This chapter presents analysis of the effects of the SICP on hospital admissions in intervention and comparator sites. We use the label ‘intervention’ to refer to the data from the Salford sites and ‘comparators’ to reflect those sites outside Salford. It is important to note the meaning of those labels. We use data from Salford as a whole, on the basis that the population has been exposed to the effects of the SICP. The SICP involves a number of mechanisms of integration (MDGs, ICC, community assets). The mechanism most clearly linked to reductions in hospital admissions is the MDGs. However, not all patients in Salford have been managed by a MDG, and some will have been exposed to other mechanisms. The analysis presented here is not a test of the specific impact of MDGs on admissions among those managed by the teams. Rather, it is a broader test of the impact of the SICP across Salford, with an assumption that any effect largely reflects the operation of the MDGs. In addition, many sites in England have their own versions of MDGs.79 Therefore, the comparison presented here explores whether or not the SICP is having an effect on admissions across the Salford population compared with the general trend (including integrated care initiatives outside Salford).
Descriptive data on population sizes, attendances and admissions from 2009/10 until 2015/16 for all adopters for the intervention and comparator groups are shown in Appendix 4, Table 64, together with data on non-adopters and the comparator sites.
We found that practice registrations of people aged ≥ 65 years increased over time, with an increase of 19% when looking at all areas in England (including Salford). Around 11–12% of the population aged ≥ 65 years in Salford are not registered to practices that are within the SICP.
Between 2009/10 and 2015/16, there was an overall increase in the number of A&E attendances, with the West comparator having the highest proportion of people aged ≥ 65 years attending A&E. Between 2009/10 and 2015/16, the number of emergency admissions increased almost in line with the rise in the population; as a result, the proportion of the population admitted to hospitals under an emergency largely remained constant or showed small reductions at all sites.
The proportion of patients discharged to usual place of residence fell in all intervention and comparator sites over time; the lowest proportion was among patients registered to general practices in Salford. The proportion of patients who were admitted with an ambulatory care-sensitive condition increased between 2009/10 and 2015/16.
Population-weighted mean values of the outcomes and explanatory variables and age bands are shown for all intervention and comparator groups (Table 31).
| Outcomes and characteristics | Site | ||||||
|---|---|---|---|---|---|---|---|
| Intervention | Comparator | ||||||
| Early | Late | All | Greater Manchester | West | West (extended) | England | |
| Outcomes (rates) | |||||||
| A&E attendances per person | 0.107 | 0.126 | 0.119 | 0.110 | 0.124 | 0.112 | 0.090 |
| A&E attendances referred by health/social care providers per person | 0.060 | 0.066 | 0.064 | 0.027 | 0.037 | 0.032 | 0.032 |
| Self-referred A&E attendances per person | 0.042 | 0.051 | 0.048 | 0.059 | 0.075 | 0.065 | 0.045 |
| Discharged to usual place of residence | 0.027 | 0.029 | 0.028 | 0.047 | 0.076 | 0.079 | 0.063 |
| Ambulatory care-sensitive conditions admissions per person | 0.038 | 0.044 | 0.042 | 0.038 | 0.038 | 0.036 | 0.031 |
| Emergency admissions per person | 0.069 | 0.081 | 0.077 | 0.066 | 0.072 | 0.070 | 0.058 |
| Emergency admissions via A&E per person | 0.062 | 0.073 | 0.069 | 0.055 | 0.054 | 0.051 | 0.044 |
| Direct emergency admissions per person | 0.005 | 0.006 | 0.006 | 0.009 | 0.014 | 0.016 | 0.011 |
| Patient age (proportion) | |||||||
| Aged 65–74 years | 0.093 | 0.086 | 0.089 | 0.092 | 0.099 | 0.100 | 0.101 |
| Aged 75–84 years | 0.056 | 0.059 | 0.058 | 0.053 | 0.061 | 0.064 | 0.062 |
| Aged ≥ 85 years | 0.019 | 0.035 | 0.029 | 0.020 | 0.021 | 0.023 | 0.026 |
| Observations (n) | 252 | 896 | 1148 | 11,760 | 2492 | 9436 | 207,984 |
The proportion of patients aged ≥ 65 years is higher in the population of England as a whole than in the intervention sites. Age distributions of > 85-year-olds show that the population in the intervention sites is, on average, older than the population of England. The exception is the early adopters, among whom the age distribution is younger.
Rates of all versions of A&E attendances and emergency admissions are higher in the intervention sites than in all of England, with the exception of direct emergency admissions. There are lower rates of patients who return to their usual place of residence in the intervention sites than in all of England. Early adopters have lower rates of all outcomes than late adopters. A&E attendances from health and social care referrals are much higher in the intervention sites (6.4%) than in comparator sites (3.2%).
Population-weighted mean values
Regression results
Table 32 shows the results comparing all adopters with the four comparator sites. Graphs of trends for all outcomes are also provided (see Appendix 4, Figures 16–23).
| Comparisons and outcomes | Site | |||
|---|---|---|---|---|
| Greater Manchester | West | West (extended) | England | |
| Early implementers | ||||
| A&E attendances | 0.005* | 0.006* | 0.005* | 0.006*** |
| A&E attendances: health and social care referral | 0.002 | 0.005* | 0.006** | 0.004** |
| A&E attendances: self-referral | 0.004*** | 0.005 | 0.002* | 0.003*** |
| Discharged to usual place of residence | –0.011*** | –0.036*** | –0.028*** | –0.012*** |
| Avoidable admissions (ACSC) | 0.002* | 0.003** | 0.003** | 0.002** |
| Emergency admissions | 0.006*** | 0.004** | 0.004*** | 0.006*** |
| Emergency admissions: via A&E | 0.009*** | 0.011*** | 0.009*** | 0.010*** |
| Emergency admissions: direct | –0.001*** | –0.007*** | –0.006*** | –0.002*** |
| Late implementers | ||||
| A&E attendances | 0.006** | 0.008* | 0.002 | 0.005** |
| A&E attendances: health and social care referral | 0.005** | 0.005** | 0.008*** | 0.007*** |
| A&E attendances: self-referral | 0.004** | –0.001 | –0.000 | 0.002 |
| Discharged to usual place of residence | –0.004* | –0.006 | –0.009** | –0.004** |
| Avoidable admissions (ACSC) | –0.001 | 0.000 | –0.000 | –0.001 |
| Emergency admissions | 0.003* | –0.001 | –0.001 | 0.002 |
| Emergency admissions: via A&E | 0.005*** | 0.005** | 0.002 | 0.004** |
| Emergency admissions: direct | –0.000 | –0.003* | –0.002* | –0.001** |
| All implementers | ||||
| A&E attendances | 0.008*** | 0.010*** | 0.005* | 0.008*** |
| A&E attendances: health and social care referral | 0.006*** | 0.007*** | 0.009*** | 0.008*** |
| A&E attendances: self-referral | 0.004*** | 0.000 | 0.001 | 0.002* |
| Discharged to usual place of residence | –0.003 | –0.005 | –0.008** | –0.005*** |
| Avoidable admissions (ACSC) | 0.000 | 0.001 | 0.001 | 0.000 |
| Emergency admissions | 0.005*** | 0.002 | 0.001 | 0.003** |
| Emergency admissions: via A&E | 0.007*** | 0.008*** | 0.004*** | 0.006*** |
| Emergency admissions: direct | –0.000 | –0.002 | –0.002** | –0.001*** |
We focus on the comparisons using the largest numbers of observations: all adopters compared with the rest of England. We find that the intervention sites showed increased numbers of A&E attendances, by 0.008 per quarter per person. Between 1 April 2015 and 31 March 2016, the intervention sites saw 1063 (95% CI 664 to 1462) more A&E attendances.
We find that the intervention sites showed a similar absolute effect on health and social care referrals to A&E, which also increased by 0.008 per person per quarter. This represents an increase of 1063 (95% CI 797 to 1462) in the number of attendances over the same period. Self-referred A&E attendances had a more modest increase of 0.002 per person per quarter, which represents an increase of 266 (95% CI 0 to 532) A&E attendances.
We find that the intervention was associated with an increase in emergency admissions of 0.003 per person per quarter, which represents an increase of 399 (95% CI 133 to 664) additional emergency admissions between 1 April 2015 and 31 March 2016. Emergency admissions via A&E increased by 0.6%, an increase of 797 (95% CI 399 to 1063) admissions. We found a fall in direct emergency admissions by 0.001 per person per quarter, resulting in a fall of 133 (95% CI 0 to 133) admissions. The effect of the intervention on avoidable emergency admissions is not statistically significant.
We found that the intervention led to a decrease in the number of patients who are discharged to the usual place of residence of 0.005%. The intervention resulted in a larger relative decrease in the number of patients returning to their usual place of residence among early implementers (0.012%) than among late implementers (0.004%).
Results using Greater Manchester, West and West (extended) show similar results to using all of England as the comparator group, when focusing on all results from all implementers. The signs of the coefficients remain the same for all estimated effects of the intervention along with similar absolute magnitudes. The small differences in estimate effects are explained by the changes in the sample size.
Robustness checks
Reducing the pre-intervention period by removing the first four and first eight financial quarters of the sample produced results that were consistent with the results obtained using data from the full sample (Table 33). We find that emergency admissions increased by 0.003 and 0.004 per person per quarter for models removing the first four and eight quarters, respectively.
| Intervention effect | Site, emergency admissions | |||
|---|---|---|---|---|
| Greater Manchester | West | West (extended) | England | |
| All years | 0.005*** | 0.002 | 0.001 | 0.003** |
| 2009/10 | 0.005*** | 0.001 | 0.001 | 0.003** |
| 2010/11 | 0.005*** | 0.002 | 0.001 | 0.004** |
| Differences in differences | 0.003 | 0.039 | 0.013 | 0.004 |
The results from the difference-in-differences estimator were not statistically significant. However, the point estimate of the effect of the intervention using all of England as the comparator group is identical to the main results. Therefore, both difference-in-differences and lagged dependent variable approaches resulted in impacts of similar magnitude, but the lagged dependent variable generates a more precise estimate.
Conclusion
Our findings suggest that, compared with the general trend, the SICP led to increases in the number of A&E attendances, particularly for those referred from health and social care providers. We also find that the intervention led to increases in the number of emergency admissions, mostly driven by admissions through A&E. Although we find increases in emergency admission, we did not find a statistically significant effect on ambulatory care-sensitive admissions. Increases in hospital utilisation may have been the result of integrated care increasing contact with health-care professionals. This assumption is made more plausible when considering that the SICP had no effect on ambulatory care-sensitive conditions, which is a better indicator of GP care quality. We find that fewer patients have been discharged to usual place of residence; possible explanations for this may be that the increase in integration in health and social care has resulted in patients being discharged into care more easily.
These results were robust to the use of other methods for estimating the impact of the programme and also reducing the time period. Removing the first four or eight quarters of data did not affect the results.
As noted in the earlier summary of previous integrated care initiatives in the UK, a number of studies of similar case management schemes have found either no impact on hospital utilisation29 or increases in some types of utilisation.32,33 Chapter 11 discusses in more detail the activities of the MDGs, which may provide insights into the mechanisms underlying the particular pattern of results, which are then considered in more detail in the discussion.