Department of Mental Health Sciences, Royal Free and University College London Medical Schools, University College London, and Camden and Islington Mental Health and Social Care Trust
Sub-Department of Clinical Health Psychology, University College London, and Camden and Islington Mental Health and Social Care Trust
Camden and Islington Mental Health and Social Care Trust
Biostatistics Unit, Cambridge
Department of Mental Health Sciences, Royal Free and University College Medical Schools, University College London, and Camden and Islington Mental Health and Social Care Trust
Camden and Islington Mental Health and Social Care Trust
Sub-Department of Clinical Health Psychology, University College London
Sub-Department Sub-Department of Clinical Health Psychology, University College London, and Camden and Islington Mental Health and Social Care Trust, London, UK
Correspondence: Dr Sonia Johnson, Department of Mental Health Sciences, Royal Free and University College London Medical Schools, Wolfson Building, 48 Riding House Street, London W1W 7EY, UK. E-mail: s.johnson{at}ucl.ac.uk
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ABSTRACT |
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Aims To compare outcomes of crises before and after introduction of a CRT.
Method A new methodology was developed for identification and operational definition of crises. A quasi-experimental design was used to compare cohorts presenting just before and just after a CRT was established.
Results Following introduction of the CRT, the admission rate in the 6 weeks after a crisis fell from 71% to 49% (OR 0.38, 95% CI 0.21-0.70). A difference of 5.6 points (95% CI 2.0-8.3) on mean Client Satisfaction Questionnaire (CSQ-8) score favoured the CRT. These findings remained significant after adjustment for baseline differences. No clear difference emerged in involuntary hospitalisations, symptoms, social functioning or quality of life.
Conclusions CRTs may prevent some admissions and patients prefer them, although other outcomes appear unchanged in the short term.
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INTRODUCTION |
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Study aims and design |
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Our primary hypotheses were that the introduction of a CRT would be associated with fewer admissions and with better patient satisfaction in the 6 weeks following a crisis. Secondary hypotheses related to other dimensions of clinical and social outcome.
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METHOD |
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Definition of crisis
The research team developed an operational definition of a crisis, shown in
the Appendix. This was intended to describe situations in which, in the
context of the local service system prior to CRT introduction, clinicians
would regard admission to an acute hospital ward as justified.
Identification of crises
Throughout the study, researchers contacted the staff of the casualty
department liaison team, the local community mental health teams and crisis
houses and, in the second phase, the CRT at least twice a week to identify all
potential crisis presentations. Vignettes of each were then evaluated by a
rating panel consisting of at least three senior psychiatrists and a clinical
psychologist. The panel was not told whether presentations had resulted in
admission and was asked to reach a consensus about whether they met study
criteria for a crisis. Those that did not were excluded from further
assessments and analyses.
Interventions
Before introduction of the CRT, acute care involved acute wards, two 24-h
staffed crisis houses, well-established community mental health teams,
available 9 a.m. to 5 p.m. on weekdays, and a multidisciplinary liaison team
available between 8 a.m. and 10 p.m. in the casualty department. Local
patterns of care were investigated during the pre-CRT phase using the European
Service Mapping Schedule (Johnson et
al, 2000). Quite high levels of community contacts were
found: 49% of continuing care community service users were seen outside health
service premises at least once during a census month. However, contacts were
not usually very frequent: 1.5% of service users were seen three or more times
in a single week.
Crisis team group
The CRT group was identified after a CRT was added to the service system
described above. This conformed to the model described in national policy
guidelines (Department of Health,
2001): it was available 24 h a day to assess and treat people in
their homes or other community settings. Members included nurses, social
workers, support workers and a junior psychiatrist. The CRT was required to
assess whether home treatment was feasible before any acute admission could
take place. Patients could be visited several times a day if necessary and
were discharged from the CRT caseload once the crisis had resolved. Johnson
(2004) has described this model
in more detail.
Six weeks elapsed between the end of the pre-CRT group recruitment period and the start of the CRT group recruitment period. The same senior staff were in post throughout the study period, except that one of the community mental health team leaders moved to manage the CRT.
Assessments
Assessments were carried out immediately after identification of the
crisis, then 6 weeks and 6 months afterwards. Except where a single source is
specified below, best available information was elicited from participants,
staff and clinical records. Participants were interviewed if the clinicians
responsible for their care felt this was feasible and informed consent could
be obtained. As systematic differences between interview responders and
non-responders were likely, we obtained ethical approval for some anonymised
data collection regarding those not interviewed.
Baseline data collection
Baseline data were collected as soon as possible after the initial crisis:
researchers aimed to carry out all assessments within a week. Structured
questionnaires were used to assess:
Follow-up assessments
Primary outcomes. Best available information was used to ascertain
whether each patient had been admitted in the 6 weeks after the crisis.
Service satisfaction was assessed using the Client Satisfaction Questionnaire
(CSQ-8; Atkisson & Zwick,
1982).
Secondary outcomes. The BPRS and MANSA were re-assessed at patient interview at 6 weeks. HoNOS and LSP ratings, admissions and adverse events were assessed 6 weeks and 6 months after the crisis. Six-month assessments were based solely on staff reports and records.
Analysis
Stata Release 8 (for PC) was used in an analysis involving the following
pre-specified stages.
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RESULTS |
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Socio-demographic data, information about crises and LSP and HoNOS ratings were obtained for all 200 at baseline. Interviews were completed with 140 participants (70%). At 6 weeks, data on admissions and adverse events and HoNOS and LSP ratings were obtained for all 200, of whom 49 out of 77 (64%) in the pre-CRT group and 78 out of 123 (63%) in the CRT group were interviewed. At 6 months, information was available for all but 10 people: the whereabouts of 4 were uncertain and 6 had died.
Sample characteristics
As Table 1 shows, most
socio-demographic characteristics of the two groups were similar, but there
were some potentially important differences, especially in presenting problems
and previous service use. The variables shown are selected from 110 univariate
tests carried out for baseline differences. Of these, P values fell
below 0.05 in 24 cases (5.5 would be expected by chance) and below 0.01 in 14
(1.1 expected by chance). Thus there were probably systematic baseline
differences between the populations from which the groups were drawn.
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Comparisons were made on all baseline variables between interview responders and non-responders at follow-up. Few differences were found, but Black Africans (P=0.039) and people assessed in casualty (P=0.013) were less likely to be interviewed, and responders had higher functioning than non-responders on the social contact LSP sub-scale (P=0.018).
In-patient admission in the 6 weeks following the crisis
As Table 2 shows, 55 (71%)
pre-CRT group members and 60 (49%) of the CRT group were admitted within 6
weeks (odds ratio 0.38, 95% confidence interval 0.21-0.70). The effects of all
110 baseline clinical and social variables on the odds ratio for the
association between experimental group and admission were tested, individually
and then for planned combinations of variables, as described above. The
finding of a highly significant association between experimental group and
admission by 6 weeks remained robust throughout all tests involving different
combinations of baseline variables, and the odds ratio did not rise above 0.38
in any case.
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Secondary hypotheses regarding admission
A 6.2-day difference in mean bed use between the groups also remained
statistically significant throughout testing for potential confounders.
Logarithmic transformation of bed use data was not used as graphing indicated
little skewness. However, there was some clumping due to a substantial number
of zero values. In view of this, a non-parametric test was carried out as a
sensitivity analysis: Wilcoxon's rank sum test also indicated a significant
difference between the groups (P=0.0034).
By 6 months, 58 pre-CRT (75%) and 74 CRT group members (60%) had been admitted at least once, a difference still just reaching the P=0.05 level of significance. A caveat is that once the CRT began work, pre-CRT group members could not be refused access to it. No pre-CRT group member used the CRT during the initial 6 weeks, but 15 used it between 6 weeks and 6 months. However, admission rates are unlikely to be much influenced by this, as 13 of these 15 individuals had been admitted at least once by 6 months despite their contact with the CRT. Adjustment for potential confounders was carried out as before, but now yielded equivocal results, with experimental condition significantly associated with admission by 6 months in some but not all the planned regressions, depending on method of selecting variables (odds ratio for experimental condition varied between 0.25 and 0.78). Confounding thus appeared more likely to account for the difference in admissions at 6 months than at 6 weeks.
The mean difference in bed use between the groups increased from 6.2 to 8.8 between the 6-week and 6-month stages, but standard deviations were wide and at 6 months the difference did not reach the P<0.05 significance level (although for Wilcoxon's rank sum test P=0.05). This finding must be treated with caution, as the availability of the CRT to pre-CRT group members may have reduced pre-CRT bed days. No difference was found in rates of involuntary hospitalisation.
Satisfaction
Table 3 shows that a highly
significant difference was found in mean and median patient satisfaction
scores. The median for the pre-CRT group indicated mild dissatisfaction, the
CRT median a very positive view. This result remained highly significant
throughout testing for potential confounders.
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How much non-response could have influenced these findings is an important question. To assess this, we considered how far scores for non-responders would have to diverge from those for responders for the overall result to change. If the mean score for all pre-CRT non-responders were 24.7 (2 points above the overall mean for responders in the study sample) and the mean score for all CRT non-responders were 20.7 (2 points below the study mean), the overall means for the pre-CRT group and CRT group would be 21.4 and 23.4, respectively. Assuming standard deviations as for responders, this would just fail to reach statistical significance (t=1.97, P=0.054). Thus, a marked reversal of the pattern observed among responders would have to be present among non-responders for a different overall result to be obtained.
Other clinical and social outcomes
Table 3 also shows symptom
severity, which was very similar in the two groups at both times. Baseline LSP
scores suggested greater impairment in the CRT group, a difference which had
disappeared by the 6-month stage. However, regression with adjustment for
baseline score did not yield a statistically significant result. A significant
difference in follow-up MANSA score persisted after adjustment for baseline
score, but not after adjustment for potential confounders. Adverse events are
shown in Table 4. More deaths
(4 of them suicides) occurred in the CRT group, but the difference was not
statistically significant.
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DISCUSSION |
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Lack of randomisation is an important limitation. The comparison groups were similar on many measures, but the differences were unlikely to be due solely to chance. However, a strength of the study is comprehensive measurement of and adjustment for baseline variables that might be associated with the primary outcomes. It remains conceivable that significant differences in these outcomes are explained by an unmeasured confounder, but residual confounding is relatively unlikely in view of the observations that no adjustment moved the odds ratio much towards 1.0 for admission by 6 weeks or the adjusted mean difference in satisfaction scores much towards 0 (Stewart, 2003).
Successive rather than simultaneous recruitment of the groups means that differences in outcome might have resulted from a change other than the introduction of the CRT, although there were no obvious candidates. Masking the researchers, clinicians or participants was not feasible. The distinctive clinical population of inner London, the newness of the team, the fact that only one CRT and two community mental health teams were involved, and the extensive experience in CRT development of J.H., who was consultant psychiatrist in one of the sectors throughout the pre-CRT and CRT periods, may limit generalisability.
Our methodology set a high threshold for identifying service users as being in crisis. Reduction in admissions may well have been less for crises meeting these relatively stringent criteria than among patients who, before the introduction of the CRT, may have been admitted to hospital despite not meeting these criteria.
Finally, the response rate was relatively low, although higher than in two recent surveys of crisis service users in which response rates were a third or less (Whittle & Mitchell, 1997; Ford et al, 2001). This probably reflects the difficulties in recruiting people who have recently experienced a mental health crisis. Our assessment of the possible effects of missing data suggests that our finding of greater service satisfaction is unlikely to be entirely attributable to response bias.
Admission patterns
At 6 weeks, there were convincing differences in admission rate and in bed
days, indicating that the CRT appeared to serve its intended function of
diversion from admission. The difference was, however, smaller than in many
earlier studies of intensive home treatment initiated in an emergency
(Stein & Test, 1980; Hoult et al, 1983),
and 60% of the CRT group had been admitted by 6 months. The poor social
circumstances of many of our service users and the large numbers with a
history of violence or involuntary admission may be inimical to home
treatment. Moreover, community mental health teams already visited many
patients at home: it may be more difficult for new teams to better the
outcomes achieved by services that are already substantially home-based.
Although the differences in bed use were limited, they made a clinically important difference to service functioning. At 6 months, mean bed use in the CRT group was 20% lower than in the pre-CRT group. While this was not statistically significant, it does fit with local routine data on bed occupancy in the study sectors, which indicated a substantial fall in bed occupancy, allowing the practice of purchasing overspill beds in the private sector to cease. There was no effect on involuntary hospitalisation, suggesting that it is easier for a CRT to prevent voluntary admissions of reasonably cooperative patients.
Patient satisfaction
Mirroring earlier randomised trials
(Hoult et al, 1983)
and recent uncontrolled surveys, our data suggest that service users prefer
CRT care. Given that pre-CRT and CRT care appear similar on most other
outcomes, this seems a reasonable justification for favouring this model in
service planning. It should be noted, however, that satisfaction was measured
at an early stage when patients had experienced only a single episode of CRT
care, and we did not investigate the views of carers.
Other outcomes
As in most home treatment studies, our study lacks power for analysis of
suicides and other serious adverse events. The greater incidence of deaths in
the CRT group is probably a chance finding. Three of the four patients who
died by suicide had been admitted to hospital by the CRT: one died by suicide
soon after discharge without re-referral to the CRT, one was allowed to
discharge himself shortly after admission and died by suicide later that day,
and one died by suicide while on leave from hospital. Only one was receiving
CRT care when he died. Although four suicides occurred during the 9-month CRT
phase of our study, only two were recorded in the following 9 months, during
which the CRT continued to operate.
Our investigation gives few grounds for believing that there are major differences between the two models of care in the symptomatic and social progress of individuals following crises. This is not surprising given that many had severe illnesses, limited social resources and long psychiatric histories. For a very brief period of CRT care to have made a detectable difference to aggregate scores for outcomes such as social functioning and quality of life would have been remarkable. If the availability of CRTs does prove to make a difference to patients' engagement and their clinical and social outcomes, this is more likely to be apparent once a cohort has repeatedly been able to avoid hospital admission.
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APPENDIX |
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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 January 5, 2004. Revision received October 14, 2004. Accepted for publication October 19, 2004.