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DH evaluation finds innovative changes to care pathways actually increase hospital admissions

By Lilian Anekwe

Exclusive: A Department of Health-funded evaluation of eight innovative community-based interventions has found new care pathways have failed to curb hospital use – after patients in the scheme were found to have higher rates of admissions and even death rates.

The major evaluation by the health policy think tank the Nuffield Trust shows GPs will struggle to achieve tough new QOF indicators on reducing emergency admissions agreed as part of this year’s GP contract deal.

A huge tranche of the QOF – one tenth of existing points – has been dedicated to incentivising GPs to design new care pathways to achieve efficiency savings in emergency admissions, referrals to secondary care and cost-efficient prescribing estimated at £800 million a year.

But the Nuffield Trust report, published this month, found ‘no evidence’ that community-based interventions led to a reduction in emergency hospital admissions, and warned in some instances ‘there were more admissions in the intervention group than in the control group’.

Researchers said their report would come as a blow to ministers, who have been pinning their hopes on incentives to drive down hospital use and slash secondary care costs.

The evaluation assessed eight DH-funded interventions that ran in older people between 2006 and 2009.

Four of the eight interventions were examined in detail – a community matron programme, an intermediate care scheme, an integrated health and social care team and daytime and out-of-hours response services – and compared to four simpler interventions.

The rigorously designed analysis included 5,146 participants, just under half the number in the schemes.

None of the eight interventions led to overall reductions in emergency hospital admissions (see box), while three resulted in a higher death rate.

The report concluded: ‘We did not find evidence of a reduction in emergency hospital admission rates for any of the eight interventions studied, and in some instances we found that there were more admissions in the intervention group than in the control group.

‘We found a higher death rate among the intervention group than the control group for three interventions.’

It continued: ‘The interventions we studied did not appear to reduce the use of acute hospitals in the six to 12 months after the intervention.’

Dr Martin Bardsley, head of research at the Nuffield Trust, said: ‘The findings will come as a disappointment to those working to redesign services with the aims of improving patients’ quality of life whilst reducing costs.’

He told Pulse: ‘There are other attributes to these schemes that may mean they are justifiable or cost-effective. But it’s disappointing that they did not achieve a reduction in bed days, which was the aim.’

A DH spokesperson said the report was ‘innovative’ but limited.

‘It only looks at a very small number of the projects and did not measure the outcomes for patients beyond reductions in admissions and bed days which weren’t the aims of some of these interventions,’ she said.

Professor Martin Roland, a GP and professor of health services research at the University of Cambridge, said: ‘The evidence that there are simple solutions to reducing hospital use is lacking.’

‘This report confirms that if you’re looking for easy solutions there are none and there is no magic bullet.’

Community-based interventions did not reduce hospital use Findings of the evaluation

• Higher death rate among the intervention group than the control group for three interventions – intermediate care, integrated teams and rapid response teams
• Community matrons have no impact on hospital use
• The intermediate care scheme increased emergency admissions and bed-days following emergency admissions, but reduced outpatient attendances
• Health and social care teams reduced the number of bed-days following emergency admissions, elective admissions and outpatient attendances, and seemed to reduce emergency admissions for some high-risk patients
• One of the short-term assessment and signposting services increased emergency hospital admissions, while another increased outpatient attendances

Source: An evaluation of the impact of community-based interventions on hospital use, March 10 2011