Community Mental Health Journal, Vol. 39, No. 6, December 2003 ( 2003)
Assessing Conformance to Medication
Treatment Guidelines for
Schizophrenia in a Community
Mental Health Center (CMHC)
Mona Goldman, Ph.D.
Daniel J. Healy, M.D.
Timothy Florence, M.D.
Lorelei Simpson, M.A.
Karen K. Milner, M.D.
ABSTRACT: The feasibility of implementing current medication treatment guidelines
in a community mental health clinic was examined in this cross-sectional and retrospec-
tive study. Specifically, two issues were addressed: 1) could we identify a set of clinical
guidelines whose utilization could be monitored with a routine medical chart review;
and 2) were the requisite data for such a review available in the medical records. An
examination of three sets of published guidelines revealed 5 specific guidelines that
could be operationalized and monitored. Records were reviewed for a random sample
of two-thirds of all patients currently diagnosed with schizophrenia and schizoaffective
disorder (n = 309). Information was collected from the medical record on patient demo-
graphics, diagnosis, duration of illness, symptoms and side effects, and medication
information. Rates of conformance to the 5 guidelines ranged from a high of 97% to a
low of 43%. The use of current guidelines to improve treatment in community clinics
appears to be limited by the deficiencies in the medical record and the structure of
the guidelines themselves. Standardized progress notes and computerized prescribing
Mona Goldman is Research Investigator, Daniel J. Healy is Lecturer, Timothy Florence is Clinical
Instructor, Lorelei Simpson is Research Assistant and Karen K. Milner is Clinical Assistant
Professor, all in Department of Psychiatry, University of Michigan Health System.
Address correspondence to Karen K. Milner, M.D., University of Michigan Health System,
B1D102, UH, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0020; e-mail: kmilner@
This study was funded by a grant from the Ethel and James Flinn Family Foundation. The
authors also thank Janet Neuhauser, M.A., for her efforts and contributions.
2003 Human Sciences Press, Inc.
Community Mental Health Journal550
programs will improve conformance, and permit the rapid and accurate assessment of
conformance to guidelines in community clinics.
KEY WORDS: schizophrenia; guideline conformance; CHMC.
The introduction of the atypical antipsychotics ushered in a new era in
patient compliance (Jibson and Tandon, 1998). However, because the
cost of the newer antipsychotics is higher than that of the older conven-
the allocation of limited resources have to be raised (Doherty, 1999).
To ensure that treatment decisions are rational and evidence-based,
professional and government agencies have published clinical practice
guidelines and algorithms for the treatment of severe mental illnesses
(American Psychiatric Association, 1997; Lehman and Steinwachs,
1998a; The Expert Consensus Guideline Series, 1999; Chiles, Miller,
Crismon, Rush, Krasnoff, and Shon, 1999). We examined the feasibility
of operationalizing guidelines and monitoring the use of medication
treatment guidelines in a CMHC. Specifically, we reviewed three na-
tional guidelines and algorithms for schizophrenia (Lehman and Stein-
wachs, 1998a; The Expert Consensus Guideline Series, 1999; Chiles,
Miller, Crismon Rush, Krasnoff, and Shon, 1999) and identified a set of
maintenance treatment recommendations that could be assessed using
data available in a cross-sectional, retrospective chart review. We then
examined the extent to which current pharmacological treatment prac-
tice at the CMHC conformed to those recommendations.
The study was conducted in a small urban CMHC in the Midwest affiliated with a
large university academic medical center. Three hundred and nine patients aged 18
years of age and older and diagnosed with schizophrenia or schizoaffective disorder,
selected randomly from the center’s data bank, comprised the study sample. A trained
research assistant, using a data abstraction form designed for the study, conducted
medical record reviews. Data were collected on patient demographics, diagnosis, dura-
tion of illness, symptoms and side effects, and medication.
We reviewed the recommendations for maintenance pharmacological treatment of
schizophrenia in three sets of national guidelines: the Patient Outcomes Research
Mona Goldman, Ph.D., et al.551
Algorithm Project (TMAP; Chiles, Miller, Crismon, Rush, Krasnoff, and Shon 1999),
and the Expert Consensus Guideline series (1999). We identified five recommendations
that could be evaluated using a cross-sectional medical chart review, and for which
the required information was available in at least 50% of the medical records. Each
recommendation was translated into a conformance criterion, which was then applied
to current practices to estimate a conformance rate (Agency for Health Care Policy and
The first guideline suggests that persons with schizophrenia or schizoaffective disor-
der who experience acute symptom relief with an antipsychotic should continue to
receive this medication for at least one year. Given the constraints of the available
were being prescribed an antipsychotic medication.
prescribed for acute or maintenance treatment. However, since more than 80% of the
sample had been ill for at least 10 years, we assumed that most patients were on
maintenance doses and created a conformance criterion that assessed whether the
antipsychotic dosages prescribed for patients were between 300–600 mg CPZ equiva-
lents/day. Only those patients prescribed one oral antipsychotic medication were in-
cluded in the assessment.
The PORT study advises that patients with severe TD be offered a trial of clozapine,
while Consensus guidelines recommend that patients with mild TD be switched to
alize these recommendations, we defined severe TD as an AIMS score of ≥3, indicating
that the patient had minimal abnormal movements in at least three parts of the body
or mild to moderate movements in at least one. Mild TD was defined as an AIMS score
of one or two.
A fourth guideline recommends that persons who experience persistent, clinically
significant positive symptoms despite adequate antipsychotic therapy receive a trial of
two or more antipsychotics, adjunctive pharmacotherapy, or clozapine. Since our cross-
sectional methodology provided no information on the use, duration, or outcome of
previous medication trials, we drafted a conformance criterion that examined whether
patients with positive symptoms noted in their medical record were receiving one or
more of the above-recommended treatments.
The PORT guidelines recommend an “ongoing assessment" of the effectiveness/need
for maintenance antipsychotic therapy and anti-parkinsonian agents. The Consensus
guidelines specifically recommended monthly clinic visits for compliant, asymptomatic
we used was whether patients had a clinic visit within four weeks of the chart review,
and an AIMS test within three months (reflecting the CMHC’s own higher standard
for TD assessments).
Of the 309 subjects, 43% were female; 64% were Caucasian and 30%
were African-American. Mean (SD) age was 46.4 (11.9) years (range:
Community Mental Health Journal552
20–86 years). Eighty-one percent were diagnosed with schizophrenia;
19% with schizoaffective disorder. Mean (SD) duration of illness was
ing (GAF) scale was 49.3 (9.5).
Medical Record Review
Much ofthe clinicalinformation neededto assessguideline conformance
was not documented in the medical record. For example, while the
presence or absence of positive symptoms was noted in three-quarters
of the charts, the presence or absence of negative symptoms was docu-
mented in only 6% (18). This lack of information limited the number of
guidelines that could be evaluated.
Conformance to Guidelines
Conformance rates for the five criteria are listed below:
Criterion 1: 299 (96.8%) of this sample were being treated with an
Criterion 2: Of the 179 prescriptions for monotherapy antipsychotic
treatment, 43% were within the recommended dose range of 300–
600 mg CPZ equivalents/day; 26% were below, and 32% were above
Criterion 3: Of the forty-six patients identified with severe TD, 63.0%
were being treated with an atypical antipsychotic (23.9% with cloz-
apine). Just over one-third (36.4%) of those with mild TD received
either an atypical antipsychotic and/or vitamin E.
Criterion 4: Information regarding the presence or absence of positive
symptoms were present in 83 and absent in 141. Of those with
positive symptoms, 70 (84.3%) were receiving at least one of the
Criterion 5: Just over one-half (54.4%) of the subjects had a clinic
visit within four weeks of data collection; similarly just over half
(54.0%) had an AIMS test within the past three months.
Nearly all patients (97%) in our study were prescribed an antipsychotic
Mona Goldman, Ph.D., et al.553
Number of Patients with Schizophrenia or Schizoaffective Disorder
Currently Prescribed an Antipsychotic at a Dose of 300–600 mg
The maintenance dosage of antipsychotic medication should be in
the range of 300–600 mg chlorpromazine (CPZ) equivalents per day.
Antipsychotic medications are prescribed in a dosage range of 300–
600 mg CPZ equivalents per day.
Percent of patients, on one antipsychotic medication, for whom the
current dosage is in the 300–600 CPZ equivalent range.
12 (26%) 34 (74%)
4 (12%) 23 (70%)
13 (35%) 19 (51%)
25–1668 20 (54%) 14 (38%)
25–3200 46 (26%) 76 (43%) 57 (32%)
*All doses are in mg CPZ equivalents.**Includes thioridazine (n = 12), trifluoperazine (n = 11), chlorpromazine (n = 2), perphenazine (n = 4), thiothixene (n = 6),
and loxapine (n = 2).
Community Mental Health Journal554
wach (1998b) reported that 92% of outpatients were treated with an
center, Chen, et al. (2000) found a 77% prescribing rate, perhaps reflect-
ing patient, rather than physician, adherence rates, since only prescrip-
tions filled were measured and not prescriptions written.
Only 43% of patients in our sample received the recommended anti-
psychotic maintenance dose of 300–600 mg CPZ equivalents, while 26%
were below treatment guidelines and 32% above. Similar results were
reported in the PORT evaluation (Lehman and Steinwachs, 1998b)
where 29.1% of patients were in the recommended range; 31.9% above
and 39.1% below. In the VA clinic study Chen et al. (2000) found 53%
of patients were within a range of 300–1000 mg CPZ equivalents, with
42% below 300 CPZ equivalents and 5% above 1000 mg. CPZ equiva-
lents. (Similarly, 8% of our patients were receiving antipsychotic doses
above 1000 mg CPZ equivalents; 9 of these 14 patients were on cloz-
Young, et al. (1998), using a combined patient interview/chart review,
management of medication side effects (akathisia, parkinsonism, and
TD). Of the forty-six CMH patients who met our criteria for severe TD
(AIMS ≥3) nearly two-thirds (63%) were being treated with an atypical
antipsychotic, 24% (11) with clozapine.
of residualpositive psychoticsymptoms. Seventyof those(84%) received
at least one of the recommended adjunctive treatments. We suspect
that conformance rates for this criterion will increase as more studies
addressing the use of adjunctive agents in refractory psychosis are pub-
In our medical record review, we found that many charts lacked
sufficient documentation of negative symptoms, medication side effects,
and comorbid conditions to assess adherence to guidelines related to
these key aspects of treatment. Similar deficiencies in the necessary
documentation have been reported in a variety of treatment settings
(Chen, Nadkarni, Levin, Miller, Tu, Ivanco, and Li, 2000; Dassori, Chiles,
van, Burnam, and Brook, 1998). It is impossible to know whether infor-
mation about symptomatology was missing because it was not present
on evaluation or not documented. Young et al. (1998) suggest the latter:
they found that half of the symptoms and less than fifteen percent of
medication side effects revealed by patients in a structured interview
were actually recorded in the medical record.
Mona Goldman, Ph.D., et al.555 Download full-text
A gap exists between national treatment recommendations for schizo-
phrenia and current practice in community mental health centers.
Guidelines are designed to improve quality of care by bridging that gap.
However, current medical records do not provide adequate data for
assessing adherence to guideline recommendations. Tools that allow for
cross-sectional assessment of guideline conformance without excessive
cost are needed. Standardized progress notes and computerized pre-
scribing programs may be the first steps to more quickly and accurate-
ly assess health care delivery for the seriously and persistently men-
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