Assertive community treatment

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					Community Tenure of People With
Serious Mental Illness in Assertive
Community Treatment in Canada
Judith A. Joannette, M.Sc., B.N.Sc.
James S. Lawson, Ph.D.
Shirley J. Eastabrook, Ph.D.
Terry Krupa, Ph.D.




                                                                                           A
Objective: This study followed consumers after admission to an as-                                 ssertive community treatment
sertive community treatment program to determine when the first hos-                               is a community treatment
pital admission was more likely to occur, which variables predicted                                model that was originally de-
community tenure, and, more specifically, whether the availability of                      veloped by Stein and Test (1) as an al-
within-program hospital beds predicted community tenure. Methods:                          ternative to hospitalization. A primary
Data were gathered from three assertive community treatment pro-                           goal of this model is to prevent hospi-
grams in southeastern Ontario—the psychosocial rehabilitation pro-                         talization. The model’s premise is that
gram, the community integration program, and the assertive commu-                          consumers have better outcomes if
nity treatment team program. Only the psychosocial rehabilitation pro-                     they are supported directly in their
gram provided within-program beds. Hospital records of consumers                           community environments. The Min-
who entered a program between July 1, 1990, and December 1, 1999,                          istry of Health and Long-Term Care
were examined prospectively until January 1, 2000, in order to record                      in Ontario, Canada, has identified as-
time to the first admission. Survival analysis based on the life-tables                    sertive community treatment as an
method was used to estimate the probability of remaining out of the                        appropriate treatment model for con-
hospital at 90-day intervals. Factors associated with time to admission                    sumers with serious mental illness,
were identified by using the Cox proportional hazards model. Results:                      particularly those who are heavy users
A total of 333 consumers were followed: 117 consumers in the psy-                          of inpatient services (2), and the min-
chosocial rehabilitation program, 105 in the community integration                         istry has invested in evaluating the
program, and 111 in the assertive community treatment team program.                        outcomes of the dissemination of the
Findings indicated that consumers were most likely to be admitted to a                     model (Krupa T, Eastabrook SJ, Ger-
hospital in the nine months after entering an assertive community                          ber G, unpublished data, 1997).
treatment program. A diagnosis of substance use disorder, higher past                         Several studies of assertive commu-
hospital use, and the availability of within-program beds were associat-                   nity treatment have demonstrated
ed with an increased risk of admission. Conclusions: Studies have                          that the model is effective in reducing
shown that hospitalization remains a reality for many consumers and                        hospitalizations (3). Investigators have
therefore warrants further study. The survival model proved advanta-                       demonstrated a reduction in the hos-
geous by allowing a more complete and comparable description of con-                       pitalization of consumers in assertive
sumers’ hospitalization patterns that cannot be achieved with previ-                       community treatment by using differ-
ously used methods, and it offered the power of regression analysis.                       ent follow-up times. One study may
(Psychiatric Services 56:1387–1393, 2005)                                                  compare the number of admissions in
                                                                                           the six-month period before the con-
                                                                                           sumer starts assertive community
                                                                                           treatment with the six-month period
                                                                                           after entry to the program, and anoth-
Ms. Joannette is affiliated with the department of research and the department of mental
                                                                                           er study may use one-year periods
health services at Providence Continuing Care Centre, 508 Freeman Crescent, Kingston,
Ontario, Canada K7K 7C9 (e-mail, joannetj@pccchealth.org). Dr. Lawson is with the de-      (4,5). Studies that use different time
partment of psychiatry, Dr. Eastabrook is with the School of Nursing, and Dr. Krupa is     frames when reporting changes in ad-
with the School of Rehabilitation Therapy at Queen’s University in Ontario. Preliminary    mission rates are very difficult to com-
results of this study were presented at the Canadian Conference on Nursing Research,       pare (6). In addition, this method does
held June 12 to 15, 2002, in Quebec City and the Canadian Psychiatric Association an-      not consider censored cases—that is,
nual meeting, held November 15 to 19, 2001, in Montreal, Quebec.                           data available from consumers who do
PSYCHIATRIC SERVICES   ♦ http://ps.psychiatryonline.org ♦ November 2005 Vol. 56 No. 11                                        1387
not experience a hospitalization.          presented here is a small substudy            es that target adults with severe and
Therefore, rather than using a statisti-   that explored community tenure by             persistent mental illness; are driven
cal method that relies on counting         using a survival model and the influ-         by consumer needs; are provided to
events that may be infrequent, such as     ence of within-program beds as a              consumers directly; are ongoing and
hospitalization, this study examined       variation of the assertive community          unlimited in duration; have staff with
community tenure—more specifical-          treatment model.                              small, fixed caseloads; are provided in
ly, the time frames in which hospital                                                    the consumer’s own environment;
admissions were most likely to oc-         Participants                                  and are provided 24 hours per day by
cur—by using a survival model.             Participants were adults who entered          a multidisciplinary team. All three
   A second issue is that, in the con-     one of the three assertive community          programs studied followed these
text of dissemination, there have been     treatment programs in southeastern            guidelines to a certain extent with key
variations in the implementation of        Ontario from July 1, 1990, to Decem-          variations among them.
the assertive community treatment          ber 1, 1999. Participants were fol-              The three assertive community
model. These variations have raised        lowed prospectively to January 1,             treatment programs—the psychosocial
concerns about their possible differ-      2000, in order to record any hospital         rehabilitation program, the community
ential effects on desired outcomes         admissions. In accordance with the            integration program, and the assertive
(7–9). One clearly identifiable varia-     provincial guidelines for receipt of as-      community treatment team pro-
tion in a local assertive community                                                      gram—were governed by two provin-
treatment program is the availability                                                    cial psychiatric hospitals in Ontario. In
of within-program hospital beds. Al-                                                     October 1998 the degree of variation of
though this variation is meant to en-                                                    the three assertive community treat-
hance continuity of care, its impact on                                                  ment programs from the original Stein
the model’s goal of community tenure                     Studies                         and Test model (1) was assessed with
is unknown.                                                                              the Index of Fidelity of Assertive Com-
   This paper reports on a longitudi-                 of assertive                       munity Treatment (IFACT) (9). Possi-
nal observational study that con-                                                        ble scores on the index range from 0 to
tributes to the knowledge base of as-          community treatment                       14, with higher scores indicating
sertive community treatment by in-                                                       greater program fidelity to the original
vestigating the following research             that use different time                   model. A lack of dedicated staff posi-
questions: Within what periods are                                                       tions for vocational and substance use
admissions more likely to occur? And          frames when reporting                      specialists and higher caseload num-
what variables predict community                                                         bers lowered the IFACT scores across
tenure; more specifically, does the            changes in admission                      all three programs. A summary of each
availability of within-program beds                                                      program follows.
predict community tenure?                            rates are very                         The psychosocial rehabilitation pro-
                                                                                         gram was established in 1993. The pro-
Methods                                                difficult to                      gram was associated with a 20-bed in-
Research design                                                                          patient unit where its office was locat-
This study examined existing data                       compare.                         ed. A distinguishing feature of this pro-
from hospital records by using a ret-                                                    gram and the one primarily account-
rospective longitudinal observational                                                    able for the IFACT score of 12.5 was
design. To maximize the usefulness of                                                    the availability of six hospital beds for
this design, a survival model was used                                                   consumers who lived in the communi-
to increase comparability among fu-        sertive community treatment servic-           ty and might require hospitalization.
ture studies, to allow for censored        es, participants had been given a di-            Created in 1991, the community
cases, and to control for observed dif-    agnosis of a significantly serious and        integration program was governed by
ferences among programs in the ab-         persistent mental illness that resulted       the same provincial psychiatric hospi-
sence of random assignment. The de-        in impaired functioning in activities         tal, but its office was located off-site.
pendent variable for the survival          of daily living and had continuous            Consumers who required admission
model was community tenure, or             high service needs (2). The research          to the hospital were usually admitted
time to hospital admission.                ethics board of Queen’s University            through the psychiatric hospital’s
  This study was part of a larger four-    approved this study.                          acute admission unit. The IFACT
year prospective study designed to ex-                                                   score for this program was 11.
amine the relationship between key         Setting                                          The assertive community treat-
elements of assertive community            The components identified by Stein            ment team program was established
treatment teams and various out-           and Test (1) are the basis for the            in 1990 by a second provincial psychi-
comes and to examine consumers’ ex-        guidelines that are currently used in         atric hospital. The program office was
perience of the services provided          the development of assertive commu-           located in a separate building at the
(Krupa T, Eastabrook SJ, Gerber G,         nity treatment programs in Ontario            psychiatric hospital. At the time of
unpublished data, 1997). The study         (2). These guidelines describe servic-        data collection, caseload numbers for
1388                                        PSYCHIATRIC SERVICES   ♦ http://ps.psychiatryonline.org ♦ November 2005 Vol. 56 No. 11
Table 1
Sample characteristics of 333 consumers of assertive community treatment in Ontario

                                    Assertive
                                    community             Psychosocial          Community
                                    treatment team        rehabilitation        integration
                                    program               program               program             Total
                                    (N=111)               (N=117)               (N=105)             (N=333)
                                                                                                                         Test
Variable                            N               %     N                %    N             %     N             %      statistic     df       p

Demographic
characteristics
  Male sex                           56             50            76       65           69    66           201    60      χ2=6.847          2 <.05
  Marital status
    Without partner                 96              86           103       88           87    83           286    86                                ns
    Unknown                           1              1             4        3            1     1             6     2                                ns
  Educationa
    Elementary                      12              11          12         10           7      7          31       9                           ns
    Secondary                       76              68          64         55         64      61         204      61                           ns
    Postsecondary                   16              14          29         25         27      26          72      22                           ns
    Unknown                           7              6          12         10           7      7          26       8                           ns
  Age (mean±SD years)b        41.7±10.5                   42.3±11.9             38.1±11.2           40.8±11.3              F=4.661     2,330 <.05
Psychiatric and
hospital use variables
  Diagnosis
    Schizophrenia                    67             60            90       77           64    61           221    66      χ2=9.014          2 <.05
    Affective psychosis              13             12             7        6           15    14            35    11            ns
    Personality disorder             10              9             2        2            4     4            16     5      χ2=6.968          2 <.05
    Substance use disorder            4              4             0        0            4     4             8     2            ns
    Organic brain disorder            1              1             4        3            1     1             6     2            ns
    Other                            16             14            14       12           17    16            47    14            ns
  Number of
    admissions (mean±SD)c,d     2.3±2.5                       1.3±1.3               1.1±1.5             1.6±1.9          F=13.627      2,330 <.01
  Number of days
    in a hospital (mean±SD)c,e 162±233                     295±330                  96±133           188±262             F=18.439      2,330 <.01
a   Achieved at least some education at this level
b   At entry into the program
c   In the three years before entering the assertive community treatment program
d   Number of admissions ranged from 0 to 11 for the assertive community treatment team program, 0 to 5 for the psychosocial rehabilitation program, 0
    to 8 for the community integration program, and 0 to 11 for all three programs.
e   Number of days hospitalized ranged from 0 to 1,095 for the assertive community treatment team program, 0 to 1,095 for the psychosocial rehabilita-
    tion program, 0 to 531 for the community integration program, and 0 to 1,095 for all three programs.



the service were affected by service                 sample with diagnoses that are not                  (10). Significance for all procedures
restructuring and rural service de-                  generally considered to be the target               was determined at the .05 probability
mands. The IFACT score for this pro-                 of assertive community treatment.                   level (two-tailed test).
gram was 10.5.                                       Hospitalization history was recorded                   The characteristics of the partici-
                                                     as the number of days in a hospital and             pants from three assertive community
Measures                                             the number of admissions to a hospital              treatment programs were compared by
Demographic and hospitalization data                 in the three years before program en-               using analysis of variance or chi square
were obtained from the clinical                      try (indirect measures of severity of ill-          analysis when appropriate. Survival
records departments of the provincial                ness). Program-related variables were               analysis that was based on the life-ta-
psychiatric hospitals. Demographic                   the age of the assertive community                  bles method was used to estimate the
data comprised age, sex, education                   treatment program at program entry                  probability of remaining out of a hospi-
level, marital status, and primary diag-             and whether or not there were within-               tal at 90-day intervals (11). A modified
nosis. Primary diagnoses were broadly                program beds available. Time to ad-                 Weibull curve was computed for the
categorized as schizophrenia psy-                    mission was defined as the number of                survival function (12,13). Survival
chosis, affective psychosis, personality             days elapsed from entry into assertive              curves were compared by using the
disorder, substance use disorder, or or-             community treatment until the first                 Wilcoxon test, which yields a test statis-
ganic brain disorder. Although only                  psychiatric hospitalization.                        tic that is distributed as a chi square
the primary diagnosis was considered                                                                     value when the null hypothesis of
for this study, participants often had               Statistical analysis                                equivalent survival experience is true.
several diagnoses. This finding may ex-              Statistical analyses were performed                    Last, the Cox proportional hazards
plain the presence of persons in this                with SPSS Advanced Models 10.0                      model, a regression model for analyz-
PSYCHIATRIC SERVICES     ♦ http://ps.psychiatryonline.org ♦ November 2005 Vol. 56 No. 11                                                        1389
Figure 1                                                                                                                                ing survival data, was used to describe
Weibull estimate of the survival experience of 333 consumers of assertive com-                                                          the relationship of selected consumer
munity treatment programs in Ontarioa                                                                                                   and program variables to time to ad-
                                                                                                                                        mission after adjustment for appro-
                                              100
                                                                                                                                        priate covariates (11). Forward step-
                                                                                                                                        wise selection of variables was used.
                                                                                                                                        The criterion for entry into the mod-
                                                                                                                                        el was p<.05, and for removal it was
                                                             80                                                                         p>.10. All variables were assessed to
Percentage not admitted (f[t])




                                                                                                                                        determine whether they met the pro-
                                                                                                                                        portional hazards assumption. None
                                                             60                                                                         of the variables significantly violated
                                                                                                                                        this assumption.

                                                                                                                                        Results
                                                             40
                                                                                                                                        Characteristics of the sample
                                                                                                                                        A total of 333 consumers were fol-
                                                                                                                                        lowed: 117 consumers in the psy-
                                                             20                                                                         chosocial rehabilitation program, 105
                                                                                                                                        in the community integration pro-
                                                                                                                                        gram, and 111 in the assertive com-
                                                              0                                                                         munity treatment team program. The
                                                                        1,000         2,000              3,000                4,000     characteristics of the sample are
                                                                                  Time in days (t)
                                                                                                                                        shown in Table 1. Where statistically
                                                                                                                                        significant overall differences were
a                f(t)=(1–α)exp(–[ρt]κ)+α; α=.013, ρ=.0010, κ=.59                                                                        found among the participants of the
                                                                                                                                        assertive community treatment pro-
                                                                                                                                        grams, breakdown analyses were
                                                                                                                                        computed to determine the source of
                                                                                                                                        the differences; these differences
                                                                                                                                        were statistically controlled for in the
                                                                                                                                        Cox regression analysis.
                                                                                                                                           Compared with the assertive com-
Figure 2
                                                                                                                                        munity treatment team program, the
                                                                                                                                        psychosocial rehabilitation program
Weibull estimates of the survival experience of 333 consumers of assertive com-                                                         and the community integration pro-
munity treatment programs in Ontario, with beds (N=117) and without beds                                                                gram had a greater proportion of
(N=216)a                                                                                                                                males. Most participants in the
                                                                  100                                                                   groups were middle aged, although
                                                                                                                                        participants in the community inte-
                                                                                                        No beds                         gration program were younger than
                                                                   80
                                                                                                        Beds                            participants in the other two pro-
                            Percentage not admitted (f[t])




                                                                                                                                        grams. Most participants did not have
                                                                                                                                        a partner, and more than half of them
                                                                                                                                        had received at least some secondary
                                                                   60
                                                                                                                                        education. More than 60 percent of
                                                                                                                                        the participants had a diagnosis of
                                                                                                                                        schizophrenia, and differences in the
                                                                   40                                                                   distribution of diagnoses existed
                                                                                                                                        among the programs. The average
                                                                                                                                        participant had less than two hospital
                                                                   20                                                                   admissions to a hospital and had
                                                                                                                                        spent about six months in a hospital in
                                                                                                                                        the three years before entering an as-
                                                                    0                                                                   sertive community treatment pro-
                                                                          1,000        2,000            3,000                4,000      gram. In these three years, partici-
                                                                                                                                        pants of the assertive community
                                                                                    Time in days (t)
                                                                                                                                        treatment team program were admit-
a                f(t)=(1–α)exp(–[ρt]κ)+α; α=.14 (no beds) and .032 (beds) (t=–19.95, df=1, p=.001); ρ=.00074 (no                        ted to a hospital more frequently than
                 beds) and .0013 (beds) (ns); κ=.63 (no beds) and .56 (beds) (ns)                                                       participants of the other two pro-
1390                                                                                     PSYCHIATRIC SERVICES     ♦ http://ps.psychiatryonline.org ♦ November 2005 Vol. 56 No. 11
grams. Compared with participants in           Table 2
the assertive community treatment              Summary of the final Cox regression model using forward stepwise selection of co-
team program and the community in-             variates predicting time to admission for three assertive community treatment
tegration program, those in the psy-           programs in Ontario
chosocial rehabilitation program
spent a greater number of days in a            Variable                           β           SE           Exp(β)     95% CI
hospital during the three years before
                                               Block 1
entering a program.                              Number of admissionsa       .144∗∗∗      .034     1.155         1.081–1.233
                                                 Number of hospital daysa .81×10–3∗∗ 2.70×10–4 1.81×10–3 1.29×10–3–1.81×10–3
Admission to a hospital                          Substance use disorderb      1.010∗      .424     2.747         1.198–6.300
A total of 185 participants (56 per-           Block 2c
cent) experienced a hospitalization              Within-program bedsb         .529∗∗      .166     1.697         1.226–2.349
before the end of the observation pe-          a In the three years before entry into assertive community treatment
riod, and 148 (44 percent) were cen-           b For coding for categorical variables (1=presence, 0=absence)
sored (that is, admission had not oc-          c Forced into the model last
                                               ∗p<.05
curred by the end of the study peri-           ∗∗p<.01
od). The participants were monitored           ∗∗∗p<.001
for an admission from one month to
nine years (mean±SD=4.2±2.7 years).
   The modified Weibull estimate of
the overall survival for the 333 partic-       pants who had not been hospitalized                 able. The hazard ratio is an estimate of
ipants of the three assertive commu-           (α parameter). Median length of                     the effect, direct or indirect, of the
nity treatment programs is shown in            community tenure for the partici-                   variable. Therefore, the results
Figure 1, in which the asymptote pa-           pants of the assertive community                    showed a 15.5 percent increase in risk
rameter α reflects the proportion who          treatment program with beds was                     of admission for each hospital admis-
would never be admitted and the rate           368 days, and it was 1,002 days for                 sion in the three years before entry
parameter ρ, as modulated by κ, re-            the assertive community treatment                   into an assertive community treat-
flects the rate of admission.                  programs without beds. Overall, par-                ment program. Also seen was a .1 per-
   The median length of community              ticipants in a program that did not                 cent increase in the risk associated
tenure for this sample was 784 days.           have beds available had a statistically             with each additional day spent in a
The survival curve shows a rapid drop          better chance of not being hospital-                hospital in the three years before as-
in the cumulative survival probability         ized (Wilcoxon matched pairs,                       sertive community treatment. Partici-
during the first three intervals (270          χ2=12.4, df=1, p<.001).                             pants with a diagnosis of substance
days), indicating that the greatest                                                                use disorder were 2.8 times as likely as
likelihood of admission to a hospital          Factors predicting                                  those without such a diagnosis to be
occurred in these nine months. Fol-            time to admission                                   admitted to a hospital. Participants in
lowing this drop, the proportion who           Finally, a Cox regression analysis                  an assertive community treatment
had not been hospitalized begins to            was performed to determine the de-                  program with beds were 1.7 times as
level off at about 25 percent.                 gree of association of selected con-                likely as those in a program without
   Comparison of the three programs            sumer and program variables with                    beds to be admitted to a hospital.
revealed a statistically significant dif-      time to admission. The aim of this
ference in length of community                 analysis was to examine the effect of               Discussion
tenure between the program with                available beds while controlling for                Hospital admission
beds and each of the two programs              possible confounding variables—                     Although assertive community treat-
without beds available. Therefore,             that is, participant characteristics.               ment programs have proven effective
the three assertive community treat-           The statistics for the final Cox mod-               in decreasing hospitalization of con-
ment programs were reconfigured                el are shown in Table 2.                            sumers, no evaluation studies that
into two groups—those with and                    Neither age at program entry nor a               used survival analysis to examine hos-
those without available beds—and               diagnosis of schizophrenia, affective               pitalization of consumers in assertive
their survival distributions were com-         psychosis, personality disorder, or or-             community treatment programs were
pared. The modified Weibull esti-              ganic brain disorder was a significant              found in the literature. The most per-
mate of survival for the assertive com-        predictor of time to admission. The                 tinent study is by Setze and Bond (14),
munity treatment program with avail-           variables selected for the final model              which used survival analysis to evalu-
able beds and those without beds is            were the number of admissions and                   ate a psychiatric rehabilitation pro-
shown in Figure 2.                             the number of days in a hospital in the             gram. Setze and Bond’s study demon-
   Comparison of the parameters of             three years before assertive communi-               strates a key advantage to using sur-
the Weibull model indicated that in            ty treatment, a diagnosis of substance              vival analysis: the comparability
the long term the group that did not           use disorder, and the availability of               among studies. These authors showed
have access to within-program beds             within-program beds. The index                      that participants in the psychiatric re-
had a greater proportion of partici-           exp(β) is the hazard ratio for the vari-            habilitation program had a 46 percent
PSYCHIATRIC SERVICES   ♦ http://ps.psychiatryonline.org ♦ November 2005 Vol. 56 No. 11                                                1391
chance of experiencing at least one       tal in the period before assertive               This study showed that the avail-
hospital admission after one year in      community treatment tended to be              ability of within-program beds con-
the program (14). Their finding was       hospitalized earlier. Indeed, some            tinued to be a predictor of admission
similar to the findings reported here:    consumers had been hospitalized for           to a hospital after other covariates,
the sample of consumers of the as-        the entire three years before entering        such as consumer characteristics,
sertive community treatment pro-          an assertive community treatment              were controlled for. For the pro-
grams had a 41 percent probability of     program. Generally, studies of as-            grams studied here, this modifica-
at least one hospital admission in the    sertive community treatment have              tion to services appeared to influ-
year after entry into an assertive com-   not taken account of the previous             ence the dynamics of service deliv-
munity treatment program (Figure 1).      number of days of hospitalization in          ery. Although there will be instances
  Data showed that after seven years      relation to return to a hospital. Given       when admission to a hospital is
approximately 25 percent of the con-      that time in a hospital can be consid-        preferable to treatment in the com-
sumers did not experience a hospital      ered an indirect measure of severity          munity, some investigators have
admission (Figure 1). However, care       of illness, future studies of assertive       speculated that hospital admission
should be taken in interpreting the       community treatment that examine              may result simply because there are
end of the survival curve (15). Never-    the effect of hospitalization history         hospital beds available (8,19).
theless, the overall trend shows that     should examine not only the previous             Other factors that may be related to
the risk of admission decreased over      number of hospitalizations but also           admission were not considered in this
time, indicating that the longer con-     the previous number of days in a hos-         study. For example, poor medication
sumers were able to stay out of a hos-    pital. Ideally, studies would include a       compliance has been shown to be re-
pital, the more likely they were to re-   direct measure of severity of illness,        lated to hospital admission (20,21),
main out. Therefore, consumers who        such as a psychiatric symptom rating          but these data were unavailable for
do not experience an admission in the     scale. A rating scale that examines           this study.
long term may be a special subgroup       specific categories of psychiatric
that warrants specific investigation. A   functioning, such as the Brief Psychi-        Conclusions
major goal of assertive community         atric Rating Scale (16), may be more          Studies have shown that although as-
treatment programs is to care for con-    appropriate than global ratings of            sertive community treatment can re-
sumers in the community, and this         functioning, which have failed in the         duce hospital admissions, hospitaliza-
study reflects progress toward achiev-    past to reliably predict readmission          tion remains a reality for many con-
ing that goal.                            to hospital (17).                             sumers and therefore warrants fur-
                                             In this study substance use disorder       ther study. A key finding of this study
Factors predicting                        was the only diagnostic category that         is that consumers are at highest risk of
time to admission                         predicted an increased risk of hospital       admission in the nine months after
Differences among programs that           admission. This finding supports that         entering an assertive community
previous research suggested might be      of Carpenter and colleagues (18), who         treatment program. This finding was
confounding were statistically con-       found that abuse of drugs or alcohol          elucidated by using a survival model
trolled for in this study through the     was related to multiple hospital ad-          that allowed a more complete and
use of Cox regression. However, sta-      missions. In the study presented here,        comparable description of con-
tistical control cannot substitute for    a diagnosis of substance use disorder         sumers’ hospitalization patterns that
random assignment, which was not          was included only if it was recorded as       could not be achieved with previously
possible in this study. Therefore, this   the consumer’s primary diagnosis.             used methods.
study provides only a preliminary un-     Nevertheless, many consumers may                 This study found that a diagnosis of
derstanding of factors affecting time     have problems with substance abuse            substance use disorder, higher past
to admission for this sample. Never-      that are considered secondary to an-          hospital use, and access to within-
theless, the study presented here pro-    other diagnosis. It is therefore possi-       program hospital beds put consumers
vides valuable pointers for future        ble that the effect of substance use          at greater risk of hospital admission.
studies that examine the effects of       disorder was underestimated in the            Although the findings reported here
program and consumer characteris-         study presented here. Future studies          cannot be generalized without the
tics on admission to a hospital.          may consider the effect of a secondary        use of a randomized experimental de-
   The results showed that a higher       diagnosis of substance use disorder           sign, the study generated both con-
number of hospital admissions in          and include a greater number of par-          sumer and program factors that
the three years before assertive          ticipants with this diagnosis. Such a         should be considered for future stud-
community treatment was associat-         study would elucidate the role of sub-        ies of consumers’ community tenure.
ed with an increase in risk of hospi-     stance use disorder in the hospitaliza-       Again, the survival model proved ad-
tal admission. The cycle of hospital      tion of assertive community treatment         vantageous for this part of the study.
admission and readmission has been        consumers. The results of the study           Cox regression embodies the power
well established, and this finding        presented here lend support to the            of regression analysis applied to sur-
was therefore expected.                   evaluation of integrating substance           vival data. Knowledge gained from
   Similarly, consumers in this study     abuse treatment into assertive com-           this and future studies may help avoid
who had spent more time in a hospi-       munity treatment programs.                    unnecessary admissions and will have
1392                                       PSYCHIATRIC SERVICES   ♦ http://ps.psychiatryonline.org ♦ November 2005 Vol. 56 No. 11
                                                       and Community Psychiatry 36:993–995,            14. Setze P, Bond G: Psychiatric recidivism in a
clear implications for the future plan-                1985                                                psychosocial rehabilitation setting: a sur-
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