1. Day Hospital versus admission for acute psychiatric disorders Dr. Simon Benson ST2 General Practice

2. 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 D

3. 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?

4. 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

5. 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

6. 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

7. Interventions 1. Acute psychiatric day hospital (unit that provides diagnostic and treatment services) 2. Standard inpatient care

8. Outcome Measures Primary Outcome Measure Loss to follow up Secondary Outcome Measures Feasability and engagement Extent of admission Clinical Outcomes Social Outcomes Costs of Care

9. 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]

10. 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

11. Results 81 studies identified 64 excluded (43 not randomised and 21 randomised) 7 studies awaiting assessment 1 ongoing study 9 trials included (2268 participants) Two types 1 - (patients ineligible for day care excluded before randomisation) 2 – (all patients presenting were randomised)

12. 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 378 No pre-test power calculation performed

13. 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

14. Results Clinical and Social Outcomes assessed by: Present State Examination Comprehensive Psychopathology Scale Brief Psychopathology Rating Scale Clinical Interview Scale Social Behaviour Assessment Schedule Social Adjustment Scale

15. Risk of Bias Allocation concealment adequate in 5 of 9 trials Blinding not possible in this type of study Follow-up rates varied from 59-92% No differences reported in individual data

16. 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)

17. 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)

18. 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)

19. 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)

20. 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

21. 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.

22. 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

23. 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

24. Implications for Practice Acute 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?

26. Thankyou for listening Questions / Discussion