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  • Measure Summary
  • NQMC:000269
  • Sep 1997

Schizophrenia: percent of patients with severe symptoms or side effects and no recent medication treatment change to address these problems.

Young AS, Niv N, Cohen AN, Kessler C, McNagny K. The appropriateness of routine medication treatment for schizophrenia. Schizophr Bull. 2010 Jul;36(4):732-9. PubMed External Web Site Policy
Young AS, Sullivan G, Burnam MA, Brook RH. Measuring the quality of outpatient treatment for schizophrenia. Arch Gen Psychiatry. 1998 Jul;55(7):611-7. PubMed External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in March 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percent of patients who have severe symptoms or side effects and no change in medication treatment change to address these problems.

Rationale

Schizophrenia is a chronic, disabling brain disorder that occurs in about 1% of the population. It accounts for more than 10% of all disabled people in the United States (U.S.) and 2.5% of all U.S. healthcare expenditures. The cost due to society of schizophrenia is enormous (more than $20 billion/year in the U.S. alone). The quality of care for schizophrenia is frequently poor. There is a critical need for measures of important domains of treatment process for this disorder.

Appropriate medication management reduces symptoms, relapse and rehospitalization and can improve functioning and quality of life.

Evidence for Rationale

Kane JM, Marder SR. Psychopharmacologic treatment of schizophrenia. Schizophr Bull. 1993;19(2):287-302. [82 references] PubMed External Web Site Policy

Young A. (Associate Professor Department of Psychiatry, UCLA). National Quality Measures Clearinghouse (NQMC) measure submission form: UCLA method for assessing quality in schizophrenia (MAQS). 2002 Dec 27.  3 p.

Primary Health Components

Schizophrenia; psychotic symptoms; antipsychotic medication side effects (weight gain, akathisia, parkinsonism, tardive dyskinesia); medication management

Denominator Description

The number of patients with schizophrenia in the sample (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

The number of patients in the denominator with severe symptoms or side effects and no recent medication treatment change to address these problems (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • Schizophrenia occurs in about 1% of the population.
  • Schizophrenia is a chronic, disabling brain disorder that accounts for more than 10% of all disabled people in the United States (U.S.).
  • Schizophrenia accounts for 2.5% of all United States (U.S.) healthcare expenditures. The cost due to society of schizophrenia is enormous (more than $20 billion/year in the U.S. alone).
  • The Schizophrenia Patient Outcomes Research Team (PORT) study, a landmark examination of clinical practices in two States, found that treatment for schizophrenia often departs from evidence-based recommendations. Comparable findings of wide variations in care have been documented in many, if not most, areas of health care. For schizophrenia, gaps between actual and recommended practice were seen in the dosing of antipsychotic medications, the use of depot medications, and the provision of effective psychosocial interventions, including family treatments, vocational rehabilitation, and assertive community treatment. These findings have been replicated in other settings and parts of the country.
  • Two studies used the appropriateness method to evaluate treatment quality in schizophrenia, and found similar results. One evaluated care at a VA and a non-VA public mental health clinic, and found that 38% of patients were receiving poor-quality medication management and 52% had inadequate psychosocial care. Another found similar or worse rates of adherence to treatment recommendations in a variety of hospitals and clinics in a southern and a midwestern state. Based upon this and prior research, it seems quite likely that variation in the appropriateness of medication management is having a substantial negative effect on patient outcomes. There is a clear and compelling need to improve the level of treatment quality provided to individuals with this disorder.
  • Numerous studies have found that routine treatment for schizophrenia varies markedly from evidence-based recommendations. In the 1990s, researchers found that about one-third of outpatients are prescribed medication within the recommended dosage range. Before second-generation medications became the dominant treatment, one such study of appropriateness found that 17% of patients had severe psychotic symptoms and no appropriate medication change, while 27% of patients had severe side effects and no appropriate medication change.
  • A recent study obtained data from a research project at 3 large Department of Veterans Affairs (VA) mental health clinics, starting in 2001. In this study, 128 participants (32%) had inappropriate management of psychotic symptoms, and 7 (2%) had inappropriate management of depressive symptoms. In regard to side effects, 32 (8%) had inappropriate management of tardive dyskinesia (TD), and 180 (45%) had inappropriate management of weight. Overall, 268 participants (67%) received inappropriate medication management in one or more domains. Although clozapine is the best available treatment for persistent and non-responsive psychosis, it is underutilized. Only 26 (6.5%) participants in this study were prescribed clozapine during the year in which they were evaluated.

Evidence for Additional Information Supporting Need for the Measure

Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998 Sep 16;280(11):1000-5. [41 references] PubMed External Web Site Policy

Fischer EP, Owen RR. Quality of public sector care for schizophrenia in Arkansas. Ment Health Serv Res. 1999 Dec;1(4):213-21. PubMed External Web Site Policy

Hermann RC, Finnerty M, Provost S, Palmer RH, Chan J, Lagodmos G, Teller T, Myrhol BJ. Process measures for the assessment and improvement of quality of care for schizophrenia. Schizophr Bull. 2002;28(1):95-104. PubMed External Web Site Policy

Lehman AF, Steinwachs DM. Patterns of usual care for schizophrenia: initial results from the Schizophrenia Patient Outcomes Research Team (PORT) Client Survey. Schizophr Bull. 1998;24(1):11-20; discussion 20-32. PubMed External Web Site Policy

Lehman AF. Quality of care in mental health: the case of schizophrenia. Health Aff (Millwood). 1999 Sep-Oct;18(5):52-65. PubMed External Web Site Policy

Perala J, Suvisaari J, Saarni SI, Kuoppasalmi K, Isometsa E, Pirkola S, Partonen T, Tuulio-Henriksson A, Hintikka J, Kieseppa T, Harkanen T, Koskinen S, Lonnqvist J. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry. 2007 Jan;64(1):19-28. PubMed External Web Site Policy

Rosenheck RA, Desai R, Steinwachs D, Lehman A. Benchmarking treatment of schizophrenia: a comparison of service delivery by the national government and by state and local providers. J Nerv Ment Dis. 2000 Apr;188(4):209-16. PubMed External Web Site Policy

Young AS, Niv N, Cohen AN, Kessler C, McNagny K. The appropriateness of routine medication treatment for schizophrenia. Schizophr Bull. 2010 Jul;36(4):732-9. PubMed External Web Site Policy

Young AS, Sullivan G, Burnam MA, Brook RH. Measuring the quality of outpatient treatment for schizophrenia. Arch Gen Psychiatry. 1998 Jul;55(7):611-7. PubMed External Web Site Policy

Young AS, Sullivan G, Duan N. Patient, provider, and treatment factors associated with poor-quality care for schizophrenia. Ment Health Serv Res. 1999 Dec;1(4):201-11. PubMed External Web Site Policy

Extent of Measure Testing

The measure has been pilot tested in 2 institutions for more than 1 year.

Evidence for Extent of Measure Testing

Young AS, Sullivan G, Burnam MA, Brook RH. Measuring the quality of outpatient treatment for schizophrenia. Arch Gen Psychiatry. 1998 Jul;55(7):611-7. PubMed External Web Site Policy

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Behavioral Health Care

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Time window precedes index event

Denominator Inclusions/Exclusions

Inclusions
Eligible patients include adults greater than or equal to 18 years with the diagnosis of schizophrenia or schizoaffective disorder who had been in treatment for at least 3 months and who had at least 1 visit with a psychiatrist during the previous 3 months

Exclusions
Patients with more than 21 days in the hospital during the previous 3 months

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Poor-quality medication management is defined as either poor-quality symptom management* or poor-quality side effects management.**

*Poor-quality symptom management: Patients with significant psychotic symptoms+ and no change in antipsychotic medication dosage or a switch to a different antipsychotic medication within 3 months, and not been offered treatment with clozapine (a medication with greater efficacy)

**Poor-quality side effects management:

  • Patients with significant akathisia++ or parkinsonism++ and no reduction in the dose of antipsychotic medication, switch to a different antipsychotic medication, or change in anti-side-effect medication within 1 month, and not been offered treatment with clozapine or risperidone (medications with fewer side effects)
  • Patients with significant tardive dyskinesia (TD)++ and no reduction in the dose of antipsychotic medication within 3 months, and not been offered treatment with clozapine (a medication that causes no TD)
  • Patients with significant (1) weight gain++, defined as (a) Body Mass Index less than 30 or less than 27 plus diabetes, hypertension, or cardiovascular disease, and (b) has not lost 8% or more of weight in the past 6 months; and, (2) (a) treated with an antipsychotic medication with weight gain potential (all antipsychotic medications except: ziprasidone, aripiprazole, and first-generation medications other than chlorpromazine or thioridizine), and (b) not switched to a medication with less weight gain potential or prescribed an augmenting weight loss medication within the past 3 months.

+Patients are defined as having significant psychotic symptoms if Brief Psychiatric Rating Scale ratings are "severe" or greater for hallucinations or suspiciousness, or "moderately severe" or greater for unusual thought content or conceptual disorganization.

++Patients are defined as having significant akathisia if they meet Barnes criteria for moderate, marked, or severe akathisia; significant parkinsonism if they respond "a great deal" to items regarding muscle stiffness or slowing of movements; and significant tardive dyskinesia if their Abnormal Involuntary Movement Scale ratings meet criteria described by Schooler and Kane (Schooler NR, Kane JM. Research diagnoses for tardive dyskinesia. Arch Gen Psychiatry 1982 Apr;39[4]:486-7). Weight gain potential is reviewed by Newcomer (Newcomer JW: Metabolic considerations in the use of antipsychotic medications: a review of recent evidence. J Clin Psychiatry. 2007; 68 Suppl 1: 20-7.)

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Paper medical record

Patient/Individual survey

Pharmacy data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

  • Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Patient Edition
  • Brief Psychiatric Rating Scale (BPRS)
  • Barnes scale
  • Liverpool University Neuroleptic Side Effect Rating Scale
  • Abnormal Involuntary Movement Scale
  • Global Assessment of Functioning (GAF)

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Poor Quality Medication Treatment: the appropriateness of medication management.

Measure Collection Name

Method for Assessing Quality in Schizophrenia (MAQS)

Submitter

Young, Alexander S., MD, MSHS; Veterans Administration Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC); and University of California Los Angeles

Developer

Young, Alexander S., MD, MSHS; Veterans Administration Desert Pacific Mental Illness Research, Education and Clinical Center (MIRECC); and University of California Los Angeles

Funding Source(s)

Support was provided for this work by the Department of Veterans Affairs, by the Robert Wood Johnson Foundation Clinical Scholars Program, by a National Alliance for Research on Schizophrenia and Depression Young Investigator Award, and by the National Institute of Mental Health University of California, Los Angeles Research Center on Managed Care for Psychiatric Disorders.

Composition of the Group that Developed the Measure

Alexander S. Young, MD, MSHS, UCLA, Los Angeles California, and the Department of Veterans Affairs, Los Angeles, California; Greer Sullivan, MD, MSPH, Department of Veterans Affairs, Little Rock, Arkansas, and the University of Arkansas for Medical Science, Little Rock, Arkansas; M. Audrey Burnam, PhD, The RAND Corporation, Santa Monica, California

Financial Disclosures/Other Potential Conflicts of Interest

None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

1997 Sep

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in March 2016.

Source(s)

Young AS, Niv N, Cohen AN, Kessler C, McNagny K. The appropriateness of routine medication treatment for schizophrenia. Schizophr Bull. 2010 Jul;36(4):732-9. PubMed External Web Site Policy

Young AS, Sullivan G, Burnam MA, Brook RH. Measuring the quality of outpatient treatment for schizophrenia. Arch Gen Psychiatry. 1998 Jul;55(7):611-7. PubMed External Web Site Policy

Measure Availability

Source not available electronically.

For more information, contact Alexander Young, MD, MSHS, at the West Los Angeles VA Healthcare Center, VISN 22 MIRECC, 11301 Wilshire Blvd. (210A), Los Angeles, CA 90073; Phone: 310-268-3647.

NQMC Status

This NQMC summary was completed by ECRI on June 6, 2003. The information was verified by the measure developer on July 11, 2003.

This NQMC summary was retrofitted into the new template on May 24, 2011.

The information was reaffirmed by the measure developer on March 11, 2016.

Copyright Statement

No copyright restrictions apply.

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