Cost-effectiveness of a patient-centred approach to managing multimorbidity in primary care: a pragmatic cluster randomised controlled trial

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  • Joanna Thorn
  • Mei-See Man
  • Katherine Chaplin
  • Peter Bower
  • Sara Brookes
  • Daisy Gaunt
  • Bridie Fitzpatrick
  • Caroline Gardner
  • Bruce Guthrie
  • Sandra Hollinghurst
  • Victoria Lee
  • Stewart W Mercer
  • Chris Salisbury

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Objective Patients with multiple chronic health conditions are often managed in a disjointed fashion in primary care, with annual review clinic appointments offered separately for each condition. This study aimed to determine the cost effectiveness of the 3D intervention, which was developed
to improve the system of care.
Design Economic evaluation conducted alongside a pragmatic cluster-randomised trial.
Setting General practices in three centres in England and Scotland.
Participants 797 adults with three or more chronic conditions were randomised to the 3D intervention, while 749 participants were randomised to receive usual care.
Intervention The 3D approach: comprehensive 6-monthly general practitioner consultations, supported by medication reviews and nurse appointments.
Primary and secondary outcome measures The primary economic evaluation assessed the cost per quality-adjusted life year (QALY) gained from the
perspective of the National Health Service (NHS) and personal social services (PSS). Costs were related to changes in a range of secondary outcomes (QALYs
accrued by both participants and carers, and deaths) in a cost–consequences analysis from the perspectives of the NHS/PSS, patients/carers and productivity losses.
Results Very small increases were found in both QALYs (adjusted mean difference 0.007 (−0.009 to 0.023)) and costs (adjusted mean difference £126 (£−739 to £991)) in the intervention arm compared with usual care after 15 months. The incremental cost-effectiveness ratio was £18 499, with a 50.8% chance of being cost-effective at a willingness-to-pay threshold of £20 000 per QALY (55.8% at £30 000 per QALY).
Conclusions The small differences in costs and outcomes were consistent with chance, and the uncertainty was substantial; therefore, the evidence for the costeffectiveness of the 3D approach from the NHS/PSS perspective should be considered equivocal.
Trial registration number ISCRTN06180958


Original languageEnglish
Article numbere030110
Number of pages10
JournalBMJ Open
Publication statusPublished - 19 Jan 2020


    Research areas

  • economic evaluation, multimorbidity, patient-centred care, primary care

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© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

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