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In 2000/01 crisis resolution and home treatment (CRHT) teams were introduced in England and have been associated in previous studies with reductions in in-patient admissions.
To examine whether the implementation of CRHT teams has been associated with reductions in admissions.
We used data from a previous national study for 229 primary care trusts (PCTs) between 1998/99 and 2003/04. We used a robust policy evaluation methodology to simultaneously examine temporal changes (PCTs before versus after the introduction of CRHT teams) and cross-sectional changes (PCTs with and without CRHT teams).
Controlling for various confounding factors, using different control groups and estimation methods, we find no significant differences in admissions between PCTs with and without CRHT teams.
Contrary to previous studies, we find no evidence that the CRHT policy per se has made any difference to admissions and suggest a need for more research on the policy as a whole.
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Jacobs and Barrenho supplementary material |
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Rowena Jacobs, Senior Research Fellow
15 July 2011
Power calculations are seldom used in the multiple regression contextparticularly with panel data and population-level data. These tend to be rather made with trial based data to estimate appropriate sample sizes. Many would argue that post-hoc power calculations are misleading and irrelevant [1,2,3]. Nevertheless, a post-hoc power calculation based on the OLS models which uses the total number of valid cases used in the analysis, the total number of predictors in the model, the model R-squared, and the assumed p-value (set at 0.05), suggests that for all models the power is 1.00. By convention, this value should be greater thanor equal to 0.80.
More importantly though, the benefit of the difference-in-difference methodology is that it provides for more precise estimates than the previous analysis and also allows for the simultaneous inclusion of covariates such as the team fidelity criteria (e.g. CRHTTs offering a twenty-four-hour service) as well as overall time trends. There are fundamental differences between the two types of analyses with the difference-in-difference methodology being a far more potent and robust policy evaluation tool.
We agree that future studies should ideally look at analysing admissions (and potentially other factors) at CRHTT level. We explored thepossibility of doing this by contacting several teams to ask about their geographical boundaries, but found, surprisingly, that many teams were in fact unable to clearly delineate their geographic ‘patch’ and that even ifthey could define their current boundaries, these had often changed over time, making an analysis of long-term trends with difference-in-differencemethodology unfeasible. Moreover, a large-scale national longitudinal study would require data from before the policy change (circa 1998) to effectively assess the policy impact, for which routine administrative data is more suited than data from individual electronic records systems which have huge variation in detail, quality and method of collection.
Declaration of interest
None.
References
1. Levine, M & Ensom, MH. Post hoc power analysis: an idea whose time has passed? Pharmacotherapy 2001; 21(4): 405-9.
2. Hoenig, JM & Heisey, DM. The abuse of power: the pervasive fallacy of power calculations for data analysis. The American Statistician2001; 55(1): 19-24.
3. Fogel, J. Post hoc power analysis: another view. Pharmacotherapy 2001; 21(9): 1150. ... More
Conflict of interest: None Declared
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Dieneke Hubbeling, Consultant Psychiatrist
17 June 2011
Jacobs and Barrenho [1] used the same data as Glover et al. [2] when they were comparing admissions in Primary Care Trusts (PCTs) with and without Crisis Resolution and Home Treatment Teams (CRHTTs). However, theyemployed different methods for their analysis and reached conflicting conclusions. According to Jacobs and Barrenho the introduction of CRHTTs did not have a statistically significant influence on the number of admissions, while Glover et al. found a significant reduction especially for CRHTTs which offered a twenty-four-hour service.
In their article, Jacobs and Barrenho [1] do report a reduction in admissions (e.g. fig. 4) but stated that it was not statistically significant. They do not mention power calculations. There were usable data available from 229 PCT’s and the authors conducted various complex analyses by using a number of control factors and by studying trends over time. It could be that their lack of statistically significant findings isbecause of a lack of power. If this is the case there is no fundamental difference between their findings and the previous analysis [2].
At the end of their article, the authors make the suggestion that perhaps data should be analysed at the level of CRHTTs and not at the level of PCTs, given that there is huge variation between CRHTTs. We concur with that suggestion and we would like to go even further and suggest that future studies look at the service actually provided to individual patients in terms of how many visits are undertaken over a specified number of days. This information is readily available from mostelectronic notes systems. Further study is needed to investigate the typesof interventions provided, such as whether medication was prescribed and administered, whether specific psychological treatments were offered, and so on. The availability of such data will allow an informed decision to bemade about what is required to avoid admission to hospital and whether a CRHTT is the best organisational format to deliver that care.
References
1.Jacobs, R., & Barrenho, E. (2011). Impact of crisis resolutionand home treatment teams on psychiatric admissions in England. The BritishJournal of Psychiatry, in press. doi: 10.1192/bjp.bp.110.079830.
2.Glover, G., Arts, G., & Babu, K. S. (2006). Crisis resolution/home treatment teams and psychiatric admission rates in England. British Journal of Psychiatry, 189, 441-445. ... More
Conflict of interest: None Declared
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