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2011 HSR&D National Meeting Abstract

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2011 National Meeting

3094 — A Cluster Randomized Controlled Trial on Standardized Disability Assessment for Service-Connected Posttraumatic Stress Disorder

Speroff T (Tennessee Valley Healthcare System), Sinnott P (HERC Palo Alto Health Care System), Marx BP (NCPTSD Boston Healthcare System), Owen R (MH QUERI Little Rock), Jackson JC (Tennessee Valley Healthcare System), Greevy R (Tennessee Valley Healthcare System), Murdoch M (Minneapolis VA), Sayer N (Minneapolis VA), Shane A (HERC Palo Alto Health Care System), Schnurr P (NCPTSD White River Jct, VT)

Objectives:
We compared a standardized disability assessment of PTSD using the Clinician-Administered PTSD Scale (CAPS) and World Health Organization Disability Assessment Schedule (WHODAS-II) to the usual non-standardized disability assessment of PTSD to evaluate the quality of clinical interviews and the examination reports.

Methods:
A cluster randomized controlled trial at six VA medical centers compared standardized disability assessment with nonstandardized assessment for PTSD. PTSD experts performed blinded review of audio recordings of the interviews using a modified Structured Clinical Interview for the DSM-IV PTSD Module to independently evaluate the completeness, accuracy, and consistency of assessments. The expert reviewers also rated the thoroughness of functional assessment. VBA Systematic Technical Accuracy Reviewers conducted a blinded quality audit for ratings of the completeness and quality of the examination report.

Results:
Standardized assessment produced more complete clinical diagnostic interviews (85% vs 31%). Thoroughness of functional assessment was also significantly greater in standardized assessment. While differences between cases accounted for variance in standardized assessments, differences between sites (10%) and between examiners (17%) were an additional source of variance in nonstandardized assessments. Using expert reviewers as the reference standard, the sensitivity of the clinical examiner was 87% and specificity 65%. However, 63% of the cases could not be determined by the expert reviewer based on the lack of completeness of the interview; the inability to determine was 30% for standardized assessment versus 89% for nonstandardized assessment. Although the VBA quality audit of the disability reports was higher for standardized exams, ratings did not differ statistically. The mean (SD) VBA rating for overall quality was 91.8 (9.2) for standardized exams and 88.9 (9.7) for nonstandardized exams.

Implications:
Standardized disability assessment using the CAPS and WHODAS were more complete, consistent, and accurate than assessments conducted using nonstandardized clinical interviews. These outcomes in the process of disability assessment did not transfer into the disability examination reports submitted to VBA.

Impacts:
Standardized clinical interviews such as the CAPS and WHODAS-II would improve the diagnostic accuracy and consistency of the disability examination and would provide greater assurance of a thorough, equivalent PTSD examination regardless of location or examiner.


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