Quality Enhancement Research Initiative in Mental Health.

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.

Performance measurement for schizophrenia: adherence to guidelines for antipsychotic dose.

OBJECTIVE: This report describes the development, application, and exploratory evaluation of a clinical performance measure based on recently published schizophrenia guidelines for antipsychotic dose. DESIGN, SETTING, PARTICIPANTS: 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. MAIN OUTCOME MEASURE: The Brief Psychiatric Rating Scale (BPRS) was used to assess symptom severity at 6-month followup. RESULTS: 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. CONCLUSIONS: 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.

Quality of public sector care for schizophrenia in Arkansas.

OBJECTIVE: Using process-of-care indicators, we examined the quality of care provided to 139 individuals receiving treatment for schizophrenia in public sector systems. METHODS: Longitudinal data on services use and medication management were abstracted from medical records. Medication adherence data were obtained by self- and informant reports. RESULTS: 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. CONCLUSIONS: 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.

Diagnosis and management of substance use disorders among inpatients with schizophrenia.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Implementing outcomes management systems in mental health settings.

Outcomes management has received considerable attention in the literature on mental health services delivery. However, relatively little practical information is available on how to implement an outcomes management system in the mental health care setting. The authors review seven key issues that must be addressed in planning such a system: involving senior organizational leaders in ownership of the project, securing the support of clinicians and patients, selecting personnel to operate the system, choosing outcomes assessment instruments, developing data collection procedures, selecting techniques for data management, and using the data to improve outcomes. Ultimately, an outcomes management system is intended to generate data that can be used to stimulate discussion, to guide clinicians in tailoring treatments, and to identify efficient treatment approaches.

Assessing the effectiveness of mental health care in routine clinical practice. Characteristics, development, and uses of patient outcomes modules.

The health care delivery system faces continually increasing pressure to be accountable for the historically unparalleled amount of resources it utilizes. This article discusses one set of recently developed tools known as outcomes modules that are used to assess how treatment affects outcomes in patients with a given disorder. These tools currently are being used to inform administrative decisions about how to improve the quality of care, and can potentially influence decisions by patients, providers, and payers of care as well. The critical components of outcomes modules, as well as their administration and applications are described, using modules for psychiatric conditions as examples.

An instrument for measurement of outcomes of care for schizophrenia. Issues in development and implementation.

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.

Awareness of illness in schizophrenia and outpatient treatment adherence.

We present a brief measure of awareness of illness in schizophrenia and test whether awareness is related to perceived need for and adherence to outpatient psychiatric treatment. A prospective design assessed treatment adherence, awareness of the signs and symptoms of schizophrenia, symptoms, neurocognitive status, and substance abuse at baseline and 6-month follow-up in 89 persons with schizophrenia. Results indicate that persons with greater awareness perceived greater need for outpatient treatment and evidenced better adherence to outpatient treatment when adherence and awareness were measured concurrently. Awareness was not related to adherence at 6-month follow-up. In addition, neurocognitive impairment was associated with lower overall adherence to treatment when reported by collaterals at baseline and 6-month follow-up. Neurocognitive impairment was, however, associated with higher self-reported adherence to medication, which suggests that neurocognitive status may bias adherence reporting in persons with schizophrenia.

Substance abuse, community service use, and symptom severity of urban and rural residents with schizoprhenia.

OBJECTIVE: This study examined the relationships of substance abuse, use of community-based services, and symptom severity among rural and urban residents with schizophrenia in the six months after discharge from short-term inpatient care. METHODS: At baseline and six-month follow-up, symptom severity of 139 subjects was assessed using the Brief Psychiatric Rating Scale (BPRS), and substance abuse status was determined using the Structured Clinical Interview for DSM-III-R (SCID). Subjects' reports of mental health service use were confirmed by record review. RESULTS: Although, on average, BPRS scores indicated symptom improvement between baseline and follow-up, symptoms worsened for 27 percent of subjects. Multivariate analysis, adjusted for baseline symptom severity, indicated poorer outcomes for rural residents, substance abusers, and subjects who did not use community services. Symptoms of rural substance abusers who used no community services were worse at follow-up than those of any other subgroup. Nearly half of all subjects had less than monthly contact with community services. The greater likelihood of symptom worsening among rural residents was attributed to their less frequent use of community services. CONCLUSIONS: The findings reinforce the importance of ensuring involvement in community-based services for individuals with comorbid schizophrenia and substance use disorders. Promotion of service use by persons with a dual diagnosis may be particularly critical to the well-being of rural residents with schizophrenia.

Medication noncompliance and substance abuse among patients with schizophrenia.

OBJECTIVE: The study examined the effect of medication noncompliance and substance abuse on symptoms of schizophrenia. METHODS: Short-term inpatients with a diagnosis of schizophrenia were enrolled in a longitudinal outcomes study and continued to receive standard care after discharge. At baseline and six-month follow-up, Brief Psychiatric Rating Scale (BPRS) scores and data on subjects' reported medication compliance, drug and alcohol abuse, usual living arrangements, and observed side effects were obtained. The number of outpatient contacts during the follow-up period was obtained from medical records. Relationships between the dependent variables-medication noncompliance and follow-up BPRS scores-and the independent variables were analyzed using logistic and linear regression models. RESULTS: Medication noncompliance was significantly associated with substance abuse. Subjects who abused substances, had no outpatient contact, and were noncompliant with medication had significantly greater symptom severity than other groups. CONCLUSIONS: Substance abuse is strongly associated with medication noncompliance among patients with schizophrenia. The combination of substance abuse, medication noncompliance, and lack of outpatient contact appears to define a particularly high-risk group.

Outcomes assessment: information for improving mental health care.

Findings from ongoing assessments in two states illustrate strategies for using outcomes information.

Assessment of critical care nurses' knowledge of the pulmonary artery catheter. The Pulmonary Artery Catheter Study Group.

OBJECTIVES: To assess the knowledge and understanding of the use of the pulmonary artery catheter and interpretation of data derived from it in a group of nurses attending the American Association of Critical Care Nurses' National Teaching Institute conference. DESIGN: A 37-question multiple choice examination that tested knowledge regarding the use of the pulmonary artery catheter was administered to a group of nurses, attending a national conference, who preregistered for a hemodynamics workshop. SETTING: American Association of Critical Care Nurses' National Teaching Institute Conference, New Orleans, LA, May 1992. MEASUREMENTS AND MAIN RESULTS: Two-hundred sixteen nurses completed the questionnaire. The mean test score was 16.5 +/- 5.7 (SD) (48.5%). Test scores were significantly associated with years of experience in critical care, critical care registered nurse certification, responsibility for repositioning and manipulating the catheter, frequency of use, and self-assessed adequacy of knowledge. CONCLUSIONS: A wide variation in the understanding of the use of the pulmonary artery catheter exists among nurses using this device in the care of seriously ill patients. The results indicate that current teaching practices regarding the pulmonary artery catheter need to be reevaluated and specific credentialing policies need to be considered.

Abnormal coagulation profile in brain tumor patients during surgery.

Neurosurgical patients are at high risk for the development of thrombosis and thromboembolism. We compared the perioperative clotting factor and coagulation parameters of 20 patients undergoing elective craniotomy for brain tumors to those of 20 patients undergoing elective abdominal surgery. We also measured the levels of plasma arginine vasopressin to determine if changes in this hormone might be associated with changes in clotting factors, activated partial thromboplastin times, or bleeding times. The results demonstrated a significant reduction in partial thromboplastin times and bleeding times in the neurosurgery group, which began at the initiation of surgery and lasted to the end of the study (12 h postoperatively). Elevations in factor assays and plasma arginine vasopressin occurred in both groups during surgery, but there were no differences between the neurosurgical and abdominal surgical patients, except with Factor IX levels, which were elevated only in the neurosurgical patients. Serum osmolality and hemoglobin levels were significantly higher in the neurosurgical cohort. These results suggest that there are hemostatic differences between neurosurgical patients with brain tumors and abdominal surgery patients that cannot be explained solely by elevations in plasma arginine vasopressin or the clotting factors measured; these differences may be the consequence of perioperative variables such as dehydration and hyperosmolality.

Characteristics of completed suicides: implications of differences among methods.

Approximately 30% of suicides in New York City are the result of jumping from a height. After describing jumping suicides and jumping sites, we used polychotomous logistic regression to compare the characteristics of suicides by jumping to those of individuals committing suicide by hanging, ingestion, or shooting. Method used was significantly associated with sociodemographics, occupation, and mental health status, even after adjustment for individual access to the means of committing suicide. Our finding of an independent association between personal characteristics and method used provides strong evidence for the hypothesis that controlling access to an agent of suicide can influence overall suicide rates, at least in the short term. Study results support the introduction of preventive programs to control access to commonly employed agents of suicide.

A multicenter study of physicians' knowledge of the pulmonary artery catheter. Pulmonary Artery Catheter Study Group.

We administered a 31-question multiple-choice examination to 496 physicians practicing in 13 medical facilities in the United States and Canada to assess their knowledge and understanding of the use of the pulmonary artery catheter and interpretation of data derived from it. The mean test score was 20.7 (67% correct), with an SD of 5.4 and a range of 6 to 31 (19% to 100%). Mean scores varied independently by training, frequency of use of pulmonary artery catheter data in patient treatment, frequency of inserting a pulmonary artery catheter, and whether the respondent's hospital was a primary medical school affiliate. Given the variability in physician understanding of the pulmonary artery catheter, we believe that credentialing policies should be reevaluated and that consideration should be given to restricting its use to individuals with documented competency.

Low sensitivity of the anion gap as a screen to detect hyperlactatemia in critically ill patients.

The anion gap is commonly used as a screening test for the presence of lactic acidosis. Analysis of the distribution of anion gaps for 56 adult surgical ICU patients with peak blood lactate levels greater than or equal to 2.5 mmol/L showed the anion gap to be an insensitive screen for elevated lactate in a critically ill, hospitalized population. All patients (11/11) with a peak lactate greater than or equal to 10 mmol/L had an anion gap greater than or equal to 16 mmol/L; however, 50% (6/12) of patients with lactates between 5.0 and 9.9 mmol/L and 79% (26/33) of those with lactates between 2.5 and 4.9 mmol/L had anion gaps less than 16 mmol/L. Hyperlactatemia was associated with considerable mortality at all levels: 100% among patients with lactate levels greater than or equal to 10 mmol/L, 75% between 5.0 and 9.9 mmol/L, and 36.4% between 2.5 and 4.9 mmol/L. Acidosis (pH less than 7.30) did not significantly alter mortality by lactate level. The observation that, for 57% of patients in this study, an elevated lactate level was not accompanied by an elevated anion gap suggests that hyperlactatemia should be included in the differential diagnosis of nonanion gap acidosis.