The number of patients with multimorbidity is becoming so high that if it is not properly addressed, care for them will soon become unsustainable.1,2 Two common characteristics are that their health problems cannot be cured and that their health status is progressively deteriorating.3 In order to improve their care, Yáñez-Cadena et al.4 have underlined the need to adopt a systematic approach to design programs that combine organizational strategies and self-care. The provision of care to these patients is an excellent opportunity for innovation in healthcare integration based on the current healthcare structure, avoiding fragmentation of healthcare, but without excessive structural changes.5

In January 2011, in the Basque Country (Spain), the integrated healthcare organization was established for bringing together the primary and specialized care.6 In this context, an integrated model was introduced, based around an assigned internist and a hospital liaison nurse. However, the effectiveness of multifaceted interventions for preventing the functional decline of elderly patients is still controversial.7 In a review of the literature, Smith et al.8 underlines the need to develop efficient interventions for patients with multimorbidity. To our knowledge, there are no published studies having demonstrated that they are really more efficient than usual care, and none assessing their economic impact in Spain. Generally, it is assumed that these models increase the efficiency and the quality of care provided to patients, and also that they are efficient. However, there is a lack of systematic evaluation, including the assessment of the relative costs and benefits. High quality evidence from well-designed studies is required to supporting decision making on the long-term funding of particular types of integrated care interventions.9

The objective of this study was to assess whether an integrated care model for patients with multimorbidity, based on an assigned internist and a hospital liaison nurse, is efficient compared to the current system based on episodic reactive care.

Between April 2011 and February 2012, we recruited a total of 140 patients with multimorbidity with a mean age of 78.2 years. From them 72% completed an entire year, 25% died, and in the remaining cases (3%), follow-up was stopped as they were admitted to residential care homes. We found no significant differences between the two groups prior to the intervention as summarized in Table 1. In both groups, more than half of the patients had diagnoses in two clinical categories. Overall, 17.8% of patients obtained baseline Barthel Index scores below 60 and hence were classified as dependent.

The description of resource consumption carried out by the control and intervention group is shown in Table 2. No statistical differences were found between the two groups.

Table 3 and Table 4 show which variables had a direct impact on cost and utility of the intervention. We can see there are clear differences in QALYs by sex, age, number of clinical categories, and baseline Barthel Index and EQ-5D utility scores but none of the variables considered had an impact on the total costs when comparing mean values through usual methodology. Results are similar when univariate GLM methods were applied for mean comparison. The crude values indicate that the intervention increased the mean cost per patient by €1,093.1, compared to that for the controls. Moreover, the efficiency in patients from the intervention group was 0.0553 QALY lower.

When analyzing the intervention effect adjusted by other relevant variables (sex, age, number of categories and baseline EQ5D), the results showed similar conclusions as intervention arm remained more expensive and less efficient, both using OLS and GLM (Table 5). In the joint multivariate statistical analysis (Table 5) using the simple model, we found an incremental cost of €1,035.9 and an incremental benefit of −0.0762 QALYs for the intervention compared to usual care, after adjusting for sex, patient age, number of clinical categories and EQ-5D utility score at the beginning of the study. When the interactions of the age and number of clinical categories with the variable group were included (Table 5) we could realize that considering the subgroups of patients under 80 years of age and with chronic health problems in three or more clinical categories, mean costs were lower among those in the IG but without statistical significance. Nonetheless, the benefit was also lower as was the case for all the subgroups analyzed.

In the cost-utility plane (Figure 1), we can see the results corresponding to the bootstrapping method applied to the original sample and the subgroup of those under 80 years old with three or more categories of chronic conditions. Considering the observed variability, we calculated the likelihood of the intervention being cost saving across the simulations performed. The subgroup of people under 80 years of age with conditions in three or more clinical categories resulted cost saving in 89% of the simulations whereas this percentage was 15% for the original sample.

Figure 1.

Cost-utility plane of the intervention under study in the entire sample and in the subsample of patients under 80 years of age with three or more categories of chronic conditions.

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The evaluated integrated healthcare intervention for patients with multimorbidity was not found to be efficient. However, the statistical analysis revealed that in the patients under 80 years of age with a high level of comorbidity (conditions in three or more clinical categories), the intervention decreased costs in 89% of the simulations, although the difference was not statistically significant in that subgroup either. The lack of efficiency was observed across all the subgroups analyzed which was to be expected, given the frailty and risk factors, of the target population.

Our intervention can be described in terms of the Kaiser Permanente model as a case management and our target population being included in the top 5% of the Kaiser pyramid.16,17 Regarding the subgroups analyzed, we consider that patients with multimorbidity who have only two clinical categories of conditions, regardless of age, correspond to the high-risk patients with a lower level of complexity in the Kaiser pyramid, and hence benefits would be more likely to be seen with disease management care models.

Authors that underline the importance of small changes in continuity of care for decreasing costs, resource use and complications, such as Hussey et al.,18 indicate a potential limitation of their research is that the findings might not extrapolate to younger populations, since it focused on adults over 65 years of age. In our study, we did not consider age as an exclusion criterion and conclude that the intervention could be more efficient in those under 80 years of age.

The patients aged 80 years and over with three or more clinical categories of chronic conditions correspond to the apex of the Kaiser pyramid. Besides healthcare (i.e., case management) they require coordination between social and healthcare services, giving priority to maintaining their independence as far as possible.16 Such patients do not benefit from the evaluated model as it has no impact on quality of life or disease progression, and there are more associated costs due to a higher use of healthcare resources. However, they may benefit from the use of care models for end-of-life patients.17,19

Vondeling9 suggested that the general principles of economic evaluation can be adapted to the assessment of integrated care. However, a lack of evidence on efficacy frequently hampers the economic evaluation of integrated care, contrasting with the wide availability of data on pharmacoeconomics. We based our study on a cluster randomized clinical trial providing a strong level of evidence.10,20,21 The statistical analysis enabled us to identify a subgroup in which future studies should be carried out as the intervention could be cost saving. Our results indicated that age, sex, comorbidity, and baseline Barthel Index and EQ-5D scores had an impact on the QALYs in each group, which seems logical given the level of multimorbidity, frailty and mortality in the sample. In addition to influencing perceived quality of life, in elderly people, comorbidity and disability are negative prognostic factors for functionality and survival. It should be taken into account that changes at the organization level and in healthcare management have a limited effect on the natural history of patients with high comorbidity. As a consequence, we should not expect marked changes in health outcomes.19

Literature shows that it is difficult to obtain good results in this population.22,23 However, our economic evaluation provided useful clues in terms of best suited target population to be taken into account in the implementation of future integrated programs. Moreover, it was supported by strong evidence-based design (cluster randomized clinical trial) and patient-data level statistical analysis. We have tried to solve the main three difficulties encountered by applying multivariante and subgroup analysis. First, complex patients tend to have a high level of multimorbidity. Patients with an average Charlson24 index of 5 have a 25% risk of death in the year of follow-up, masking any impact of the intervention. Second, the multifaceted nature of the healthcare model itself makes these types of intervention complex.25 Finally, we are not dealing with a clinical intervention but rather changes at the organizational level and in patient management.

This study has enabled us to assess an integrated healthcare model in terms of cost-utility. Despite the intervention not being efficient, our results are relevant as they contradict the usual assumption that integrated care models increase efficiency and quality of life, as well as leading to cost savings by decreasing hospitalizations.8,18,26 Even though this study was focused on an overall analysis of patients with multimorbidity, the subgroup analysis carried out allowed us to identify a narrow target population that should be analyzed in depth. Future research should involve studying the results of implementing the model in patients under 80 years of age with high level of comorbidity. In the light of our results, it seems clear that there is a need for more economic assessment studies to provide evidence on the efficiency of integrated models, to support their widespread use in health systems.

Miguel Ángel Negrín Hernández.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

I. Lanzeta has participated in all the research stages (study design, clinical trial fieldwork, interpretation of the results and writing the manuscript). J. Mar has contributed to the study design and he has collaborated in the statistical analysis, in the interpretation of results and in the review of the manuscript. A. Arrospide has participated in the design of methodology and performed the statistical analysis, supported the interpretation of the results and contributed to the drafting of the manuscript. All results were discussed among the authors. All authors contributed to and have approved the final manuscript.

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