Latimer E A
Douglas Hospital Research Centre, Verdun, Quebec.
Can J Psychiatry. 1999 Jun;44(5):443-54. doi: 10.1177/070674379904400504.
Assertive community treatment (ACT) is an extensively studied and widely imitated community support treatment model for severely mentally ill individuals. Several previous reviews have documented its favourable effects on clients and their families. This is the first review to focus on economic outcomes.
Nineteen randomized studies and 15 nonrandomized studies describing ACT programs were identified based on 2 criteria: 1) provision of services primarily in the community and 2) shared caseloads. Percentage reduction in hospital days was calculated for the 34 study sites where reported data allowed it. Multiple-regression methods were used to relate reduction in hospital days to program fidelity and other contextual factors. The impacts of ACT on emergency-room use, use of outpatient services, housing, costs, and other economic outcomes were also examined.
Higher-fidelity programs appear to reduce hospital days by about 23 percentage points more than lower-fidelity programs (95% CI = -41.2, -5.2). The estimated regression coefficients imply that a high-fidelity program reduces hospitalizations by about 58% over 1 year if the alternative involves some type of case management and by 78% if it does not. ACT appears to increase the proportion of clients who live in independent housing situations, but the effect on use of supervised housing, and therefore on housing costs, is ambiguous. The effects on use of most other resources are inconsistent across studies. Overall, ACT appears to result in somewhat lower costs, whatever the perspective of analysis adopted.
The most reliable cost offset to ACT treatment costs appears to be reduced hospital use. Using Quebec costs, an ACT program must enroll people with prior hospital use of about 50 days yearly, on average, to break even. As care systems evolve to reduce their reliance on hospitalization as a care modality with or without ACT, this threshold will become increasingly difficult to achieve. The primary justification for implementing ACT services will then become their clinical benefits.
积极社区治疗（ACT）是一种针对严重精神疾病患者进行了广泛研究且被广泛模仿的社区支持治疗模式。此前的多项综述记录了其对患者及其家庭的有益影响。这是首次聚焦于经济结果的综述。
基于两个标准确定了19项描述ACT项目的随机研究和15项非随机研究：1）主要在社区提供服务；2）共享病例量。在有报告数据的34个研究地点计算了住院天数的减少百分比。使用多元回归方法将住院天数的减少与项目保真度及其他背景因素相关联。还研究了ACT对急诊室使用、门诊服务使用、住房、成本及其他经济结果的影响。
高保真度项目似乎比低保真度项目多减少约23个百分点的住院天数（95%置信区间 = -41.2，-5.2）。估计的回归系数表明，如果替代方案涉及某种类型的病例管理，高保真度项目在1年内可使住院率降低约58%；如果不涉及，则降低78%。ACT似乎会增加居住在独立住房中的患者比例，但对使用受监管住房的影响以及因此对住房成本的影响尚不明确。不同研究对大多数其他资源使用的影响不一致。总体而言，无论采用何种分析视角，ACT似乎都会导致成本有所降低。
ACT治疗成本最可靠的成本抵消似乎是减少住院使用。以魁北克的成本计算，一个ACT项目平均每年必须招收之前住院天数约为50天的患者才能实现收支平衡。随着医疗系统不断发展以减少对住院作为一种治疗方式的依赖（无论是否有ACT），这一门槛将越来越难以达到。届时，实施ACT服务的主要理由将变为其临床益处。
