St George's Hospital Medical School London, UK
London School of Economics and Institute of Psychiatry, London, UK
London School of Economics, London, UK
Correspondence: Jocelyn Catty, Research Fellow, Social and Community Psychiatry, St George's Hospital Medical School, Jenner Wing, Cranmer Terrace, London SW17 0RE, UK. Tel: 020 8725 3489; fax: 020 8725 3538; e-mail: jcatty{at}sghms.ac.uk
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ABSTRACT |
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Aims We aimed to determine whether North American studies find greater reductions in days in hospital and whether experimental service patients in North American studies spend less time in hospital.
Method The results of a systematic review were analysed with respect to study location. Service components ascertained through follow-up were utilised to interpret the meta-analyses conducted.
Results Most of the 91 studies found were from the USA and UK. North American studies found a difference of one hospital day (per patient per month) more than European studies but there was no difference in experimental data between the two locations.
Conclusions North American studies demonstrate greater differences in days in hospital but patients in their experimental services seem to spend no fewer days in hospital, implying a disparity in control services.
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INTRODUCTION |
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Aims
We aimed to identify international differences in home treatment services
for mental health problems through a systematic review of studies using
Cochrane methodology. We aimed to answer the question, Does the
effectiveness of home treatment services vary internationally in terms of
reducing days in hospital? This analysis was an a priori aim
of the review.
Specific hypotheses, focused on Europe compared with North America, were that:
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METHOD |
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Literature search
Five databases CINAHL (1982 to October 1999), the Cochrane
Schizophrenia Group Register (up to September, 1999), EMBASE (1980 to October
1999), MEDLINE (1966 to December 1999) and PsychLIT (1887 to September 1999)
were searched systematically using terms for mental health problems
and home treatment (defined above). Studies of day, foster and residential
care were excluded. Studies were included as randomised controlled trials
(RCTs) if they met Cochrane standards
(Mulrow & Oxman, 1997).
Non-randomised studies (non-RCTs) comparing two or more services were also
included. RCTs with flawed randomisation were relegated to the non-randomised
study group. Non-RCTs were only included in the meta-analysis if they were
prospective and provided evidence for baseline comparability of groups. The
outcome measure was days in hospital per patient per month. Full details of
the search strategy and methodology for the whole review are reported
elsewhere (Catty et al,
2002a).
Follow-up
A questionnaire was sent to each author, asking about 20 possible
components of home treatment, derived from a Delphi exercise with leading
psychiatrists (Burns et al,
2001). This was to ascertain the components of the experimental
service and of the control service, if the latter was described as a community
mental health team (CMHT). Missing data were supplemented from the papers
where possible. The components were all considered item by item in the
subsequent analyses, rather than as a scale score.
In response to the perception that North American studies are more likely
than European studies to find significant differences in hospitalisation in
favour of the experimental services, we noted the numbers of studies in each
location finding significant results and tested these proportions using
-squared tests. We used days in hospital where they had used this
measure; if they had not, we used another hospitalisation measure if reported.
This was a crude measure of differences in study findings, reflecting both the
number of patients in the study and the size of any differences found. It is
intended merely as a description, to shed some light on the common
perception.
Meta-analysis
Studies were divided into North American,
European and Other and their service components,
study design and hospitalisation findings compared. In practice, there were
insufficient studies from the Other locations to include them,
so the results focus only on North American and European studies. Studies were
designated either in-patient control (where the control service was an initial
period of in-patient treatment, with discharge when appropriate) or community
control (control service not in-patient treatment).
Studies were only included in the outcome meta-analysis if data were available in the form of mean hospital days. The primary outcome measure was mean monthly hospital days for the entire study. Studies of less than a year's duration were excluded.
Two analytical strategies were used:
In the main analyses for the review, key service components were tested for association with the outcome measure, using weighted regression analyses (Catty et al, 2002a). These analyses were not repeated for each location but their results will be used to illuminate the findings of the meta-analyses reported here.
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RESULTS |
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There were no significant differences between European and North American studies in the proportion of studies using in-patient treatment as the control service, refuting hypothesis (c). There were also no differences in the control service being a CMHT, or in the year of publication (Table 1).
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Study findings
More North American studies (18 studies: 31%) than European ones (5
studies: 19%) found significant reductions in hospitalisation, but this
difference was non-significant (Table
2). It was still non-significant when RCTs and non-randomised
studies were treated separately. European studies had larger mean sample sizes
(224 compared with 160), but this was non-significant.
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Follow-up
Authors of 55 studies (60%) responded to follow-up: 18 European (15 UK, 2
Scandinavian and 1 German), 35 North American (33 US and 2 Canadian) and 2
Other (both Australian). Responders were more commonly European
than were non-responders and less likely to be from Other
countries, but this was non-significant. The response rate was higher from
authors of RCTs (77%).
Service characterisation
The findings below are for all studies for which we had information. For
differences in components when only considering those studies in the
meta-analyses, see below.
Experimental services
As Table 3 shows,
significantly more European teams had occupational therapists. All the North
American services had in-service training, compared with 62% of
the European services (Fisher's exact P < 0.001). The mean
average contact frequency for the North American teams was 2.5
times the European mean contact frequency (P=0.003).
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Control services
Twenty North American services (57% of responders) and seven European (39%)
described themselves as CMHTs. The following findings pertain only to
them.
More European control services had an occupational therapist (P=0.017). More European control services had in-service training, but this was not statistically significant. North American control services had a significantly higher average contact frequency, with eight contacts per month compared with 1.5 for European control services (U=11.0, P=0.018).
All seven of the responding European control services that were CMHTs visited patients at home, compared with under half of the North American services (Fisher's exact P=0.052; Table 4).
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Meta-analyses
Despite the extensive follow-up, only 28 studies could be used in the
meta-analyses by location because of insufficient mean hospital days data for
a minimum of 1 year's follow-up. Characteristics of these studies are shown in
Table 1.
Comparative analysis
There were insufficient in-patient-control studies with available data to
test for differences in location (only one out of the four eligible studies
was European). For the 24 community-control RCTs for which we had appropriate
available data, the results were significantly different for North American
compared with European studies. North American RCTs found an overall reduction
of 0.8 hospital days per patient per month in favour of the experimental
services, whereas the European studies found an increase of 0.3 days. We were
unable to put confidence intervals on the within-group overall mean
differences because of lack of standard deviation data. The difference between
the two locations (1.1 days), however, was significant (t=2.79, d.f.
22, P=0.01). When we included the three community-control non-RCTs
for which we had data, the difference between the two locations became smaller
and failed to reach significance (Table
5).
Experimental services analysis
This included both in-patient-control and community-control RCTs (28
studies). The difference between North America and Europe in mean days spent
in hospital by experimental patients was only 0.2 per patient per month and
non-significant (Table 5). The
difference between locations became even smaller after adjusting for whether
or not the study stated that it was specifically for patients with high
service use.
Service characteristics of meta-analysed studies
To explore possible reasons for the difference in hospital days reduction
found between locations, we considered again the service characteristics of
the 24 RCTs included in this analysis. For their experimental services, having
an occupational therapist on the team, in-service training and hours of
operation were no longer significant. Average contact frequency was still
significantly different, and weekly multi-disciplinary review approached
significance. The days of operation for this group were significantly higher
for North American services, and more North American services had a social
worker (Table 3).
Only 10 of these RCTs said that their control service had been a CMHT. For these studies, there was no significant difference in having an occupational therapist. The difference in average contact frequency was no longer statistically significant; furthermore, regular visits at home and the number of staff on the team also ceased to be significant, possibly because of the small number of studies tested here.
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DISCUSSION |
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Limitations
There were very few studies from outside North America and Europe, and for
this reason they could not be included. Moreover, US and UK studies dominated
the two groups. The meagre number of studies from other areas could have been
a result of an English-language bias in our search strategy, although several
non-English-language studies were found but did not meet our inclusion
criteria (Kluiter et al,
1992; Otero & Rebolledo,
1993; De Cangas,
1994; Hu et al,
1994; van Minnen et
al, 1997).
The availability of hospital days data limited the analysis. We also attempted to collect service utilisation data to ascertain cost differences (Burns et al, 2001; Catty et al, 2002b), but insufficient data were available.
The controversy about relative effectiveness has focused on assertive community treatment. Although studies of assertive community treatment form a substantial proportion of the studies included and meta-analysed here, our definition of home treatment was deliberately broad and not limited to such treatment. It should also be noted that we could not include in-patient-control studies in the comparative meta-analysis of hospitalisation reduction, and this group of course includes the original Madison study (Stein & Test, 1980); they were, however, included in the experimental services analysis. Exclusion of studies from elsewhere than North America and Europe, moreover, meant that the findings of another study that has featured in the controversy (Hoult et al, 1983) could not be included.
Study design and services
The North American studies were no more likely than the European studies to
have used in-patient treatment as the control service, so this could not in
itself account for their perceived greater success rate. Despite the
perception that North American services work with smaller case-loads, the
difference in case-load size between locations was not significant. European
CMHT control services were more likely to visit patients at home
regularly, although the difference compared with the North
American services just failed to reach significance. This difference would
seem in line with the finding of the UK700 study of intensive case management
that 76.5% of control service (standard CMHT case management) contacts were
delivered in non-service settings (Burns
et al, 2000).
Perceptions of difference
Although more North American than European studies have demonstrated
significant reductions in hospitalisation, this is at least partly because of
the relatively low number of European studies conducted at all (25 compared
with 59). The difference in proportions here was not significant, although the
proportions of studies reporting an advantage to the control service were
actually the same. European studies had larger sample sizes than North
American studies, which might imply that they had greater power to detect
significant differences, but the difference in average sample sizes was
non-significant. It could be that a few high-profile studies on either side of
the Atlantic have given rise to the impression that North American studies
find greater differences. A basic comparison of hospitalisation results does
not support this idea.
Reducing hospitalisation
There was clear evidence to support the hypothesis that North American
studies are more successful at reducing hospitalisation than are European
ones. This finding could have been affected by the heterogeneity of the
studies included. North American studies seem, nevertheless, to find a greater
difference between experimental and control patients than European ones
do.
One explanation offered for this disparity has been that European services have implemented home treatment poorly (Tyrer, 2000). Our analysis of experimental service components yields inconclusive results in this respect. Six components differed between the two locations, of which three (having an occupational therapist, in-service training and hours of operation) became non-significant when we analysed only the 24 RCTs used in the meta-analysis. Average contact frequency, however, remained significantly higher for North American teams, even when only these 24 RCTs were analysed. It is possible that this difference might account for some of the difference in reduction in hospitalisation. The difference between experimental and control North American services in this respect, however, was small; this makes this interpretation less plausible. Having a social worker on the team was significantly more common for the North American teams in the meta-analysis, but this seems unlikely to account for the difference found. Finally, North American teams operated 6-day weeks, on average, compared with the European 5-day week and also compared with the average 5-day weeks of North American control services. This might seem a more plausible explanation. None of these components, however, was associated with reduction in hospital days in our meta-analysis of service components across all studies (Catty et al, 2002a).
European control services: too close to the experimental
services?
An alternative suggestion has been that European control services might be
more effective than North American ones, that is, closer to the experimental
services (Burns et al,
1999a). Our experimental services analysis suggests that
this could indeed be the case. This analysis found that patients in North
American experimental services spent no fewer days in hospital than those in
European services. Differences in hospitalisation policies would have a
potential influence on this finding, as well as differences in severity of
illness of patients included. We made some adjustment for the latter, but it
might not have adjusted fully for differences in severity. Nevertheless, the
lack of a difference found between experimental services is consistent with
the hypothesis that it is the control services that differ between North
America and Europe.
Our analysis of components yields contradictory evidence to support this conclusion. North American control services had significantly higher contact frequencies than European ones across the board: a difference which would seem to be in their favour. This difference was not statistically significant for the studies in the meta-analysis, however, possibly because of the small number of studies. European control services were significantly more likely to visit their patients at home regularly, although this only approached significance across all studies and was non-significant within the 24 RCTs used in the meta-analysis. Although these findings are thus equivocal, it is possible that the tendency for European control services to visit patients at home could have at least partially accounted for their studies' failure to demonstrate differences in hospitalisation relative to North American studies. Regularly visiting at home was associated with reducing hospital days across all the studies (Catty et al, 2002a), so this component could be particularly meaningful.
For the two-thirds of control services that were not CMHTs, we have scant information. For the 24 RCTs meta-analysed, only 10 used CMHTs as their control services. We cannot therefore rule out substantial differences in the control services of these studies between North America and Europe. It is plausible that such differences too could account for the differences in the overall mean reductions in hospital days between North American and European studies.
The conundrum
Although it seems clear that North American studies find greater reductions
in hospitalisation than do European ones, determining the cause of this
difference is difficult. Our evidence is that patients in North American
experimental services were spending no fewer days in hospital than were
patients in European services; that is, that experimental and control services
differ in North America to a greater extent than in Europe. Our interpretation
of this is necessarily tentative, given the difficulties of obtaining full
data and methodological limitations. Nevertheless, it seems plausible to
suggest that European control services are close to their experimental
counter-parts perhaps particularly in home visiting and that
this, or other unknown control service features, could account for the failure
of European studies to replicate the findings of certain North American
studies. The implications of this are farreaching and should be an important
check on current European service initiatives. Future research is likely to
need greater design sophistication and power than that of many of the studies
included in this review if it is to yield convincing answers to the questions
raised here.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication November 12, 2001. Revision received May 8, 2002. Accepted for publication May 29, 2002.
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