Controlled trial of a collaborative primary care team model for patients with diabetes and depression: rationale and design for a comprehensive evaluation.

Back to table of contents Previous article Next article Professional NewsFull AccessBipolar Patients in Integrated Systems May Need More-Intensive CareMark MoranMark MoranSearch for more papers by this authorPublished Online:12 May 2014https://doi.org/10.1176/appi.pn.2014.5b12AbstractFederally qualified primary care clinics, as well as primary care clinics where both uninsured and Medicaid patients are treated, are likely to have a significant percentage of patients with bipolar illness.Primary care patients with bipolar disorder may require more-intensive services—including direct psychiatric care—than is currently provided in a collaborative care primary care model.That’s the finding from the study “Bipolar Disorder in Primary Care: Clinical Characteristics of 740 Primary Care Patients With Bipolar Disorder,” published April 15 in Psychiatric Services in Advance.“Primary care patients with bipolar disorder experienced persistent depressive and anxiety symptoms despite higher-intensity collaborative care treatment, but they were infrequently referred to a community mental health center,” the researchers stated. “Successful treatment of bipolar disorder in primary care may require additional clinical interventions aimed at either further improving the care delivered to patients in primary care or through more effective referrals to community mental health centers.”The authors were Joseph Cerimele, M.D., Ya-Fen Chan, Ph.D., Lydia Chwastiak, M.D., Marc Avery, M.D., Wayne Katon, M.D., and Jürgen Unützer, M.D., M.P.H., of the University of Washington, who have pioneered the development of collaborative care models integrating behavioral and general medical care. Key PointsBottom Line: Primary care patients with bipolar disorder may require more intensive care, or better outreach with specialty mental health clinics, than is currently provided in a collaborative care system.Only about one-third of primary care patients in a statewide mental health integrated care program who had bipolar disorder and baseline PHQ-9 scores of 10 or more experienced significant clinical improvement in depressive symptoms.More than half of the patients reported concerns about housing, and 15 percent reported homelessness, while 22 percent reported lack of a support person.Only one-third of the patients were referred to a specialty mental health clinic.They identified 740 primary care patients with bipolar disorder in the statewide mental health integration program (MHIP) between January 2008 and December 2011 using the Composite International Diagnostic Interview and clinician diagnosis. The MHIP uses collaborative care based on the IMPACT model (Improving Mood–Promoting Access to Collaborative Treatment), which was developed at the University of Washington to improve recognition and systematic treatment of patients with psychiatric disorders in primary care settings.Primary care patients with bipolar disorder had high symptom severity on both depression and anxiety measures using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder scale. Only about one-third of patients with bipolar disorder with baseline PHQ-9 scores of 10 or more experienced significant clinical improvement in depressive symptoms (with a PHQ score of less than 10 or a reduction in PHQ-9 score by 50 percent or more) during the time from initial MHIP assessment until treatment in MHIP or until the study ended.Psychosocial problems were common, with approximately 53 percent reporting concerns about housing, 15 percent reporting homelessness, and 22 percent reporting lack of a support person. Yet only 26 percent of patients were referred to specialty mental health treatment. The average time from initial assessment to psychiatric consultation was 5.7 weeks among patients with bipolar disorder.Wayne Katon, M.D., says integration of psychiatrists, on site or by telemedicine, may be necessary for the care of bipolar patients in collaborative care systems.Courtesy of Wayne Katon, M.D.Katon, vice chair of the Department of Psychiatry at the University of Washington, told Psychiatric News that the study indicates that these patients may need more-intensive care than is currently provided in a collaborative care model, in which a care manager, supervised by a psychiatrist, provides the direct patient care.“The importance of this article is that the U.S. federally qualified primary care clinics, as well as many primary care clinics that treat both uninsured and Medicaid patients, are likely to have a significant percentage of patients with bipolar illness, especially bipolar II illness,” Katon said. “This article emphasizes that despite the fact that only about one-third improve with treatment in these clinics, few are being referred to community mental health clinics or actually attend when referred. These clinics already had integrated collaborative care—that is, the use of a care manager supervised by a psychiatrist—so the inference is that these patients may need more-intensive psychiatric treatment, which could occur if psychiatrists are integrated into the clinics either in person or via telemedicine. Alternatively, the clinics need to establish better links with community mental health.” ■“Bipolar Disorder in Primary Care: Clinical Characteristics of 740 Primary Care Patients With Bipolar Disorder” is posted here. ISSUES NewArchived

Depression and anxiety outcomes of adults undergoing intermittent theta burst stimulation (iTBS) treatment for major depressive disorder: A naturalistic study

Payors Train PCPs to Treat Mental Health in House

BackgroundDementia affects over 4 million people in the US and is frequently unrecognized and underdiagnosed in primary care. Routine dementia screening in primary care is not recommended by the US Preventive Services Task Force due to lack of empirical data on the benefits and harms of screening. This trial seeks to fill this gap and contribute information about the benefits, harms, and costs of routine screening for dementia in primary care.Methods/DesignSingle-blinded, parallel, randomized controlled clinical trial with 1:1 allocation. A total of 4,000 individuals aged ≥65 years without a diagnosis of dementia, cognitive impairment, or serious mental illness receiving care at primary care practices within two cities in Indiana. Subjects will be randomized to either i) screening for dementia using the Memory Impairment Screen Telephone version or ii) no screening for dementia. Subjects who screen positive for dementia will be referred to the local Aging Brain Care program that delivers an evidence-based collaborative care model for dementia and depression. Research assistants will administer the 15-item Health Utility Index, Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and Medical Outcomes Study at baseline, 1, 6, and 12 months. Information about advanced care planning will be collected at baseline and 12 months. All enrollees’ medical records will be reviewed to collect data on health care utilization and costs.DiscussionWe have two primary hypotheses; first, in comparison to non-screened subjects, those who are screened and referred to a dementia collaborative care program will have a higher health-related quality of life as measured by the Health Utility Index at 12 months post-screening. Second, in comparison to non-screened subjects, those who are screened and referred to a dementia collaborative care program will not have higher depression or anxiety at one month post-screening as measured by the Patient Health Questionnaire and Generalized Anxiety Disorder Scale scales. Our secondary hypothesis is that screened subjects will have an Incremental Cost-Effectiveness Ratio below the maximum acceptable threshold of $60,000 per quality adjusted life year saved at 12 months.Trial registrationOngoing; registered on September 19, 2012. ClinicalTrials.gov Identifier: 2012 NCT01699503.

Data Needs for Economic Evaluations of Screening in Pediatric Primary Care: A Research Framework.

Depressive disorders are among the most prevalent mental health conditions; however, significant barriers to treatment access persist. This study examined differences in depression outcomes between younger and older adults in a large-scale implementation demonstration of the collaborative care model (CoCM). Secondary data analysis of a longitudinal, observational implementation demonstration at eight primary care clinics across low-resourced rural or frontier areas of the Western United States. Seven of these clinics were federally qualified health centers. The sample consisted of 3722 younger (18-64 years) and older (65+ years) adult primary care patients diagnosed with unipolar depression. All participants received depression treatment via CoCM, which enhances usual primary care and makes efficient use of specialists by using a behavioral healthcare manager and a psychiatric consultant to support primary care providers. Clinics were followed for up to 27 months. Patients were followed until they completed treatment or dropped out. The Patient Health Questionnaire (PHQ-9) assessed depressive symptoms at baseline (enrollment) and at most follow-up contacts. The primary treatment outcome was a change between a patient's first and last recorded PHQ-9 scores. Across both age groups, there was an average overall reduction of 6.9 points on the PHQ-9. Older adults demonstrated a greater decrease in depression scores of 2.06 points (95% CI -2.98 to -1.14, p < 0.001) on the PHQ-9 compared with younger adults. Estimates were robust when adjusting for gender, race, and clinic. CoCM resulted in meaningful improvement in depressive symptoms across age groups.

CMS Proposes Rule to Reimburse for Psychiatric Collaborative Care

&lt;p&gt; &lt;/p&gt; &lt;p&gt;&lt;strong&gt;Objective&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;To assess the cost-effectiveness of collaborative versus usual care in adults with poorly-controlled type 2 diabetes and depression in India.&lt;/p&gt; &lt;p&gt;&lt;strong&gt;Research Design and Methods&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;We performed a within-trial cost-effectiveness analysis of a 24-month parallel, open-label, pragmatic randomized clinical trial at four urban clinics in India from multipayer and societal perspectives. The trial randomized 404 patients with poorly-controlled type 2 diabetes (HbA1c≥8.0% or systolic BP≥140mmHg or LDL-c≥130mg/dl) and depressive symptoms (PHQ-9≥10) to collaborative care (support from non-physician care coordinators, electronic registers, and specialist-supported case review) for 12 months, followed by 12 months usual care or 24 months usual care. We calculated incremental cost-effectiveness ratios (ICER) in Indian rupees (INR) and international dollars (Int’l) and the probability of cost-effectiveness using quality-adjusted life years (QALYs) and depression-free days (DFDs).&lt;/p&gt; &lt;p&gt;&lt;strong&gt;Results&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;From a multipayer perspective, collaborative care costed additional INR309,558 (Int’l-$15,344) per QALY and additional INR290.2 (Int’l-$14.4) per DFD gained compared to usual care. The probability of cost-effectiveness was 56.4% using a willingness-to-pay of INR336,000 (Int’l-$16,654) per QALY (~3-times per-capita GDP). The willingness-to-pay per DFD to achieve a probability of cost-effectiveness &gt;95% was INR401.6 (Int’l-$ 19.9). From a societal perspective, cost-effectiveness was marginally lower. In sensitivity analyses, integrating collaborative care in clinical workflows reduced incremental costs by ~47% (ICER: 162,689/QALY; cost-effectiveness probability: 89.4%) but cost-effectiveness decreased when adjusting for baseline values.&lt;/p&gt; &lt;p&gt;&lt;strong&gt;Conclusions&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;Collaborative care for patients with type 2 diabetes and depression in urban India can be cost-effective, especially when integrated in clinical workflows. Long-term cost-effectiveness might be more favorable. Scalability across lower- and middle-income country settings depends on heterogeneous contextual factors. &lt;/p&gt;

Associations Between Depressive Symptoms and HFpEF-Related Outcomes

At present, there is a paucity of naturalistic studies directly comparing the effectiveness of psychotherapy alone versus collaborative psychotherapy and psychiatric care in the management of depression and anxiety in patients with cancer. This study tested the hypothesis that collaborative psychiatric and psychological care would lead to greater reductions in depression and anxiety symptoms in patients with cancer compared with psychotherapy alone. We analyzed treatment outcomes of 433 adult patients with cancer, of which 252 patients received psychotherapy alone and 181 patients received collaborative psychotherapy and psychiatric care. Longitudinal changes in depressive (i.e., PHQ-9) and anxiety symptoms (GAD-7)were examined between groups using latent growth curve modeling. After controlling for treatment length and psychotherapy provider effects, results indicated collaborative care was more effective than psychotherapy alone for depressive symptoms (γ12 = -0.13, p = 0.037). The simple slope for collaborative care was -0.25 (p = 0.022) and the simple slope for psychotherapy alone was -0.13 (p = 0.006), suggesting collaborative care resulted in greater reductions in depressive symptoms compared with psychotherapy alone. In contrast, there were no significant differences between psychotherapy alone and collaborative psychotherapy and psychiatric care in reducing anxiety symptoms (γ12 = -0.08, p = 0.158). Collaborative psychotherapy and psychiatric care may individually address unique aspects of mental health conditions in patients with cancer, namely depressive symptoms. Mental healthcare efforts may benefit from implementing collaborative care models where patients receive psychiatric services and psychotherapy to effectively address depressive symptoms in the treatment of this patient population.

Effectiveness of collaborative care for depression in Italy. A randomized controlled trial

The goals of the study were to evaluate participant engagement and effects of an Internet-based, self-directed program for depressive symptoms. We compared outcomes of adults with multiple sclerosis (MS) with those of adults with other chronic diseases. This was a secondary analysis of a randomized controlled pilot study. Data were explored for differences between people diagnosed with MS and those with other chronic disease diagnoses. Data were obtained from 47 participants who participated in the original parent study (11 had MS). Participants with at least a moderate preexisting depressive symptom burden on the Patient Health Questionnaire (PHQ) were randomly divided into either a control group or the 8-week "Think Clearly About Depression" online depression self-management program. Study tools were administered at baseline, week 4, and week 8 to evaluate whether the online program improved depressive symptom self-management. Analysis examined differences between participants with and without an MS diagnosis in the treatment and control groups. Average baseline depressive symptom burdens were severe for those with MS and those without MS as measured by the PHQ. Number needed to treat analysis indicated that 1 in every 2 treatment group participants with MS found clinically significant reductions in depressive symptoms by week 8. All participants with MS completed all online program modules. When compared with those with other chronic diseases, participants with MS showed a trend toward greater improvements in the PHQ and health distress scores in addition to self-efficacy in exercising regularly, social/recreational activities, and controlling/managing depression at the end of 8 weeks. An online depressive symptom self-management program is acceptable to people with MS and may be helpful to address undertreated depressive symptoms. The number of participants limits available statistics and ability to generalize results.

Collaborative care is effective for depression management in the USA. There is little UK evidence on its clinical effectiveness and cost-effectiveness. To determine the clinical effectiveness and cost-effectiveness of collaborative care compared with usual care in the management of patients with moderate to severe depression. Cluster randomised controlled trial. UK primary care practices (n = 51) in three UK primary care districts. A total of 581 adults aged ≥ 18 years in general practice with a current International Classification of Diseases, Tenth Edition depressive episode, excluding acutely suicidal people, those with psychosis, bipolar disorder or low mood associated with bereavement, those whose primary presentation was substance abuse and those receiving psychological treatment. Collaborative care: 14 weeks of 6-12 telephone contacts by care managers; mental health specialist supervision, including depression education, medication management, behavioural activation, relapse prevention and primary care liaison. Usual care was general practitioner standard practice. Blinded researchers collected depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety (General Anxiety Disorder-7) and quality of life (European Quality of Life-5 Dimensions three-level version), Short Form questionnaire-36 items) outcomes at 4, 12 and 36 months, satisfaction (Client Satisfaction Questionnaire-8) outcomes at 4 months and treatment and service use costs at 12 months. In total, 276 and 305 participants were randomised to collaborative care and usual care respectively. Collaborative care participants had a mean depression score that was 1.33 PHQ-9 points lower [n = 230; 95% confidence interval (CI) 0.35 to 2.31; p = 0.009] than that of participants in usual care at 4 months and 1.36 PHQ-9 points lower (n = 275; 95% CI 0.07 to 2.64; p = 0.04) at 12 months after adjustment for baseline depression (effect size 0.28, 95% CI 0.01 to 0.52; odds ratio for recovery 1.88, 95% CI 1.28 to 2.75; number needed to treat 6.5). Quality of mental health but not physical health was significantly better for collaborative care at 4 months but not at 12 months. There was no difference for anxiety. Participants receiving collaborative care were significantly more satisfied with treatment. Differences between groups had disappeared at 36 months. Collaborative care had a mean cost of £272.50 per participant with similar health and social care service use between collaborative care and usual care. Collaborative care offered a mean incremental gain of 0.02 (95% CI -0.02 to 0.06) quality-adjusted life-years (QALYs) over 12 months at a mean incremental cost of £270.72 (95% CI -£202.98 to £886.04) and had an estimated mean cost per QALY of £14,248, which is below current UK willingness-to-pay thresholds. Sensitivity analyses including informal care costs indicated that collaborative care is expected to be less costly and more effective. The amount of participant behavioural activation was the only effect mediator. Collaborative care improves depression up to 12 months after initiation of the intervention, is preferred by patients over usual care, offers health gains at a relatively low cost, is cost-effective compared with usual care and is mediated by patient activation. Supervision was by expert clinicians and of short duration and more intensive therapy may have improved outcomes. In addition, one participant requiring inpatient treatment incurred very significant costs and substantially inflated our cost per QALY estimate. Future work should test enhanced intervention content not collaborative care per se. Current Controlled Trials ISRCTN32829227. This project was funded by the Medical Research Council (MRC) (G0701013) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.

&lt;p dir="ltr"&gt;&lt;b&gt;Background&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;As the population ages, the number of adults living with multimorbidity- defined as having two or more chronic conditions-is increasing. The current healthcare system often focuses on treating one disease at a time, can fail to meet these individuals ' needs with risk of on the one hand unmet care needs and on the other risk of more visits to more healthcare providers and medications than benefits the individual. To better serve older individuals with multimorbidity, the healthcare system, particularly primary care, needs to adapt and evolve. This involves adopting a more person-centred and holistic approach to care, considering the individual' wants and needs, all health conditions, and overall well-being, rather than treating each disease separately. By doing so, the healthcare system can provide coordinated, person-centred care that effectively meets the complex needs of these individuals.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Aim&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;The aim of this thesis was to develop and pilot a complex intervention to improve wellbeing and quality of life in individuals with multiple health conditions and common mental health problems in Swedish primary care.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Methods&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;This thesis involves four studies involving quantitative, qualitative and mixed methods methodologies. Study 1 is a systematic literature review and qualitative synthesis of collaborative care interventions for individuals with multimorbidity and common mental health problems in primary care and community settings and a map of intervention components. Study 2 is a total population-based cohort study investigating the association between having multimorbidity with an increasing number of chronic diseases and potentially inappropriate prescribing of benzodiazepines in the total adult population in Stockholm, Sweden in two cohorts, one before and one during COVID-19. Study 3 is a qualitative study exploring GP's experiences of managing individuals with multimorbidity and common mental health problems in primary care in Stockholm, Sweden using reflexive thematic analysis. From the findings of study 1 and 3 the intervention Health and Life in Balance was developed for improving patient capacity for older people with multimorbidity. The intervention includes the collaborative care components of relational continuity, a shared care plan, and teamwork identified in study 1. Moreover, it uses a person-centred approach to care, minimally disruptive medicine, to assess patient capacity and workload in individuals with multimorbidity. This approach was identified in the literature sharing similarities with the findings from study 3. Study 4 is a pragmatic convergent mixed methods non- randomised pilot study. The study aimed to assess the acceptance, feasibility and further need of development of Health and Life in Balance.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Results&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;In study 1, 12 Randomised controlled studies were included. Eleven studies with medium to high quality showed positive results in reducing depressive symptoms in individuals with multimorbidity involving depression and one chronic disease. The last study had medium to low quality and investigated the effect on anxiety and depressive symptoms. There was a lack of medium to high quality studies addressing collaborative care for individuals with multimorbidity and anxiety, and for individuals with more than two health conditions. The qualitative synthesis identified a map of shared content in the 11 studies of collaborative care models with medium to high quality. In study 2, an association between an increasing number of chronic conditions and potentially inappropriate prescribing of benzodiazepines was identified in both cohorts, before and during COVID-19. The logistic regression model was adjusted for age and socioeconomic status and stratified for sex. The association remained although decreased when adjusting for each of the clinical confounders: number of healthcare visits, polypharmacy, and having a psychiatric diagnosis. In study 3 two themes were generated: Unmet patient needs and fragmented care send patients and physicians off balance and Dancing with the patient individually and together with others leads to confident and satisfied patients and physicians. General practitioners found it hard to address common mental health problems in individuals with multimorbidity, limited by disease-specific guidelines and fragmentation. They highlighted that aspects of person-centred care, involving relational continuity, flexibility and teamwork, would help them better address these individuals. In study 4, Health and Life in Balance was acceptable and feasible regarding to have relational continuity to a district nurse addressing non-disease-specific issues for individuals in need of it. However, the intervention needs further development. The intervention needs to be targeted for individuals with the greatest care needs including aspects of frailty, deprived psychosocial situation and many healthcare providers. Further, it needs to be further developed to provide person-centred care in a busy primary care setting, including raising priority for individuals with multimorbidity involving non- disease-specific needs, addressing how to provide and implement a person- centred care, and addressing how to provide teamwork and cooperation with others.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Conclusions&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;This thesis identifies individuals with multiple health conditions to be at risk of potentially inappropriate prescribing of benzodiazepines and poorly addressed non-disease-specific issues in today's fragmented healthcare system and shows person-centred care as a potential solution to address these issues. Furthermore, it describes the development and piloting of Health and Life in Balance, a person-centred intervention aiming to address these risks. The findings from the pilot study identified the intervention to be acceptable and feasible when at-need individuals had relational continuity to a district nurse who could address non-disease-specific needs. Yet, the intervention needs further development to identify and target individuals with the greatest care needs, make these individuals a priority in primary care, and to ensure teamwork and delivery and implementation of person-centred care. The results from this thesis and included studies can inform policy makers and other stakeholders of the need of prioritising a shift from fragmented care to person- centred and holistic care for vulnerable individuals and a need of further intervention development to address these individuals' needs. Furthermore, the findings can be used in further intervention development. However, in future intervention development it is important to involve individuals with multimorbidity and other stakeholders in both the research group and in different phases of the intervention development.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. Specific content of collaborative care: a systematic review of collaborative care interventions for patients with multimorbidity involving depression and/or anxiety in primary care. &lt;b&gt;C Kappelin&lt;/b&gt;, A Carlsson, C Wachtler Fam Pract 2021 Sep 21;39(4):725-734. &lt;a href="https://doi.org/10.1093/fampra/cmab079" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/fampra/cmab079&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. The association between number of chronic diseases and potentially inappropriate benzodiazepine prescribing: A total population-based cohort study in Region Stockholm, Sweden. &lt;b&gt;Caroline Kappelin&lt;/b&gt;, Caroline Wachtler, Gunnar Ljunggren, Axel Carlsson. [Submitted]&lt;/p&gt;&lt;p dir="ltr"&gt;III. Dancing with the patient: a qualitative study of general practitioners' experiences of managing patients with multimorbidity and common mental health problems. &lt;b&gt;Kappelin C,&lt;/b&gt; Sandlund C, Westman J, Wachtler C. BMC Prim Care. 2023 Apr 20;24:104. &lt;a href="https://doi.org/10.1186/s12875-023-02056-y" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1186/s12875-023-02056-y&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;IV. Health and Life in Balance an intervention to improve patient capacity for older people with multimorbidity: A pragmatic mixed methods non-randomised pilot study. &lt;b&gt;Caroline Kappelin&lt;/b&gt;, Klas Ytterbrink Nordenskiöld, Elisabeth Bos Sparén, Annica Lagerin, Caroline Wachtler. [Submitted]&lt;/p&gt;

Recent years have seen an emergence of collaborative primary care models in the English National Health Service and other international health systems. Primary Care Networks (PCNs) were introduced in England in July 2019, marking the first time collaboration between general practices was incentivised through a nationwide policy. While participation was not mandatory, nearly all general practices joined a PCN, largely due to strong financial incentives. Our study aim was to estimate the impact of PCNs on emergency hospitalisations using an interrupted time series design. Quarterly data between October 2016 and March 2023 from the North West London Whole Systems Integrated Care dataset was used to construct two primary outcomes: all-cause and ambulatory care sensitive conditions (ACSC) emergency hospitalisations, as well as Accident and Emergency attendances, considered as a secondary outcome. Furthermore, we analysed whether the impact of PCNs varied based on practice characteristics. A reduction in all-cause and ACSC hospitalisations was observed following the PCNs' introduction, until the start of the COVID-19 pandemic. The analysis also revealed a smaller reduction in ACSC hospitalisations among practices with more deprived patient populations and larger populations of patients with long-term conditions. While PCNs' implementation appears to have led to a reduction in emergency hospitalisations in North West London, this effect was only observed in the very short term as it stopped with the COVID-19 pandemic. Future studies should examine the effect across England and evaluate their continued impact.