What this evidence tells us

IAU evaluations of three MDT initiatives in England

Across the three MDT programmes we evaluated, emergency hospital use among those enrolled in MDTs was higher than for those in the comparison groups over the study periods (Figure 1). Individuals were followed for on average 7 months in the EPC and ICT evaluations and 13 months in the ECS evaluation.

ICT: Integrated care teams in North East Hampshire and Farnham; ECS: Extensive care services in Fylde Coast; EPC: Enhanced primary care in Fylde Coast

Note: for results on a wider number of outcomes, see original reports

Potential limitations of the analysis

The evaluations compared hospital use between patients referred to MDTs and other individuals who were similar across a range of characteristics, including demographics, level of deprivation, long-term conditions and prior hospital use. However, the groups could differ in subtle ways. For example, in NEHF, patients were identified through clinical judgement, which could be based on information we did not have access to, such as social isolation. Among patients enrolled on the EPC in Fylde Coast, a statistically significant higher number died than in the comparison group, which might indicate they were more severely ill than their comparison group. However, because of the large differences in emergency hospital use between MDT patients and those in the comparison groups, it is unlikely that any difference between the groups could mask an actual decrease in hospital use. We therefore concluded that the three MDTs did not reduce emergency hospital use during the period of the studies, and may even have led to increases.

Evidence was mixed on a variety of other hospital measures, including elective admissions and outpatient appointments. Emergency hospital bed days were higher for patients enrolled in EPC in Fylde Coast and emergency hospital average length of stay was higher in NEHF.,

IAU evaluations of the longer term impact of integrated care programmes with MDTs

When we looked at the longer term impact of the integrated care programmes, the results were not consistent across outcomes, vanguard areas or population groups. However, in general the programmes had very little impact on emergency hospital use in the first couple of years, but there were indications of a reduction in some areas over a longer time period.

Looking at the population aged 65 years and older – which better reflects the MDT patient population – results were also inconsistent between studies, but some of the emergency hospital use metrics showed signs of improvement relative to the comparison area over a period of 3 to 5 years (Figure 2).

In NEHF we saw evidence of reductions in emergency admissions from year 3 relative to the comparison area and there were consistently fewer emergency admissions requiring an overnight stay in years 3–5. The average length of overnight stay, however, was higher from year 2. There was no significant difference in A&E attendances in NEHF apart from lower rates in year 1.

In both Blackpool and Fylde and Wyre, there was an indication that rates in emergency admissions relative to the comparison areas were decreasing over time, though this was not statistically significant. Both vanguards showed signs of a trend towards lower A&E attendances over time, although this was only significant in Blackpool in year 4.

In Mid-Nottinghamshire, emergency admissions were higher in year 4 but there was a trend towards lower rates in years 5 and 6 relative to the comparison area. Rates of A&E attendances were no longer significantly higher relative to the comparison area in years 5 and 6.

Note: The vertical line denotes the start of the integrated care programme.

Wider evidence of MDT impacts

Overall, broader evidence of the impact of MDTs was limited and mixed (see Appendix, Table 2 for further details). Studies assessing the impact of MDTs on health outcomes, such as mortality or quality of life, typically found no, limited or mixed evidence of impact.,,, A review of MDTs on quality of life for patients with chronic conditions, for instance, found most studies reported mixed outcomes. A review of ‘intensive’ primary care interventions involving MDTs found most studies showed no significant impact on mortality.

Evidence on quality and use of services was also mixed.,,,,,, Meta-analysis of nurse-led integrated care models involving MDTs, for instance, found no effect on hospital admissions, emergency department visits or nursing home admissions. Meta-analysis of case management interventions for ‘at risk’ patients in primary care also found no effect on primary and secondary care use, whether case management was delivered by an MDT or not. A review of integration between primary care professionals and care homes looked at a mix of measures on the effectiveness of interventions, such as prescribing and health outcomes, and found mixed or no effect.

Some reviews found more positive impacts for some types of MDTs. One focused on a wide variety of integrated care interventions and overall found that these models may increase access to care and improve patient experience., Evidence was mixed for the MDT interventions overall within this review, though results of UK studies of MDTs implemented alongside other interventions – described by the authors as more ‘complex’ MDT interventions – were generally positive, including perceived improvements in quality and access and some reductions in hospital use.

Another review explored the impact of MDTs on hospital use for patients with chronic conditions. It found that MDTs focused on general chronic disease management reported mixed or no effect, while MDTs focused on single conditions (typically heart failure) reported some reductions in hospital use. Across the mix of studies we reviewed, robust evidence on the impacts of MDTs on care costs was limited.,,,

* In the population aged 18 years and older, there were significantly fewer A&E attendances and emergency admissions by years 6 and 5, respectively.

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