The effectiveness and cost effectiveness of the PAtient-Centred Team (PACT) model: study protocol of a prospective matched control before-and-after study

Trine S Bergmo, Gro K Berntsen, Monika Dalbakk, Markus Rumpsfeld, Trine S Bergmo, Gro K Berntsen, Monika Dalbakk, Markus Rumpsfeld

Abstract

Background: The present study protocol describes the evaluation of a comprehensive integrated care model implemented at two hospital sites at the University Hospital of North Norway (UNN). The PAtient Centred Team (PACT) model includes proactive, patient-centred interdisciplinary teams that aim to improve the continuum and quality of care of frail elderly patients and reduce health care costs. The main objectives of the evaluation are to analyse the effectiveness and cost effectiveness of using patient-centred teams as part of routine service provision for this patient group. The evaluation will analyse the effect on patient health and functional status, patient experiences and hospital utilisation, and it will conduct an economic evaluation. This paper describes the PACT model and the rationale for and design of the planned effectiveness and cost-effectiveness study.

Methods/design: This is a prospective, non-randomised matched control before-and-after intervention study. Patients in the intervention group will be recruited from the hospital sites that have implemented the PACT model. The controls will be recruited from two hospitals without the model. The control patients and the index patients will be matched according to sex, age and number of long-term conditions. The study aims to include 600 patients in each group, which will provide sufficient power to detect a clinical change in the primary outcome. The primary outcome is the physical dimension of the Short Form Health Survey (SF-36). Secondary outcomes are the Patient Generated Index (PGI), the Patient Activation Measure (PAM), the Patient Assessment of Chronic Illness Care (PACIC), hospitalisation and length of stay. The cost-effectiveness study takes a health provider perspective and calculates the cost per quality-adjusted life-years (QALYs) gained. The data will be collected at baseline, 6 and 12 months. The data will be analysed using techniques and models that recognise the lack of randomisation and the correlation of cost and effect data.

Discussion: The study results will provide knowledge about whether the integrated care model implemented at UNN improves the quality of care for the frail elderly with multiple conditions. The study will establish whether the PAC. T model improves health and functional status and is cost effective compared to the usual care for this patient group.

Trial registration: ClinicalTrials.gov: NCT02541474.

References

    1. Courtney MD, Edwards HE, Chang AM, Parker AW, Finlayson K, Hamilton K. A randomised controlled trial to prevent hospital readmissions and loss of functional ability in high risk older adults: a study protocol. BMC Health Serv Res. 2011;11:202. doi: 10.1186/1472-6963-11-202.
    1. The Norwegian Directorate of Health, Oslo. 2015. Norwegian Patient Register. Accessed 1 May 2015.
    1. Merrill CT, Elixhauser A. Hospitalization in the United States, 2002. HCUP fact book no. 6. Rockville, MD: Agency for Healthcare Research and Quality, June 2005. (AHRQ publication no. 05-0056.)
    1. Conroy S, Ferguson C, Woodard J, Banerjee J. Interface geriatrics: evidence-based care for frail older people with medical crises. Br J Hosp Med. 2010;71(2):98–101. doi: 10.12968/hmed.2010.71.2.46488.
    1. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002;39(3):238–247. doi: 10.1067/mem.2002.121523.
    1. Tinetti ME, Fried T, Boyd C. Designing health care for the most common chronic condition—multimorbidity. JAMA. 2012;307(23):2493–2494. doi: 10.1001/jama.2012.5265.
    1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646–651. doi: 10.1046/j.1525-1497.2003.20722.x.
    1. Mesteig M, Helbostad JL, Sletvold O, Røsstad T, Saltvedt I. Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study. BMC Health Serv Res. 2010;10(1):1. doi: 10.1186/1472-6963-10-1.
    1. Ministery of Health and Care Services. The Coordination Reform, Proper treatment - at the right place at the right time. Report no. 47 to the Storting. Oslo 2009.
    1. Mudge A, Laracy S, Richter K, Denaro C. Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care. Intern Med J. 2006;36(9):558–563. doi: 10.1111/j.1445-5994.2006.01135.x.
    1. Glynn LG, Valderas JM, Healy P, Burke E, Newell J, Gillespie P, Murphy AW. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract. 2011;28(5):516–523. doi: 10.1093/fampra/cmr013.
    1. Baker DP, Day R, Salas E. Teamwork as an essential component of high-reliability organizations. BMC Health Serv Res. 2006;41(4 Pt 2):1576–1598. doi: 10.1111/j.1475-6773.2006.00566.x.
    1. Trivedi D, Goodman C, Gage H, Baron N, Scheibl F, Iliffe S, Manthorpe J, Bunn F, Drennan V. The effectiveness of inter-professional working for older people living in the community: a systematic review. Health Soc Care Community. 2013;21(2):113–128. doi: 10.1111/j.1365-2524.2012.01067.x.
    1. Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 2012;18(4):Cd006560.
    1. Ke KM, Blazeby JM, Strong S, Carroll FE, Ness AR, Hollingworth W. Are multidisciplinary teams in secondary care cost-effective? A systematic review of the literature. Cost Eff Resour Alloc. 2013;11(1):7. doi: 10.1186/1478-7547-11-7.
    1. Bakker FC, Robben SH, Olde Rikkert MG. Effects of hospital-wide interventions to improve care for frail older inpatients: a systematic review. BMJ Qual Saf. 2011;20(8):680–691. doi: 10.1136/bmjqs.2010.047183.
    1. Berntsen G, Høyem A, Gammon D. [The health service seen from a patient perspective]. Norwegian Center for Integrated Care and Telemedicine, Helse Nord RHF; 2014 (In Norwegian)
    1. Ministy of Health and Care Services. The Coordination Reform, Proper treatment - at the right place at the right time. Report no. 47 to the Storting. Oslo 2009.
    1. Institute of Medicine, authors. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
    1. World Health Organization. Innovative care for chronic conditions: building blocks for action. Geneva: World Health Organization; 2002
    1. Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Hirani S, Cartwright M, Rixon L, Knapp M, Henderson C. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ. 2012;344:e3874. doi: 10.1136/bmj.e3874.
    1. Scott IA. Chronic disease management: a primer for physicians. Intern Med J. 2008;38(6):427–437. doi: 10.1111/j.1445-5994.2007.01524.x.
    1. de Bruin SR, Versnel N, Lemmens LC, Molema CCM, Schellevis FG, Nijpels G, Baan CA. Comprehensive care programs for patients with multiple chronic conditions: A systematic literature review. Health Policy. 2012;107(2-3):108–145. doi: 10.1016/j.healthpol.2012.06.006.
    1. Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, Trescott CE, Erikson M, Larson EB. The group health medical home at year Two: Cost savings, higher patient satisfaction, and less burnout for providers. Health Aff. 2010;29(5):835. doi: 10.1377/hlthaff.2010.0158.
    1. Bayliss EA, Ellis JL, Steiner JF, Main DS, Bayliss EA. Initial validation of an instrument to identify barriers to self-management for persons with co-morbidities. Chronic Illn. 2005;1(4):315–320. doi: 10.1177/17423953050010040101.
    1. Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH. Improving the quality of health care for chronic conditions. Qual Saf Health Care. 2004;13(4):299–305. doi: 10.1136/qshc.2004.010744.
    1. Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ. 2007;335(7609):24. doi: 10.1136/bmj.39246.581169.80.
    1. Reeves BC, Deeks JJ, Higgins JP. Including non-randomized studies. Cochrane handbook for systematic reviews of interventions. 2008;1:391.
    1. Rubin DB. Estimating causal effects from large data sets using propensity scores. Ann Intern Med. 1997;127:757–763. doi: 10.7326/0003-4819-127-8_Part_2-199710151-00064.
    1. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70(1):41–55. doi: 10.1093/biomet/70.1.41.
    1. Ware JE, Bayliss MS, Rogers WH, Kosinski M, Tarlov AR. Differences in 4-year health outcomes for elderly and poor, chronically III patients treated in HMO and fee-for-service systems: results from the medical outcomes study. JAMA. 1996;276(13):1039–1047. doi: 10.1001/jama.1996.03540130037027.
    1. Cohen HJ, Feussner JR, Weinberger M, Carnes M, Hamdy RC, Hsieh F, Phibbs C, Courtney D, Lyles KW, May C. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Eng J Med. 2002;346(12):905–912. doi: 10.1056/NEJMsa010285.
    1. Reuben DB, Frank JC, Hirsch SH, McGuigan KA, Maly RC. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. J Am Geriatr Soc. 1999;47(3):269–76. doi: 10.1111/j.1532-5415.1999.tb02988.x.
    1. Fortin M, Dionne J, Pinho G, Gignac J, Almirall J, Lapointe L. Randomized controlled trials: do they have external validity for patients with multiple comorbidities? Ann Fam Med. 2006;4(2):104–108. doi: 10.1370/afm.516.
    1. Van Royen P, Rees CE, Groenewegen P. Patient-centred interprofessional collaboration in primary care: challenges for clinical, educational and health services research. Eur J Gen Pract. 2014;20(4):327–32. doi: 10.3109/13814788.2014.908462.
    1. Klokkerud M, Grotle M, Løchting I, Kjeken I, Hagen KB, Garratt AM. Psychometric properties of the Norwegian version of the patient generated index in patients with rheumatic diseases participating in rehabilitation or self-management programmes. Rheumatology (Oxford) 2013;52(5):924–932. doi: 10.1093/rheumatology/kes401.
    1. Martin F, Camfield L, Rodham K, Kliempt P, Ruta D. Twelve years’ experience with the Patient Generated Index (PGI) of quality of life: a graded structured review. Qual Life Res. 2007;16(4):705–715. doi: 10.1007/s11136-006-9152-6.
    1. Hibbard JH, Mahoney ER, Stockard J, Tusler M, Hibbard JH, Mahoney ER, Stockard J, Tusler M. Development and testing of a short form of the patient activation measure. BMC Health Serv Res. 2005;40:1918–1930. doi: 10.1111/j.1475-6773.2005.00438.x.
    1. Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM. Development and validation of the Patient Assessment of Chronic Illness Care (PACIC) Med Care. 2005;43(5):436–444. doi: 10.1097/01.mlr.0000160375.47920.8c.
    1. A community for measureing health outcomes using SF tools. SF-36® Health Survey Update. .
    1. Brazier J, Harper R, Jones N, O’cathain A, Thomas K, Usherwood T, Westlake L. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ. 1992;305(6846):160. doi: 10.1136/bmj.305.6846.160.
    1. Torrance N, Smith BH, Lee AJ, Aucott L, Cardy A, Bennett MI. Analysing the SF-36 in population-based research. A comparison of methods of statistical approaches using chronic pain as an example. J Eval Clin Pract. 2009;15(2):328–334. doi: 10.1111/j.1365-2753.2008.01006.x.
    1. Kuznetsov L, Simmons RK, Sandbaek A, Maindal HT. The impact of intensive multifactorial treatment on perceptions of chronic care among individuals with screen-detected diabetes: results from the ADDITION-Denmark trial. J Eval Clin Pract. 2015;69(4):466–473. doi: 10.1111/ijcp.12570.
    1. Aung E, Donald M, Williams GM, Coll JR, Doi SAR. Joint influence of patient-assessed chronic illness care and patient activation on glycaemic control in type 2 diabetes. Int J Qual Health Care. 2015;27(2):117–124.
    1. Casillas A, Iglesias K, Flatz A, Burnand B, Peytremann-Bridevaux I. No consistent association between processes-of-care and health-related quality of life among patients with diabetes: a missing link? BMJ Open Diabetes Res Care. 2015;3(1):e000042. doi: 10.1136/bmjdrc-2014-000042.
    1. Fan J, McCoy RG, Ziegenfuss JY, Smith SA, Borah BJ, Deming JR, Montori VM, Shah ND. Evaluating the structure of the patient assessment of chronic illness care (PACIC) survey from the patient’s perspective. Ann Behav Med. 2015;49(1):104–111. doi: 10.1007/s12160-014-9638-3.
    1. Nocon RS, Gao Y, Gunter KE, Jin J, Casalino LP, Quinn MT, Derrett S, Summerfelt WT, Huang ES, Lee SM, et al. Associations between medical home characteristics and support for patient activation in the safety net: understanding differences by race, ethnicity, and health status. Med Care. 2014;52(11 Suppl 4):S48–55. doi: 10.1097/MLR.0000000000000198.
    1. Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods. 2002;7(2):147–177. doi: 10.1037/1082-989X.7.2.147.
    1. Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, Augustovski F, Briggs AH, Mauskopf J, Loder E. Consolidated health economic evaluation reporting standards (CHEERS) statement. Cost Eff Resour Alloc. 2013;11(1):6. doi: 10.1186/1478-7547-11-6.
    1. Brazier J, Roberts J, Deverill M. The estimation of a preference-based measure of health from the SF-36. J Health Econ. 2002;21(2):271–292. doi: 10.1016/S0167-6296(01)00130-8.
    1. Brazier JE, Roberts J. The estimation of a preference-based measure of health from the SF-12. Med Care. 2004;42(9):851–859. doi: 10.1097/01.mlr.0000135827.18610.0d.
    1. Manca A, Hawkins N, Sculpher MJ. Estimating mean QALYs in trial-based cost-effectiveness analysis: the importance of controlling for baseline utility. Health Econ. 2005;14(5):487–496. doi: 10.1002/hec.944.
    1. Manca A, Rice N, Sculpher MJ, Briggs AH. Assessing generalisability by location in trial-based cost-effectiveness analysis: the use of multilevel models. Health Econ. 2005;14(5):471–485. doi: 10.1002/hec.914.
    1. Drummond M, O’Brien B, Stoddart G, Torrance G. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 1997.
    1. The Norwegian Directorate of Health. Economic evaluation of health services - a guide. Oslo: The Norwegian Directorate of Health; 2012. (Publication no. IS-1985)
    1. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, Tyrer P. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000;321(7262):694–696. doi: 10.1136/bmj.321.7262.694.
    1. Coulter A, Entwistle Vikki A, Eccles A, Ryan S, Shepperd S, Perera R. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev. 2015;3:CD010523.
    1. Pal K, Eastwood Sophie V, Michie S, Farmer Andrew J, Barnard Maria L, Peacock R, Wood B, Inniss Joni D, Murray E. Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2013;3:CD008776.
    1. Gibson Peter G, Powell H, Wilson A, Abramson Michael J, Haywood P, Bauman A, Hensley Michael J, Walters EH, Roberts Jennifer JL. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev. 2003;1:CD001117.
    1. Holman H, Lorig K. Patient self-management: a key to effectiveness and efficiency in care of chronic disease. Public Health Rep. 2004;119(3):239. doi: 10.1016/j.phr.2004.04.002.
    1. Horne M, Khan H, Corrigan P. People powered health: health for people, by people and with people. London: Nesta; 2013.

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