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

Abstract

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

Personal continuity versus specialisation of care approaches in mental healthcare: experiences of patients and clinicians—results of the qualitative study in five European countries

“…Our qualitative study is of unique value by complementing the quantitative exploration where no significant differences between PCC and SC were found in terms of patient outcomes over a 1-year period [12]. It identifies and highlights substantial differences in terms of perceived advantages and shortcomings of both approaches.…”

“…Advantages as much as disadvantages of both approaches may balance or counterweight each other resulting in similar primary outcomes in the quantitative follow-up, as specific aspects of care may have different relevance in specific contexts and logistic and organisational considerations may favour one approach over the other. Therefore, even though there appears to be no quantitative differences in primary outcomes between personal continuity and specialisation of care [12], the issue remains important for many clinicians and patients and influences their experiences.…”

“…The COFI project was a prospective, multi-country natural experiment conducted in 57 hospitals involving over seven thousands of patients using specialisation and personal continuity of care. Its quantitative results showed no difference between specialisation and personal continuity care approaches in rehospitalisation rates, number of inpatient bed days, untoward events and social functioning in the total sample [12]. Therefore, a complementary qualitative approach was crucial to increase our general understanding of both approaches in mental health care.…”

Continuity of care and a functionally split system of care

“…Similarly, Sanatinia et al (2016) found that frequent staff changes resulted in reduced patient satisfaction with care and a reduced quality of care provided. Conversely, Giacco et al (2018) found that there was no difference in patient outcomes over a period of 1 year between those treated under a specialization or COC system. Thus, they concluded that rather than focusing on the model in which care is provided; a greater focus needs to be placed upon the quality of the therapeutic relationships.…”

Laying new foundations for 21st century community mental health services: An Australian perspective

“…Giacco et al . () when comparing 1‐year clinical outcomes of the integrated and functional models in routine care across five European countries found no substantial impact on patient outcomes. However, Bird et al .…”