what does research tell us about assertive outreach? tom burns andrew molodynski social psychiatry...
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What Does Research tell us about Assertive Outreach?
Tom BurnsAndrew Molodynski
Social Psychiatry Group, Oxford University
What do we want or need to Know?
Depends to some extent who you are:
• Patient or Carer
• Clinician
• Manager
• Commissioner
Patient/Carer
• What is it?
• Will it help me and if so in what way?
• Are there any disadvantages?
• Is it ‘experimental’ or risky?
• In what way is it different?
• (increasingly) Is it available?
Clinician
• Does it work?
• What does ‘work’ mean? Symptom control, social functioning, occupation, relationships, violence?
• What do we need to do (and not do perhaps)?
Manager/Commissioner
• Should we or do we need to provide this service?
• If so what is the most cost effective way?
• What components are most important?
• Which components are less needed, if any?
• How do we measure it both in terms of process and outcomes?
General themes across groups
• Practitioners shouldn’t want to work in and deliver services that don’t work, patients shouldn’t want them, and commissioners and managers shouldn’t want to pay for them.
• We all want to know similar stuff but perhaps in different ways and with different emphases
• Does it improve outcomes for people?
• What are its key components?
• In what ways (if any) is it better than ‘standard care’? What is so-called standard care anyway?
MRC stages of investigation
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Grading of Evidence (NICE)
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Stein and Test (1980)
• Conceptual model did exist- material support, skill development, motivation
• Response to a ward closing rather than part of pre-planned program of research
• Inspirational leaders, highly motivated staff• Alternative included OP follow up and ‘partial
hospitalisation’• Readmission 4% (E) v 58%(C)• Differences largely dissolved afterwards
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Hoult (1983)
• Replication in Sydney
• Again, charismatic leader and highly motivated staff
• 8.4(E) v 53.5(C) days in hospital in 12 months
• Preferred by patients and relatives to admission
• No clear description of ‘standard care’
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Rosenheck
• USA, multicentre RCT
• 873 participants
• 89 days less inpatient care in 2 years
• Costs of experimental treatment were 20% lower
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UK700 (Burns et al)
• 1999, London and Manchester
• Again, specially set up/ ‘experimental’ teams but much larger scale
• C group was CMHTs as we know them
• No significant gains in clinical or social functioning or reductions in bed use
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REACT (Killaspy et al)
• London 2006
• RCT, n= 251
• No significant differences from CMHT control in clinical or social outcomes or inpatient bed use.
• Differences in engagement/satisfaction
• CMHTs work ‘as effectively’ as ACT teams
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Cochrane Collaborations(1998)
• Case management ‘increases admissions to hospital and is not effective’
• ACT ‘clearly superior’ in maintaining contact and reducing hospital use, while increasing satisfaction
• Very important effect upon policy makers and fed in to the National Service Framework the next year
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Pioneer effect : CBT for psychosis
• Cochrane database 2000– Currently, for those with schizophrenia willing to receive CBT,
access to this treatment approach is associated with a substantially reduced risk of relapse
• Cochrane database 2004– Currently, trial-based data supporting the wide use of CBT for
people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach.
• Cochrane database 2011– Trial-based evidence suggests no clear and convincing
advantage for CBT over other and sometimes much less sophisticated therapies for people with schizophrenia
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Attempting to answer the question empirically:
Going beyond definitions
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Meta-regression used to test for impact on variation of:
• Date of study – Earlier studies more reduction?
• Size of study– Smaller studies bigger effect size as evidence of publication bias
• Baseline (control) hospitalisation rates– Higher rates permits greater reduction
• Model fidelity– Higher model fidelity greater reduction
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Copyright ©2007 BMJ Publishing Group Ltd.
Burns, T. et al. BMJ 2007;335:336
Metaregression of Intensive Case management studiesControl group mean v mean days per month in hospital.
Negative treatment effect indicates reduction relative to control
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Fidelity
• Dartmouth ACT Scale (DACTS) 1998• 28 different components: caseload,
embedded psychiatrist, full responsibility, 24 hr cover, admissions
• Very influential and crossed over to Early Intervention and Individual Placement and Support services
• PLAO- ‘wide variation in the practice of AO in London’ (2003)
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Meta regression of fidelity v IP days
-20
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6m
ean
diffe
renc
e
2 4 6 8 10 12total fidelity score
mean difference Fitted values
Separating the IFACT Domains
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M-R of Team organisation v Reduction in IP days
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6m
ea
n d
iffere
nce
0 2 4 6 8team organisation
mean difference Fitted values23
M-R of Team staffing v Reduction in IP days
-20
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6m
ean
diffe
rence
0 1 2 3 4staffing
mean difference Fitted values
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What about components?
• Research on models can be hard to interpret, with poor descriptions, overlap etc
• When things get complicated it is often best to go back to more basic concepts:
• Fidelity
• Components research
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Components Analysis
• What bits might work? Wright et al 2004
• Visiting patients at home
• Joint responsibility for health and social care
• Continuity (Catty et al 2011)
• These cross service boundaries.
• Experimental teams only survive intact in 25% of cases anyway
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Associations between service components & Hospitalisation:
regression analysisSmaller caseloads
RegularlyVisiting at home
High % ofContacts at home
Responsible forHealth and social care
PsychiatristIntegrated in team
Multidisciplinaryteams
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Where are we now?
• Financial austerity putting serious pressure on services that can be seen (by some) as added extras- AOT, EIS, Therapies
• AO research has actually helped improve and regularise CMHT care (limited caseloads etc)
• Can research be used to help protect essential elements of services while allowing for the streamlining of practices that are not supported by evidence?
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Conclusion
• There is a need for dialogue between commissioners and providers and users of services on these issues
• Strong advocacy is needed for service elements that work and are valued
• Though these times are threatening they do offer a chance of change that was probably not present before 2008
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