Effect of Scattered-Site Housing Using Rent Supplements and Intensive Case Management on Housing Stability Among Homeless Adults With Mental Illness: A Randomized Trial

May combine two claims.

A statistically significant treatment × time interaction was observed in community functioning at 18 months: compared with usual care, the intervention group showed a statistically significant improvement in the difference in mean change relative to baseline (1.16 [95% CI, 0.08 to 2.24]), but this improvement was not sustained at 24 months (1.06 [95% CI, -0.004 to 2.13]).

“A statistically significant treatment × time interaction was also observed in community functioning at 18 months: compared with the usual care group, the intervention group showed a statistically significant improvement in the difference in mean change relative to baseline values (1.16 [95% CI, 0.08 to 2.24]), but the improvement was not sustained at 24 months (1.06 [95% CI, -0.004 to 2.13]).”

• AssumptionRests on an assumption: The missing data are missing at random, so that multiple imputation yields valid results.

The quote only partly states this claim.

Between baseline and 24 months, the mean EQ-5D score change did not differ statistically between the intervention and usual care groups (difference in mean changes, 0.10 [95% CI, -2.92 to 3.13], P=.95).

“The mean change in EQ-5D score from baseline to 24 months among the intervention group was not statistically different from the usual care group”

Probably not a substantial claim: may not pass S3 (load-bearing).

Nearly three-quarters of the sample (72.4%) were not hospitalized during the study period.

“Nearly three-quarters of our sample (72.4%) were not hospitalized during the study period.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Among the randomized participants, 52 (4.3%) were veterans.

“Of this number, 52 participants (4.3%) were veterans.”

May combine two claims.

The proportion of participants reporting at least one hospitalization during the 24-month follow-up was 28.9% in the intervention group and 25.6% in the usual care group, a difference of 3.30 (95% CI, -1.90% to 8.51%) (P = .22).

“The proportion of participants reporting at least 1 hospitalization during the 24-month follow-up was 28.9% for the intervention group and 25.6% for the usual care group, which corresponds to a difference of 3.30 (95% CI, -1.90% to 8.51%) (P = .22).”

• AssumptionRests on an assumption: The missing data are missing at random, so that multiple imputation yields valid results.

Classified as probably not a substantial claim.

A total of 1198 individuals with moderate needs were randomized to either the intervention or usual care group.

“A total of 1198 individuals with moderate needs were randomized to the intervention group or the usual care group.”

May combine two claims.

The adjusted mean difference in percentage of days stably housed between the intervention and usual care groups varied significantly across the four sites (P < .01 for interaction), with site-specific differences of 33.0% (Site A), 49.5% (Site B), 35.6% (Site C), and 45.3% (Site D).

“although adjusted mean differences varied across the 4 sites (Site A, 33.0% [95% CI, 26.2% to 39.8%]; Site B, 49.5% [95% CI, 41.1% to 58.0%]; Site C, 35.6% [95% CI, 29.4% to 41.8%]; and Site D, 45.3% [95% CI, 38.2% to 52.5%]; P < .01 for interaction)”

May combine two claims.

The intervention group had a higher adjusted percentage of days stably housed than the usual care group, but adjusted mean differences varied by site.

“During the 24 months after randomization, the adjusted percentage of days stably housed was higher among the intervention group than the usual care group, although adjusted mean differences varied across sites.”

May combine two claims.

The most important cost offsets came from reduced use of emergency shelters and single-room occupancy with support, while costs of office visits with other nonstudy medical (physicians) and clinical community (e.g., social workers and nurses) providers increased.

“The most important cost offsets emerged from reduced use of emergency shelters and single-room occupancy with support, whereas the costs of office visits with other nonstudy medical (physicians) and clinical community (eg, social workers and nurses) providers rose.”

• AssumptionRests on an assumption: Participants' self-reported service use and income data are accurate.

May combine two claims.

The intervention resulted in an average net cost offset of CaD $4,849 per participant per year, or 34% of the cost of the intervention.

“resulted in an average net cost offset of CaD $4849 per participant per year, or 34% of the cost of the intervention.”

• AssumptionRests on an assumption: Participants' self-reported service use and income data are accurate.

May combine two claims.

Our study participants had lower levels of hospitalizations at baseline than the previous study and clients typically served by ACT teams.

“unlike this former study and clients typically served by ACT teams, our study participants had lower levels of hospitalizations at baseline”

May combine two claims.

At 24 months, treatment effects on generic quality of life varied by site, with a statistically significant effect only at Site D.

“Specifically, at 24 months, treatment effects varied by site: (Site A, 0.72 [95% CI, -0.91 to 2.36], P = .39;Site B, -0.56 [95% CI, -2.67 to 1.54], P = .60;Site C, -0.29 [95% CI, -1.80 to 1.22], P = .71;Site D, 2.64 [95% CI, 0.93 to 4.34], P = .003).”

May combine two claims.

At study end, gains in the total quality-of-life score and in the leisure, living situation, and safety subscales continued to be significant among the intervention group compared with the usual care group.

“In particular, at study end, gains in the total quality-of-life score, as well as the subscales pertaining to leisure, living situation, and safety continued to be significant among the intervention group compared with the usual care group.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In our sample served by ICM services, 22% had psychosis and 62% had a diagnosis or history of alcohol or substance use disorders.

“compared with 22% of participants with psychosis and 62% of participants with a diagnosis or history of alcohol or substance use disorders among our sample served by ICM services.c”

May combine two claims.

Unlike the HUD-VASH study, which focused exclusively on homeless veterans, only 4% of our participants were veterans, all met criteria for a diagnosis of severe mental illness (vs 45% in the previous study), and a third (33%) were women (vs 4% in the former study).

“However, unlike this latter study, which focused exclusively on homeless veterans, only 4% of our participants were veterans, all met criteria for a diagnosis of severe mental illness (vs 45% in the previous study) and a third of the participants (33%) were women (vs 4% in former study).”

May combine two claims.

The safety subscale of condition-specific quality of life showed significant improvement at 6, 12, and 24 months, but not at 18 months.

“Safety | 1.93 (1.12 to 2.75) | <.001 1.14 (0.28 to 1.99) | .009 0.74 (-0.08 to 1.55) | .08 | 1.11 (0.27 to 1.96) | .01”

May combine two claims.

Additional site variation was observed in hospitalization outcomes and the family subdomain of the condition-specific quality-of-life instrument.

“Additional site variation was observed in hospitalization outcomes and the family subdomain of the condition-specific quality-of-life instrument.”

• Also stated in: § Discussion · plain

  “treatment × site interaction (P value for interaction = .03).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Each site's Intensive Case Management teams were trained and had fidelity checks to confirm they followed the program's principles.

“Intensive Case Management teams at each site received training and underwent fidelity assessments to ensure adherence to program principles.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Allocation used adaptive methods, was run automatically by the central data system, and kept the allocation algorithm hidden from researchers and participants.

“Randomization, using adaptive techniques, was automated by the central data collection system with concealment of the allocation algorithm from researchers and participants.”

Classified as probably not a substantial claim.

All analyses were performed on an intention-to-treat basis.

“All analyses were performed on an intentionto-treat basis.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Based on interviewer assessment of no confidence in participant responses, data were considered missing and imputed for 55 interviews across the five time points.

“In addition, data were considered missing and imputed for 55 interviews across the 5 time points based on an assessment by interviewers of no confidence in participant responses.”

May combine two claims.

For homeless populations, the Residential Time-Line Follow-Back Inventory has been shown to have strong test-retest reliability and good concurrent validity.

“The Residential Time-Line Follow-Back Inventory has high test-retest reliability and good concurrent validity in homeless populations.25”

• cites [25]Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The trial was unblinded.

“This unblinded randomized trial was conducted in 5 Canadian cities”

Probably not a substantial claim: may not pass S3 (load-bearing).

The Multnomah Community Ability Scale measures how well adults with serious mental illness function in the community.

“the Multnomah Community Ability Scale (MCAS), 16 which assesses community functioning in adults with serious mental illness.”

• cites [16]Not checked yet

  Not checked in the free run.

May combine two claims.

In three study cities, minor site-specific adaptations to ICM met program fidelity standards at each of two fidelity visits, so all ICM study groups at each site were included in the analysis.

“These minor adaptations met program fidelity standards at each of 2 fidelity visits 24 and, therefore, all ICM study groups at each site have been included in this analysis.”

Probably not a substantial claim: may not pass S3 (load-bearing).

For deceased participants, imputed data were used up to the date of death.

“Imputed data for deceased participants were used up to the date of their death.”

May combine two claims.

A previously published trial of scattered-site housing and intensive case management for homeless veterans with mental illness and/or substance use problems found that the intervention group spent 66% of days housed and the standard care group 53% of days housed in the past 90 days, with a common standard deviation of 26%, yielding an effect size of d = 0.5.

“Such magnitude of effect size is consistent with that observed in a previously published study, 12 which reported that homeless veterans with mental illness or substance use problems or both participating in a trial of scattered-site housing and ICM services spent an average of 66% of days housed in the intervention group and 53% of days housed in the standard care group in the past 90 days, with”

• cites [12]Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Four participants from each group withdrew from the study.

“Four participants from each group withdrew from the study.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Prior to assignment, participants were divided into high-needs and moderate-needs groups according to their clinical and service-use profiles.

“Before randomization to the intervention or usual care groups, participants were stratified based on their clinical and service use profiles into high needs and moderate needs groups.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Mental illness was evaluated using the Mini International Neuropsychiatric Interview (MINI).

“presence of a mental illness, with or without a concurrent substance use disorder, as evaluated using the Mini International Neuropsychiatric Interview (MINI).15”

• cites [15]Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Secondary and all exploratory outcomes, except the PCS and MCS of the SF-12 survey, were imputed using sequential regression multivariate imputation.

“Secondary and all exploratory outcomes (except for PCS and MCS of the SF-12 survey) were imputed using the sequential regression multivariate imputation approach.”

Classified as probably not a substantial claim. May combine two claims.

Interviews were completed with 1104 participants (92.2%) at 12 months and 1016 participants (84.8%) at 24 months.

“Interviews were completed with 1104 participants (92.2%) at 12 months and 1016 participants (84.8%) at 24 months.”

Probably not a substantial claim: may not pass S3 (load-bearing).

During follow-up, there were 47 known deaths: 25 (3.6%) in the intervention group and 22 (4.3%) in the usual care group.

“There were 47 known deaths (25 participants [3.6%] in the intervention group and 22 participants [4.3%] in the usual care group) during the follow-up period.”

Probably not a substantial claim: may not pass S3 (load-bearing).

No adjustments for multiple comparisons were applied.

“No adjustments for multiple comparisons were applied.”

The quote only partly states this claim.

Among homeless adults with mental illness and moderate support needs in four Canadian cities, scattered-site housing with rent supplements plus intensive case management, versus usual community housing and support services, increased housing stability over 24 months.

“Among homeless adults with mental illness in 4 Canadian cities, scattered site housing with ICM services compared with usual access to existing housing and community services resulted in increased housing stability over 24 months”

May combine two claims.

For the primary outcomes of percentage of days stably housed and number of days hospitalized, data were missing for only 48 participants (4.0%), so no imputation was performed for these outcomes.

“Data on percentage of days stably housed and number of days hospitalized were missing for only 48 participants (4.0%); thus, no imputation was necessary for these outcomes.”

Probably not a substantial claim: may not pass S3 (load-bearing).

All participating institutions' research ethics boards approved the study protocol.

“The study protocol has been described previously and was approved by the research ethics board at all participating institutions”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Outcomes were assessed up to 24 months, and it is possible that longer periods are required for the full beneficial effects to manifest.

“Outcomes were assessed up to 24 months; it is possible that longer periods are required for the full beneficial effects to manifest.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Another single-site randomized trial from New York City examining the effectiveness of a scattered-site supportive housing program with ACT found that intervention participants were more likely to be housed.

“Another single-site randomized trial from New York City examining the effectiveness of a scattered-site supportive hous-ing program with ACT found that intervention participants were more likely to be housed,”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The funder had no role in the analysis and interpretation of the data or in the preparation, review, or approval of the manuscript.

“However, the funder had no role in the analysis and interpretation of the data and preparation, review, or approval of the manuscript.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Although all study cities had excellent fidelity to the program model, some heterogeneity in the intervention between sites cannot be discounted.

“Although all study cities had excellent fidelity to the program model, we cannot discount that some heterogeneity in the intervention existed between sites.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Site differences may have arisen from variation in program fidelity across sites and resource availability in the respective communities, including differences in available affordable housing units and the existing basket of mental health and other support services.

“These site differences may have arisen from variation in program fidelity across sites and resource availability in the respective communities, including site differences in available affordable housing units and the existing basket of mental health and other support services.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Researchers and participants were not blinded to treatment assignment because the nature of the intervention prohibited blinding.

“Researchers and participants were not blinded to treatment assignment; the nature of the intervention prohibiting blinding.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

It is possible that the benefits observed may be short-lived.

“It is also possible that the benefits observed may be short-lived.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A recent observational study found significant improvements in satisfaction with living situation, frequency of contact with others, and adequacy of monthly income among participants who spent 1 year in a permanent supportive housing program.

“Furthermore, a recent observational study noted significant improvements in satisfaction with their living situation, frequency of contact with others, and adequacy of monthly income among participants who spent 1 year in a permanent supportive housing program, 39”

• cites [39]Not checked yet

  Not checked in the free run.

May combine two claims.

A previous single-site randomized trial by HUD-VASH concluded that the combination of rent supplements and ICM services led to greater housing stability and increased social networks for homeless veterans with a psychiatric or substance use disorder compared with standard care or ICM services alone, at modest cost.

“Similar to this study, a previous single-site randomized trial by the US Departments of Housing and Urban Development and Veteran Affairs Supportive Housing (HUD-VASH) concluded that the combination of rent supplements and ICM services led to greater housing stability and in- creased social networks for homeless veterans with a psychiatric or substance use disorder when compared with standard care”

• cites [12]Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The secondary and exploratory outcomes should be considered hypothesis generating because they were not adjusted for multiple comparisons.

“The secondary and exploratory outcomes should be considered hypothesis generating, because they were not adjusted for multiple comparisons.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The current study was conducted in a country with a system of universal health insurance, so the findings may differ from those in a jurisdiction without such coverage.

“Furthermore, the current study was conducted in a country with a system of universal health insurance, and thus our findings may be different from those that might be observed in a jurisdiction without such coverage.”