Analyzing the duration of recurrent events in clinical trials: A comparison of approaches using data from the UK700 trial of psychiatric case management

In studies of chronic disease the outcome measure may be based upon the duration of recurring illness. Our example is the UK700 trial of psychiatric case management, where the total number of days spent in hospital over a 2-year follow-up was the primary outcome. Investigations of treatment effect modifiers were undertaken using an analysis of that primary outcome, a comparison of length of hospitalizations, and also a multi-state modeling approach. The days in hospital outcome was relatively straightforward to analyze, and allowed the complete randomized treatment groups to be compared. In contrast, the comparison of length of hospitalizations included only hospitalized patients, with censored observations not being well accommodated. The multi-state model provided separate treatment effect estimates for admission and discharge, this being more informative about how any reduction in days spent in hospital is achieved. Estimation of the treatment effects through the use of proportional hazards regression allowed appropriate incorporation of censored observations. However, with the multi-state model approach treatment effect estimates are not based upon comparisons of complete randomized treatment groups, as individuals are removed from the risk set for admission whilst at risk for discharge, and vice versa. We conclude that total duration is an appropriate primary outcome for clinical trials, but that multi-state models deserve greater use as an informative secondary analysis.