Day Hospital versus admission for acute psychiatric disorders

Dr. Simon BensonST2 General Practice

Journal Club

Cochrane Review

Day hospital versus admission for acute psychiatric disorders (Review)

Marshall M, Crowther R, Almaraz-Serrano AM, Sledge WH, Kluiter H, Roberts C, Hill E, Wiers

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Background

Inpatient treatment is an expensive way of caring for patients with acute psychiatric disorders and surveys suggest that it is often unnecessary.

Can patients with psychiatric disorders be cared for in a day hospital environment versus inpatient care?

What is a day hospital?

A unit that provides diagnostic and treatment services for acutely ill patients that would otherwise be treated as inpatients.

Patients attend during the day but sleep at home

Objectives

To assess the effects of admission to a day hospital compared to inpatient care

To determine what proportion of acutely ill patients were suitable for day hospital treatment

To determine whether patients recover at the same rate in terms of symptoms and social functioning

Selection Criteria

Randomised Controlled Trials

Patients with acute psychiatric disorders needing admission if not alternative available

Majority of patients included between 18 and 65yo

Primary diagnosis of substance abuse excluded

Organic cause excluded

Interventions

1. Acute psychiatric day hospital (unit that provides diagnostic and treatment services)

2. Standard inpatient care

Outcome Measures

Primary Outcome Measure

Loss to follow up

Secondary Outcome Measures

Feasability and engagementExtent of admissionClinical OutcomesSocial OutcomesCosts of Care

Literature Search

1. CINAHL (1982-2000)2. Cochrane Library (1980-2000)3. Embase (1980-2000)4. Medline (1966-2000)5. PsycLit (1967-2000)

Search term

[((DAY adj2 HOSP*) or (DAY adj2 CARE) or (DAY adj2 TREATMENT*) or (DAY adj2 CENT*) or (DAY adj2 UNIT*) or (PARTIAL adj2 HOSP*) or (DISPENSARY)) AND MENTAL DISORDERS/All subheadings exploded]

Data Collection

Selection of Trials

Two independent assessors blindly reviewed retrieved abstracts and selected papers for inclusion. There was complete agreement.

Quality Assessment

Only trials in categories A and B were included

Feasability of day hospital care

Defined as percentage reduction in acute inpatient admission

Results

81 studies identified

64 excluded (43 not randomised and 21 randomised)7 studies awaiting assessment1 ongoing study

9 trials included (2268 participants)Two types

1 - (patients ineligible for day care excluded before randomisation)2 – (all patients presenting were randomised)

Results

2 studies in Manchester, UK (1990, 1996)1 study in Dundee, Scotland (1985)4 studies in USA (1964, 1965, 1971)

2 studies in Netherlands (1989, 1993)

Number of participants varied from 90 to 378No pre-test power calculation performed

Results

Interventions for day hospital varied

All were staffed by nurses and occupational therapists

Three had out of hours cover

One had community input to check on DNAs

All had some form of psychotherapy in addition to medication

Results

Clinical and Social Outcomes assessed by:

Present State ExaminationComprehensive Psychopathology ScaleBrief Psychopathology Rating ScaleClinical Interview ScaleSocial Behaviour Assessment ScheduleSocial Adjustment Scale

Risk of Bias

Allocation concealment adequate in 5 of 9 trialsBlinding not possible in this type of study

Follow-up rates varied from 59-92%No differences reported in individual data

Key Results

Feasability of day hospital treatment(percentage reduction in acute admissions)

Type 1 trials = 37.5%Type 2 trials = 18.4 – 39.1%

Combined: 23% (n=2268, CI 21-25)

Key Results

Loss to follow up

Five type 1 trials and one type 2 trial reported

No difference between inpatient and day hospital treatment (n=667, RR=0.97, CI 0.74-1.27)

Other Results

No differences in total number of days of treatment between the two patient groups

(n=465, 3 RCTs, WMD -0.38 days/month CI -1.32 to 0.55)

Other Results

There was no significant difference in readmission rates between day hospital patients and controls

(n=667, RR 0.91 CI 0.72 to 1.15)

Other Results

For patients judged suitable for day hospital care, there was evidence to suggest a more rapid

improvement in mental state

(n=407, Chi-squared 9.66, p=0.002)

But not social functioning

(n= 295, Chi-squared 0.006, p=0.941)

Compared to inpatient controls

Cost of Care

Day hospital care was between 33.5% and 49.6% cheaper for the initial admission

Day hospital care was between 20.9% and 36.9% cheaper in total cost of care.

Important Limitations

Good quality in terms of allocation concealment

Only RCTs used

None were blind to group allocation

Sub-optimal follow-up rates (less than 80%)

Effect on suicide rates on mortality would have been useful

Key Messages

Potential to reduce hospital admissions by 23%

Evidence suggests that in terms of clinical and social outcomes there is no difference in

efficacy

Significant cost savings are possible

Implications for PracticeAcute day hospitals can achieve a reduction in

inpatient admissions but these need to be outweighed against other community based initiatives such as assertive outreach (23%

compared to 55%)

Cost savings are substantial but it relies on the closure of inpatient beds to shift the cost

equation of care in favour of day hospitals

Where do day hospitals fit with the vast number of services available already – can others

achieve?

Thankyou for listening

Questions / Discussion