This study is important for a number of reason
- This is the sixth country ( and health care system) in which an RCT of IHT was conducted
- It is the first RCT since the 2005 one in North Islington by Sonia Johnson et al ( Post # 1 under research )
- There was every reason to expect Johnson’s RCT to be the last . Johnson explained that, due to the changes in research ethical standards, unlike in earlier studies, patients could not be randomized without their consent. Consequently, there was a risk that the most severely ill patients, who likely would have lacked capacity to consent at the time of admission to the trial , would be excluded. The researchers overcame that risk by various arduous complex enrolment procedures that would be off putting for those contemplating a future RCT
- This study overcame these ethical barrier by utilizing a ” single randomized content design ” as suggested by Marvin Zelen PhD as outlined in a NEJM article in May 31 2019
Patients were referred by a single intake facility. An unusual feature of this study , is that almost all patients were admitted at first, such that-in contrast to other studies, only 4.6 % avoided admission entirely .
This feature was explained by the following three factors 1. The study could not accommodate randomization at night or weekends, and there were even limitations on getting express randomization during office hours .2. Limitations imposed by the Zelen design . 3. What the authors claim to be a ” particularly acute and severely ill patient sample, compared to previous studies”. However, I note that the 2005 Johnson North Islington patient sample had a higher proportion of patients with schizophrenia, other psychoses and bipolar affective disorder patients. And, the mean Health of the Nation Outcome Scale ( HoNOS) scores were higher in that study ( HoNOS is a clinician rated scale developed by the Royal College of Psychiatrists to measure progress and outcomes)
So, what was the main finding ? A 30.4 % reduction in patient bed days within 24 months of the initial crisis. There was no difference in clinical and social outcomes between the hospital and home treatment group
The total fidelity score on the English CORE Crisis Resolution Team Fidelity Scale was slightly higher for this team than the sum of item median scores for 75 CRHT teams in the UK
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