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

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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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.


Economic evaluation conducted alongside a pragmatic cluster-randomised trial.


General practices in three centres in England and Scotland.


797 adults with three or more chronic conditions were randomised to the 3D intervention, while 749 participants were randomised to receive usual care.


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.


Very small increases were found in both QALYs (adjusted mean difference 0.007 (-0.009 to 0.023)) and costs (adjusted mean difference 126 pound (-739 pound to 991)) pound in the intervention arm compared with usual care after 15 months. The incremental cost-effectiveness ratio was 18 pound 499, with a 50.8% chance of being cost-effective at a willingness-to-pay threshold of 20 pound 000 per QALY (55.8% at 30 pound 000 per QALY).


The small differences in costs and outcomes were consistent with chance, and the uncertainty was substantial; therefore, the evidence for the cost-effectiveness of the 3D approach from the NHS/PSS perspective should be considered equivocal.

Original languageEnglish
Article number030110
Number of pages10
JournalBMJ Open
Issue number1
Publication statusPublished - 19 Jan 2020


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

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