***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Intensive case management is commonly advocated for the care of the severely mentally ill , but evidence of its cost-effectiveness is lacking . AIMS To investigate the cost-effectiveness of intensive compared with st and ard case management for patients with severe psychosis . METHOD 708 patients with psychosis and a history of repeated hospital admissions were r and omly allocated to st and ard ( case-loads 30 - 35 ) or intensive ( case-loads 10 - 15 ) case management . Clinical and re source use data were assessed over two years . RESULTS No statistically significant difference was found between intensive and st and ard case management in the total two-year costs of care per patient ( means 24,550 Pounds and 22,700 Pounds , respectively , difference 1850 Pounds , 95 % CI--1600 Pounds to 5300 Pounds ) . There was no evidence of differential effects in African-Caribbean patients or in the most disabled .  Psychiatric in-patient hospital stay accounted for 47 % of the total costs , but neither such hospitalisation nor other clinical outcomes differed between the r and omised groups . CONCLUSION Reduced case-loads have no clear beneficial effect on costs , clinical outcome or cost-effectiveness . The policy of advocating intensive case management for patients with severe psychosis is not supported by these results Objective : To compare the clinical outcome and costs of care of psychiatric patients  allocated to community multidisciplinary teams or to hospital based care programmes  after discharge from inpatient care . Design : R and omised controlled trial . Setting : Inner London ( Paddington and North Kensington ) and outer London ( Brent ) psychiatric services . Subjects : 155 patients with severe mental illness with a previous admission within the past 2 years . Main outcome measures : Ratings of clinical psychopathology , depression , anxiety , and social functioning ; comprehensive costs of health care . Results : Clinical outcomes were available for 133 patients and  cost data for 144 patients after 1 year . The clinical outcomes of the two models of care were essentially similar , but admission to hospital was more likely in the hospital based care group and the costs of health care were 14 % greater per patient than in the community group . This difference , however , was dwarfed by a twofold difference in the costs of care in the outer London services compared with those in inner London . This was explained largely by greater inpatient care for outer London patients ( 58 median bed days v 18 for inner London patients ) , more of which was provided by extracontractual referrals to other psychiatric hospitals as Brent had only 0.28/1000 beds available for acute adult patients compared with 0.82/1000 in Paddington and North Kensington over the period of the study . Conclusion : Aftercare by community teams for psychiatric patients with severe mental illness has a similar outcome to hospital based aftercare but with fewer admissions to hospital . When psychiatric bed requirements are insufficient for a population , however , neither form of aftercare is effective as greater use of hospital beds elsewhere swamps any advantage of community care programmes , with disintegration and discontinuity of psychiatric services leading to escalating costs . Key messages Community psychiatric care has generally been shown to require fewer beds than more hospital focused care Clinical outcomes in psychiatric patients with recurrent psychotic illness r and omised to community focused or hospital focused care after discharge from hospital and followed up for 1 year were similar Costs were lower for patients in the community group , which had fewer admissions to hospital Costs were twice as high in one of the areas covered by the study , mainly because of the insufficient number of beds in the area , with great reliance on psychiatric beds outside the catchment area When the number of psychiatric beds in an area becomes too low there is no advantage in providing better community care because the impact of this is swamped by the disintegrating effects of inpatient care outside the catchment Background : This paper presents the quality of life ( QOL ) outcome results from the UK700 r and omised controlled trial of case management . Method : A total of 708 patients with severe mental illness were r and omly assigned to intensive and st and ard forms of case management  in four sites in the UK .  QOL was assessed using the Lancashire Quality of Life Profile , which provides a self-reported objective and subjective appraisal of eight life domains ( finances , work , leisure , family , social relations , living situation , safety and health ) . The outcome after 2 years was examined using univariate and multivariate analyses . Results : Significant improvements in QOL over the 2 years were observed . The QOL outcome did not differ significantly by case management treatment conditions or by diagnosis . A better outcome was associated with improvements in depression and with the location ( site ) of treatment . In one site there were significant improvements in all eight domains and overall QOL , with moderate or better effect sizes ( > 0.4 ) in three domains and overall QOL . Conclusions : Depression should be assessed when subjective QOL measures are used . Better means for describing service organisations and the context /place in which they operate should be developed in order to explain more of the variance in QOL outcomes BACKGROUND Part of the  community psychiatric nurse ( CPN )  service was reorganised into a community support team ( CST ) , with staff acting as case managers . An economic evaluation ran parallel to the comparison with generic CPN care . METHOD Eighty-two clients were r and omly allocated to  experimental and control groups .  Costs were comprehensively measured over a pre-referral period ( three months ) , and then at 6 , 12 , and 18 months . RESULTS The economic evaluation found a cost difference between the groups . Generic group costs averaged 89 pounds per patient per week more than CST group costs . The difference was only significant for the first six months . Changes in the burden of cost across agencies were observed . CONCLUSIONS Although CPN inputs and costs were higher for the CST group , there was a significant short-term reduction in total cost . Beyond the short term , the CST did not confer cost or cost-effectiveness advantages BACKGROUND In Italy , Residential Facilities ( RFs ) have completely replaced Mental Hospitals ( MHs ) for the residential care of mentally ill patients . We studied all patients resident in 265 r and omly sample d Italian RFs ( 20 % of the total ) . METHOD Structured interviews focusing on each patient were conducted by trained research assistants with the manager and staff of each RF . Patients were rated with the HoNOS and the GAF , and comprehensive information about their sociodemographic and clinical status and care history were gathered . RESULTS Of the 2962 patients living in the sample d facilities , most were males ( 63.2 % ) who had never married , more than 70 % were over 40 years ; 85 % on a pension , most commonly because of psychiatric disability . A substantial proportion ( 39.8 % ) had never worked and very few were currently employed ( 2.5 % ) ; 45 % of the sample was totally inactive , not even assisting with domestic activities in the facility . Two-thirds had a diagnosis of schizophrenia ; co-morbid or primary substance abuse were uncommon . Twenty-one per cent had a history of severe interpersonal violence , but violent episodes in the RFs were infrequent . The managers judged almost three-quarters appropriately placed in their facilities and considered that very few had short-term prospect s of discharge . CONCLUSIONS Italian RFs cater for a large patient population of severely mentally ill requiring residential care . Discharge to independent accommodation is uncommon . Future studies should attempt to clarify how to match residential programmes with patients ' disabilities BACKGROUND The Daily Living Programme ( DLP ) offered intensive home-based care with problem-centred case management for seriously mentally ill people facing crisis admission to the Maudsley Hospital , London . The cost-effectiveness of the DLP was examined over four years . METHOD A r and omised controlled study examined cost-effectiveness of DLP versus st and ard in/out-patient hospital care over 20 months , followed by a r and omised controlled withdrawal of half the  DLP patients into st and ard care . Three patient groups were compared over 45 months : DLP throughout the period , DLP for 20 months followed by st and ard care , and st and ard care throughout . Bivariate and multivariate analyses were conducted ( the latter to st and ardise for possible inter- sample differences stemming from sample attrition and to explore sources of within- sample variation ) . RESULTS The DLP was more cost-effective than control care over months 1 - 20 , and also over the full 45-month period , but the difference between groups may have disappeared by the end of month 45 . CONCLUSIONS The reduction of the cost-effectiveness advantage for home-based care was perhaps partly due to the attenuation of DLP care , although sample attrition left some comparisons under-powered BACKGROUND A controlled study tested whether the superior outcome of community care for serious mental illness ( SMI ) in Madison and in Sydney would also be found in inner London . METHOD Patients from an inner London catchment area who faced emergency admission for SMI ( many were violent or suicidal ) were r and omised to 20 months or more of either home-based care ( Daily Living Programme , DLP ; n = 92 ) , or st and ard in-patient and later out-patient care ( controls , n = 97 ) . Most DLP patients had brief in-patient stays  at some time . Measures included number and duration of in-patient admissions , independent ratings of clinical and social function , and patients ' and relatives ' satisfaction . RESULTS Outcome was superior with home-based care . Until month 20 , DLP care improved symptoms and social adjustment slightly more , and enhanced patients ' and relatives ' satisfaction . From 3 to 18 months DLP care greatly reduced the number of in-patient bed days as long as the DLP team was responsible for any in-patient phase its patients had . Cost was less . DLP care did not reduce the number of admissions , nor of deaths from self-harm ( 3 DLP , 2 control ) . One DLP patient killed a child . Even at 20 months many DLP and control patients still had severe symptoms , poor social adjustment , no job , and need for assertive follow-up and heavy staff input . ( Beyond 20 months most gains were lost apart from satisfaction . ) CONCLUSIONS It is unclear how much the gain until 20 months from home-based care was due to its site of care , its being problem-centred , its teaching of daily living skills , its assertive follow-up , the home care team 's keeping responsibility for any in-patient phase , its coordination of total care ( case management ) , or to other care components . Home-based care is hard to organise and vulnerable to many factors , and needs careful training and clinical audit if gains are to be sustained Treatment records of 94 patients treated in an experimental home-based psychiatric service and 78 control patients in st and ard care were collected over one year . There was a substantial reduction in in-patient care in the experimental group , both in terms of proportion admitted and duration of admissions , despite similar out-patient and general practice care . The total treatment costs were significantly larger ( > 50 % ) for st and ard care when controlled for by diagnostic grouping . Costs were further examined by including all specialist psychiatric care , and by excluding patients with primary diagnoses of brain damage or alcoholism . Sensitivity analysis explored the effects of increasing the cost of home visits . The relative cost effectiveness of the experimental service persisted . Clinical and social outcome was similar in control and experimental groups BACKGROUND This study evaluated whether a community psychiatric nurse ( CPN ) team providing a comprehensive aftercare service , using a case management approach , improves psychopathology and social functioning of the long-term mentally ill , and reduces hospital use compared with a generic CPN team . METHOD Patients suffering from severe and persistent mental health problems were r and omised to  intensive aftercare or generic care after referral to the CPN manager .  Each group contained 41 patients who were assessed at baseline and at 6 , 12 and 18 months by an independent research psychologist . Outcome measures included the GAS , PSE , SAS , patient and relatives ' satisfaction , number of admissions , and length of stay . RESULTS No difference between the groups was found on any of the outcome measures , despite the much higher number of contacts of the intensive ( n = 52 ) versus generic CPNs ( n = 13 ) and the much greater range of interventions . CONCLUSIONS Intensive aftercare for people with persistent mental health problems was not found to be of greater benefit than generic CPN care . Many factors need to be considered for aftercare to be effective , including community re sources , process of care , and staff training BACKGROUND The Daily Living Programme ( DLP ) offered problem-oriented , home-based care for people aged 17 - 64 with severe mental illness facing emergency admission to the Bethlem-Maudsley Hospital . The multidisciplinary DLP team acted as direct provider and link with other services . Each patient had a key worker . Cost-effectiveness was assessed . METHOD The comprehensive costs of DLP and st and ard in-patient care were compared within a r and omised controlled trial . Cost measures ranged over all service inputs and living expenses . The costs of informal care and lost employment were also considered . Assessment s of service use , costs and outcomes were conducted at referral , 4 , 11 and 20 months . RESULTS The DLP was significantly less costly than st and ard treatment in both short and medium term ( P = 0.000 ) . Cost savings accrued almost exclusively to the NHS , with no other agency 's costs being higher . CONCLUSIONS Coupled with mildly encouraging outcome results over the 20 month period , the DLP was clearly cost-effective in this medium term BACKGROUND There has been a widespread development of community multi-disciplinary teams aim ed to deliver coordinated comprehensive mental health care , yet there is little published evidence on the quality of care and economics of providing such care for people with severe mental illness . METHOD This is a clustered r and omized controlled economic comparison of the quality of care for patients with chronic schizophrenia by a multi-dis 
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Community-based models of care are not inherently more costly than institutions , once account is taken of individuals ' needs and the quality of care .
New community-based care arrangements could be more expensive than long-stay hospital care but may still be seen as more cost-effective because , when properly set up and managed , they deliver better outcomes .