A comparison of clinical outcomes, service satisfaction, and well-being in people using Acute Day Units and Crisis Resolution Teams: a cohort study in England
Summary (4 min read)
Introduction
- The authors aimed to investigate readmission rates, satisfaction andwellbeing outcomes for people using ADUs and CRTs.
- Within the National Health Service (NHS), support for people in mental health crisis is typically provided by multidisciplinary crisis resolution teams (CRTs), which aim to avoid in-patient admission by providing care at home via frequent visits.
Acute day units
- Acute day units (ADUs), previously known as ‘day hospitals’,4 provide an additional clinical resource for those in mental health crisis.
- ADU care is provided by a multidisciplinary team, usually including nurses, therapists, psychiatrists and other mental health professionals.
- As a result, patients are provided with structured days, more staff contact time and continuity than is available via CRTs, with opportunities for peer support from other clients, and a wider range of psychological, social and medical interventions.
- Evidence of the effectiveness of ADUs is limited, with the most recent meta-analysis conducted in 2011.4.
- Furthermore, to date there has been no comparison of outcomes and experiences of people using ADUs compared with those using CRTs, arguably a more directly comparable type of service.
The current study
- The authors need evidence regarding any additional benefit ADUs may offer to patients, not only in terms of clinical outcomes, but also on patient-reported outcomes such as patient experience, well-being BJPsych Open (2021) 7, e68, 1–8. doi: 10.1192/bjo.2021.30 1 Downloaded from https://www.cambridge.org/core.
- The aims of this study were to describe and compare the clinical and sociodemographic characteristics of people using ADUs and CRTs; and to compare outcomes in terms of readmission, well-being, depression and patient satisfaction for those who received ADU care with those who received only CRT care.
- The authors hypothesised that people receiving ADU care would have fewer admissions, greater satisfaction and well-being, and less depression at 6 months, compared with those receiving CRT care alone.
Method
- The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
- All procedures were approved by the London Bloomsbury Research Ethics Committee (reference number 16/LO/2160).
Design and setting
- The authors established a quasi-experimental cohort study of people using ADU and CRT services and compared readmission to the acute care pathway during a 6-month period from baseline, as well as measures of depression, well-being and satisfaction with services.
- The authors recruited four NHS trusts with ADUs and CRTs in England.
- 6 Participant recruitment took place between March 2017 and April 2019, with follow-up completed in September 2019.
- Recruitment and data collection could occur at any point during the initial admission, and up to 14 days after discharge from the service.
- Telephone or online follow-up was carried out 8–12 weeks after baseline, with electronic health record (EHR) outcome data collected at 6 months after baseline.
Participants
- Inclusion and exclusion criteria Inclusion criteria were as follows: aged ≥18 years, used an ADU/ CRT service for at least 1 week, read and understand English (or translator available), capacity to provide informed consent and did not pose too high a risk to others or themselves to participate (as judged by their current clinical team).
- ADU participants could use CRTs concurrently or during the follow-up period; however, CRT participants were excluded if they used an ADU at any point during study period.
- This was to determine the benefits of ADUs as an addition to the acute care pathway, over and above CRTs.
Measures
- Exposure Ourmain exposure was being under the care of an ADU (solely or in combination with CRT use) for at least 1 week before baseline, compared with CRT care only.
- The authors primary outcome was time to readmission for acute treatment, after discharge fromCRT or ADU, during the 6-month study period (starting from the date of recruitment to the study).
- The authors collected data from EHRs on admissions and service use; clinical characteristics (ICD-10 diagnosis and any comorbid diagnoses, physical health diagnoses, substance misuse, smoking, medication, previous hospital admission); Health of the Nation Outcome Scales scores10 and content of care (physical assessment carried out, carers involved in care, psychological input from service used at baseline).
- Where patients had multiple diagnoses recorded in their EHR, the authors recorded the diagnosis considered to be more severe.
- The authors recorded whether the person had a serious mental illness (SMI), typically defined as 2 Downloaded from https://www.cambridge.org/core.
Procedure
- At baseline, ADU/CRT staff screened all people consecutively admitted to their service from the study start date.
- Potential participants were given at least 24 hours to consider whether they would like to take part, and then if still interested, they provided written consent to a researcher, who also collected the baseline data.
- Consent and data collection could occur up to 14 days after discharge from initial service use.
- Participants were offered £20 reimbursement for taking part (£10 for the baseline interview and £10 for the followup interview at 8–12 weeks after baseline).
- At 6 months after baseline, readmission data were collected from EHRs.
Sample size
- It would also afford 90% power to detect an effect size difference of 0.3 on the CSQ.
- This calculation included inflation for clustering by NHS trust.
Analysis
- The authors calculated descriptive statistics comparing the baseline characteristics of people using ADUs versus those using CRTs for the sample as a whole, and within NHS trusts.
- For their primary outcome, the authors compared time to readmission in ADU and CRT participants.
- The authors adjusted for variables chosen a priori, which previous research suggested may be relevant (trust, age, gender, SMI diagnosis, employment, baseline HoNOS score, baseline SWEMWBS score and whether the person had previously been an in-patient).
- For the secondary outcomes, the authors analysed mean satisfaction, well-being and depression scores at weeks 8–12, using linear regression.
- Stata version 16 for Windows was used for all analyses.
Results
- Figure 1 below shows the flow of participants into the study, and those followed up at 8–12 weeks.
- The mean difference between ADU and CRT participants in time from index admission to recruited was 7 days, which was statistically significant (P = 0.0001, 95% CI 3.2–9.8).
- For the primary outcome at the 6-month time point, 21.4% of ADU participants were readmitted, compared with 23.4% of CRT participants, with no statistically significant difference evident.
- Versus CRT participants are shown in Table 2.
Summary of results
- In a fully adjusted model, there was no significant difference between ADU and CRT participants in terms of readmission over 6 months.
- These results indicate that, despite serving a more unwell client group (as suggested by the lower proportion of ADU participants in employment, and higher proportions with SMI diagnoses and previous hospital admission), overall, ADUs produce comparable outcomes in terms of readmission, and better satisfaction, depression outcomes and well-being than CRTs.
- In terms of the primary outcome, readmission to acute services, the authors are not aware of previous research directly comparing ADU and CRT services.
- Similarly, another study of people using CRTs found a readmission rate of 38%,14 which is comparable with their study.
- The very wide confidence intervals evident in their study are probably because of a lack of statistical power, since the study was powered for an overall effect.
Strengths and limitations
- There are four key strengths of this cohort study: the direct comparison of those using ADUs and CRTs, which has not been undertaken previously; the robust methodology (large sample size and adjustment for clinical and demographic differences at baseline); the range of geographical locations of participating services and high follow-up rates.
- The authors were able to follow up on 99.99% of participants via their EHRs at the 6-month time point, which included their primary outcome of service use during the 6 months, and 76% of participants (ADU 75.4%, CRT 77.2%) at the 8–12 week time point, which included the secondary outcomes of satisfaction, well-being and depression.
- There are four main limitations of the study: selection and attrition bias; differences in index admission and recruitment periods; power, and lack of randomisation of participants and EHR data quality.
- This indicates that their sample did include people with complex mental health needs.
- Their research showed that people using ADUs were more likely to receive psychological input, physical healthcare and carer involvement.
Author contributions
- D.L. ran the study, collected and analysed data, and wrote the first draft of this manuscript.
- T.S. collected data and provided comments on the manuscript.
- L.M. contributed to the data analysis and provided comments on the manuscript.
- D.O. conceived and designed the study, and provided comments on the manuscript.
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References
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