Effectiveness of Crisis Resolution Home Treatment for the Management of Acute Psychiatric Crises in Southern Switzerland: A Natural Experiment Based on Geography

Effectiveness of Crisis Resolution Home Treatment for the Management of Acute Psychiatric Crises in Southern Switzerland: A Natural Experiment Based on Geography | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of Crisis Resolution Home Treatment for the Management of Acute Psychiatric Crises in Southern Switzerland: A Natural Experiment Based on Geography Emiliano Soldini, Maddalena Alippi, Maria Caiata Zufferey, Angela Lisi, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1064873/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Crisis Resolution Home Treatment (CRHT) is an alternative to inpatient treatment for acute psychiatric crises management. However, evidence on CRHT effectiveness is still limited. In the Canton of Ticino (Southern Switzerland), in 2016 the regional public psychiatric hospital replaced one acute ward with a CRHT. The current study was designed within this evaluation setting to assess the effectiveness of CRHT compared to standard inpatient treatment. Methods CRHT was offered to patients aged 18 to 65 with an acute psychiatric crisis that would have required hospitalization. Exclusion criteria were acute drug/alcohol intoxications, extreme agitation/aggressive behaviour, risk of suicide/self-harm, compulsory hospitalization, being an inmate and, due to practical reasons, living in the southern area of Ticino. We used a natural experiment based on geography, where intervention and control groups were formed according to the place of residence. Primary endpoints were reduction of psychiatric symptoms at discharge, treatment duration in days, and rate and length of readmissions during a two-year follow-up period after discharge. Safety during the treatment period was measured with the number of serious adverse events (suicide/suicide attempts, major self-harm episodes, acute alcohol/drug intoxications, aggressions to caregivers or family members). We used linear, log-linear, logistic and difference-in-differences regression models with propensity scores for the main analysis. Results We enrolled 321 patients; 67 were excluded because the treatment period was too short and 17 because they were transferred before the end of the treatment. 237 patients were available for data analysis, 93 in the intervention group and 144 in the control group. No serious adverse event was observed during the treatment period in both groups. Reduction of psychiatric symptoms at discharge (p-value=0.359), readmission rates (p-value=0.563) and length of readmissions (p-value=0.770) during the two-year follow-up period did not differ significantly between the two groups. Treatment duration was significantly higher in the treatment group (+29.6% on average, p-value=0.002) Conclusions The effectiveness of CRHT for the management of acute psychiatric crises was comparable to standard hospitalization. Further research is needed to identify relevant implementation elements, processes, and procedures, and the system level integration and scalability of CRHT in mental health services. Trial registration ISRCTN38472626 (17/11/2020, retrospectively registered) Psychiatry Acute psychiatric crises Crisis Resolution Home Treatment inpatient treatment effectiveness quasi-experimental design Figures Figure 1 Figure 2 Background The worldwide growing emphasis on the socio-psychiatric approach in mental healthcare has contributed to the development of a variety of community-based services, which may help to reduce hospitalizations in psychiatric hospitals and clinics and to reorient mental health systems and services towards more community-based, patient-centred, integrated care ( 1 – 3 ). Crisis Resolution Home Treatment (CRHT) provides an alternative setting to psychiatric hospitals for the treatment and care of acute psychiatric crises ( 4 – 6 ). CRHT has gained a growing consensus over time because of its potential to leverage the psychosocial dimension intrinsically related to mental health crises ( 5 ) and preserve social participation and integration of people suffering from acute psychiatric crises, while also reducing the stigma associated with institutionalisation in traditional psychiatric settings ( 7 , 8 ). During the last 60 years, several CRHT experiences have been evaluated worldwide using a variety of study designs, including randomised controlled trials (RCT) ( 9 – 21 ), non-randomised comparative ( 22 – 26 ), and non-comparative ( 27 – 30 ) studies. Evidence synthesis endeavours are reported in systematic reviews ( 5 , 31 , 32 ), and highlight that CRHT can be an alternative to hospitalisation appreciated by patients and families. Ample evidence suggests that CRHT can be useful to foster the availability, accessibility, acceptability and integration of mental health services, as well as a multisectoral approach to attain a continuous and holistic care centred on needs of patients and their families. Next, observational evidence suggests that CRHT can contribute to reduce hospital admission/readmission rates and the number of inpatient days ( 33 , 34 ). However, the effectiveness of CRHT in the treatment of acute psychiatric crises is erratic. There is marked heterogeneity in the evidence pertaining to the reduction of severity of psychiatric symptoms and social outcomes (e.g. social inclusion, employment rates) after treatment. Moreover, evidence on the effectiveness of CRHT is difficult to reconcile and consolidate because the internal validity of some studies may be reduced by suboptimal comparability between the study groups. CRHT is a complex intervention and its evaluation poses design and studies implementation challenges, as well as the stringent application of a robust, stepped evaluation framework. The majority of the CRHT experiences were evaluated more than 20 years ago ( 9 – 18 , 22 , 23 ), when guidance and methods to evaluate complex interventions did not exist or were not common yet. Some of the more recent studies applied clinical trial designs with or without randomization of participants ( 19 , 20 , 24 – 26 ), while the others were flawed because they included only patients treated with CRHT without a control group ( 27 – 30 ). Therefore, evidence in favour of the effectiveness of CRHT as a substitute of hospitalization for acute crises treatment in current mental health systems remains limited. From 2001 onwards, many different experiences of psychiatric home treatment have been implemented in Switzerland. The Cantons of Vaud ( 35 – 37 ), Thurgau and Basel introduced home treatment services after hospital discharge, but not as a replacement of hospital treatment and only for some patients, typically heavy users. CRHT teams that entirely replace an inpatient treatment have been implemented in the Cantons of Luzern ( 38 ), Aargau ( 20 ), Zürich ( 26 ) and Ticino, the Italian speaking region of the Swiss Confederation bordering northern Italy. In the latter case, a fully operational ward of the regional public psychiatric hospital (Cantonal Psychiatric Clinic, CPC) was shut down, and the staff of the ward was trained to build the CRHT team with the intention to substitute inpatient treatment. The aim of the present study was to formally evaluate the effectiveness of the CRHT unit in Ticino as a substitute of standard in-hospital treatment. Main outcomes were reduction of psychiatric symptoms at the end of the treatment, treatment duration in days and rate and length of readmissions during a two-year follow-up period after discharge. Methods The protocol of the study was recently published ( 39 ). The CRHT intervention, the quantitative study design and the statistical analysis to assess the effectiveness of CRHT in comparison with standard inpatient treatment are described in details here below. All methods were carried out in accordance with relevant guidelines and regulations. The intervention In April 2016 one of the CPC acute wards was closed and replaced by a CRHT team, available 24/7 (on call from 10:30 pm to 7 am), formed of three doctors fully trained in psychiatry (i.e. a full-time consultant psychiatrist, a part-time psychiatrist, and a part-time senior consultant psychiatrist on call), ten mental health nurses, one team manager, a part-time clinical psychologist and a part-time social worker. Access to the CRHT service was managed by the CPC triage, by Accident and Emergency teams, local community mental health professionals, private psychiatrists and general practitioners. The treatment was administered in daily home visits to the patients, the family members and/or the caregivers, and consisted in a structured psychoeducational approach to acute psychiatric crises aimed at reducing symptoms and preventing future relapses. The number of home visits per day varied based on patients’ needs. The intervention included standard elements of acute care, such as crisis management, pharmacotherapy, psychoeducation, psychotherapy and social care. Though standardization was sought, every intervention was individually tailored according to the specific needs of each patient. The CRHT team’s activities included monitoring of symptoms; adherence to and side effects of pharmacological treatment; identification and management of contextual life-threatening hazards; provision of emotional, social and psychological support to patients, families and/or caregivers; connection with other health and social care services and providers; planning of discharge meetings and follow-ups. The CRHT team also ensured an active collaboration with local services/practitioners to provide long-term support to patients. The CRHT service was offered to patients aged 18 to 65 who suffered from an acute psychiatric crisis that would have required hospitalization. CRHT was not offered to patients with acute alcohol or drug intoxication, extreme agitation and/or aggressive behaviour, acute risk of suicide/self-harm or representing a significant risk for others. Further CRHT exclusion criteria were compulsory admission, being an inmate and place of residence (patients living in the southern area of Ticino could not be served due to practical reasons). Study design, sample and data collected We used a quasi-experimental design based on existing groups, namely a natural experiment based on geography ( 40 ), to allocate patients to the intervention and control groups according to the place of residence. The assumption of casual distribution of socio-demographic and relevant health characteristics across geographic groups was supported by preliminary statistics on patients treated in the acute wards of the northern (n=108) and southern (n=263) areas of the Canton during a period of six month before the introduction of CRHT. Bivariate χ 2 and Mann-Whitney tests showed no significant difference in both the socio-demographic (gender, p-value=0.069; age, p-value=0.266; education, p-value=0.404; civil status, p-value=0.404; etc.) and clinical (main psychiatric diagnosis, p-value=0.843; number of previous admissions, p-value=0.527; severity of psychiatric symptoms at admission p-value=0.855; etc.) characteristics. We used intention-to-treat (ITT) for all analyses, thus patients living in the southern area of the Canton were recruited only if theoretically willing to accept CRHT, and could be legitimately allocated to the control group and deemed comparable to those allocated to the intervention group. Under these conditions, when accounting for a set of pre-treatment covariates (like age, gender, psychiatric diagnosis, number of previous hospitalizations and other variables), the assumption of conditional geographic treatment ignorability (CTGI) is likely to hold ( 40 ), providing a setting where the assignment to treatment and control groups can be considered to approach randomization. The recruitment of patients took place over a two-years period, from mid-March 2017 to the beginning of April 2019. All patients recruited living in the northern area of the Canton were treated with CRHT and included in the intervention group, those from the southern area received care-as-usual (i.e. hospitalization) and were included in the control group. Eligibility for the study was assessed according to the criteria giving access to CRHT (above), with the additional condition of a hospitalization period of at most 48 hours before being transferred to the CRHT service. Moreover, certificates of compulsory hospitalization rescinded and/or acute drug or alcohol intoxications resolved within 48 hours from hospitalization granted eligibility for the corresponding patients. Finally, patients with a treatment period too short (less than seven days) were further excluded because they most likely did not actually meet the criteria for a major acute psychiatric crisis. The minimal sample size needed to ensure a statistical power of 80% at the 5% significance level for a two-tailed hypothesis test was 142 patients in each study arm, based on previous evidence on mean differences over a 12 to 24 months period of the Health of the Nation Outcome Scales (HoNOS) overall score ( 19 ). HoNOS is a validated 12-items measure, commonly used to assess the health and social functioning of people with severe mental illness ( 41 ). For both groups we collected data on four main outcomes. During the treatment period, we used the HoNOS total score to quantify the change in the severity of symptoms between admission and discharge, and computed the number of inpatient days. During the 2-years follow-up period, we focused on readmission rates, to either CPC or CRHT, and total number of inpatient days after readmission. We also collected data on patients’ socio-demographic and clinical characteristics, namely gender, age, nationality, educational level, civil status, living arrangement, working condition, primary psychiatric diagnosis, presence of a secondary diagnosis, compulsory admission, number of previous hospitalizations and HoNOS score at the admission. Finally, safety was measured during the treatment period according to the frequency of serious adverse events, defined as suicide or suicide attempts, major self-harm episodes requiring emergency room visits or hospitalizations, acute alcohol/drug intoxications and major aggressions to caregivers or family members. Statistical analysis We compared the main outcomes and the socio-demographic and clinical characteristics of the patients between the intervention and control group using descriptive statistics and χ 2 and Mann-Whitney tests (for count and continuous variables, respectively), and applied the Monte Carlo method to estimate the Mann-Whitney test p-value because of the expected skewness in the distribution of continuous variables (e.g. number of inpatient days). To improve causal inference, we used propensity scores (PS) matching ( 42 ) for the main analysis of differences between the intervention and control group for each outcome. First, we selected the variables to include in the PS reference model using the approach proposed by Cattaneo, Drukker and Holland ( 43 ). We ran a set of independent logistic regression models with intervention/control group membership as dependent variable and all the possible combinations of sociodemographic and clinical variables as predictors, and quantified the goodness-of-fit using the Bayesian Information Criterion (BIC). We selected as reference PS model the one with the best goodness-of-fit (i.e. the lowest BIC). Then, using the socio-demographic and clinical variables retained in the PS reference model, we estimated the Average Treatment Effect (ATE) of CRHT separately on each of the outcomes using the Augmented Inverse Probability Weighting (AIPW). Moreover, we used log-transformation for the strongly skewed outcomes, Weighted Nonlinear Least Squares (WNLS) instead of maximum likelihood and bootstrapped standard errors to provide additional robustness to the estimates. We controlled for the covariates balance between the intervention and control groups according to the overidentification test for covariate balance proposed by Imai and Ratkovic ( 44 ). Finally, to account also for unobserved individual heterogeneity, the Difference-in-differences (DID) technique ( 45 ) with kernel-based PS matching was applied to the HoNOS score, the only outcome for which we had before and after treatment measurements. We conducted all statistical analyses with Stata/IC 16.0 (StataCorp, 4905 Lakeway Drive, College Station, Texas, USA). Results Patients’ disposition and safety Between mid-March 2017 and the beginning of April 2019, 1’281 patients were referred to the CPC for hospital admission and assessed for study eligibility. 834 patients were excluded because they did not meet the inclusion criteria, while 25 declined participation and 101 were excluded for other reasons (e.g. therapeutic reasons, cognitive problems, lack of suitable living environment, linguistic problems). Figure 1 shows the flowchart of participants, according to the Consolidated Standards of Reporting Trials (CONSORT) recommendations. Overall, we enrolled 321 patients, 192 in the control group (i.e. hospitalized) and 129 in the intervention group (i.e. CRHT care). 67 patients (23 in the intervention group and 44 in the control group) were further excluded because the treatment period was too short (less than seven days), while 17 additional patients had to be excluded because they were transferred to another healthcare facility outside the CPC before the end of the treatment (13 in the intervention group and 4 in the control group). A total of 237 patients (93 in the intervention group and 144 in the control group) were finally available for the data analysis. No patient in the intervention group was hospitalized at the CPC before the end of the home treatment, and no serious adverse event was observed during the treatment period in both arms. It should be noted that, according to the sample size calculation (above), the intervention and control groups were originally planned to be of equal size. However, the recruitment of patients for the intervention group was characterized by a “saturation” effect. Throughout time less and less new patients living in the northern region of the Canton referred for hospital admission resulted eligible for the study and/or accepted to participate, which led to a smaller sample size for the intervention group at the end of the recruitment period. Statistical analysis results Table 1 presents the demographic and clinical characteristics of patients in the intervention and control groups at admission. There were no significant differences between groups by median age (CRHT: 41.7 years old vs CPC: 45.7 years old; p-value=0.152), citizenship (CRHT: 79.6% Swiss vs CPC: 71.5% Swiss; p-value=0.164), educational level (CRHT: 43% no/compulsory education and 50.5% secondary education vs CPC: 46.5% no/compulsory education and 41% secondary education; p-value=0.187) and working status (CRHT: 19.4% employed vs CPC: 22.9% employed; p-value=0.515). Instead, in the intervention group we found higher percentages of women (CRHT: 61.3% vs CPC: 38.2%; p-value=0.001) and of married people (CRHT: 36.6%, vs CPC: 22.2%, p-value=0.016), while the proportion of patients living alone was significantly higher in the control group (CRHT: 34.4% vs CPC: 51.4%; p-value=0.010). Table 1 – Demographic and clinical characteristics of intervention and control groups Characteristics Intervention group (n=93) Control group (n=144) Statistical test for the difference a Demographic Female gender, n(%) 57 (61.3) 55 (38.2) χ 2 (1) = 12.173*** Age, years: median (IQR b ) 41.7(20.3) 45.7 (20.1) z = 1.432 Swiss citizenship, n(%) 74 (79.6) 103 (71.5) χ 2 (1) = 1.969 Educational level, n(%) None/compulsory 40 (43.0) 67 (46.5) χ 2 (2) = 3.467 Secondary 47 (50.5) 59 (41.0) Tertiary 6 (6.5) 18 (12.5) Married, n(%) 34 (36.6) 32 (22.2) χ 2 (1) = 5.700* Living alone, n (%) 32 (34.4) 74 (51.4) χ 2 (1) = 6.665* Employed, n (%) 18 (19.4) 33 (22.9) χ 2 (1) = 0.429 Clinical Compulsory admission, n (%) 15 (16.1) 43 (29.9) χ 2 (1) = 6.001* Primary diagnosis (ICD-10), n (%) Mental and behavioural disorders 4 (4.3) 19 (13.2) χ 2 (5) = 20.706** due to use of psychoactive substances (F1) Schizophrenia, schizotypal and delusional 24 (25.8) 45 (31.3) disorders (F2) Mood [affective] disorders (F3) 29 (31.2) 41 (28.5) Neurotic, stress-related and somatoform 12 (12.9) 19 (13.2) disorders (F4) Disorders of personality and behaviour in 24 (25.8) 14 (9.7) adult persons (F6) Other disorders (F5, F8, F9, Z) 0 (0.0) 6 (4.2) Presence of a secondary diagnosis, n (%) 59 (63.4) 87 (60.4) χ 2 (1) = 0.219 Num. previous hospitalizations: median (IQR) 1 (3) 2 (4) z = 2.887** HoNOS at admission c : median (IQR) 18 (8) 16 (9) z = -1.045 * p<0.05, ** p<0.01, *** p<0.001 a χ 2 test for categorical variables; Fisher’s exact test was used in presence of cells with a count lower than 5. Mann-Whitney test for continuous variables; the 95% confidence intervals for p-values used to assess statistical significance were estimated using the Monte Carlo method based on 10’000 samples. b IQR = Interquartile range c Data on the HoNOS were missing for 6 patients in the intervention group and 12 in the control group. Participants in the intervention group had on average significantly lower mental and behavioural disorders due to the use of psychoactive substances (F1, CRHT: 4.3% vs CPC: 13.2%; p-value=0.024) and significantly higher personality and behaviour disorders in adult persons (F6, CRHT: 25.8% vs CPC: 9.7%; p-value=0.001). Moreover, the intervention group counted fewer certificates of compulsory hospitalization rescinded before recruitment (CRHT: 16.1% vs CPC: 29.9%; p-value=0.016) and a lower median number of previous hospitalizations at the clinic (CRHT: 1 vs CPC: 2; p-value=0.004). No significant differences were found in the presence of a secondary diagnosis (CRHT: 63.4% vs CPC: 60.4%; p-value=0.640) and in the median HoNOS score at admission (CRHT: 18 vs CPC: 16; p-value=0.296). Table 2 shows the outcomes for the intervention and control groups. While the median reduction in the HoNOS total score at discharge resulted homogeneous between the two groups (CRHT: -8 vs CPC: -8; p-value=0.731), the median number of inpatient days was higher for the treatment group (CRHT: 36 days vs CPC: 27 days; p-value=0.001). Irrespective of the group considered, around half of the patients were readmitted to the CPC or to CRHT at least once within two years from discharge (CRHT: 49.5% vs CPC: 51.4%; p-value=0.772). Despite the lower median in the treatment group, also the total number of inpatient days related to single or multiple readmissions did not differ significantly between the two groups (CRHT: 40.5 days vs CPC: 52 days; p-value=0.800). Table 2 – Outcomes for the intervention and control groups Outcomes Intervention group (n=93) Control group (n=144) Statistical test for the difference a HoNOS difference at discharge b : median (IQR c ) -8 (8) -8 (8) z = -0.345 Number of inpatient days: median (IQR) 36 (23.5) 27 (17) z = -3.251** Readmission within 2 years d , n(%) 46 (49.5) 74 (51.4) χ 2 (1) = 0.084 Number of readmission days e : median (IQR) 41 (56.8) 52 (62.5) z = 0.254 * p<0.05, ** p<0.01, *** p<0.001 a χ 2 test for categorical variables. Mann-Whitney test for continuous variables; the 95% confidence intervals for p-values used to assess statistical significance were estimated using the Monte Carlo method based on 10’000 samples. b The HoNOS difference at discharge corresponds to the difference between the total HoNOS score at discharge and the total HoNOS score at admission. Data were missing for 8 patients in the intervention group and 21 in the control group. c IQR = Interquartile range d Readmission within 2 years indicates if a patient was readmitted to the CPC and/or to CRHT at least once during the 2 years period following discharge. e The number of readmission days corresponds to the total number of inpatient/CRHT days related to single or multiple readmissions during the 2 years period following discharge. Data were available for 39 patients in the intervention group and 74 in the control group. Table 3 displays the PS model selected according to the approach proposed by Cattaneo, Drukker and Holland ( 43 ). The variables important for balancing the two groups were gender, living arrangement, compulsory admission, diagnosis of personality and behaviour disorders in adult persons (F6) and number of previous hospitalizations; the latter was included in the model in spite of not being statistically significant at the 5% level. Predicted probabilities, ranging on average from 0.337 to 0.663, were sufficiently far from the extreme values of 0 and 1 to suggest no particular concern about the selected model. Table 3 – Propensity Scores model selected Covariates Dependent variable: Intervention/control group membership Coefficient (SE a ) 95% confidence interval Female gender 0.837** (0.271;1.403) (0.289) Living alone -0.623* (-1.215;-0.032) (0.302) Compulsory admission -0.721* (-1.413;-0.029) (0.353) Disorders of personality and behaviour in adults (F6) 1.338** (0.561;2.115) (0.397) Number of previous hospitalizations -0.028 (-0.077;0.022) (0.025) Constant -0.557* (-1.082;-0.032) (0.268) Number of observations (n) 237 LR χ 2 (5) 34.59*** Bayesian Information Criterion (BIC) 315.707 Predicted probabilities b CPC c Pr d (CPC): mean (SD e ) 0.663 (0.156) Pr(CRHT): mean (SD) 0.337 (0.156) CRHT f Pr(CPC): mean (SD) 0.521 (0.188) Pr(CRHT): mean (SD) 0.479 (0.188) * p<0.05, ** p<0.01, *** p<0.001 a SE = Standard Error b Predicted probabilities for each treatment level were computed and summarized conditional to each treatment level. c CPC = Cantonal Psychiatric Clinic d Pr = Probability e SD = Standard Deviation f CRHT = Crisis Resolution Home Treatment Table 4 presents the estimates of the ATE of CRHT on the outcomes, as well as the results of the DID model for the HoNOS score. The overidentification test for covariate balance showed that the selected PS model successfully balanced the intervention and control groups (p-values of the test of 0.334 or higher for all models). We found no significant ATE of CRHT on the HoNOS score difference at discharge (p-value=0.315), on readmission rates within two years from discharge (p-value=0.563) and on the number of readmission days for patients readmitted at least once within two years from discharge (p-value=0.771). The ATE on the treatment length was instead statistically significant; the number of inpatient days in the intervention group was higher (+29.6% on average; p-value=0.002). Table 4 – Estimate of the ATE of CRHT and of the DID model for the HoNOS score AIPW a PS b models 1) linear outcome model 2) + 4) log-linear outcome model 3) logistic outcome model Coefficient (Bootstrap SE c ) 95% confidence interval 1) HoNOS difference at discharge d ATE e (CRHT f vs CPC g ) 1.026 (-0.791;2.842) (n = 208) (0.927) CPC -9.434*** (-10.706;-8.163) (0.649) 2) ln h (Number of inpatient days) ATE (CRHT vs CPC) 0.296** (0.088;0.504) (n = 237) (0.106) CPC 3.182*** (3.046;3.319) (0.070) 3) Readmission within 2 years i ATE (CRHT vs CPC) 0.039 (-0.093;0.170) (n = 237) (0.067) CPC 0.493*** (0.408;0.577) (0.067) 4) ln(Number of readmission days j ) ATE (CRHT vs CPC) -0.071 (-0.460;0.319) (n = 120) (0.199) CPC 3.833*** (3.580;4.085) (0.129) DID k model with Kernel-based PS matching linear model (n = 220 before, n = 215 after) Coefficient (Standard Error) 95% confidence interval HoNOS score Difference between CHRT and CPC before 1.576* (0.135;3.017) (0.735) Difference between CHRT and CPC after 2.304** (0.867;3.741) (0.733) Difference-in-differences (DID) 0.728 (-1.306;2.762) (1.038) * p<0.05, ** p<0.01, *** p<0.001 a AIPW = Augmented Inversed Probability Weighting b PS = Propensity Scores. c Bootstrap SE = Bootstrapped Standard Errors: they were obtained through 1’000 replications. d The HoNOS difference at discharge corresponds to the difference between the total HoNOS score at discharge and the total HoNOS score at admission. e ATE = Average Treatment Effect f CRHT = Crisis Resolution Home Treatment g CPC = Cantonal Psychiatric Clinic h ln = Natural logarithm i Readmission within 2 years indicates if a patient was readmitted to the CPC and/or to CRHT at least once during the 2 years period following discharge. j The number of readmission days corresponds to the total number of inpatient/CRHT days related to single or multiple readmissions during the 2 years period following discharge. k DID = Difference-in-differences The DID estimate for the HoNOS score confirmed the results of the AIPW model, since no statistically significant DID between the 2 groups emerged (p-value=0.437). CRHT patients had significantly higher HoNOS scores at admission and discharge, but the change in the HoNOS score attributable to the treatment was perfectly comparable between the two groups. Discussion The findings of our study show that CRHT could actually be an effective substitute of care-as-usual for patients suffering from an acute mental crisis that would require hospitalization. The psychiatric symptoms largely improved at discharge without differences between the intervention and control groups (median reduction of eight points in the HoNOS score for both groups), indicating a very similar effectiveness of the two treatment options. This result is perfectly in line with several previous findings( 12 , 19 – 21 , 24 , 26 ), thus reinforcing the empirical evidence suggesting that CRHT and care-as-usual are equally effective in reducing psychiatric symptoms of patients suffering from acute crises. The treatment has proven to be significantly longer in the intervention group, with a median of 36 inpatients days against 27 in the control group (after PS matching +29.6% on average, p-value=0.002). This result is in line with a recent Swiss study ( 26 ), but in contrast with two others that found no significant difference between CRHT and care-as-usual treatment length ( 20 , 25 ). It should be noted that the median duration of CRHT in Ticino lowered over time from 37 days in 2016 to 29 days in 2020 (as shown in Figure 2 ). Since in our study patients were mainly recruited in 2017 and 2018, a higher CRHT duration could be related to the lack of experience in the new clinical setting, and this difference might decline over time due to a “learning effect”. Moreover, additional bivariate analysis showed that a higher CRHT duration might be related to some patients’ characteristics. For example, a higher median CRHT duration was related to a primary diagnosis of schizophrenia, schizotypal and delusional disorders (F2, CRHT: 42.5 days vs CPC: 29 days; p-value=0.005) and to patients not living alone (CRHT: 41 days vs CPC: 26 days; p-value = 0.011). Further research is therefore needed to assess under which conditions CRHT and care-as-usual treatment lengths are actually comparable. In both the intervention and the control groups, 50% of the patients were readmitted to the CPC and/or to CRHT at least once during the two years following discharge; the number of inpatient days related to these readmissions did not differ significantly between the two groups. The finding concerning the readmission rate is in line with several studies ( 17 , 20 , 21 , 26 ) but in contrast with some others reporting lower readmission rates for CRHT patients ( 7 , 9 , 10 , 12 , 19 , 24 , 25 ), while the result regarding the number of readmission inpatient days is line with a recent Swiss study ( 26 ) but in contrast with the majority of previous findings ( 10 , 16 , 17 , 19 , 20 , 23 , 25 ). Such differences might be due to several factors of heterogeneity across studies, as for example the type of patients considered (e.g. some studies included also patients without an immediate need of hospitalization ( 7 , 19 )), the aim of CRHT (e.g. reduce hospital days by rapid and facilitated discharge instead of focusing on readmissions prevention( 20 )), or any other element that could influence the long-term effect of the treatment after discharge. Further detailed studies are needed to investigate the effect of different CRHT regimes on readmission rates and lengths. This study is characterized by some limitations. The first was the impossibility of randomizing the recruited patients because of logistic and ethical problems; we could overcome this limitation, at least approximately, by using the natural experiment design based on geography that allowed approaching real randomisation. The second was the “saturation” effect related to patient’s recruitment for the intervention group, which prevented from having similar sample sizes for both groups and may have increased the chances of Type II errors (i.e. the fact of incorrectly assessing the non-significance of a difference between the two groups). However, with the exception of the statistically significant difference in the number of inpatient days, the comparison between the two groups showed a high degree of homogeneity in the outcomes, suggesting a good reliability of the obtained statistical results. Third, the study was conducted in a single psychiatric hospital, which may prevent the generalizability of findings to other settings. Conclusions The study confirmed the effectiveness of CRHT as a substitute of hospitalization for patients suffering from acute psychiatric crises. Our results showed the comparability between CRHT and inpatient treatment outcome in terms of psychiatric symptoms reduction at discharge, findings that are robustly supported in the literature. However, a longer treatment for CRHT patients and similar readmission rates and readmission inpatients days do not find unanimous support in the literature. This is probably due to heterogeneity across settings, since CRHT is a very complex intervention where details matter and these aspects may differ across studies (e.g. geographic setting, aim of CRHT, patients considered, team composition, etc.). In this sense, additional studies are needed in order to understand in deeper details the effects of the various characteristics of CRHT on the treatment outcomes. The results of an ongoing grounded theory study on the CRHT experience in Ticino will elicit the complex interactions between the patient, the family members and the team, and unpack the ”black box” of the intervention by shedding light on the conditions and logics of its functioning. Moreover, recent contributions investigating the characteristics of patients who benefited the most from CRHT ( 46 ) and of patients relapsing after CRHT ( 47 ) pave the way for future research in this direction. List Of Abbreviations CRHT: Crisis Resolution Home Treatment RCT: Randomised Controlled Trial CPC: Cantonal Psychiatric Clinic ITT: Intention-to-treat CTGI: Conditional Geographic Treatment Ignorability HoNOS: Health of the Nation Outcome Scales PS: Propensity scores BIC: Bayesian Information Criterion ATE: Average Treatment Effect AIPW: Augmented Inverse Probability Weighting WNLS: Weighted Nonlinear Least Squares DID: Difference-in-differences CONSORT: Consolidated Standards of Reporting Trials Declarations Ethics approval and consent to participate All patients signed an informed consent for participation in the study. The study was approved by the local ethics committee (Comitato etico cantonale, c/o Ufficio di sanità, Via Orico 5, 6501 Bellinzona). Project-ID 3177, BASEC 2017-00247. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the Cantonal Psychiatric Clinic (contact: Maddalena Alippi) on reasonable request. Competing interests MA, RAC, SR, ECB, ZM, GL, SC and RT work at the Cantonal Psychiatric Clinic. All the other authors have no conflict of interest. Funding The project was funded by the National Research Programme “Smarter Health Care” (NRP 74) of the Swiss National Science Foundation (SNSF). Project number: 407440_167375. Authors’ contributions L.C., M.C.Z., A.L., M.L., E.A., R.A.C., R.T., S.R., M.A., E.C.B., Z.B.M., G.L., W.K. and E.S. conceptualized and designed the study. S.R., M.A., Z.B.M., G.L. and S.C. collected the data from patients recruited. M.A., A.L., M.L. and E.S. prepared the datasets and performed the statistical analysis. E.S. drafted the manuscript and prepared all Figures and Tables. All authors revised the manuscript and accepted the final version. Acknowledgments We would like to thank PD Dr. Niklaus Stulz for his support in designing the study and Prof. Dr. Marco Borghi for his help in integrating the dimension of ethics and patients’ rights in it. References Thornicroft G, Tansella M. The balanced care model for global mental health. Psychological Medicine. 2013. Thornicroft G, Tansella M. Components of a modern mental health service: A pragmatic balance of community and hospital care. Overview of systematic evidence. British Journal of Psychiatry. 2004. Thornicroft G, Tansella M. Balancing community-basedand hospital-based mental health care. World psychiatry: official journal of the World Psychiatric Association (WPA). 2002; Smyth MG, Hoult J. The home treatment enigma. British Medical Journal. 2000. Johnson S, Needle J, Bindman JP, Thornicroft G. Crisis resolution and home treatment in mental health. Crisis Resolution and Home Treatment in Mental Health. 2008. 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Alternative to Mental Hospital Treatment: I. Conceptual Model, Treatment Program, and Clinical Evaluation. Archives of General Psychiatry. 1980; Hoult J, Reynolds I, Charbonneau-Powis M, Coles P, Briggs J. A controlled study of psychiatric hospital versus community treatment - the effect on relatives. Australasian Psychiatry. 1981; Pai S, Kapur RL. Evaluation of home care treatment for schizophrenic patients. Acta Psychiatrica Scandinavica. 1983; Merson S, Tyrer P, Lack S, Birkett P, Lynch S, Onyett S, et al. Early intervention in psychiatric emergencies: a controlled clinical trial. The Lancet. 1992; Marks IM, Connolly J, Muijen M, Audini B, McNamee G, Lawrence RE. Home-based versus hospital-based care for people with serious mental illness. British Journal of Psychiatry. 1994; Knapp M, Marks I, Wolstenholme J, Beecham J, Astin J, Audini B, et al. Home-based versus hospital-based care for serious mental illness: Controlled cost-effectiveness study over four years. British Journal of Psychiatry. 1998; Johnson S, Nolan F, Pilling S, Sandor A, Hoult J, McKenzie N, et al. Randomised controlled trial of acute mental health care by a crisis resolution team: The north Islington crisis study. British Medical Journal. 2005; Stulz N, Wyder L, Maeck L, Hilpert M, Lerzer H, Zander E, et al. Home treatment for acute mental healthcare: randomised controlled trial. The British Journal of Psychiatry. 2019; Muijen M, Marks I, Connolly J, Audini B. Home based care and standard hospital care for patients with severe mental illness: A randomised controlled trial. British Medical Journal. 1992;304(6829). Sainsbury P, Grad J. Evaluating the community psychiatric service in Chichester. Aims and methods of research. The Milbank Memorial Fund quarterly. 1966; Dean C, Phillips J, Gadd EM, Joseph M, England S. Comparison of community based service with hospital based service for people with acute, severe psychiatric illness. British Medical Journal. 1993; Johnson S, Nolan F, Hoult J, White IR, Bebbington P, Sandor A, et al. Outcomes of crises before and after introduction of a crisis resolution team. British Journal of Psychiatry. 2005; Weinmann S, Wiedmann S, Breidert T, Bohe M, Pfeiffer J, Rosenberger E, et al. Clinical Effectiveness of FlexiTeam (Home Treatment and Intensive Outpatient Treatment) - Comparison of a Model Project According to §64b in Berlin with Inpatient Treatment-as-Usual. Psychiatrische Praxis. 2019; Mötteli S, Schori D, Schmidt H, Seifritz E, Jäger M. Utilization and effectiveness of home treatment for people with acute severe mental illness: A propensity-score matching analysis of 19 months of observation. Frontiers in Psychiatry. 2018; Huang HCH, Taylor M, Carmichael A. The outcomes of home treatment for schizophrenia. BJPsych Bulletin. 2018; Gotink RA, Bergsma G, Hoogwegt MT, Mulder CL, van Gool AR. Intensive home treatment: A first observational evaluation. Tijdschrift voor Psychiatrie. 2017; Alba Palé L, León Caballero J, Córcoles Martínez D, González Fresnedo AM, Bellsolà Gonzalez M, Martín López LM, et al. Psychiatric Home Hospitalization Unit of the Hospital del Mar. A crisis resolution and home treatment team in Barcelona. Revista de Psiquiatria y Salud Mental. 2019; Sakellaridou E, Chrysanthou C, Nienaber A. Treatment at Home in Lengerich (Westfalia) - A Model of Community-Based Mental Health Care. Gesundheitswesen. 2018; Murphy SM, Irving CB, Adams CE, Waqar M. Crisis intervention for people with severe mental illnesses. Cochrane Database of Systematic Reviews. 2015. Burns T, Knapp M, Catty J, Healey A, Henderson J, Watt H, et al. Home treatment for mental health problems: A systematic review. Health Technology Assessment. 2001. Keown P, Tacchi MJ, Niemiec S, Hughes J. Changes to mental healthcare for working age adults: Impact of a crisis team and an assertive outreach team. Psychiatric Bulletin. 2007; Glover G, Arts G, Babu KS. Crisis resolution/home treatment teams and psychiatric admission rates in England. British Journal of Psychiatry. 2006; Bonsack C, Adam L, Haefliger T, Besson J, Conus P. Difficult-to-engage patients: A specific target for time-limited assertive outreach in a Swiss setting. Canadian Journal of Psychiatry. 2005; Bonsack C, Golay P, Manetti SG, Gebel S, Ferrari P, Besse C, et al. Linking primary and secondary care after psychiatric hospitalization: Comparison between transitional case management setting and routine care for common mental disorders. Frontiers in Psychiatry. 2016; Morandi S, Silva B, Golay P, Bonsack C. Intensive Case Management for Addiction to promote engagement with care of people with severe mental and substance use disorders: An observational study. Substance Abuse: Treatment, Prevention, and Policy. 2017; Kraan K. Integrated home treatment in acute episodes of mental illness. Results from a Pilot Project in Lucerne. In: European Congress of Social Psychiatry. Geneva, 4-6 July; 2012. Levati S, Mellacqua ZB, Caiata Zufferey M, Soldini E, Albanese E, Alippi M, et al. Home treatment for acute mental healthcare in Ticino: protocol of the Financial Outputs, Risks, Efficacy, Satisfaction Index and Gatekeeping of Home Treatment (FORESIGHT) study (Preprint). JMIR Research Protocols. 2021; Keele L, Titiunik R. Natural Experiments Based on Geography. Political Science Research and Methods. 2016;4(1). Wing JK, Beevor AS, Curtis RH, Park SGB, Hadden J, Burns A. Health of the Nation Outcome Scales (HoNOS). British Journal of Psychiatry. 1998;172(1). Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70(1). Cattaneo MD, Drukker DM, Holland AD. Estimation of multivalued treatment effects under conditional independence. Stata Journal. 2013;13(3). Imai K, Ratkovic M. Covariate balancing propensity score. Journal of the Royal Statistical Society Series B: Statistical Methodology. 2014;76(1). Wing C, Simon K, Bello-Gomez RA. Designing Difference in Difference Studies: Best Practices for Public Health Policy Research. Annual Review of Public Health. 2018;39(1). Mötteli S, Jäger M, Hepp U, Wyder L, Vetter S, Seifritz E, et al. Home Treatment for Acute Mental Healthcare: Who Benefits Most? Community Mental Health Journal. 2020; Werbeloff N, Chang CK, Broadbent M, Hayes JF, Stewart R, Osborn DPJ. Admission to acute mental health services after contact with crisis resolution and home treatment teams: an investigation in two large mental health-care providers. The Lancet Psychiatry. 2017;4(1). Additional Declarations Competing interest reported. M.A., R.A.C., S.R., E.C.B., Z.M., G.L., S.C. and R.T. work at the Cantonal Psychiatric Clinic. All the other authors have no conflict of interest. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 08 Mar, 2022 Reviews received at journal 20 Dec, 2021 Reviewers agreed at journal 02 Dec, 2021 Reviewers agreed at journal 01 Dec, 2021 Reviewers invited by journal 01 Dec, 2021 Editor assigned by journal 01 Dec, 2021 Editor invited by journal 18 Nov, 2021 Submission checks completed at journal 18 Nov, 2021 First submitted to journal 09 Nov, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1064873","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":64300191,"identity":"7af01d0d-786f-4e9d-8f72-95e40bdc0bc5","order_by":0,"name":"Emiliano 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15:44:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1064873/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1064873/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":15721081,"identity":"5fb96c00-ac86-4b71-b52a-a035874fe1ce","added_by":"auto","created_at":"2021-11-19 16:16:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":121459,"visible":true,"origin":"","legend":"Patients’ disposition (CONSORT Flowchart) ","description":"","filename":"fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1064873/v1/b1cb9bd7525cb4117312cd15.jpg"},{"id":15721136,"identity":"f4df90cc-e6cd-4d29-9754-c674026b7cd2","added_by":"auto","created_at":"2021-11-19 16:19:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":68677,"visible":true,"origin":"","legend":"Evolution of the median duration of a Crisis Resolution Home Treatment (CRHT) intervention in Ticino","description":"","filename":"fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1064873/v1/58c86869b868599973708151.jpg"},{"id":15721139,"identity":"bc29814d-7486-4945-95b9-9f270f47ecf3","added_by":"auto","created_at":"2021-11-19 16:20:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":729305,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1064873/v1/9b155b14-c865-48d8-b23b-1b0c488e8b46.pdf"}],"financialInterests":"Competing interest reported. M.A., R.A.C., S.R., E.C.B., Z.M., G.L., S.C. and R.T. work at the Cantonal Psychiatric Clinic. All the other authors have no conflict of interest.","formattedTitle":"\u003cp\u003eEffectiveness of Crisis Resolution Home Treatment for the Management of Acute Psychiatric Crises in Southern Switzerland: A Natural Experiment Based on Geography\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe worldwide growing emphasis on the socio-psychiatric approach in mental healthcare has contributed to the development of a variety of community-based services, which may help to reduce hospitalizations in psychiatric hospitals and clinics and to reorient mental health systems and services towards more community-based, patient-centred, integrated care (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Crisis Resolution Home Treatment (CRHT) provides an alternative setting to psychiatric hospitals for the treatment and care of acute psychiatric crises (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). CRHT has gained a growing consensus over time because of its potential to leverage the psychosocial dimension intrinsically related to mental health crises (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and preserve social participation and integration of people suffering from acute psychiatric crises, while also reducing the stigma associated with institutionalisation in traditional psychiatric settings (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDuring the last 60 years, several CRHT experiences have been evaluated worldwide using a variety of study designs, including randomised controlled trials (RCT) (\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), non-randomised comparative (\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and non-comparative (\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) studies. Evidence synthesis endeavours are reported in systematic reviews (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and highlight that CRHT can be an alternative to hospitalisation appreciated by patients and families. Ample evidence suggests that CRHT can be useful to foster the availability, accessibility, acceptability and integration of mental health services, as well as a multisectoral approach to attain a continuous and holistic care centred on needs of patients and their families. Next, observational evidence suggests that CRHT can contribute to reduce hospital admission/readmission rates and the number of inpatient days (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). However, the effectiveness of CRHT in the treatment of acute psychiatric crises is erratic. There is marked heterogeneity in the evidence pertaining to the reduction of severity of psychiatric symptoms and social outcomes (e.g. social inclusion, employment rates) after treatment. Moreover, evidence on the effectiveness of CRHT is difficult to reconcile and consolidate because the internal validity of some studies may be reduced by suboptimal comparability between the study groups. CRHT is a complex intervention and its evaluation poses design and studies implementation challenges, as well as the stringent application of a robust, stepped evaluation framework. The majority of the CRHT experiences were evaluated more than 20 years ago (\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), when guidance and methods to evaluate complex interventions did not exist or were not common yet. Some of the more recent studies applied clinical trial designs with or without randomization of participants (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), while the others were flawed because they included only patients treated with CRHT without a control group (\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Therefore, evidence in favour of the effectiveness of CRHT as a substitute of hospitalization for acute crises treatment in current mental health systems remains limited.\u003c/p\u003e \u003cp\u003eFrom 2001 onwards, many different experiences of psychiatric home treatment have been implemented in Switzerland. The Cantons of Vaud (\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), Thurgau and Basel introduced home treatment services after hospital discharge, but not as a replacement of hospital treatment and only for some patients, typically heavy users. CRHT teams that entirely replace an inpatient treatment have been implemented in the Cantons of Luzern (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), Aargau (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), Z\u0026uuml;rich (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) and Ticino, the Italian speaking region of the Swiss Confederation bordering northern Italy. In the latter case, a fully operational ward of the regional public psychiatric hospital (Cantonal Psychiatric Clinic, CPC) was shut down, and the staff of the ward was trained to build the CRHT team with the intention to substitute inpatient treatment.\u003c/p\u003e \u003cp\u003eThe aim of the present study was to formally evaluate the effectiveness of the CRHT unit in Ticino as a substitute of standard in-hospital treatment. Main outcomes were reduction of psychiatric symptoms at the end of the treatment, treatment duration in days and rate and length of readmissions during a two-year follow-up period after discharge.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe protocol of the study was recently published (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). The CRHT intervention, the quantitative study design and the statistical analysis to assess the effectiveness of CRHT in comparison with standard inpatient treatment are described in details here below. All methods were carried out in accordance with relevant guidelines and regulations.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe intervention\u003c/h2\u003e \u003cp\u003eIn April 2016 one of the CPC acute wards was closed and replaced by a CRHT team, available 24/7 (on call from 10:30 pm to 7 am), formed of three doctors fully trained in psychiatry (i.e. a full-time consultant psychiatrist, a part-time psychiatrist, and a part-time senior consultant psychiatrist on call), ten mental health nurses, one team manager, a part-time clinical psychologist and a part-time social worker.\u003c/p\u003e \u003cp\u003eAccess to the CRHT service was managed by the CPC triage, by Accident and Emergency teams, local community mental health professionals, private psychiatrists and general practitioners. The treatment was administered in daily home visits to the patients, the family members and/or the caregivers, and consisted in a structured psychoeducational approach to acute psychiatric crises aimed at reducing symptoms and preventing future relapses. The number of home visits per day varied based on patients\u0026rsquo; needs. The intervention included standard elements of acute care, such as crisis management, pharmacotherapy, psychoeducation, psychotherapy and social care. Though standardization was sought, every intervention was individually tailored according to the specific needs of each patient. The CRHT team\u0026rsquo;s activities included monitoring of symptoms; adherence to and side effects of pharmacological treatment; identification and management of contextual life-threatening hazards; provision of emotional, social and psychological support to patients, families and/or caregivers; connection with other health and social care services and providers; planning of discharge meetings and follow-ups. The CRHT team also ensured an active collaboration with local services/practitioners to provide long-term support to patients.\u003c/p\u003e \u003cp\u003eThe CRHT service was offered to patients aged 18 to 65 who suffered from an acute psychiatric crisis that would have required hospitalization. CRHT was not offered to patients with acute alcohol or drug intoxication, extreme agitation and/or aggressive behaviour, acute risk of suicide/self-harm or representing a significant risk for others. Further CRHT exclusion criteria were compulsory admission, being an inmate and place of residence (patients living in the southern area of Ticino could not be served due to practical reasons).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy design, sample and data collected\u003c/h2\u003e \u003cp\u003eWe used a quasi-experimental design based on existing groups, namely a natural experiment based on geography (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), to allocate patients to the intervention and control groups according to the place of residence. The assumption of casual distribution of socio-demographic and relevant health characteristics across geographic groups was supported by preliminary statistics on patients treated in the acute wards of the northern (n=108) and southern (n=263) areas of the Canton during a period of six month before the introduction of CRHT. Bivariate χ\u003csup\u003e2\u003c/sup\u003e and Mann-Whitney tests showed no significant difference in both the socio-demographic (gender, p-value=0.069; age, p-value=0.266; education, p-value=0.404; civil status, p-value=0.404; etc.) and clinical (main psychiatric diagnosis, p-value=0.843; number of previous admissions, p-value=0.527; severity of psychiatric symptoms at admission p-value=0.855; etc.) characteristics. We used intention-to-treat (ITT) for all analyses, thus patients living in the southern area of the Canton were recruited only if theoretically willing to accept CRHT, and could be legitimately allocated to the control group and deemed comparable to those allocated to the intervention group. Under these conditions, when accounting for a set of pre-treatment covariates (like age, gender, psychiatric diagnosis, number of previous hospitalizations and other variables), the assumption of conditional geographic treatment ignorability (CTGI) is likely to hold (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), providing a setting where the assignment to treatment and control groups can be considered to approach randomization.\u003c/p\u003e \u003cp\u003eThe recruitment of patients took place over a two-years period, from mid-March 2017 to the beginning of April 2019. All patients recruited living in the northern area of the Canton were treated with CRHT and included in the intervention group, those from the southern area received care-as-usual (i.e. hospitalization) and were included in the control group. Eligibility for the study was assessed according to the criteria giving access to CRHT (above), with the additional condition of a hospitalization period of at most 48 hours before being transferred to the CRHT service. Moreover, certificates of compulsory hospitalization rescinded and/or acute drug or alcohol intoxications resolved within 48 hours from hospitalization granted eligibility for the corresponding patients. Finally, patients with a treatment period too short (less than seven days) were further excluded because they most likely did not actually meet the criteria for a major acute psychiatric crisis. The minimal sample size needed to ensure a statistical power of 80% at the 5% significance level for a two-tailed hypothesis test was 142 patients in each study arm, based on previous evidence on mean differences over a 12 to 24 months period of the Health of the Nation Outcome Scales (HoNOS) overall score (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). HoNOS is a validated 12-items measure, commonly used to assess the health and social functioning of people with severe mental illness (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor both groups we collected data on four main outcomes. During the treatment period, we used the HoNOS total score to quantify the change in the severity of symptoms between admission and discharge, and computed the number of inpatient days. During the 2-years follow-up period, we focused on readmission rates, to either CPC or CRHT, and total number of inpatient days after readmission. We also collected data on patients\u0026rsquo; socio-demographic and clinical characteristics, namely gender, age, nationality, educational level, civil status, living arrangement, working condition, primary psychiatric diagnosis, presence of a secondary diagnosis, compulsory admission, number of previous hospitalizations and HoNOS score at the admission. Finally, safety was measured during the treatment period according to the frequency of serious adverse events, defined as suicide or suicide attempts, major self-harm episodes requiring emergency room visits or hospitalizations, acute alcohol/drug intoxications and major aggressions to caregivers or family members.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eWe compared the main outcomes and the socio-demographic and clinical characteristics of the patients between the intervention and control group using descriptive statistics and χ\u003csup\u003e2\u003c/sup\u003e and Mann-Whitney tests (for count and continuous variables, respectively), and applied the Monte Carlo method to estimate the Mann-Whitney test p-value because of the expected skewness in the distribution of continuous variables (e.g. number of inpatient days).\u003c/p\u003e \u003cp\u003eTo improve causal inference, we used propensity scores (PS) matching (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) for the main analysis of differences between the intervention and control group for each outcome. First, we selected the variables to include in the PS reference model using the approach proposed by Cattaneo, Drukker and Holland (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). We ran a set of independent logistic regression models with intervention/control group membership as dependent variable and all the possible combinations of sociodemographic and clinical variables as predictors, and quantified the goodness-of-fit using the Bayesian Information Criterion (BIC). We selected as reference PS model the one with the best goodness-of-fit (i.e. the lowest BIC). Then, using the socio-demographic and clinical variables retained in the PS reference model, we estimated the Average Treatment Effect (ATE) of CRHT separately on each of the outcomes using the Augmented Inverse Probability Weighting (AIPW). Moreover, we used log-transformation for the strongly skewed outcomes, Weighted Nonlinear Least Squares (WNLS) instead of maximum likelihood and bootstrapped standard errors to provide additional robustness to the estimates. We controlled for the covariates balance between the intervention and control groups according to the overidentification test for covariate balance proposed by Imai and Ratkovic (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Finally, to account also for unobserved individual heterogeneity, the Difference-in-differences (DID) technique (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) with kernel-based PS matching was applied to the HoNOS score, the only outcome for which we had before and after treatment measurements.\u003c/p\u003e \u003cp\u003eWe conducted all statistical analyses with Stata/IC 16.0 (StataCorp, 4905 Lakeway Drive, College Station, Texas, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003ePatients\u0026rsquo; disposition and safety\u003c/h2\u003e\n \u003cp\u003eBetween mid-March 2017 and the beginning of April 2019, 1\u0026rsquo;281 patients were referred to the CPC for hospital admission and assessed for study eligibility. 834 patients were excluded because they did not meet the inclusion criteria, while 25 declined participation and 101 were excluded for other reasons (e.g. therapeutic reasons, cognitive problems, lack of suitable living environment, linguistic problems). Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the flowchart of participants, according to the Consolidated Standards of Reporting Trials (CONSORT) recommendations.\u003c/p\u003e\n \u003cp\u003eOverall, we enrolled 321 patients, 192 in the control group (i.e. hospitalized) and 129 in the intervention group (i.e. CRHT care). 67 patients (23 in the intervention group and 44 in the control group) were further excluded because the treatment period was too short (less than seven days), while 17 additional patients had to be excluded because they were transferred to another healthcare facility outside the CPC before the end of the treatment (13 in the intervention group and 4 in the control group). A total of 237 patients (93 in the intervention group and 144 in the control group) were finally available for the data analysis. No patient in the intervention group was hospitalized at the CPC before the end of the home treatment, and no serious adverse event was observed during the treatment period in both arms.\u003c/p\u003e\n \u003cp\u003eIt should be noted that, according to the sample size calculation (above), the intervention and control groups were originally planned to be of equal size. However, the recruitment of patients for the intervention group was characterized by a \u0026ldquo;saturation\u0026rdquo; effect. Throughout time less and less new patients living in the northern region of the Canton referred for hospital admission resulted eligible for the study and/or accepted to participate, which led to a smaller sample size for the intervention group at the end of the recruitment period.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003eStatistical analysis results\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic and clinical characteristics of patients in the intervention and control groups at admission. There were no significant differences between groups by median age (CRHT: 41.7 years old vs CPC: 45.7 years old; p-value=0.152), citizenship (CRHT: 79.6% Swiss vs CPC: 71.5% Swiss; p-value=0.164), educational level (CRHT: 43% no/compulsory education and 50.5% secondary education vs CPC: 46.5% no/compulsory education and 41% secondary education; p-value=0.187) and working status (CRHT: 19.4% employed vs CPC: 22.9% employed; p-value=0.515). Instead, in the intervention group we found higher percentages of women (CRHT: 61.3% vs CPC: 38.2%; p-value=0.001) and of married people (CRHT: 36.6%, vs CPC: 22.2%, p-value=0.016), while the proportion of patients living alone was significantly higher in the control group (CRHT: 34.4% vs CPC: 51.4%; p-value=0.010).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash; Demographic and clinical characteristics of intervention and control groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention group (n=93)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControl group (n=144)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStatistical test for the difference\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003eDemographic\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale gender, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (61.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e(1) = 12.173***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge, years: median (IQR\u003csup\u003eb\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.7(20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.7 (20.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ez = 1.432\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSwiss citizenship, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103 (71.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e(1) = 1.969\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducational level, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNone/compulsory\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (46.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e(2) = 3.467\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eSecondary\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (50.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (41.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eTertiary\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e (1) = 5.700*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLiving alone, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (34.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (51.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e (1) = 6.665*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployed, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e (1) = 0.429\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003eClinical\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompulsory admission, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e (1) = 6.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary diagnosis (ICD-10), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMental and behavioural disorders\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e4 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e19 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"10\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e(5) = 20.706**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003edue to use of psychoactive substances (F1)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eSchizophrenia, schizotypal and delusional\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e24 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e45 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003edisorders (F2)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMood [affective] disorders (F3)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNeurotic, stress-related and somatoform\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e12 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e19 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003edisorders (F4)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDisorders of personality and behaviour in\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e24 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e14 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eadult persons (F6)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eOther disorders (F5, F8, F9, Z)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresence of a secondary diagnosis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 (63.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87 (60.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e (1) = 0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNum. previous hospitalizations: median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ez = 2.887**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHoNOS at admission\u003csup\u003ec\u003c/sup\u003e: median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ez = -1.045\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e* p\u0026lt;0.05, ** p\u0026lt;0.01, *** p\u0026lt;0.001\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e \u0026chi;\u003csup\u003e2\u003c/sup\u003e test for categorical variables; Fisher\u0026rsquo;s exact test was used in presence of cells with a count lower than 5. Mann-Whitney test for continuous variables; the 95% confidence intervals for p-values used to assess statistical significance were estimated using the Monte Carlo method based on 10\u0026rsquo;000 samples.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e IQR = Interquartile range\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ec\u003c/sup\u003e Data on the HoNOS were missing for 6 patients in the intervention group and 12 in the control group.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eParticipants in the intervention group had on average significantly lower mental and behavioural disorders due to the use of psychoactive substances (F1, CRHT: 4.3% vs CPC: 13.2%; p-value=0.024) and significantly higher personality and behaviour disorders in adult persons (F6, CRHT: 25.8% vs CPC: 9.7%; p-value=0.001). Moreover, the intervention group counted fewer certificates of compulsory hospitalization rescinded before recruitment (CRHT: 16.1% vs CPC: 29.9%; p-value=0.016) and a lower median number of previous hospitalizations at the clinic (CRHT: 1 vs CPC: 2; p-value=0.004). No significant differences were found in the presence of a secondary diagnosis (CRHT: 63.4% vs CPC: 60.4%; p-value=0.640) and in the median HoNOS score at admission (CRHT: 18 vs CPC: 16; p-value=0.296).\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the outcomes for the intervention and control groups. While the median reduction in the HoNOS total score at discharge resulted homogeneous between the two groups (CRHT: -8 vs CPC: -8; p-value=0.731), the median number of inpatient days was higher for the treatment group (CRHT: 36 days vs CPC: 27 days; p-value=0.001). Irrespective of the group considered, around half of the patients were readmitted to the CPC or to CRHT at least once within two years from discharge (CRHT: 49.5% vs CPC: 51.4%; p-value=0.772). Despite the lower median in the treatment group, also the total number of inpatient days related to single or multiple readmissions did not differ significantly between the two groups (CRHT: 40.5 days vs CPC: 52 days; p-value=0.800).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash; Outcomes for the intervention and control groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcomes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention group (n=93)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControl group (n=144)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStatistical test for the difference\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHoNOS difference at discharge\u003csup\u003eb\u003c/sup\u003e: median (IQR\u003csup\u003ec\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-8 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-8 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ez = -0.345\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of inpatient days: median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ez = -3.251**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReadmission within 2 years\u003csup\u003ed\u003c/sup\u003e, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (49.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (51.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e (1) = 0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of readmission days\u003csup\u003ee\u003c/sup\u003e: median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (56.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ez = 0.254\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e* p\u0026lt;0.05, ** p\u0026lt;0.01, *** p\u0026lt;0.001\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e \u0026chi;\u003csup\u003e2\u003c/sup\u003e test for categorical variables. Mann-Whitney test for continuous variables; the 95% confidence intervals for p-values used to assess statistical significance were estimated using the Monte Carlo method based on 10\u0026rsquo;000 samples.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e The HoNOS difference at discharge corresponds to the difference between the total HoNOS score at discharge and the total HoNOS score at admission. Data were missing for 8 patients in the intervention group and 21 in the control group.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ec\u003c/sup\u003e IQR = Interquartile range\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ed\u003c/sup\u003e Readmission within 2 years indicates if a patient was readmitted to the CPC and/or to CRHT at least once during the 2 years period following discharge.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ee\u003c/sup\u003e The number of readmission days corresponds to the total number of inpatient/CRHT days related to single or multiple readmissions during the 2 years period following discharge. Data were available for 39 patients in the intervention group and 74 in the control group.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e displays the PS model selected according to the approach proposed by Cattaneo, Drukker and Holland (\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e). The variables important for balancing the two groups were gender, living arrangement, compulsory admission, diagnosis of personality and behaviour disorders in adult persons (F6) and number of previous hospitalizations; the latter was included in the model in spite of not being statistically significant at the 5% level. Predicted probabilities, ranging on average from 0.337 to 0.663, were sufficiently far from the extreme values of 0 and 1 to suggest no particular concern about the selected model.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash; Propensity Scores model selected\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eCovariates\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDependent variable:\u003c/p\u003e\n \u003cp\u003eIntervention/control group membership\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoefficient\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(SE\u003c/strong\u003e\u003csup\u003ea\u003c/sup\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% confidence interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFemale gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.837**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e(0.271;1.403)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.289)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLiving alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.623*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e(-1.215;-0.032)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.302)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCompulsory admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.721*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e(-1.413;-0.029)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.353)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDisorders of personality and behaviour in adults (F6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.338**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e(0.561;2.115)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.397)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNumber of previous hospitalizations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e(-0.077;0.022)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.025)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.557*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e(-1.082;-0.032)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.268)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNumber of observations (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLR \u0026chi;\u003csup\u003e2\u003c/sup\u003e (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.59***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eBayesian Information Criterion (BIC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e315.707\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePredicted probabilities\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCPC\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePr\u003csup\u003ed\u003c/sup\u003e(CPC): mean (SD\u003csup\u003ee\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.663 (0.156)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePr(CRHT): mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.337 (0.156)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCRHT\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePr(CPC): mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.521 (0.188)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePr(CRHT): mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.479 (0.188)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e* p\u0026lt;0.05, ** p\u0026lt;0.01, *** p\u0026lt;0.001\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e SE = Standard Error\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e Predicted probabilities for each treatment level were computed and summarized conditional to each treatment level.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ec\u003c/sup\u003e CPC = Cantonal Psychiatric Clinic\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ed\u003c/sup\u003e Pr = Probability\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ee\u003c/sup\u003e SD = Standard Deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003ef\u003c/sup\u003e CRHT = Crisis Resolution Home Treatment\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e presents the estimates of the ATE of CRHT on the outcomes, as well as the results of the DID model for the HoNOS score. The overidentification test for covariate balance showed that the selected PS model successfully balanced the intervention and control groups (p-values of the test of 0.334 or higher for all models). We found no significant ATE of CRHT on the HoNOS score difference at discharge (p-value=0.315), on readmission rates within two years from discharge (p-value=0.563) and on the number of readmission days for patients readmitted at least once within two years from discharge (p-value=0.771). The ATE on the treatment length was instead statistically significant; the number of inpatient days in the intervention group was higher (+29.6% on average; p-value=0.002).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u003ctable border=\"1\" id=\"Tab4\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash; Estimate of the ATE of CRHT and of the DID model for the HoNOS score\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eAIPW\u003csup\u003ea\u003c/sup\u003e PS\u003csup\u003eb\u003c/sup\u003e models\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e1) linear outcome model\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e2) + 4) log-linear outcome model\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e3) logistic outcome model\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCoefficient\u003c/p\u003e\n \u003cp\u003e(Bootstrap SE\u003csup\u003ec\u003c/sup\u003e)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% confidence interval\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1) HoNOS difference at discharge\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATE\u003csup\u003ee\u003c/sup\u003e (CRHT\u003csup\u003ef\u003c/sup\u003e vs CPC\u003csup\u003eg\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(-0.791;2.842)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e(n = 208)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.927)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-9.434***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(-10.706;-8.163)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.649)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2) ln\u003csup\u003eh\u003c/sup\u003e(Number of inpatient days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATE (CRHT vs CPC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.296**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(0.088;0.504)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e(n = 237)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.106)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.182***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(3.046;3.319)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.070)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3) Readmission within 2 years\u003csup\u003ei\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATE (CRHT vs CPC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(-0.093;0.170)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e(n = 237)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.067)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.493***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(0.408;0.577)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.067)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4) ln(Number of readmission days\u003csup\u003ej\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eATE (CRHT vs CPC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(-0.460;0.319)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e(n = 120)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.199)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.833***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(3.580;4.085)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.129)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eDID\u003c/strong\u003e\u003csup\u003ek\u003c/sup\u003e \u003cstrong\u003emodel with Kernel-based PS matching\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003elinear model\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e(n = 220 before, n = 215 after)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoefficient\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Standard Error)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% confidence interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHoNOS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDifference between CHRT and CPC before\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.576*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(0.135;3.017)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.735)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDifference between CHRT and CPC after\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.304**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(0.867;3.741)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(0.733)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDifference-in-differences (DID)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.728\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e(-1.306;2.762)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(1.038)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e* p\u0026lt;0.05, ** p\u0026lt;0.01, *** p\u0026lt;0.001\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e AIPW = Augmented Inversed Probability Weighting\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003eb\u003c/sup\u003e PS = Propensity Scores.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ec\u003c/sup\u003e Bootstrap SE = Bootstrapped Standard Errors: they were obtained through 1\u0026rsquo;000 replications.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ed\u003c/sup\u003e The HoNOS difference at discharge corresponds to the difference between the total HoNOS score at discharge and the total HoNOS score at admission.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ee\u003c/sup\u003e ATE = Average Treatment Effect\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ef\u003c/sup\u003e CRHT = Crisis Resolution Home Treatment\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003eg\u003c/sup\u003e CPC = Cantonal Psychiatric Clinic\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003eh\u003c/sup\u003e ln = Natural logarithm\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ei\u003c/sup\u003e Readmission within 2 years indicates if a patient was readmitted to the CPC and/or to CRHT at least once during the 2 years period following discharge.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ej\u003c/sup\u003e The number of readmission days corresponds to the total number of inpatient/CRHT days related to single or multiple readmissions during the 2 years period following discharge.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ek\u003c/sup\u003e DID = Difference-in-differences\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eThe DID estimate for the HoNOS score confirmed the results of the AIPW model, since no statistically significant DID between the 2 groups emerged (p-value=0.437). CRHT patients had significantly higher HoNOS scores at admission and discharge, but the change in the HoNOS score attributable to the treatment was perfectly comparable between the two groups.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of our study show that CRHT could actually be an effective substitute of care-as-usual for patients suffering from an acute mental crisis that would require hospitalization.\u003c/p\u003e\n\u003cp\u003eThe psychiatric symptoms largely improved at discharge without differences between the intervention and control groups (median reduction of eight points in the HoNOS score for both groups), indicating a very similar effectiveness of the two treatment options. This result is perfectly in line with several previous findings(\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e), thus reinforcing the empirical evidence suggesting that CRHT and care-as-usual are equally effective in reducing psychiatric symptoms of patients suffering from acute crises.\u003c/p\u003e\n\u003cp\u003eThe treatment has proven to be significantly longer in the intervention group, with a median of 36 inpatients days against 27 in the control group (after PS matching +29.6% on average, p-value=0.002). This result is in line with a recent Swiss study (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e), but in contrast with two others that found no significant difference between CRHT and care-as-usual treatment length (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). It should be noted that the median duration of CRHT in Ticino lowered over time from 37 days in 2016 to 29 days in 2020 (as shown in Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Since in our study patients were mainly recruited in 2017 and 2018, a higher CRHT duration could be related to the lack of experience in the new clinical setting, and this difference might decline over time due to a \u0026ldquo;learning effect\u0026rdquo;. Moreover, additional bivariate analysis showed that a higher CRHT duration might be related to some patients\u0026rsquo; characteristics. For example, a higher median CRHT duration was related to a primary diagnosis of schizophrenia, schizotypal and delusional disorders (F2, CRHT: 42.5 days vs CPC: 29 days; p-value=0.005) and to patients not living alone (CRHT: 41 days vs CPC: 26 days; p-value = 0.011). Further research is therefore needed to assess under which conditions CRHT and care-as-usual treatment lengths are actually comparable.\u003c/p\u003e\n\u003cp\u003eIn both the intervention and the control groups, 50% of the patients were readmitted to the CPC and/or to CRHT at least once during the two years following discharge; the number of inpatient days related to these readmissions did not differ significantly between the two groups. The finding concerning the readmission rate is in line with several studies (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) but in contrast with some others reporting lower readmission rates for CRHT patients (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e), while the result regarding the number of readmission inpatient days is line with a recent Swiss study (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) but in contrast with the majority of previous findings (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). Such differences might be due to several factors of heterogeneity across studies, as for example the type of patients considered (e.g. some studies included also patients without an immediate need of hospitalization (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e)), the aim of CRHT (e.g. reduce hospital days by rapid and facilitated discharge instead of focusing on readmissions prevention(\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e)), or any other element that could influence the long-term effect of the treatment after discharge. Further detailed studies are needed to investigate the effect of different CRHT regimes on readmission rates and lengths.\u003c/p\u003e\n\u003cp\u003eThis study is characterized by some limitations. The first was the impossibility of randomizing the recruited patients because of logistic and ethical problems; we could overcome this limitation, at least approximately, by using the natural experiment design based on geography that allowed approaching real randomisation. The second was the \u0026ldquo;saturation\u0026rdquo; effect related to patient\u0026rsquo;s recruitment for the intervention group, which prevented from having similar sample sizes for both groups and may have increased the chances of Type II errors (i.e. the fact of incorrectly assessing the non-significance of a difference between the two groups). However, with the exception of the statistically significant difference in the number of inpatient days, the comparison between the two groups showed a high degree of homogeneity in the outcomes, suggesting a good reliability of the obtained statistical results. Third, the study was conducted in a single psychiatric hospital, which may prevent the generalizability of findings to other settings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe study confirmed the effectiveness of CRHT as a substitute of hospitalization for patients suffering from acute psychiatric crises. Our results showed the comparability between CRHT and inpatient treatment outcome in terms of psychiatric symptoms reduction at discharge, findings that are robustly supported in the literature. However, a longer treatment for CRHT patients and similar readmission rates and readmission inpatients days do not find unanimous support in the literature. This is probably due to heterogeneity across settings, since CRHT is a very complex intervention where details matter and these aspects may differ across studies (e.g. geographic setting, aim of CRHT, patients considered, team composition, etc.). In this sense, additional studies are needed in order to understand in deeper details the effects of the various characteristics of CRHT on the treatment outcomes. The results of an ongoing grounded theory study on the CRHT experience in Ticino will elicit the complex interactions between the patient, the family members and the team, and unpack the \u0026rdquo;black box\u0026rdquo; of the intervention by shedding light on the conditions and logics of its functioning. Moreover, recent contributions investigating the characteristics of patients who benefited the most from CRHT (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) and of patients relapsing after CRHT (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) pave the way for future research in this direction.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eCRHT: Crisis Resolution Home Treatment\u003c/p\u003e\n\u003cp\u003eRCT: Randomised Controlled Trial\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCPC: Cantonal Psychiatric Clinic\u003c/p\u003e\n\u003cp\u003eITT: Intention-to-treat\u003c/p\u003e\n\u003cp\u003eCTGI: Conditional Geographic Treatment Ignorability\u003c/p\u003e\n\u003cp\u003eHoNOS: Health of the Nation Outcome Scales\u003c/p\u003e\n\u003cp\u003ePS: Propensity scores\u003c/p\u003e\n\u003cp\u003eBIC: Bayesian Information Criterion\u003c/p\u003e\n\u003cp\u003eATE: Average Treatment Effect\u003c/p\u003e\n\u003cp\u003eAIPW: Augmented Inverse Probability Weighting\u003c/p\u003e\n\u003cp\u003eWNLS: Weighted Nonlinear Least Squares\u003c/p\u003e\n\u003cp\u003eDID: Difference-in-differences\u003c/p\u003e\n\u003cp\u003eCONSORT: Consolidated Standards of Reporting Trials\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll patients signed an informed consent for participation in the study.\u003c/p\u003e\n\u003cp\u003eThe study was approved by the local ethics committee (Comitato etico cantonale, c/o Ufficio di sanit\u0026agrave;, Via Orico 5, 6501 Bellinzona). Project-ID 3177, BASEC 2017-00247.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the Cantonal Psychiatric Clinic (contact: Maddalena Alippi) on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMA, RAC, SR, ECB, ZM, GL, SC and RT work at the Cantonal Psychiatric Clinic. All the other authors have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe project was funded by the National Research Programme \u0026ldquo;Smarter Health Care\u0026rdquo; (NRP 74) of the Swiss National Science Foundation (SNSF). Project number: 407440_167375.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eL.C., M.C.Z., A.L., M.L., E.A., R.A.C., R.T., S.R., M.A., E.C.B., Z.B.M., G.L., W.K. and E.S. conceptualized and designed the study. S.R., M.A., Z.B.M., G.L. and S.C. collected the data from patients recruited. M.A., A.L., M.L. and E.S. prepared the datasets and performed the statistical analysis. E.S. drafted the manuscript and prepared all Figures and Tables. All authors revised the manuscript and accepted the final version.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank PD Dr. Niklaus Stulz for his support in designing the study and Prof. Dr. Marco Borghi for his help in integrating the dimension of ethics and patients\u0026rsquo; rights in it.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThornicroft G, Tansella M. The balanced care model for global mental health. Psychological Medicine. 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThornicroft G, Tansella M. Components of a modern mental health service: A pragmatic balance of community and hospital care. Overview of systematic evidence. British Journal of Psychiatry. 2004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThornicroft G, Tansella M. 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Outcomes of crises before and after introduction of a crisis resolution team. British Journal of Psychiatry. 2005;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinmann S, Wiedmann S, Breidert T, Bohe M, Pfeiffer J, Rosenberger E, et al. Clinical Effectiveness of FlexiTeam (Home Treatment and Intensive Outpatient Treatment) - Comparison of a Model Project According to \u0026sect;64b in Berlin with Inpatient Treatment-as-Usual. Psychiatrische Praxis. 2019;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026ouml;tteli S, Schori D, Schmidt H, Seifritz E, J\u0026auml;ger M. Utilization and effectiveness of home treatment for people with acute severe mental illness: A propensity-score matching analysis of 19 months of observation. Frontiers in Psychiatry. 2018;\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang HCH, Taylor M, Carmichael A. The outcomes of home treatment for schizophrenia. 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The Lancet Psychiatry. 2017;4(1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute psychiatric crises, Crisis Resolution Home Treatment, inpatient treatment, effectiveness, quasi-experimental design","lastPublishedDoi":"10.21203/rs.3.rs-1064873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1064873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCrisis Resolution Home Treatment (CRHT) is an alternative to inpatient treatment for acute psychiatric crises management. However, evidence on CRHT effectiveness is still limited. In the Canton of Ticino (Southern Switzerland), in 2016 the regional public psychiatric hospital replaced one acute ward with a CRHT. The current study was designed within this evaluation setting to assess the effectiveness of CRHT compared to standard inpatient treatment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCRHT was offered to patients aged 18 to 65 with an acute psychiatric crisis that would have required hospitalization. Exclusion criteria were acute drug/alcohol intoxications, extreme agitation/aggressive behaviour, risk of suicide/self-harm, compulsory hospitalization, being an inmate and, due to practical reasons, living in the southern area of Ticino. We used a natural experiment based on geography, where intervention and control groups were formed according to the place of residence. Primary endpoints were reduction of psychiatric symptoms at discharge, treatment duration in days, and rate and length of readmissions during a two-year follow-up period after discharge. Safety during the treatment period was measured with the number of serious adverse events (suicide/suicide attempts, major self-harm episodes, acute alcohol/drug intoxications, aggressions to caregivers or family members). We used linear, log-linear, logistic and difference-in-differences regression models with propensity scores for the main analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe enrolled 321 patients; 67 were excluded because the treatment period was too short and 17 because they were transferred before the end of the treatment. 237 patients were available for data analysis, 93 in the intervention group and 144 in the control group. No serious adverse event was observed during the treatment period in both groups. Reduction of psychiatric symptoms at discharge (p-value=0.359), readmission rates (p-value=0.563) and length of readmissions (p-value=0.770) during the two-year follow-up period did not differ significantly between the two groups. Treatment duration was significantly higher in the treatment group (+29.6% on average, p-value=0.002)\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe effectiveness of CRHT for the management of acute psychiatric crises was comparable to standard hospitalization. Further research is needed to identify relevant implementation elements, processes, and procedures, and the system level integration and scalability of CRHT in mental health services.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eISRCTN38472626 (17/11/2020, retrospectively registered)\u003c/p\u003e","manuscriptTitle":"Effectiveness of Crisis Resolution Home Treatment for the Management of Acute Psychiatric Crises in Southern Switzerland: A Natural Experiment Based on Geography","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-11-19 16:16:53","doi":"10.21203/rs.3.rs-1064873/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-03-08T22:03:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-12-20T14:29:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39a32743-ef35-4ca8-aaee-a6028aedceaa","date":"2021-12-02T20:40:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cbc24918-f0c2-44ef-a6fa-f1b3e5ac6976","date":"2021-12-01T17:17:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-12-01T13:25:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-12-01T13:18:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-11-18T09:10:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-11-18T09:07:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2021-11-09T15:29:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"08fc5445-c9c7-40c7-9118-22a634399dbd","owner":[],"postedDate":"November 19th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":8622458,"name":"Psychiatry"}],"tags":[],"updatedAt":"2022-05-25T10:14:10+00:00","versionOfRecord":[],"versionCreatedAt":"2021-11-19 16:16:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1064873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1064873","identity":"rs-1064873","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}