Shared decision-making and evidence-based practice: a commentary.
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Cooperative Behavior↗
Biomedical subjects
Ellen P Fischer
Publications and source records attributed to Ellen P Fischer.
The Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ): an instrument to assess outcomes of schizophrenia care.
Advances in treatment technologies and development of evidence-based standards of care demand better methods for routine assessment of outcomes for schizophrenia in systems of care. This article describes the development and psychometrics of a new instrument to assess outcomes of routine care for persons with schizophrenia in service systems. Candidate items for the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ) were drawn from existing measures. Domains covered include disease outcomes (symptoms, subjective medication effects, substance abuse), functional status, health status, quality of life, and public safety. A sample of 1,584 patients with schizophrenia or schizoaffective disorder who were recruited into a large prospective, naturalistic study on the course of treatment for schizophrenia completed the SCAP-HQ at baseline and 1 year later (n = 434), providing data for factor analysis, assessment of internal consistency, convergent validity, and responsiveness to change. A subsample of 121 patients completed a test-retest protocol. Fifteen scales were derived by factor analysis from 55 outcome items on the SCAP-HQ. These factors covered psychiatric symptoms, life satisfaction, instrumental activities of daily living, health-related disability, subjective medication side effects, vitality, legal problems, social relations, mental health-related disability, suicidality, drug and alcohol use, daily activities, victimization, violence, and employment. For most scales, standard psychometric parameters, including internal consistency and test-retest reliability, convergent validity, and responsiveness to change, were acceptable for application to large sample evaluations of care systems. This new measure represents an advance in the development of outcome measures for schizophrenia for use in large-scale studies of routine care.
Activities of Daily Living↗
Using an explicit guideline-based criterion and implicit review to assess antipsychotic dosing performance for schizophrenia.
OBJECTIVE: Using structured implicit review as the gold standard, this study assessed the sensitivity and specificity of an explicit antipsychotic dose criterion derived from schizophrenia guidelines. DESIGN: Two psychiatrists reviewed medical records and made consensus-structured implicit review ratings of the appropriateness of discharge antipsychotic dosages for hospitalized patients who participated in a schizophrenia outcomes study. Structured implicit review ratings were compared with the explicit criterion: whether antipsychotic dose was within the guideline-recommended range of 300-1000 chlorpromazine milligram equivalents (CPZE). In addition, reasons for deviation from guideline dose recommendations were examined. SETTING AND STUDY PARTICIPANTS: A total of 66 patients hospitalized for acute schizophrenia at a Veterans Affairs medical center or state hospital in the southeastern US. MAIN OUTCOME MEASURES: The sensitivity and specificity of the explicit dose criterion at hospital discharge were determined in comparison with the gold standard of structured implicit review. RESULTS: At hospital discharge, 61% of patients (n = 40) were receiving doses within the guideline-recommended range. According to structured implicit review ratings, antipsychotic dose management was appropriate for 80% (n = 53) of patients. When the 300-1000 CPZE dose criterion (dosage within or outside the recommended range) was compared with structured implicit review, it demonstrated 84.6% sensitivity and 71.7% specificity for detecting inappropriate antipsychotic dose. CONCLUSIONS: The explicit antipsychotic dose criterion may provide a useful and efficient screen to identify patients at significant risk for quality of care problems; however, the relatively low specificity suggests that the measure may not be appropriate for quality measurement programs that compare performance among health plans.
Adult↗
Priorities of consumers, providers, and family members in the treatment of schizophrenia.
OBJECTIVE: This study explored the extent and nature of agreement on outcome and service priorities between consumers, their providers, and their family members as well as providers' and family members' awareness of consumers' priorities. METHODS: Interviews were conducted with members of 60 stakeholder sets that included a person with schizophrenia, one of his or her mental health care providers, and one of his or her family members. Each member of the set ranked seven outcomes and nine services in order of importance and rated the relative importance of each. Family members and providers also ranked the outcomes and services in the order in which they believed the consumer would rank them. Magnitude-estimation-preference-weight ratios and Kendall's rank-order correlation were used to evaluate pairwise (consumer and provider, consumer and family member, and family member and provider) and within-set agreement. RESULTS: Pairwise and within-set agreement was low. In general, no more than a third of the pairs agreed on outcome priorities, and no more than half agreed on service priorities. In about half of the 60 sets, none of the three pairs agreed on outcome priorities. Awareness of consumers' priorities was limited. Family members' and providers' estimates of consumers' outcome priorities were more similar to their own preferences than to consumers'. Low rates of agreement were also noted for providers' estimates of consumers' service priorities. Within-set agreement was lower than agreement by type of stakeholder. CONCLUSIONS: Current goal-setting in nonresearch clinical settings is generating neither consensus nor a shared understanding of consumers' priorities. Priorities vary widely among consumers, among providers, and among family members.
Adult↗
Clinical practice variations in prescribing antipsychotics for patients with schizophrenia.
Few studies have examined the variations among individual physicians in prescribing antipsychotics for schizophrenia. This study examined clinical practice variations in the route and dosage of antipsychotic medication prescribed for inpatients with schizophrenia by 11 different psychiatrists. The sample consisted of 130 patients with a DSM-III-R diagnosis of schizophrenia who had received inpatient care at a state hospital or Veterans Affairs medical center in the southeastern United States in 1992-1993. Mixed-effects regression models were developed to explore the influence of individual physicians and hospitals on route of antipsychotic administration (oral or depot) and daily antipsychotic dose, controlling for patient case-mix variables (age, race, sex, duration of illness, symptom severity, and substance-abuse diagnosis). The average daily antipsychotic dose was 1092 +/- 892 chlorpromazine mg equivalents. Almost half of the patients (48%) were prescribed doses above or below the range recommended by current practice guidelines. The proportion of patients prescribed depot antipsychotics was significantly different at the 2 hospitals, as was the antipsychotic dose prescribed at discharge. Individual physicians and patient characteristics were not significantly associated with prescribing practices. These data, which were obtained before clinical practice guidelines were widely disseminated, provide a benchmark against which to examine more current practice variations in antipsychotic prescribing. The results raise several questions about deviations from practice guidelines in the pharmacological treatment of schizophrenia. To adequately assess quality and inform and possibly further develop clinical practice guideline recommendations for schizophrenia, well-designed research studies conducted in routine clinical settings are needed.
Adult↗