Emily McKenzie

Essential Evidence-Based Components of First-Episode Psychosis Services

OBJECTIVE The purpose of this study was to identify essential evidence-based components of first-episode psychosis services. METHODS The study was conducted in two stages. In the first stage a systematic review of both peer-reviewed and gray literature (January 1980 to April 2010) was conducted. Databases searched included MEDLINE, PsycINFO, and EMBASE. In the second stage, a consensus-building technique, the Delphi, was used with an international panel of experts. The panelists were presented the evidence-based components identified in the review, together with the level of supporting evidence for each component. They rated the importance of each component on a 5-point scale. A score of 5 was required to determine that a component was essential. RESULTS The review identified 1,020 citations; abstracts were reviewed for relevance. A total of 280 peer-reviewed articles met criteria for relevance. Two researchers independently reviewed these articles and identified 75 unique service components. Each component was assigned a level of supporting evidence. Twenty-seven experts completed the first Delphi round, of whom 23 participated in the second. Consensus was achieved in two rounds, with 32 components rated as essential. CONCLUSIONS The two-step process yielded a manageable list of 32 evidence-based components of first-episode psychosis services. Given the proliferation of such services and the absence of an evidence-based fidelity scale, this list can form a foundation for developing a fidelity scale for such services. It may also be helpful to funders and providers as a summary of essential services.

Relationship Between Relapse and Hospitalization in First-Episode Psychosis

OBJECTIVE Relapse is a frequently used outcome measure in schizophrenia research. However, difficulties in reliably measuring relapse diminish its usefulness. Hospitalization is a potential alternative, but its relationship to relapse has not been assessed. METHODS This study used data from a two-year, prospective study to examine associations between relapse and hospitalization in a cohort of 200 Canadian patients with first-episode psychosis. First, the relationship between relapse and hospitalization was assessed by cross-tabulating relapse and hospitalization. Next, survival curves of time to first relapse or hospitalization were compared. Finally, to examine the convergent validity of relapse and hospitalization, the predictive capacity of three predictors were examined: a substance use disorder diagnosis, prior hospitalization, and medication adherence. RESULTS Rates of both relapse and hospitalization were similar. During the two-year follow-up, 37% of the patients experienced a relapse, and 26% were hospitalized. As an indicator of relapse, hospitalization had a low sensitivity (47%) and high specificity (87%). A higher risk of hospitalization and relapse was associated with prior hospitalization, a substance use disorder diagnosis, and medication nonadherence. CONCLUSIONS Results indicated that relapse and hospitalization are separate but related outcome measures. They had similar frequencies and were found to have similar relationships with some predictors. Relapse is a more useful outcome measure in smaller clinical studies in which routine standardized clinical measures can be used. Hospitalization is more relevant in larger studies or as a quality indicator for studies using administrative databases, and it serves as a good measure for quality management in health systems.

Patient and Family Member-Led Research in the Intensive Care Unit: A Novel Approach to Patient-Centered Research.

Introduction Engaging patients and family members as partners in research increases the relevance of study results and enhances patient-centered care; how to best engage patients and families in research is unknown. Methods We tested a novel research approach that engages and trains patients and family members as researchers to see if we could understand and describe the experiences of patients admitted to the intensive care unit (ICU) and their families. Former patients and family members conducted focus groups and interviews with patients (n = 11) and families of surviving (n = 14) and deceased (n = 7) patients from 13 ICUs in Alberta Canada, and analyzed data using conventional content analysis. Separate blinded qualitative researchers conducted an independent analysis. Results Participants described three phases in the patient/family “ICU journey”; admission to ICU, daily care in ICU, and post-ICU experience. Admission to ICU was characterized by family shock and disorientation with families needing the presence and support of a provider. Participants described five important elements of daily care: honoring the patient’s voice, the need to know, decision-making, medical care, and culture in ICU. The post-ICU experience was characterized by the challenges of the transition from ICU to a hospital ward and long-term effects of critical illness. These “ICU journey” experiences were described as integral to appropriate interactions with the care team and comfort and trust in the ICU, which were perceived as essential for a community of caring. Participants provided suggestions for improvement: 1) provide a dedicated family navigator, 2) increase provider awareness of the fragility of family trust, 3) improve provider communication skills, 4) improve the transition from ICU to hospital ward, and 5) inform patients about the long-term effects of critical illness. Analyses by independent qualitative researchers identified similar themes. Conclusions Patient and family member-led research is feasible and can identify opportunities for improving care.

Stakeholder Engagement to Identify Priorities for Improving the Quality and Value of Critical Care.

Background Large amounts of scientific evidence are generated, but not implemented into patient care (the ‘knowledge-to-care’ gap). We identified and prioritized knowledge-to-care gaps in critical care as opportunities to improve the quality and value of healthcare. Methods We used a multi-method community-based participatory research approach to engage a Network of all adult (n = 14) and pediatric (n = 2) medical-surgical intensive care units (ICUs) in a fully integrated geographically defined healthcare system serving 4 million residents. Participants included Network oversight committee members (n = 38) and frontline providers (n = 1,790). Network committee members used a modified RAND/University of California Appropriateness Methodology, to serially propose, rate (validated 9 point scale) and revise potential knowledge-to-care gaps as priorities for improvement. The priorities were sent to frontline providers for evaluation. Results were relayed back to all frontline providers for feedback. Results Initially, 68 knowledge-to-care gaps were proposed, rated and revised by the committee (n = 32 participants) over 3 rounds of review and resulted in 13 proposed priorities for improvement. Then, 1,103 providers (62% response rate) evaluated the priorities, and rated 9 as ‘necessary’ (median score 7–9). Several factors were associated with rating priorities as necessary in multivariable logistic regression, related to the provider (experience, teaching status of ICU) and topic (strength of supporting evidence, potential to benefit the patient, potential to improve patient/family experience, potential to decrease costs). Conclusions A community-based participatory research approach engaged a diverse group of stakeholders to identify 9 priorities for improving the quality and value of critical care. The approach was time and cost efficient and could serve as a model to prioritize areas for research quality improvement across other settings.

Validity of Hospital Admission as an Outcome Measure of Services for First-Episode Psychosis

OBJECTIVE The objective of this study was to assess the external validity of hospitalization as an outcome measure for first-episode psychosis services. METHODS A two-year, prospective cohort design was used to examine the associations between hospitalization, general psychopathology, and quality of life in a cohort of 606 participants treated for a first episode of psychosis. RESULTS In bivariate analyses, general psychopathology and quality of life were each significantly associated with hospitalization at both time points. After analyses controlled for all covariates in the logistic models, both clinical measures continued to be significantly correlated with hospitalization at both one and two years. CONCLUSIONS These results validate hospitalization as an outcome measure for first-episode psychosis services, and they extend the existing research showing a relationship between hospitalization and process measures to include other valid and reliable clinical measures.

Development and Testing of the First-Episode Psychosis Services Fidelity Scale

OBJECTIVE The purpose of this study was to test the reliability and validity of the First-Episode Psychosis Services Fidelity Scale (FEPS-FS) and compare it with similar scales. METHODS A fidelity scale was developed from previously identified essential components of first-episode psychosis services. The scale was tested in six programs in two countries and compared with three existing scales. RESULTS Program data collection from multiple sources indicated the feasibility and reliability of the FEPS-FS (intraclass correlation coefficient for interrater reliability=.842; 95% confidence interval=.795-.882). Satisfactory programs scored an average of 86% of the maximum total score; the single unsatisfactory program scored 70%. Compared with the other scales, the FEPS-FS has fewer items, but it has the highest proportion of items common to all scales. CONCLUSIONS The FEPS-FS is a feasible, compact, reliable, and valid measure of adherence to evidence-based practices for first-episode psychosis services that can be applied to any first-episode psychosis service.

Conformance to evidence-based treatment recommendations in schizophrenia treatment services.

Objective: To assess quality of health care provided in a representative Canadian mental health service using conformance to evidence-based treatment recommendations, and to examine differences from published US results. Method: We used a cross-sectional cohort design involving a randomly selected sample of patients diagnosed with schizophrenia attending 1 of 3 mental health clinics in 1 Canadian regional health system. The sample size was calculated to detect differences with the US sample. Conformance criteria were based on a published protocol. Data were collected using patient interviews and a structured review of health records. Conformance to 9 key Schizophrenia Patient Outcomes Research Team recommendations was assessed. Results: Conformance ranged between 58% and 90% for pharmacological recommendations, and 0% to 81% for psychosocial recommendations. No patients who met criteria for assertive case management had been referred to an assertive case management team. Significant differences in conformance rates to some treatment recommendations were found between Canadian and published US results. Conclusions: It proved possible to assess health care quality using process measures of conformance to treatment recommendations. Conformance to clinical recommendations for pharmacotherapy is higher than for psychosocial therapies. The absence of barriers to access for pharmacological therapies likely enhances the higher conformance to these recommendations. Limited or variable access to psychosocial services, specifically assertive community treatment, likely negatively affects conformance to psychosocial treatment recommendations. Methodological limitations preclude drawing conclusions on comparisons between Canadian and US services.

Performance measures for evaluating services for people with a first episode of psychosis

Aim:  The purpose of this project was to operationalize and apply a previously identified set of performance measures designed to evaluate services for those experiencing a first episode of a schizophrenia spectrum disorder.

A comparison of early psychosis treatment services using consensus and evidence‐based performance measures: moving towards setting standards

Objective: This study used data from two Canadian early psychosis programs to assess the feasibility of using common performance measures and to assess the extent to which each program meets suggested standards for early intervention.