Ellen P Fischer

Overton Brooks VA Medical Center, Shreveport, Louisiana, United States

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Publications (22)32.83 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: Posttraumatic stress disorder (PTSD) is prevalent among users of the Veterans Affairs (VA) health care system. Effective approaches to involving family in care for PTSD are critical because family functioning both affects and is affected by treatment outcomes. Although multifamily group treatment is an evidence-based practice for schizophrenia and other serious mental illnesses, no data have been published on its effectiveness for those living with PTSD and their family members. This study examined the impact of participation in REACH (Reaching out to Educate and Assist Caring, Healthy Families), an adaptation of the multifamily group psychoeducation program tailored for delivery to veterans with PTSD and their family members. One hundred veterans with PTSD and 96 family members who participated in the 9-month, 3-phase clinical program between 2006 and 2010 also participated in this longitudinal evaluation. Veterans showed significant (p
    Professional Psychology Research and Practice 01/2013; 44(3):127. · 1.34 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
  • Michelle D Sherman, Ellen P Fischer
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    ABSTRACT: The Veterans Affairs (VA) healthcare system is dedicated to providing high-quality mental health services to all veterans, including the nearly 40% of enrolled veterans living in rural areas. Family education programs regarding mental illness and posttraumatic stress disorder, mandated for delivery in all VA medical centers and some community-based outpatient clinics (CBOCs), have been developed and provided primarily in large, urban medical centers. This qualitative investigation involved interviews with CBOC providers and veterans and families who live in rural areas and/or seek care in CBOCs to ascertain their perceptions of the benefits, feasibility, structural and cultural barriers, and logistical preferences regarding family education. The perspectives and concerns that emerged in these interviews were combined with expert knowledge to identify the resources and considerations a VAMC would want to address when translating and implementing similar programming into CBOCs. Although institutional, logistic, and attitudinal challenges were described, all three stakeholder groups endorsed the need for family education, did not see the barriers as insurmountable, and provided creative solutions. Administrators and CBOC clinicians may benefit by anticipating and problem solving around the key issues raised when developing family programming.
    Psychological Services 02/2012; 9(1):89-100. · 1.08 Impact Factor
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    ABSTRACT: The Oklahoma City Veterans Affairs (VA) Medical Center modified an evidence-based model of family psychoeducation (the multifamily group model; McFarlane, 2002) and implemented it for the first time in a VA setting and with veterans living with posttraumatic stress disorder (PTSD). Named the REACH Program (Reaching out to Educate and Assist Caring, Healthy Families), the 3-phase program begins with 4 weekly “joining sessions” with the individual veteran and his/her family focused on rapport building, assessment, and goal setting. Phase II consists of 6 weekly diagnosis-specific educational/support sessions for cohorts of 4 to 6 veterans and their families. In Phase III, veterans/families attend 6 monthly multifamily groups to support the maintenance of gains. This article describes the rationale for modifying the original Multifamily Group Program (MFG) for a unique setting (the VA) and the needs of families of veterans in a new diagnostic group (PTSD). The changes to the MFG curriculum are specifically described, and details of the new REACH intervention are explained. Attendance, retention, and satisfaction data for 2 diagnostic cohorts, PTSD and affective disorders, are also presented. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
    07/2011; 1(S):74-84.
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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: [Correction Notice: An erratum for this article was reported in Vol 41(4) of Professional Psychology: Research and Practice (see record 2010-17073-006). The copyright for this article was incorrectly listed. This article is in the Public Domain. The online version has been corrected.] The Oklahoma City Veterans Affairs (VA) Medical Center modified an evidence-based model of family psychoeducation (the multifamily group model; McFarlane, 2002) and implemented it for the first time in a VA setting and with veterans living with posttraumatic stress disorder (PTSD). Named the REACH Program (Reaching out to Educate and Assist Caring, Healthy Families), the 3-phase program begins with 4 weekly “joining sessions” with the individual veteran and his/her family focused on rapport building, assessment, and goal setting. Phase II consists of 6 weekly diagnosis-specific educational/support sessions for cohorts of 4 to 6 veterans and their families. In Phase III, veterans/families attend 6 monthly multifamily groups to support the maintenance of gains. This article describes the rationale for modifying the original Multifamily Group Program (MFG) for a unique setting (the VA) and the needs of families of veterans in a new diagnostic group (PTSD). The changes to the MFG curriculum are specifically described, and details of the new REACH intervention are explained. Attendance, retention, and satisfaction data for 2 diagnostic cohorts, PTSD and affective disorders, are also presented. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
    Professional Psychology Research and Practice 11/2009; 40(6):593-600. · 1.34 Impact Factor
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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 brief report describes the engagement strategy used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a nine-month family psychoeducation program for veterans with serious mental illness or posttraumatic stress disorder (PTSD). A motivational interviewing-based strategy was created and implemented in a Veterans Affairs hospital to engage providers and veterans and their families into the intervention. Of the 1,539 veterans told about the program, 41% had a family member living nearby and were willing to meet with a provider to learn more. REACH providers met with 505 veterans for a motivational-interviewing session to explore family participation. Of the 436 veterans who were eligible to participate in REACH, 28% of veterans with PTSD, 34% of veterans with an affective disorder, and 25% of veterans with a schizophrenia spectrum disorder went on to participate in at least one session of the REACH program with a family member; these rates compare favorably with those for programs requiring a much shorter commitment. This engagement strategy shows promise as an effective tool in recruiting veterans and their families into family psychoeducation.
    Psychiatric services (Washington, D.C.) 03/2009; 60(2):254-7. · 2.81 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: It is well documented that family psychoeducation decreases relapse rates of individuals with schizophrenia. Despite the evidence, surveys indicate that families have minimal contact with their relative's treatment team, let alone participate in the evidence-based practice of family psychoeducation. The Department of Veterans Affairs (VA) sponsored a conference, the Family Forum, to assess the state of the art regarding family psychoeducation and to form a consensus regarding the next steps to increase family involvement. The forum reached consensus on these issues: family psychoeducation treatment models should be optimized by efforts to identify the factors mediating their success in order to maximize dissemination; leadership support, training in family psychoeducation models for managers and clinicians, and adequate resources are necessary to successfully implement family psychoeducation; because family psychoeducation may not be appropriate, indicated, or acceptable for all families, additional complementary strategies are needed that involve families in the mental health care of the patient; and work is required to develop and validate instruments that appropriately assess the intervention process and consumer and family outcomes. A treatment heuristic for working with families of persons with severe mental illness is also offered and provides a match of interventions at varying levels of intensity, tailored to family and consumer needs and circumstances. The article describes opportunities for the research and clinical communities to expand the proportion of families served.
    Psychiatric Services 02/2008; 59(1):40-8. · 2.01 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
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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

Publication Stats

180 Citations
32.83 Total Impact Points

Institutions

  • 2012
    • Overton Brooks VA Medical Center
      Shreveport, Louisiana, United States
  • 2011
    • University of California, Los Angeles
      Los Angeles, California, United States
  • 2002–2011
    • 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