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International Journal for Quality in Health Care 14:199-206 (2002)
© 2002 International Society for Quality in Health Care

Using an explicit guideline-based criterion and implicit review to assess antipsychotic dosing performance for schizophrenia

RICHARD R. OWEN1,2, CAROL R. THRUSH1,2, TERESA J. HUDSON1,2, SUSAN R. MALLORY3, ELLEN P. FISCHER1,2, JAMES A. CLARDY2 and D. KEITH WILLIAMS2,4

1Veterans Affairs Health Services Research and Development Service, Center for Mental Healthcare and Outcomes Research (CeMHOR), Central Arkansas Veterans Healthcare System,
2Centers for Mental Healthcare Research, Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, Little Rock, AR,
3Valley Mental Health, Salt Lake City, UT and
4Division of Biometry, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Objective. Using structured implicit review as the gold standard, this study assessed the sensitivity and specificity of an explicit antipsychotic dose criterion derived from schizophrenia guidelines.

Design. Two psychiatrists reviewed medical records and made consensus-structured implicit review ratings of the appropriateness of discharge antipsychotic dosages for hospitalized patients who participated in a schizophrenia outcomes study. Structured implicit review ratings were compared with the explicit criterion: whether antipsychotic dose was within the guideline-recommended range of 300–1000 chlorpromazine milligram equivalents (CPZE). In addition, reasons for deviation from guideline dose recommendations were examined.

Setting and study participants. A total of 66 patients hospitalized for acute schizophrenia at a Veterans Affairs medical center or state hospital in the southeastern US.

Main outcome measures. The sensitivity and specificity of the explicit dose criterion at hospital discharge were determined in comparison with the gold standard of structured implicit review.

Results. At hospital discharge, 61% of patients (n= 40) were receiving doses within the guideline-recommended range. According to structured implicit review ratings, antipsychotic dose management was appropriate for 80% (n= 53) of patients. When the 300–1000 CPZE dose criterion (dosage within or outside the recommended range) was compared with structured implicit review, it demonstrated 84.6% sensitivity and 71.7% specificity for detecting inappropriate antipsychotic dose.

Conclusions. The explicit antipsychotic dose criterion may provide a useful and efficient screen to identify patients at significant risk for quality of care problems; however, the relatively low specificity suggests that the measure may not be appropriate for quality measurement programs that compare performance among health plans.

Keywords: antipsychotic agents, guidelines, quality indicators, schizophrenia, sensitivity and specificity


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