|Summary / Abstract |
The rising burden of chronic disease, and the number of people with complex
care needs in particular, require the development of delivery systems that bring
together a range of professionals and skills from both the cure (health-care) and
care (long-term and social-care) sectors. Failure to better integrate or coordinate
services along the care continuum may result in suboptimal outcomes and
available evidence of integrated care programmes points to a positive impact
on the quality of patient care and improved health or patient satisfaction
outcomes. However, uncertainty remains about the relative effectiveness of
different system-level approaches on care coordination and outcomes, with
particular scarcity of robust evidence on the economic impacts of integrated
This report provides a summary of published reviews on the economic
impacts of integrated care approaches. Given the wide range of defi nitions
and interpretations of the concept, we propose a working defi nition that
builds on the goal of integrated care and which considers 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.
Based on a systematic search of Pubmed, Embase and the Cochrane Library,
we identifi ed a total of 963 references, of which 19 reviews were identifi ed
as eligible for inclusion. We analysed reviews for three economic outcomes:
utilization, cost–effectiveness and cost or expenditure. The latter were
combined because most studies used these interchangeably. For completeness,
we also extracted data on core health outcomes such as health status, quality
of life or mortality, as well as process measures.
None of the reviews identifi ed by our searches explicitly defi ned
‘integrated care’ as the topic of review.
The most common concepts or terms were case management, care
coordination, collaborative care or a combination of these; four reviews focused
on disease management interventions. The majority of reviews iconsidered
a wide range of approaches and typically only about half of primary studies
included in individual reviews could be considered as integrated care under
our defi nition. Care initiatives frequently targeted the hospital-primary care or
community services interface, while several reviews examined the coordination
of primary care and community services, often, although not always, involving
medical specialists, or extending further into social care services. Utilization and cost were the most common economic outcomes
assessed by reviews but reporting of measures was inconsistent
and the quality of the evidence was often low.
The majority of economic outcomes focused on hospital utilization through
(re)admission rates, length of stay or admission days and emergency department
visits. Findings tended to be mixed within each review, which makes it diffi cult
to draw fi rm conclusions. Also, results were commonly not quantifi ed, making
an overall assessment of the size of possible effects problematic. Seventeen
reviews reported cost and/or expenditure data in some form, typically reporting
cost in terms of health-care cost savings resulting from the intervention, most
frequently in relation to hospital costs. There was some evidence of cost
reduction in a number of reviews; however, fi ndings were frequently based on
a small number of original studies only, or studies that only used a before–after
design without control, or both.
There is evidence of cost–effectiveness of selected integrated care
approaches but the evidence base remains weak. Eight of the nineteen
studies reported on cost–effectiveness.
There was some evidence from one review of approaches targeting frequent
hospital emergency department users that found one trial to report the
intervention to be cost-effective. Based on one economic evaluation, one other
review concluded that there was little or no evidence of incremental QALY gain
over usual care of structured home-based, nurse-led health promotion for older
people at risk of hospital or care home admission. Six reviews reported on cost
per QALY as a measure of cost–utility, suggesting increased cost associated
with the integrated care approach in question in some studies but not others.
Overall the evidence was diffi cult to interpret.
The majority of studies reviewed echo the concerns reported in earlier
assessments of the evidence of integrated care interventions. Thus, it remains
challenging to interpret the evidence from existing primary studies, which tend
to be characterized by heterogeneity in the defi nition and description of the
intervention and components of care under study. Variation in defi nitions and
components of care, and failure to recognize these variations, might lead to
inappropriate conclusions about programme effectiveness and the application
of fi ndings.
Based on the evidence presented here, there may be a need to revisit our
understanding of what integrated care is and what it seeks to achieve, and
the extent to which the strategy lends itself to evaluation in a way that would
allow for the generation of clear-cut evidence, given its polymorphous nature.
Fundamentally, it is important to understand whether integrated care is to be
considered an intervention that, by implication, ought to be cost-effective and support fi nancial sustainability, or whether it is to be interpreted and evaluated
as a complex strategy to innovate and implement long-lasting change in the
way services in the health and social-care sectors are being delivered and
that involve multiple changes at multiple levels. Evidence presented here and
elsewhere strongly points to the latter, and initiatives and strategies underway
will require continuous evaluation over extended periods of time enabling
assessment of their impacts both economic and on health outcomes if we are
to generate appropriate conclusions about programme effectiveness and the
application of fi ndings to inform decision making.