Investigating the use and impact of community Care (Education) and Treatment Reviews (C(E)TRs) in people with intellectual disability and autistic people: protocol for a cohort study using electronic health records

Introduction

Care (Education) and Treatment Reviews (C(E)TRs) are intended to reduce unnecessary psychiatric hospital admission and length of stay for people with intellectual disability and autistic people. The use and impact of C(E)TRs has not been systematically evaluated since their introduction in England in 2015. The aims of this study are to describe the demographic and clinical profiles of people who receive a community C(E)TR and to investigate their effects on admission, length of hospital stay, and clinical and functional change.

Methods and analysis

We will conduct a retrospective cohort study using de-identified data from electronic health records derived from two large National Health Service mental health providers in London, England, including one replication site. Data will be extracted using the Clinical Record Interactive Search (CRIS) tool for all people with recorded intellectual disability and/or autism who received mental healthcare from 2015. We will identify community C(E)TR events using keyword searches. Community C(E)TRs will be examined in two ways: 1) in a community cohort, we will capture data in the 6-month periods before and after a community C(E)TR and compare this to a matched control group, and 2) in a hospital cohort, we will compare groups who did and did not receive a community C(E)TR prior to their admission. We will describe the socio-demographic and clinical profiles of each group and their health service use and compare C(E)TR and no C(E)TR groups using t-tests (or a non-parametric equivalent). The primary outcomes are admission to psychiatric hospital (community cohort) and length of psychiatric hospital admission and clinical change (hospital cohort), which will be estimated using propensity score weighting and difference-in-differences methods for psychiatric hospitalization, and Cox’s proportional hazard model for length of hospital admission, and repeated-measures ANOVA for clinical change.

Ethics and dissemination

Use of CRIS to examine de-identified clinical data for research purposes has overarching ethical approval. This study has been granted local approval by the South London and Maudsley CRIS Oversight Committee. Findings will be disseminated in an open access peer-reviewed academic publication, at conference presentations, and to service users and carers in accessible formats.

Strengths and limitations of this study

• This study will provide a much-needed evidence base to guide the provision of community C(E)TRs their effectiveness in the care pathway of people with intellectual disability and autistic people.

• Routinely collected health data represent real-world clinical practice and enable us to generate a relatively large cohort not biased by participant selection.

• The study will be undertaken in a large NHS Trust with a diverse catchment area. We will replicate the study in a second NHS Trust to provide evidence for the generalizability of the initial findings across a different population.

• The number of people in the dataset who have received a community C(E)TRs is unknown; if there are relatively few events, our dataset may be under-powered to demonstrate differences between those who do and do not receive the intervention (type 2 error).

• Electronic health record data are generated as part of routine clinical practice. There may be a high level of missing data which could limit our analysis.