Does not apply to this measure

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.

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.

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

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

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 in ththe Complete Summary).

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

Overall poor quality for the performance measured
Variation in quality for the performance measured

Current routine use

Internal quality improvement

Ambulatory Care
Behavioral Health Care

Physicians

Single Health Care Delivery Organizations

Age greater than or equal to 18 years

Either male or female

Unspecified

Schizophrenia occurs in about 1% of the population.

• Young AS. Personal communication: NQMC submission form. 2002 Dec 27.  3 p.

Unspecified

Schizophrenia is a chronic, disabling brain disorder that accounts for more than 10% of all disabled people in the United States (U.S.).

• Young AS. Personal communication: NQMC submission form. 2002 Dec 27.  3 p.

Unspecified

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).

• Young AS. Personal communication: NQMC submission form. 2002 Dec 27.  3 p.

Living with Illness

Effectiveness

Users of care only

Adult patients 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

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

All cases in the denominator are equally eligible to appear in the numerator

Clinical Condition
Diagnostic Evaluation

Time window precedes index event

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)

  ⁺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.

• **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 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).

Exclusions
Unspecified

The measure results are somewhat or substantially under the control of the health care professionals, organizations and/or policymakers to whom the measure applies.

Fixed time period

Medical record
Patient survey
Pharmacy data

Individual Case

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

Rate

Better quality is associated with a lower score

Unspecified

Internal time comparison

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

Poor Quality Medication Treatment: the appropriateness of medication management.

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

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.

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

None

Measure was not adapted from another source.

1997 Sep

This is the current release of the measure.

The individual measure, "Poor Quality Medication Treatment: the Appropriateness of Medication Management," is published in "Measuring the Quality of Outpatient Treatment for Schizophrenia."

For further information, contact: Alexander Young, M.D., M.S.H.S., West Los Angeles VA Healthcare Center, VISN 22 MIRECC, 11301 Wilshire Blvd. (210A), Los Angeles, CA 90073; Phone: 310-268-3647.

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

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