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      Utilization of Psychiatric Hospital Services Following Intensive Home Treatment : A Nonrandomized Clinical Trial

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          Key Points

          Question

          What are the outcomes of intensive home treatment (IHT) compared with inpatient treatment (IT) in terms of utilization of psychiatric hospital services?

          Findings

          In this 12-month follow-up nonrandomized trial involving 400 participants from 10 psychiatric hospitals in Germany, IHT was associated with lower inpatient readmission rate (−18%), lower rate of readmission to either inpatient, day clinic, or IHT (−13%) as well as fewer inpatient treatment days (−6.82 days) compared with IT. There were no significant group differences in clinical and social outcomes at the 12-month follow-up.

          Meaning

          These results suggest that IHT is a viable alternative to IT for individuals with psychiatric crises otherwise requiring hospital admission.

          Abstract

          This nonrandomized clinical trial investigates the association of intensive home treatment vs inpatient treatment with readmission rate, social outcomes, and clinical outcomes.

          Abstract

          Importance

          Home treatment (HT) has been associated with fewer inpatient treatment (IT) readmission days but lacks evidence on reducing combined psychiatric hospital service use (IT, HT, day clinic).

          Objective

          To assess the association of intensive home treatment (IHT) compared with IT regarding readmission rate, social outcomes, and clinical outcomes.

          Design, Setting, and Participants

          This quasi-experimental, nonrandomized trial was conducted from 2020 to 2022 in 10 psychiatric hospitals in Germany. Propensity score (PS) matching was used to compare both treatment models at the 12-month follow-up using standardized instruments and routine hospital data. All patients were screened until the target sample size was reached, based on these criteria: stable residence with privacy for sessions, no child welfare risk, primary diagnosis within International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes F0X to F6X, residence in the catchment area, no commitment order, no acute suicidality or severe aggression requiring hospitalization, capacity to consent, not participating in other interventional studies, sufficient German language skills, no substantial cognitive deficits or intellectual impairment, and no more than 7 days in IHT or IT before recruitment. Statistical analysis was performed from February to November 2023.

          Intervention

          IHT provided daily acute psychiatric treatment at home, while IT was psychiatric inpatient treatment as usual. The mean treatment duration of the index treatment was 37.2 days for IHT and 28.2 days for IT.

          Main Outcomes and Measures

          The inpatient readmission rate was the primary outcome. Secondary outcomes were combined readmission rate, total inpatient days, job integration, quality of life, psychosocial functioning, symptom severity, and recovery.

          Results

          Of 1396 individuals, 200 patients receiving IHT and 200 patients receiving IT were included (264 female [65%]; mean [SD] age, 45.45 [15.83] years [range, 18-88 years]). Baseline sociodemographic and psychometric characteristics did not differ significantly between the groups. At 12-month follow-up, patients in the IHT group had lower inpatient readmission rate (IHT vs IT: 31.12% vs 49.74% IT; mean difference, 18% [95% CI, 9%-28%; P < .001), combined readmission rate (mean difference, 13% [95% CI, 4%-24%; P < .001), and fewer inpatient days (mean difference, 6.82 days; P < .001) than the IT group.

          Conclusions and Relevance

          This nonrandomized clinical trial found that patients receiving IHT had a lower likelihood of utilizing hospital-based psychiatric services and spent fewer inpatient days, suggesting that IHT is a viable alternative to IT.

          Trial Registration

          ClinicalTrials.gov Identifier: NCT04745507

          Related collections

          Most cited references23

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          Flexible Imputation of Missing Data, Second Edition

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            Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study.

            To evaluate the effectiveness of a crisis resolution team. Randomised controlled trial. 260 residents of the inner London Borough of Islington who were experiencing crises severe enough for hospital admission to be considered. Acute care including a 24 hour crisis resolution team (experimental group), compared with standard care from inpatient services and community mental health teams (control group). Hospital admission and patients' satisfaction. Patients in the experimental group were less likely to be admitted to hospital in the eight weeks after the crisis (odds ratio 0.19, 95% confidence interval 0.11 to 0.32), though compulsory admission was not significantly reduced. A difference of 1.6 points in the mean score on the client satisfaction questionnaire (CSQ-8) was not quite significant (P = 0.07), although it became so after adjustment for baseline characteristics (P = 0.002). Crisis resolution teams can reduce hospital admissions in mental health crises. They may also increase satisfaction in patients, but this was an equivocal finding.
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              Crisis resolution and home treatment teams: an evolving model

              S. Johnson (2013)
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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                15 November 2024
                November 2024
                15 November 2024
                : 7
                : 11
                : e2445042
                Affiliations
                [1 ]Department of Psychiatry, Psychotherapy, and Psychosomatics incorporating FRITZ am Urban and soulspace, Vivantes Hospital am Urban and Vivantes Hospital im Friedrichshain, Berlin, Germany
                [2 ]Department of Psychiatry and Psychotherapy, CCM, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
                [3 ]German Center for Mental Health (DZPG), Berlin-Potsdam site, Germany
                [4 ]Faculty of Health Sciences Brandenburg, Brandenburg Medical University Theodor Fontane, Neuruppin, Germany
                [5 ]Department of Psychiatry and Psychotherapy, Center for Mental Health, Immanuel Hospital Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
                [6 ]Center for Psychiatry South Württemberg, Department of Psychiatry and Psychotherapy Zwiefalten, Zwiefalten, Germany
                [7 ]Clinic for Psychiatry and Psychosomatics of Reutlingen (PP.rt), Academic Teaching Hospital of the University of Tübingen, Reutlingen, Germany
                [8 ]General Psychiatry and Psychotherapy Division, Department of Psychiatry and Psychotherapy, University Hospital Tübingen and Medical Faculty of the University of Tübingen, Tübingen, Germany
                [9 ]kbo-Isar-Amper Hospital Munich Region, Academic Teaching Hospital of Ludwig-Maximilians-University Munich, Haar near Munich, Germany
                [10 ]Competence Center for Clinical Studies Bremen, Biometrics Department, University of Bremen, Bremen, Germany
                [11 ]Section of Health Economics and Health Services Research, Department of Psychiatry and Psychotherapy II of Ulm University at Bezirkskrankenhaus Günzburg, Günzburg, Germany
                [12 ]Center for Psychiatry South Württemberg, Department of Psychiatry and Psychotherapy I, University of Ulm, Weissenau, Germany
                [13 ]Department of Psychiatry, Psychotherapy, and Psychosomatics, Vivantes Neukölln Hospital, Berlin, Germany
                [14 ]Mainkofen District Hospital, Deggendorf, Germany
                [15 ]Reichenau Center for Psychiatry, Academic Teaching Hospital University of Konstanz, Reichenau, Germany
                [16 ]Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm, Germany
                [17 ]Psychiatric University Hospital Zurich, Zurich, Switzerland
                [18 ]Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
                [19 ]Scientific Institute of the AOK (WIdO), Berlin, Germany
                [20 ]University Psychiatric Clinics (UPK) Basel, Faculty of Medicine University of Basel, Basel, Switzerland
                [21 ]Center for Integrative Psychiatry, University Hospital Schleswig-Holstein, Germany
                Author notes
                Article Information
                Accepted for Publication: September 12, 2024.
                Published: November 15, 2024. doi:10.1001/jamanetworkopen.2024.45042
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Bechdolf A et al. JAMA Network Open.
                Corresponding Author: Andreas Bechdolf, MD, MSc, Vivantes Klinikum Am Urban, Dieffenbachstraße 1, 10967 Berlin, Germany ( andreas.bechdolf@ 123456vivantes.de ).
                Author Contributions: Profs Bechdolf and Timm had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Bechdolf, von Peter, Längle, Brieger, Kilian, Hirschmeier, Baumgardt, Weinmann.
                Acquisition, analysis, or interpretation of data: Bechdolf, Nikolaidis, von Peter, Längle, Brieger, Timm, Kilian, Fischer, Raschmann, Schwarz, Holzke, Rout, Hamann, Herwig, Richter, Weinmann.
                Drafting of the manuscript: Bechdolf, Nikolaidis, Brieger, Kilian, Hirschmeier, Weinmann.
                Critical review of the manuscript for important intellectual content: Bechdolf, von Peter, Längle, Brieger, Timm, Kilian, Fischer, Raschmann, Schwarz, Holzke, Rout, Hamann, Herwig, Richter, Baumgardt, Weinmann.
                Statistical analysis: Timm, Fischer.
                Obtained funding: Bechdolf, von Peter, Brieger, Kilian, Schwarz, Holzke, Baumgardt.
                Administrative, technical, or material support: Nikolaidis, von Peter, Längle, Brieger, Raschmann, Schwarz, Hamann, Richter, Weinmann.
                Supervision: Bechdolf, von Peter, Längle, Brieger, Timm, Kilian, Weinmann.
                Conflict of Interest Disclosures: Dr Bechdolf reported personal fees from JanssenCilag, Lundbeck, Otsuka, and Recordati outside the submitted work. No other disclosures were reported.
                Funding/Support: The research discussed in this article received funding from the innovation fund of the Federal Joint Committee (Gemeinsamer Bundesausschuss) with grant number 01VSF19048.
                Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Meeting Presentation: This work was presented at the 23rd Congress of the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology; December 1, 2024; Berlin, Germany.
                Data Sharing Statement: See Supplement 4.
                Additional Contributions: We are thankful to all patients who participated in the trial and all researchers and administrative staff in the study centers who contributed to this trial.
                Article
                zoi241285
                10.1001/jamanetworkopen.2024.45042
                11568461
                39546314
                b00e5cb8-2c17-45a1-8826-0a4f48f76d46
                Copyright 2024 Bechdolf A et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 1 June 2024
                : 12 September 2024
                Categories
                Research
                Original Investigation
                Online Only
                Psychiatry

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