The same or different psychiatrists for in- and out-patient treatment? A multi-country natural experiment.

D Giacco,V Lorant,T Ahmad,A Lasalvia,J Moskalewicz,E Miglietta,P Nicaise,M Welbel,A Pfennig,V.J Bird,S Priebe,M Bauer

doi:10.1017/s2045796018000732

Abstract

A core question in the debate about how to organise mental healthcare is whether in- and out-patient treatment should be provided by the same (personal continuity) or different psychiatrists (specialisation). The controversial debate drives costly organisational changes in several European countries, which have gone in opposing directions. The existing evidence is based on small and low-quality studies which tend to favour whatever the new experimental organisation is.We compared 1-year clinical outcomes of personal continuity and specialisation in routine care in a large scale study across five European countries. This is a 1-year prospective natural experiment conducted in Belgium, England, Germany, Italy and Poland. In all these countries, both personal continuity and specialisation exist in routine care. Eligible patients were admitted for psychiatric in-patient treatment (18 years of age), and clinically diagnosed with a psychotic, mood or anxiety/somatisation disorder.Outcomes were assessed 1 year after the index admission. The primary outcome was re-hospitalisation and analysed for the full sample and subgroups defined by country, and different socio-demographic and clinical criteria. Secondary outcomes were total number of inpatient days, involuntary re-admissions, adverse events and patients' social situation. Outcomes were compared through mixed regression models in intention-to-treat analyses. The study is registered (ISRCTN40256812). We consecutively recruited 7302 patients; 6369 (87.2%) were followed-up. No statistically significant differences were found in re-hospitalisation, neither overall (adjusted percentages: 38.9% in personal continuity, 37.1% in specialisation; odds ratio = 1.08; confidence interval 0.94-1.25; p = 0.28) nor for any of the considered subgroups. There were no significant differences in any of the secondary outcomes. Whether the same or different psychiatrists provide in- and out-patient treatment appears to have no substantial impact on patient outcomes over a 1-year period. Initiatives to improve long-term outcomes of psychiatric patients may focus on aspects other than the organisation of personal continuity v. specialisation.

Highlights

Following major reforms over the past 50 years, mental healthcare systems in many countries provide acute treatment in hospitals and varying types of longer-term out-patient care (Killaspy, 2006)
A core question in the debate about how to organise mental healthcare is whether inand out-patient treatment should be provided by the same or different psychiatrists
This study aims to assess whether personal continuity or specialisation of psychiatrists is associated with more favourable patient outcomes over a 1-year period following an index hospitalisation

Summary

Introduction

Following major reforms over the past 50 years, mental healthcare systems in many countries provide acute treatment in hospitals and varying types of longer-term out-patient care (Killaspy, 2006). A core question in the debate about how best to organise mental healthcare is whether in- and out-patient treatment should be provided by the same (personal continuity) or by different psychiatrists (specialisation). The debate is controversial and has driven organisational changes in several European countries (Khandaker et al, 2009; Schmidt-Kraepelin et al, 2009; Karow et al, 2012; Killaspy, 2012; Lodge, 2012; Begum et al, 2013). These changes have gone in opposite directions

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