Ellen P Fischer

University of California, Los Angeles, Los Angeles, California, United States

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Publications (24)38.63 Total impact

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    ABSTRACT: Objective. A substantial gap exists between patients and their mental health providers about patient's perceived barriers, facilitators, and motivators (BFMs) for taking antipsychotic medications. This article describes how we used an intervention mapping (IM) framework coupled with qualitative and quantitative item-selection methods to develop an intervention to bridge this gap with the goal of improving antipsychotic medication adherence. Methods. IM is a stepwise method for developing and implementing health interventions. A previous study conducted in-depth qualitative interviews with patients diagnosed with schizophrenia and identified 477 BFMs associated with antipsychotic medication adherence. This article reports the results of using a variety of qualitative and quantitative item reduction and intervention development methods to transform the qualitative BFM data into a viable checklist and intervention. Results. The final BFM checklist included 76 items (28 barriers, 30 facilitators, and 18 motivators). An electronic and hard copy of the adherence progress note included a summary of current adherence, top three patient-identified barriers and top three facilitators and motivators, clarifying questions, and actionable adherence tips to address barriers during a typical clinical encounter. Discussion. The IM approach supplemented with qualitative and quantitative methods provided a useful framework for developing a practical and potentially sustainable antipsychotic medication adherence intervention. A similar approach to intervention development may be useful in other clinical situations where a substantial gap exists between patients and providers regarding medication adherence or other health behaviors.
    Health Education &amp Behavior 12/2013; · 1.54 Impact Factor
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    ABSTRACT: More than 240 000 women in the United States die of coronary heart disease annually. Identifying women's symptoms that predict a coronary heart disease event such as myocardial infarction (MI) could decrease mortality. For this longitudinal observational study, we recruited 1097 women, who were either clinician referred or self-referred to a cardiologist and undergoing initial evaluation by a cardiologist, to assess the utility of the prodromal symptoms (PS) section of the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) in predicting the occurrence of cardiac events in women. Seventy-seven women experienced events (angioplasty, stent placement, coronary artery bypass, MI, death) during the 2-year follow up. The most common events were stents alone (38.9%) or in combination with angioplasty (18.2%). Ten women had MIs; 4 experienced cardiac death. Cox proportional hazards was used to model time to event. The prodromal score was significantly associated with risk of an event (hazard ratio, 1.10; 95% confidence interval, 1.06-1.13), as was the number of PSs endorsed by each woman per visit. After covariate adjustment, 5 symptoms were significantly associated with increased risk: discomfort in jaws/teeth, unusual fatigue, arm discomfort, shortness of breath, and general chest discomfort (hazard ratio, 3.97; 95% confidence interval, 2.32-6.78). Women reporting 1 or more of these symptoms were 4 times as likely to experience a cardiac event as women with none. Both the MAPMISS PS scores and number of PS were significantly associated with cardiac events, independent of risk factors, suggesting that there are specific PSs that can be easily assessed using the MAPMISS. This instrument could be an important component of a predictive screen to assist clinicians in deciding the course of management for women.
    The Journal of cardiovascular nursing 11/2013; · 1.47 Impact Factor
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    ABSTRACT: BACKGROUND: Coronary heart disease (CHD) mortality rates are higher among women, particularly black, than men. Women's mortality rates may reflect difficulty in recognizing CHD prodromal symptoms (PS) but reliable screening instruments for women are scarce. The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (MAPMISS) captures women's PS presentation, but has limited testing among black women. AIM: To assess the test-retest reliability of the MAPMISS PS section for black and white women. METHODS: The sample was recruited from women enrolled in a longitudinal study examining the predictive validity of the MAPMISS. The MAPMISS was re-administered to 42 women (22 white, 20 black) 3-5 days after baseline assessment. RESULTS: Women endorsed an average of 7.5 PS (SD 4.8; range 0-20) initially and 7.6 (SD 4.7; range 0-20) at retest. Over half of the women (54.8%) of both races endorsed the same number of PS at test and retest; for 69%, the number endorsed at both testings differed by no more than one. Percentage agreement and kappa statistics on the number ofPS endorsed were excellent overall and by race. PS test and retest scores, reflecting PS intensity and frequency, were highly correlated overall (r = 0.92, p < 0.001) and separately for white (r = 0.93, p < 0.001) and black women (r = 0.91, p < 0.001). Racial differences were insignificant. CONCLUSIONS: Findings indicate (i) the MAPMISS PS score has excellent test-retest reliability (r = 0.92) when administered to women without a history of CHD, and (ii) test-retest reliability is as strong for black (r = 0.91) as for white women (r = 0.93).
    European Journal of Cardiovascular Nursing 10/2012; · 2.04 Impact Factor
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    ABSTRACT: In schizophrenia, treatments that improve outcomes have not been reliably disseminated. A major barrier to improving care has been a lack of routinely collected outcomes data that identify patients who are failing to improve or not receiving effective treatments. To support high quality care, the VA Mental Health QUERI used literature review, expert interviews, and a national panel process to increase consensus regarding outcomes monitoring instruments and strategies that support quality improvement. There was very good consensus in the domains of psychotic symptoms, side-effects, drugs and alcohol, depression, caregivers, vocational functioning, and community tenure. There are validated instruments and assessment strategies that are feasible for quality improvement in routine practice.
    Community Mental Health Journal 04/2011; 47(2):123-35. · 1.03 Impact Factor
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    ABSTRACT: The aim of this study was to describe the rates of enrollment in tobacco dependence treatment among smoking adults who accepted a fax referral from health care providers at a children's hospital, and to examine smoker characteristics associated with enrollment. Secondary analysis of the state-sponsored fax referral and treatment program data on all referrals from Arkansas Children's Hospital in 2005 to 2007 was conducted. Enrollment was defined as attendance at 1 or more counseling sessions within 1 year of referral. Logistic regression analyses were used to identify demographic and tobacco-related characteristics associated with enrollment versus nonenrollment in a treatment program among those contacted by the program. Of the 749 faxed referrals to the program, 157 (21.0%) enrolled in a treatment program and received 1 or more treatment sessions; 505 were contacted by the program, and of these, 147 (29%) enrolled. Women were more likely to enroll than men (odds ratio [OR] 1.81; 95% confidence interval [95% CI], 1.09-3.01). Whites were twice as likely to enroll than African Americans (OR 2.35; 95% CI, 1.28-4.33). Older age (OR 1.04; 95% CI, 1.01-1.06) and higher self-efficacy scores (OR 1.13; 95% CI, 1.02-1.26) increased the likelihood of enrollment. Approximately 1 in 5 smokers who accepted a fax referral enrolled in and received intensive treatment services for tobacco dependence. Thus, innovative approaches are needed to increase enrollment among younger, African American, and male smokers.
    Academic pediatrics 01/2010; 10(3):200-4.
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    ABSTRACT: High recruitment and retention rates are hallmarks of scientifically rigorous longitudinal research. However, recruitment and retention are challenging, especially with older adults and minorities. In this article, we discuss strategies that have enabled us to retain more than 80% of both Black and White women in a 5-year observational study. To overcome challenges such as staff turnover and introduction of computerized record systems, we developed a time-saving handout, streamlined procedures for documenting contact information, and motivated site staff through weekly personal contact. We responded to problems with mailed privacy consent forms by garnering approval for verbal consent that allowed immediate response to participants' questions. In addition to standard steps to minimize attrition, we encouraged ongoing participation with personal letters following interviews, "refrigerator reminders" of the next interview date, and "missing you" letters following missed appointments. We believe these and other strategies described in this article were responsible for our high retention rate.
    Research in Gerontological Nursing 10/2009; 2(4):256-64. · 0.66 Impact Factor
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    ABSTRACT: This observational study assessed the influence of family support and substance abuse on patterns of service use by individuals with schizophrenia. Polychotomous logistic regression was used to analyze an existing database for 258 individuals with schizophrenia who were between the ages of 18 and 67 and were recruited from public mental health care settings. Analyses determined the extent to which two consumer-identified factors, family support and substance abuse status, influenced patterns of outpatient service use (regular, irregular, and infrequent) for schizophrenia. After the analysis adjusted for insight into illness, cognitive functioning, rural or urban residence, and gender, comorbid substance abuse and the interaction between substance abuse status and family support were significantly associated with patterns of service use. Comorbid substance abuse predicted irregular or infrequent patterns of service use over time. Stratified analyses indicated that weekly family support substantially reduced the adverse impact of substance abuse status on consumers' patterns of service use, especially for those living in rural areas. This study provides evidence that ongoing family support is associated with substantial reductions in the adverse impact of substance abuse on consumers' patterns of service use, especially for consumers living in rural areas. If confirmed in other populations, study findings suggest that reinforcing services and support for family members who provide informal care helps to sustain involvement in care by the especially vulnerable population of individuals with a dual diagnosis of schizophrenia and substance abuse.
    Psychiatric services (Washington, D.C.) 09/2008; 59(8):902-8. · 2.81 Impact Factor
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    ABSTRACT: Inconsistent service use for schizophrenia and bipolar disorder is associated with poorer outcomes of care. We analyzed VHA National Psychosis Registry data for 164,150 veterans with these disorders to identify characteristics associated with 5-year patterns of survival and with retention in VHA care. Most cohort members (63%) survived the period with no break in VHA healthcare lasting over 12 months. Inconsistent utilization was associated with younger age, no service-connected disability, and less physical comorbidity, regardless of diagnosis. The influence of gender and ethnicity on attrition varied by diagnosis and gap-duration. Variation in attrition by gender and ethnicity warrants additional attention.
    Community Mental Health Journal 05/2008; 44(5):321-30. · 1.03 Impact Factor
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    ABSTRACT: We examine the impact of two dimensions of access-geographic accessibility and availability-on VA health system and mental health treatment retention among patients with serious mental illness (SMI). Among 156,631 patients in the Veterans Affairs (VA) health care system with schizophrenia or bipolar disorder in fiscal year 1998 (FY98), we used Cox proportional hazards regression to model time to first 12-month gap in health system utilization, and in mental health services utilization, by the end of FY02. Geographic accessibility was operationalized as straight-line distance to nearest VA service site or VA psychiatric service site, respectively. Service availability was assessed using county-level VA hospital beds and non-VA beds per 1,000 county residents. Patients who died without a prior gap in care were censored. There were 32, 943 patients (21 percent) with a 12-month gap in health system utilization; 65,386 (42 percent) had a 12-month gap in mental health services utilization. Gaps in VA health system utilization were more likely if patients were younger, nonwhite, unmarried, homeless, nonservice-connected, if they had bipolar disorder, less medical morbidity, an inpatient stay in FY98, or if they lived farther from care or in a county with fewer VA inpatient beds. Similar relationships were observed for mental health, however being older, female, and having greater morbidity were associated with increased risks of gaps, and number of VA beds was not significant. Geographic accessibility and resource availability measures were associated with long-term continuity of care among patients with SMI. Increased distance from providers was associated with greater risks of 12-month gaps in health system and mental health services utilization. Lower VA inpatient bed availability was associated with increased risks of gaps in health system utilization. Study findings may inform efforts to improve treatment retention.
    Health Services Research 07/2007; 42(3 Pt 1):1042-60. · 2.29 Impact Factor
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    ABSTRACT: We examined data from a community sample of rural stimulant users (n = 691) in three diverse states to identify gender and racial/ethnic differences in HIV risk behaviors. Bivariate and logistic regression analyses were conducted with six risk behaviors as dependent variables: injecting drugs, trading sex to obtain money or drugs, trading money or drugs to obtain sex, inconsistent condom use, multiple sex partners, and using drugs with sex. Controlling for state, income, age, heavy drinking, and type of stimulant used, men had lower odds than women for trading sex to obtain money or drugs (adjusted odds ratio [AOR] =0.4, confidence interval [CI] = 0.28-0.59; p < .0001), greater odds than women for trading money or drugs to obtain sex (AOR = 44.4, CI = 20.30-97.09; p < .0001), greater odds than women of injecting drugs (adjusted odds ratio (AOR =1.6, CI = 1.11-2.42; p = .01), and lower odds than women of using condoms inconsistently (AOR = 0.6, CI = 0.35-0.92; p = .02); African Americans had lower odds than Whites of injecting drugs (AOR = .08, CI = 0.04-0.16; p < .0001), greater odds than Whites for trading sex to obtain money or drugs (AOR = 1.7, CI = 1.01-2.85; p = .04) and for trading money or drugs to obtain sex (AOR = 2.9, CI = 1.53-5.59; p = .001), and greater odds than Whites of using drugs with sex (AOR = 3.9, CI = 1.47-10.09; p = .006). These findings indicate HIV prevention efforts should be tailored to address gender and racial/ethnic differences in risk behaviors among rural stimulant users.
    AIDS Education and Prevention 04/2007; 19(2):137-50. · 1.59 Impact Factor
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    ABSTRACT: Medication adherence continues to be a challenge for patients with schizophrenia. Many interventions have been tested but not widely adopted. To fill this gap, this qualitative study examined patient and provider perspectives on barriers, facilitators, and motivators related to adherence. Twenty-six patients (15 veterans and 11 nonveterans) diagnosed as having schizophrenia or schizoaffective disorder completed in-depth qualitative interviews. Each patient's mental health provider completed an open-ended paper-and-pencil questionnaire that followed the format of the patient qualitative interview. Patients and their providers were asked about seven domains of an explanatory model for schizophrenia and about barriers to, facilitators for, and motivators to taking antipsychotic medication. Patients and providers responded from the perspective of the patient. Patient interviews were audiotaped and transcribed. The data were analyzed with content analysis and constant comparison methods. Explanatory model agreement between patients and their providers ranged from 40 to 100 percent, depending on the explanatory model domain. Patients identified 214 unique barriers, facilitators, and motivators, and agreement between patients and their providers ranged from 54 to 65 percent. Sample patient quotes are provided. Substantial disagreement arose between patients and their providers with regard to their explanatory models for schizophrenia and the barriers, facilitators, and motivators thought to affect patients' medication adherence decisions. These findings will be used to develop and test a patient-centered strategy to enhance medication adherence.
    Psychiatric Services 09/2006; 57(8):1170-8. · 2.01 Impact Factor
  • Ellen P Fischer
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    ABSTRACT: Without Abstract
    Community Mental Health Journal 03/2006; 42(1):107-11. · 1.03 Impact Factor
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    ABSTRACT: 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.
    American Journal of Medical Quality 01/2003; 18(4):140-6. · 1.47 Impact Factor
  • Ellen P Fischer, Martha Shumway, Richard R Owen
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    ABSTRACT: 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. 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. 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. 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.
    Psychiatric Services 07/2002; 53(6):724-9. · 2.01 Impact Factor
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    ABSTRACT: 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. 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. A total of 66 patients hospitalized for acute schizophrenia at a Veterans Affairs medical center or state hospital in the southeastern US. The sensitivity and specificity of the explicit dose criterion at hospital discharge were determined in comparison with the gold standard of structured implicit review. 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. 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.
    International Journal for Quality in Health Care 07/2002; 14(3):199-206. · 1.79 Impact Factor
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    ABSTRACT: This report describes the development, application, and exploratory evaluation of a clinical performance measure based on recently published schizophrenia guidelines for antipsychotic dose. The performance measure, which assesses adherence to antipsychotic dose recommendations for acute schizophrenia treatment, was calculated at hospital discharge for 116 patients with schizophrenia who had participated in a 6-month outcomes study. The Brief Psychiatric Rating Scale (BPRS) was used to assess symptom severity at 6-month followup. At discharge, almost one-half of the patients were prescribed doses outside the recommended range. For the entire sample, linear regression models showed that the performance measure variable was not significantly associated with followup symptom severity (BPRS total scores). However, a significant association was observed for patients prescribed oral antipsychotics only (n = 69). Patients prescribed recommended doses had lower adjusted mean BPRS totals than patients prescribed doses either greater than (P < 0.05) or less than (P < 0.05) recommended. Our findings suggest that the antipsychotic dose performance measure may be useful for monitoring quality. It assesses a modifiable aspect of care for which clinical improvement is needed, and such improvement is likely to improve patient outcomes. Future research is needed to confirm our findings and to develop and test interventions to improve the quality of care for schizophrenia that incorporate this clinical performance measure.
    International Journal for Quality in Health Care 12/2000; 12(6):475-82. · 1.79 Impact Factor
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    ABSTRACT: The Veterans Administration (VA) recently introduced its Quality Enhancement Research Initiative (QUERI) to facilitate the translation of best practices into usual clinical care. The Mental Health QUERI (MHQ) was charged with developing strategic plans for major depressive disorder (MDD) and schizophrenia. Twenty percent or more of VA service users are affected by 1 of these 2 disorders, disorders that often have a devastating impact on affected individuals. Despite the increasing availability of efficacious treatments for each disorder, substantial gaps remain between best practices and routine care. In this context, the MHQ identified steps critical to the success of a sustained process of rapid-cycle health care improvement for MDD and schizophrenia, including research initiatives to close gaps in knowledge of best treatment practices, demonstration projects to close gaps in practice and to expand understanding of effective strategies for implementing clinical guidelines, targeted enhancements of the VA information system, and research and dissemination initiatives to increase the availability of resources to support the accelerated incorporation of best practices into routine care. This article presents an overview of the elements in the initial MHQ strategic plans and the rationale behind them.
    Medical Care 07/2000; 38(6 Suppl 1):I70-81. · 3.23 Impact Factor
  • E P Fischer, R R Owen
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    ABSTRACT: Using process-of-care indicators, we examined the quality of care provided to 139 individuals receiving treatment for schizophrenia in public sector systems. Longitudinal data on services use and medication management were abstracted from medical records. Medication adherence data were obtained by self- and informant reports. Overall, 39% of participants had less than monthly contact with community-based service (CBS) providers. When participants in day treatment or partial hospitalization programs were excluded, less than monthly CBS contact increased to 70%. Of participants, 40%-60% were prescribed medications outside guideline-recommended dose ranges. Up to half of participants reported taking half or less of prescribed antipsychotics. The adverse impact on patient outcomes of these practice patterns is well established. Public sector organizations face powerful challenges to the behavioral changes needed to sustain best practice care. Overcoming these challenges to assure high-quality care for schizophrenia will require tremendous creativity and commitment.
    Mental Health Services Research 01/2000; 1(4):213-21.
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    ABSTRACT: The study examined the extent of clinical recognition of comorbid substance use disorders and the clinical management of these disorders among inpatients hospitalized for an acute exacerbation of schizophrenia. Medical records of 42 inpatients who met research diagnostic criteria for both schizophrenia and a current substance use disorder were reviewed for information about admission evaluation, inpatient management, discharge diagnosis, and disposition. Alcohol use disorders were the most frequent co-occurring substance-related diagnoses, found for 86 percent of the dually diagnosed inpatients. Twenty-four patients (57 percent) did not receive a diagnosis of a substance-related disorder at admission, and 19 (45 percent) did not receive a substance-related diagnosis at discharge. Referral to inpatient or outpatient substance abuse treatment was documented for a minority of subjects. The results suggest that improvements are needed in the process of clinical care for inpatients with schizophrenia who have co-occurring substance-related disorders. They highlight a need for education of health care providers and continuous quality improvement in this area.
    Psychiatric Services 02/1998; 49(1):82-5. · 2.01 Impact Factor
  • B J Cuffel, E P Fischer, R R Owen, G R Smith
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    ABSTRACT: To advance effectiveness research in mental health, we need common, standardized, validated instruments that can be used easily in routine practice settings. The Schizophrenia Outcomes Module is a relatively brief, comprehensive instrument for monitoring and assessing the outcomes of treatment for schizophrenia in clinical care settings. The module was developed with the guidance of a multiinstitutional, multidisciplinary expert panel; the clinical and theoretical considerations that framed the expert panel's deliberations and determined the module's content and characteristics are described. Initial field testing of the instrument involved longitudinal observation of 100 individuals with schizophrenia over a 6-month period. To our knowledge, it is the only brief and easily administered instrument that encompasses the four major outcome domains defined by the National Institute of Mental Health's Plan for Research on the Severely Mentally Ill. As such, it is a promising tool for effectiveness research in schizophrenia.
    Evaluation &amp the Health Professions 04/1997; 20(1):96-108. · 1.48 Impact Factor

Publication Stats

337 Citations
38.63 Total Impact Points


  • 2011
    • University of California, Los Angeles
      Los Angeles, California, United States
  • 1996–2011
    • University of Arkansas at Little Rock
      Little Rock, Arkansas, United States
  • 2006–2008
    • Central Arkansas Veterans Healthcare System
      Washington, Washington, D.C., United States
    • University of Arkansas for Medical Sciences
      • Department of Psychiatry
      United States