Michael A Ruderman1,2, Bo Kim1,2, Kelly Stolzmann1, Samantha Connolly1,2, Christopher J Miller1,2, Mark S Bauer1,2. 1. Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, Massachusetts, United States of America. 2. Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America.
Abstract
BACKGROUND: Health systems are undergoing widespread adoption of the collaborative chronic care model (CCM). Care structured around the CCM may reduce costly psychiatric hospitalizations. Little is known, however, about the time course or heterogeneity of treatment effects (HTE) for CCM on psychiatric hospitalization. RATIONALE: Assessment of CCM implementation support on psychiatric hospitalization might be more efficient if the timing were informed by an expected time course. Further, understanding HTE could help determine who should be referred for intervention. OBJECTIVES: (i) Estimate the trajectory of CCM effect on psychiatric hospitalization rates. (ii) Explore HTE for CCM across demographic and clinical characteristics. METHODS: Data from a stepped wedge CCM implementation trial were reanalyzed using 5 570 patients in CCM treatment and 46 443 patients receiving usual care. Time-to-event data was constructed from routine medical records. Effect trajectory of CCM on psychiatric hospitalization was simulated from an extended Cox model over one year of implementation support. Covariate risk contributions were estimated from subset stratified Cox models without using simulation. Ratios of hazard ratios (RHR) allowed comparison by trial arm for HTE analysis, also without simulation. No standard Cox proportional hazards models were used for either estimating the time-course or heterogeneity of treatment effect. RESULTS: The effect of CCM implementation support increased most rapidly immediately after implementation start and grew more gradually throughout the rest of the study. On the final study day, psychiatric hospitalization rates in the treatment arm were 17% to 49% times lower than controls, with adjustment for all model covariates (HR 0.66; 95% CI 0.51-0.83). Our analysis of HTE favored usual care for those with a history of prior psychiatric hospitalization (RHR 4.92; 95% CI 3.15-7.7) but favored CCM for those with depression (RHR 0.61; 95% CI: 0.41-0.91). Having a single medical diagnosis, compared to having none, favored CCM (RHR 0.52; 95% CI 0.31-0.86). CONCLUSION: Reduction of psychiatric hospitalization is evident immediately after start of CCM implementation support, but assessments may be better timed once the effect size begins to stabilize, which may be as early as six months. HTE findings for CCM can guide future research on utility of CCM in specific populations.
BACKGROUND: Health systems are undergoing widespread adoption of the collaborative chronic care model (CCM). Care structured around the CCM may reduce costly psychiatric hospitalizations. Little is known, however, about the time course or heterogeneity of treatment effects (HTE) for CCM on psychiatric hospitalization. RATIONALE: Assessment of CCM implementation support on psychiatric hospitalization might be more efficient if the timing were informed by an expected time course. Further, understanding HTE could help determine who should be referred for intervention. OBJECTIVES: (i) Estimate the trajectory of CCM effect on psychiatric hospitalization rates. (ii) Explore HTE for CCM across demographic and clinical characteristics. METHODS: Data from a stepped wedge CCM implementation trial were reanalyzed using 5 570 patients in CCM treatment and 46 443 patients receiving usual care. Time-to-event data was constructed from routine medical records. Effect trajectory of CCM on psychiatric hospitalization was simulated from an extended Cox model over one year of implementation support. Covariate risk contributions were estimated from subset stratified Cox models without using simulation. Ratios of hazard ratios (RHR) allowed comparison by trial arm for HTE analysis, also without simulation. No standard Cox proportional hazards models were used for either estimating the time-course or heterogeneity of treatment effect. RESULTS: The effect of CCM implementation support increased most rapidly immediately after implementation start and grew more gradually throughout the rest of the study. On the final study day, psychiatric hospitalization rates in the treatment arm were 17% to 49% times lower than controls, with adjustment for all model covariates (HR 0.66; 95% CI 0.51-0.83). Our analysis of HTE favored usual care for those with a history of prior psychiatric hospitalization (RHR 4.92; 95% CI 3.15-7.7) but favored CCM for those with depression (RHR 0.61; 95% CI: 0.41-0.91). Having a single medical diagnosis, compared to having none, favored CCM (RHR 0.52; 95% CI 0.31-0.86). CONCLUSION: Reduction of psychiatric hospitalization is evident immediately after start of CCM implementation support, but assessments may be better timed once the effect size begins to stabilize, which may be as early as six months. HTE findings for CCM can guide future research on utility of CCM in specific populations.
Authors: Bradley E Belsher; Daniel P Evatt; Xian Liu; Michael C Freed; Charles C Engel; Erin H Beech; Lisa H Jaycox Journal: J Gen Intern Med Date: 2018-04-27 Impact factor: 5.128
Authors: Christopher J Miller; Andrew Grogan-Kaylor; Brian E Perron; Amy M Kilbourne; Emily Woltmann; Mark S Bauer Journal: Med Care Date: 2013-10 Impact factor: 2.983
Authors: Calum Davey; James Hargreaves; Jennifer A Thompson; Andrew J Copas; Emma Beard; James J Lewis; Katherine L Fielding Journal: Trials Date: 2015-08-17 Impact factor: 2.279
Authors: Jo M Longman; Megan E Passey; Dan P Ewald; Elizabeth Rix; Geoffrey G Morgan Journal: BMC Health Serv Res Date: 2015-10-16 Impact factor: 2.655