This recent report, commissioned by the European Commission and compiled by RAND Europe, aims to summarise economic evaluation evidence on the impact of integrated care. The authors restricted their evidence search to systematic reviews and meta analyses, which is understandable as this is described as a rapid review but the authors acknowledge this has limitations, most notably that very recent studies will have been excluded. Inclusion of grey literature would have identified more studies but on this level, probably wouldn’t have been a small undertaking. The studies identified (19 in total) are listed.
FindingsThe key problem for the authors lies in the quality of the evidence base: studies vary in terms of interventions evaluated and the costs considered; they also tend to be small and results are often not statistically significant. As such, drawing firm conclusions just isn’t possible. The definition of integrated care differs widely – what integrated care means will vary depending on professional perspective, setting and the context of the local health economy. Studies tended to focus on case management, disease management, collaborative care or care coordination. The authors helpfully point to literature categorising integrated care by type, breadth, degree and process; they also suggest their own definition:
Initiatives seeking to improve outcomes for those with (complex) chronic health problems and needs by overcoming issues of fragmentation through linkage or coordination of services of different providers along the continuum of care.
The report opens with a description of the challenges ahead for policy makers: rising numbers of people with long term conditions and multiple comorbidities set against the current fragmentation of health care systems. The authors note the “Triple Aim” approach of integrated care which aims to improve health outcomes, improve patient experience and reduce costs. The report recognises there is some evidence to suggest that savings can be made; however, it is also noted that by identifying unmet needs, even if interventions may be shown to be cost effective, they may not deliver savings. In such instances, longer term outcomes may not be adequately captured in the literature. Studies tend to focus on admissions, readmissions, length of stay and A&E attendance; though the report does identify two studies which include nursing home admissions. Even within studies, the findings are often mixed making it difficult to draw conclusions as to impact. Also, the focus on secondary care measures in research studies (more widely available and easier to extract) does mean we have a gap in our understanding of the impact on the wider health economy such as general practice and social care.
The conclusion that the evidence base remains patchy probably won’t be a surprise to commissioners. Given that many commissioners are working on strategic plans (e.g. in England, the Better Care Fund plans are to be resubmitted), these findings may help to manage expectations.
The authors question whether the focus of integrated care should be on financial sustainability or service transformation, suggesting the evidence suggests the latter.
The report is a timely reminder of the need for rigorous evaluation of initiatives. The report recommends more rigorous evaluation over longer periods of time, with clear definitions of integrated care and its component interventions (and what is considered to be “usual care”) if opportunities to learn from implementations are not lost.
Nolte and Pitchforth (2014) What is the evidence on the economic impacts of integrated care? European Commission, Available at: http://www.euro.who.int/en/about-us/partners/observatory/news/news/2014/06/what-is-the-evidence-on-the-economic-impacts-of-integrated-care