The effects of community treatment orders (CTOs) on readmission to hospital using electronic health records

Background: Community treatment orders (CTOs) are used to manage community-based care for individuals with severe mental health conditions who have been discharged from inpatient care. Evidence examining whether CTOs are successful at reducing rehospitalisation has been mixed. Methods: Using deidentified electronic health records from 2009-21, we compared patients who had ever been placed on a CTO (n=836) and two other groups of patients who had never been placed on CTO: patients admitted under Section 3 of the Mental Health Act (n=1,182) and outpatients with severe mental health issues (n=7,651). We examined the association between CTOs and rehospitalisation using within-individual stratified multivariable Cox regression. Results: Patients on CTO were more likely to be male, single, of Black or Mixed ethnicity, and have a severe mental illness diagnosis than patients in the comparison groups. Time spent on CTO was associated with a lower risk of hospitalisation compared to time spent off CTO for the same individual (HR 0.60; 95% CI 0.56-0.64). This decreased risk of hospitalisation remained when we restricted analysis to individuals with a single CTO episode (HR 0.05; 95% CI 0.02-0.11) and when we restricted follow-up time to a patient's first CTO episode (HR 0.20; 95% CI 0.17-0.25). However, there was no difference in re-hospitalisations when we observed patients starting from the first CTO (HR 1.07; 95% CI 1.00-1.16). Conclusions: We found that patients on CTO were at lower risk of hospitalisation, though this pattern was not observed when we excluded time prior to the first CTO. Further research should consider whether CTOs provide genuine clinical benefit. Keywords: community treatment orders, compulsory community treatment, hospitalisation rates, within individual analysis, electronic health records, clinical informatics ### Competing Interest Statement JCY, JHT, NWB, DK, DM, and DPJO have no conflicts to disclose. JFH has received consultancy fees from Wellcome Trust and juli Health. ### Funding Statement This work was supported by the Medical Research Council (MR/W014386/1). David P.J. Osborn is also supported by the University College London Hospitals NIHR Biomedical Research Centre and the NIHR North Thames Applied Research Collaboration. Joseph F. Hayes is supported by UKRI grant MR/V023373/1, the University College London Hospitals NIHR Biomedical Research Centre and the NIHR North Thames Applied Research Collaboration. The funder had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for use of the C&I CRIS database was obtained from the East of England - Cambridge Central Research Ethics Committee (19/EE/0210) and the project was approved by the C&I Research Oversight Committee. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study are available to approved researchers through Camden & Islington NHS Foundation Trust. The data are not publicly available due to restrictions on data access by the Data Controller in the interest of patient confidentiality.