marital status. There were no significant differences between the intervention group and control group with respect to well-being and health-related quality of life at 12 months follow-up. There were no significant differences between the groups in total costs over 12 months. We found significant improvements in perceived quality of care in the intervention group over time. Discussion and conclusion: We found no evidence for the (cost-)effectiveness of the proactive, integrated care approach FFF. However, based on earlier research we expect improvements in quality of care to positively influence patient outcomes in the long term. Our study contributes to the emerging body of evidence that underlines the complexity of integrated care. We will therefore provide valuable insights into the processes, barriers and facilitators, and underlying theoretical mechanisms of integrated primary care that help to increase our understanding of the complexity and (lack of) effectiveness. Lessons learned: Our study indicates that the implementation and evaluation of integrated primary care is challenging and complex. Limitations: Selection bias is an important concern in non-randomized studies. We therefore controlled for important factors in the analysis and used one-to-one matching. Suggestions for future research: More research is needed to provide a deeper understanding of the effects of integrated primary care and the underlying mechanisms. An implication for future research is to extend the follow-up period.