title: Effectiveness of multidisciplinary team case management: difference-in-differences analysis.
abstract: OBJECTIVE
  To evaluate a multidisciplinary team (MDT) case management intervention, at the individual (direct effects of intervention) and practice levels (potential spillover effects).
  
  
  METHODS
  Difference-in-differences design with multiple intervention start dates, analysing hospital admissions data. In secondary analyses, we stratified individual-level results by risk score.
  
  
  METHODS
  Single clinical commissioning group (CCG) in the UK's National Health Service (NHS).
  
  
  METHODS
  At the individual level, we matched 2049 intervention patients using propensity scoring one-to-one with control patients. At the practice level, 30 practices were compared using a natural experiment through staged implementation.
  
  
  METHODS
  Practice Integrated Care Teams (PICTs), using MDT case management of high-risk patients together with a summary record of care versus usual care.
  Primary measures of intervention effects were accident and emergency (A&E) visits; inpatient non-elective stays, 30-day re-admissions; inpatient elective stays; outpatient visits; and admissions for ambulatory care sensitive conditions. Secondary measures included inpatient length of stay; total cost of secondary care services; and patient satisfaction (at the practice level only).
  
  
  RESULTS
  At the individual level, we found slight, clinically trivial increases in inpatient non-elective admissions (+0.01 admissions per patient per month; 95% CI 0.00 to 0.01. Effect size (ES): 0.02) and 30-day re-admissions (+0.00; 0.00 to 0.01. ES: 0.03). We found no indication that highest risk patients benefitted more from the intervention. At the practice level, we found a small decrease in inpatient non-elective admissions (-0.63 admissions per 1000 patients per month; -1.17 to -0.09. ES: -0.24). However, this result did not withstand a robustness check; the estimate may have absorbed some differences in underlying practice trends.
  
  
  CONCLUSIONS
  The intervention does not meet its primary aim, and the clinical significance and cost-effectiveness of these small practice-level effects is debatable. There is an ongoing need to develop effective ways to reduce unnecessary attendances in secondary care for the high-risk population.
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
authors.forename: Jonathan
authors.identifier: http://orcid.org/0000-0002-3266-1474
authors.initials: J
authors.lastname: Stokes
authors.affiliation: Manchester Centre for Health Economics, University of Manchester, Manchester, UK.
authors.forename: Søren Rud
authors.initials: SR
authors.lastname: Kristensen
authors.affiliation: NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
authors.forename: Kath
authors.initials: K
authors.lastname: Checkland
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Bower
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019090:Case Management / Q000592:standards*; D003362:Cost-Benefit Analysis; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009313:National Health Programs; D010348:Patient Care Team / Q000592:standards*; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D006113:United Kingdom; D055815:Young Adult
keywords: case management; difference-in-differences; integrated care; multidisciplinary team