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

Owen RR, Thrush CR, Hudson TJ, Mallory SR, Fischer EP, Clardy JA, Williams DK. Using an explicit guideline-based criterion and implicit review to assess antipsychotic dosing performance for schizophrenia. International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua. 2002 Jun 1; 14(3):199-206.

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Abstract:

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.