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Unit for Social and Community Psychiatry, Bart’s and the London School of Medicine, Queen Mary, University of London
Personal Social Services Research Unit, University of Kent, Canterbury
Personal Social Services Research Unit, University of Kent, Canterbury and Centre for Economics of Mental Health, Institute of Psychiatry, London, UK
Correspondence: Professor Stefan Priebe, Unit for Social and Community Psychiatry, Newham Centre for Mental Health, London E13 8SP, UK. E-mail: s.priebe{at}qmul.ac.uk
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Aims To establishthe effectiveness and costs of care in a day hospital providing acute treatment exclusively.
Method In a randomised controlled trial, 206 voluntarily admitted patients were allocated to either day hospital treatment or conventional wards. Psychopathology, treatment satisfaction and subjective quality of life atdischarge, 3 months and 12 months after discharge, readmissions to acute psychiatric treatment within 3 and 12 months, and costs in the index treatment period were taken as outcome criteria.
Results Day hospital patients showed significantly more favourable changes in psychopathology at discharge but not at follow-up.They also reported higher treatment satisfaction atdischarge and after 3 months, but not after12 months. There were no significant differences in subjective quality of life or in readmissions during follow-up.Meantotal supportcosts were higher for the day hospital group.
Conclusions Day hospital treatment for voluntary psychiatric patients in an inner-city area appears more effective in terms of reducing psychopathology in the shortterm and generates greater patient satisfaction than conventional in-patient care, but may be more costly.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Treatment settings
The in-patient wards provided conventional psychiatric care, including a
limited programme of optional daily activities. The day hospital was based on
an approach first established in Germany in the 1970s
(Priebe & Gruyters, 1994).
It exclusively treated acute patients as an alternative to in-patient care,
and did not provide after-care to shorten in-patient treatment or facilitate
the transition from hospital to community
(Priebe, 2002). The day
hospital had 20 places. Patients were expected to attend the full programme
from 09.30 to 16.30 h every weekday; patients who did not attend for 3
consecutive days were discharged. These stringent attendance requirements were
based on the experience that a more flexible approach makes it difficult for
day hospitals to sustain their focus on acute treatment over a long time. At
weekends there was an optional drop-in service. The day hospital was organised
around a structured, intensive group-based programme which included a range of
verbal, non-verbal, creative and work-based interventions. There were two
alternative ‘strands’ to meet the different needs of the patients
and ensure manageable sizes for group activities: one was more structured with
a focus on practical activities and protected interactions; the other was more
stimulating with a focus on creative group programmes and verbal
communication. The day hospital was integrated into a modern community care
system, i.e. the consultant responsibility remained with the catchment area
consultants and care programme approach coordination with the care
co-coordinators in the fully developed and integrated community mental health
teams.
The study took place over a 3-year period during which there were no significant changes to policy and practice in the day hospital or other aspects of the service. The study was approved by the Ethics Committee of the East London Health Authority.
Outcome measures
Effectiveness
Psychopathology, subjective quality of life and treatment satisfaction at
discharge, 3 months and 12 months after discharge, as well as readmissions
within 3 and 12 months of discharge, were taken as measures of the
effectiveness of treatment. Discharge was used as a reference assessment point
because it represents the end-point of the treatment. Psychopathology and
subjective quality of life were also assessed at the time of randomisation
(baseline) so they could be controlled for in the analyses.
Psychopathology was measured using the 24-item version of the Brief Psychiatric Rating Scale (BPRS; Ventura et al, 1993). Subjective quality of life was assessed using the Manchester Short Assessment of Quality of Life (MANSA; Priebe et al, 1999) whereby patients assess their satisfaction with 12 life domains on a Likert-type rating scale. Treatment satisfaction was assessed with the Client’s Assessment of Treatment Scale (CAT; Priebe et al, 1995) whereby patients also use a Likert-type scale to assess seven aspects of treatment. Each participant’s mean score of the items on each scale was calculated and used in the analysis. Information on readmissions to either the day hospital or an acute psychiatric ward was collected from patients’ self-reports and hospital records.
Costs
Data on resource use were captured on a specially adapted version of the
Client Service Receipt Inventory (CSRI;
Beecham & Knapp, 2001). Data were collected on resource use over the 3 months prior to admission
(baseline) and over the ‘treatment period’ between admission and
discharge from the ward or day hospital. Data were collected on: specialised
and domestic accommodation arrangements and living expenses; in-patient
admissions; day hospital attendance; out-patient and emergency room
attendance; other day activity services; medication; contact with
community-based health and mental health services, primary care, services
offering complementary therapies, social care services (such as social
workers), and police and the courts. By combining data on the frequency and
duration of service use with unit costs, the total support costs reflecting
the intensity of support actually used were calculated for each patient. Unit
costs were taken from a compendium of nationally applicable unit costs
(Netten & Curtis, 2002) or
calculated specially for this project using an equivalent methodology. All
unit costs are the closest approximation of their long-run marginal
opportunity value calculated using average revenue costs plus the costs
associated with capital and overheads
(Beecham, 1995). Costs per
person are presented at 2001–2002 levels and informal care costs were
not included in this analysis. Socio-demographic information was also
collected at each time-point.
Data collection
All questionnaires were administered by trained researchers, with the
interviews taking place in the hospitals, patients’ homes or a research
office as appropriate. As first interviews were conducted in the acute
settings, researchers were not masked to allocation status.
Statistics
The Statistical Package for the Social Sciences (version 10 for Windows)
was used to compare the day hospital and in-patient groups in an
intention-to-treat analysis. One-way analyses of covariance (ANCOVA) were
conducted on mean scores of BPRS and MANSA at discharge and at follow-up.
Baseline mean scores were entered as covariates. Where dependent variables
were scores at discharge, length of stay (in days) was also entered as a
covariate to control for differing lengths of treatment. Mean CAT scores of
the two groups were compared at discharge and 3 months and 12 months after
discharge using t-tests. The number of readmissions among those
randomised to the day hospital compared with those randomised to the ward were
compared using 
2 tests, with t-tests employed to
compare the number of days spent in readmissions. The mean treatment costs for
the two groups were compared using t-tests, with the results
confirmed by bootstrapped (1000 replications) confidence intervals using Stata
software, release 8.0 for Windows.
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RESULTS |
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Tests were also performed to determine whether patients lost to follow-up at each time-point differed from those interviewed. There were no significant differences in baseline characteristics (Table 2), baseline psychopathology or baseline subjective quality of life between patients interviewed and those lost to follow-up. There were also no significant baseline cost differences between patients for whom costs over the treatment period could be estimated and those for whom they could not.
Acute treatment
Patients randomised to the day hospital experienced a significantly longer
admission than those randomised to the ward. The mean length of admission
(including leave from the ward and days of non-attendance at the day hospital)
for patients randomised to the day hospital was 55.7 days (s.d.=46.0, range
0–198) compared with 30.5 days (s.d.=35.6, range 2–175) for the
ward group.
Several patients randomised to the day hospital had very short admissions and a few were not provided with acute treatment exclusively by the day hospital. After randomisation to the day hospital, some patients either stayed on the ward or returned to the ward after a very short stay at the day hospital. Several others required short or longer transfers to the ward during their stay at the day hospital. In line with an intention-to-treat analysis, all patients originally randomised to the day hospital were followed-up and treated in the analyses as part of the day hospital group. Figure 2 shows the actual acute treatment received by patients randomised to the day hospital and the flow between day hospital and ward. It is a reminder that the randomised controlled trial operated in a ‘real world’ situation. The use of in-patient facilities by day hospital patients is included in the cost analyses.
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Subjective quality of life
There were no statistically significant differences in the mean MANSA
scores of the day hospital and in-patient groups at discharge and at 3 and 12
months after discharge. However, at discharge there was a trend towards
greater subjective quality of life among the day hospital group
(n=71, mean MANSA score= 4.28, s.e.=0.11) compared with the
in-patient group (n=29, mean MANSA score=3.87, s.e.=0.18;
F=3.29, d.f.=1, P=0.073, 95% CI –0.85 to 0.04). When
entered as a covariate, length of stay did not have a significant effect on
the subjective quality of life at discharge (P=0.977).
Treatment satisfaction
Mean CAT scores were significantly higher for the day hospital group
(n=70) than the in-patient group (n=34) at discharge (8.10,
s.d.=1.99 v. 6.77, s.d.=2.26; P=0.004;
Table 4). At 3 months after
discharge day hospital patients (n=79) were still more satisfied with
the treatment they had received than those randomised to in-patient treatment
(n=41) (mean CAT score=7.31, s.d.=1.93 v. 6.15, s.d.=2.48;
P=0.005). At 12 months after discharge there were no significant
differences.
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Readmissions
Out of 65 patients randomised to the ward, 12% (8) were admitted one or
more times in the 3 months after discharge compared with 19% (26 out of 140)
randomised to the day hospital. (Note: data could be obtained for only 140 of
the 141 individuals randomised to the day hospital.) When the time frame was
extended to within 12 months of discharge, these figures rose to 26% (17 out
of 65) of the ward group and 37% (52 out of 140) of the day hospital group,
but these differences were not statistically significant. The mean number of
days spent in readmissions in the 12 months after discharge was 70.6
(s.d.=78.6) for the day hospital group compared with 48.1 (s.d.=59.1), but
again this was not statistically significant.
Costs
Total support costs over the treatment period could be estimated for 75
people in the day hospital group for whom at least one outcome measure was
collected at discharge and 32 people in the ward group. For this sample, the
mean treatment period, that is the time between admission to the ward or day
hospital and discharge, was 25 days (s.d.= 33, range 3–175) for the ward
group and 67 days (s.d.=45, range 4–198) for the day hospital group. The
proportion of people using community-based services tended to be higher for
the day hospital group, but rarely did this translate to significant
between-group cost differences (Table
3). Mean total support costs were higher for the day hospital
group over the treatment period: £6523 v. £3619
(bootstrapped 95% CI 375–4511). The observed between-group difference
for the costs of hospital services (including all in-patient admissions, day
hospital attendance and out-patient visits) was large but not statistically
significant (bootstrapped 95% CI –1185 to 2689). Hospital costs for the
day hospital group are higher than anticipated, in part because nearly half
(n=35) of this group also received in-patient care
(Table 3). Moreover, the cost
per day at the day hospital is relatively high (around 70% of the cost of a
day on the in-patient wards).
Hospital costs accounted for nearly all costs (95%) for the in-patient group but 70% of the total costs for the day hospital group. For the latter, medication, community-based mental health and general health services, social care and legal services accounted for a further 4% of total support costs, with accommodation accounting for the remainder (26%). In these analyses, costs for services that were not actually used (e.g. accommodation costs for in-patients, day hospital costs when patients did not attend) were not included in the calculations.
Cost-effectiveness
In the simple cost comparison, the day hospital service appears to be more
effective but more costly than in-patient care. This is not an uncommon
finding when evaluating new interventions; but how much more expensive is day
treatment? Cost-effectiveness was assessed by using the primary clinical
measure (BPRS) to estimate the incremental cost-effectiveness ratio for the
day hospital treatment group. This provides a measure of the additional cost
of one extra unit of change in the outcome scale. As there were no significant
differences in either costs or psychopathology at baseline, data for the
treatment period were used. Using the total cost figure and the mean BPRS
score at discharge, the total support cost per additional unit of output is
£12 267. Using the partial cost measure, which includes only hospital
services and was not significantly different between the groups, the figure is
£3917. Translating this incremental cost-effectiveness ratio into a
clinically meaningful index, improving the BPRS mean score by 0.1 points (the
mean score at discharge was 1.62 and 1.88 in the day hospital and ward groups
respectively) costs £1227 in total support costs or £392 in
hospital costs; improving the BPRS score by 0.1 points amounts to a small
effect size of 0.2 (based on the s.d. of the BPRS score at discharge of
0.5).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Limitations of the study
There are two main methodological limitations of this study. First,
although 44% (346 out of 791) of all voluntary patients had no social or
clinical reason to be excluded and thus were regarded as eligible for day
hospital treatment, only 60% of these patients (209 out of 346) gave consent
to participate in the trial. Two further patients withdrew consent after
randomisation. We do not know whether this rate of consent would have improved
if day hospital treatment had been offered as a treatment alternative outside
the context of a trial. Second, almost half of the randomised patients were
lost to follow-up at discharge and 12 months after discharge, although the
response rate at 3 months after discharge was more favourable. This may have
introduced a selection bias, the influence of which must remain unclear. The
randomisation procedure required all patients to be referred for and to accept
in-patient care in order to be recruited to the study. We therefore missed two
groups that in practice might be candidates for day hospital treatment: those
patients who were sectioned because they did not accept in-patient referral,
but might have agreed to voluntary treatment in the day hospital; and acute
patients who were not referred because their clinicians, or they themselves,
did not consider conventional in-patient care as appropriate.
Comparison with previous studies
Direct comparison with previous studies is difficult because they have used
different time-points for evaluation and different outcome measures but where
treatment satisfaction has been measured it has been higher in the day
hospital group (Dick et al,
1985; Schene et al,
1993). Generally day hospital care has been as effective as
in-patient treatment, but not more so (Dick
et al, 1985; Creed
et al, 1990; Schene
et al, 1993; Sledge
et al, 1996). This trial is unique in finding a
statistically significant difference in psychopathology at discharge in those
receiving day hospital treatment. The reasons for this difference remain
unclear but may be related to differences between the day hospital models. One
of the day hospitals studied was combined with a residential crisis respite
centre, with the emphasis on flexibility compared with the relatively
stringent model used here (Sledge et
al, 1996). The other study only included outcome data on
patients who attended the day hospital for more than 28 days
(Schene et al,
1993).
The most recent randomised controlled trial of an acute day hospital found day hospital care to be cheaper than conventional ward treatment (Creed et al, 1997). In contrast, this study established higher costs for day hospital patients, or equivalent costs if only hospital services are considered. The model of day hospital treatment studied here might provide a more intensive service, with the resultant higher costs generating better patient outcomes than in other studies. This suggests the need for a fuller investigation of the association between interventions, costs and outcomes both at discharge and in the longer term. In addition, the day hospital rarely operated at full capacity during the study period because admission was restricted through the research protocol. If staffing remained constant and the day hospital were to work at full capacity, i.e. with 20 patients, the cost per patient day would be lower, thus reducing support costs, but there is no guarantee that it would also have achieved the additional effectiveness.
Range of care options
Acute day hospital models similar to the one studied here are feasible and
effective alternatives to conventional in-patient care for a significant
number of patients, although clearly only for a minority of all patients who
are referred to in-patient treatment in a deprived East London Borough. Such a
day hospital model, with an exclusive focus on acute treatment, might be an
important addition to the range of treatment options within a modern community
mental healthcare system (Priebe,
2002).
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Clinical Implications and Limitations |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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The study was funded by grants from the National Health Service (NHS) Executive Organisation and Management Programme and the Research Directorate of the European Commission.
The views expressed in this paper are those of the authors and not necessarily those of the National Health Service or the Department of Health.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Beecham, J. & Knapp, M. (2001) Costing psychiatric interventions. In Measuring Mental Health Needs (2nd edn) (ed.G. Thornicroft), pp. 200 –224. London: Gaskell.
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Received for publication May 18, 2004. Revision received May 18, 2005. Accepted for publication June 3, 2005.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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