Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trial

Abstract

Aim: We evaluated the introduction of a predictive risk stratification model (PRISM) into primary care. Contemporaneously National Health Service (NHS) Wales introduced Quality and Outcomes Framework payments to general practices to focus care on those at highest risk of emergency admission to hospital. The aim of this study was to evaluate the costs and effects of introducing PRISM into primary care.

Methods: Randomised stepped wedge trial with 32 general practices in one Welsh health board. The intervention comprised: PRISM software; practice-based training; clinical support through two 'general practitioner (GP) champions' and technical support. The primary outcome was emergency hospital admissions.

Results: Across 230 099 participants, PRISM implementation increased use of health services: emergency hospital admission rates by 1 % when untransformed (while change in log-transformed rate Δ_L=0.011, 95% CI 0.010 to 0.013); emergency department (ED) attendance rates by untransformed 3 % (while Δ_L=0.030, 95% CI 0.028 to 0.032); outpatient visit rates by untransformed 5 % (while Δ_L=0.055, 95% CI 0.051 to 0.058); the proportion of days with recorded GP activity by untransformed 1 % (while Δ_L=0.011, 95% CI 0.007 to 0.014) and time in hospital by untransformed 3 % (while Δ_L=0.029, 95% CI 0.026 to 0.031). Thus NHS costs per participant increased by £76 (95% CI £46 to £106).

Conclusions: Introduction of PRISM resulted in a statistically significant increase in emergency hospital admissions and use of other NHS services without evidence of benefits to patients or the NHS.

Keywords: cluster trials; cost-effectiveness; emergency department; health services research; primary care.

Figure 1

Stepped wedge study design with dates of practice training as planned and undertaken (x).