Faculty Bibliography

The authors surveyed pharmacotherapy in a group of 136 newly admitted patients with a DSM-III diagnosis of schizophrenia. They found that nine antipsychotic agents were used; the median daily dose (in chlorpromazine equivalents) was 1088 mg (mean +/- SD = 1428 +/- 1260 mg; range = 75-6186 mg). Women received greater mean daily doses of antipsychotics than men (1688 versus 1284 mg). Using a Cox model survival analysis, the authors found no statistical association between length of stay and the mean daily dose of antipsychotic medication. The mean daily dose of high-potency agents was 2.7 times greater than the dose of low-potency agents. The excess exposure to haloperidol alone resulted in 16.3% of the overall neuroactive drug costs

Our purpose was to evaluate the analgesic efficacy of single oral doses of ketoprofen 25, 50, and 100 mg compared with aspirin 650 mg and placebo in the relief of moderate to severe postepisiotomy, uterine cramping, or cesarean section pain. One hundred and fifty-six patients participated in a randomized, double-blind, stratified, parallel-group study. They were observed over a six-hour period by one nurse-observer. Several of the standard summary measures of analgesia were derived from the interview data, including the sum of pain intensity differences (SPID) and the sum of the hourly relief values (TOTAL). The study showed significant differences between aspirin and placebo for four-hour SPID and several other parameters and between ketoprofen at all dose levels and placebo for the four- and six-hour SPID and many other parameters. The two higher doses of ketoprofen were significantly more effective than aspirin as as assessed by the four- and six-hour SPID, TOTAL, and other summary measures. The low dose of ketoprofen, although not significantly different from aspirin for SPID and TOTAL, showed a significantly faster onset of relief and had a better global rating. This study suggests that 50 mg of ketoprofen may be the clinical dose of choice as an analgesic. There were no adverse effects reported.

Statistical problems in clinical trials frequently involve fitting regression lines when the underlying data are categorical or ordinal response variables. Usually an ad hoc a priori quantification is used to assign values to these ordinal responses. For pain intensity data collected in analgesic trials, the usual approach is to set none equal to 0, mild equal to 1, moderate equal to 2, and severe equal to 3. While this scheme has been generally accepted, on the basis that for similar clinical trials reasonably similar results are obtained by different investigators, concern exists that the distances between pain scores are probably not equal. A method is presented for quantifying categorical responses so that the resulting scores maximize the simultaneous fit of the dose-response regression lines. The optimal scores derived by this technique may then be used in a bioassay analysis to estimate the relative potency of 2 compounds. As illustrative examples, this method was applied to data from 2 clinical trials and the results were compared to the usual method.

A clinical trial comparing ibuprofen, 400, 600, and 800 mg, with aluminum ibuprofen, 400 mg, and placebo was conducted in patients with moderate or severe pain subsequent to third molar extraction. Pain intensity ratings and ibuprofen serum levels were obtained at baseline, 30 minutes, 1 hour, and hourly thereafter for 3 hours. Pain intensity ratings were also obtained at hours 4, 5, and 6. Serum levels at 1, 2, and 3 hours correlated significantly with the log dose of ibuprofen (r = 0.35, 0.49, and 0.48, respectively) and with global analgesic response as measured by the percentage of the sum of the pain intensity scores (r = 0.28, 0.34, and 0.26, respectively). However, possibly because of differences in drug formulation, the percentage of the sum of the pain intensity scores did not correlate significantly with log dose. The highest correlations were found between contemporaneous serum levels and pain intensity difference values, particularly at hour 1 (r = 0.54). Our results support the proposition that increased ibuprofen serum levels lead to increased analgesia

A statistical methodology based on the Cox proportional hazards model (a survival time analysis method), an alternative to the approach underlying DRGs, is presented. The method is used to obtain an estimate of the length-of-stay (LOS) distribution of a patient incorporating either patient-specific or hospital variables. A percentile of the distribution chosen to minimize prediction error serves as the assigned LOS. Absolute deviation is used as the loss function both to determine the choice of a predicted LOS and to examine how well the scheme works. Multiple assignment schemes may also be developed from this approach. The results of the method, tested on a national probability sample of 4,608 psychiatric patients treated in psychiatric units of general hospitals, suggest that with respect to average absolute deviation, the proposed methodology may provide a scheme that is superior to the present DRG scheme. For the sample, the average percent improvement obtained using the median of the estimated LOS distribution as the predicted LOS over the sample mean of the DRG group is 19%. A two assignment strategy results in average improvements over DRGs of 43%

Legislative mandates for the development of prospective payment methodologies for reimbursing inpatient care have spurred the psychiatric community into its own independent effort, applying both clinical and service research, to develop schemes which are fair to psychiatric patients, their providers and payers. Many of the issues involved in the development of an equitable prospective payment system (PPS) for psychiatric care are not new to the field, namely, problems of limited diagnostic accuracy, a limited knowledge of the outcomes of clearly defined treatment protocols, and a lack of integration, efficiency and efficacy in a highly differentiated service system. The research community needs to respond to these problems in the context of cost containment with an awareness that its response will influence care for psychiatric patients for the remainder of this century. In this paper, we will describe the background issues that have brought the psychiatric community to the present point in its response to PPS, and discuss some of the research problems posed by the need for a PPS with the right incentives for clinical effectiveness and efficiency

A follow-up study of a cohort of suburban alcoholics who are comprehensively served by the public mental health sector used a Cox survival time analyses to examine the relationship of patient characteristics, receipt of outpatient services and readmission to inpatient care. Patients were followed up until their first readmission to inpatient care or for 2 yr subsequent to an inpatient episode. As expected, established chronicity was associated with short 'survival' in the community, as were youth and living alone. For first admissions, the receipt of aftercare was associated with a decreased likelihood of readmission, especially in conjunction with inpatient stays of treatment that included rehabilitation services. Patients who had established a pattern of chronicity, however, appeared resistant to the effect of these services. The transition from inpatient to aftercare services was identified as a crucial point in treatment. Aftercare patients who did not receive services beyond 6 months in the community were likely to be readmitted, suggesting that this period is also an important focus for treatment planning

A study was carried out across 11 psychiatric and mental retardation, and developmental disabilities facilities to investigate the impact of a computerized drug prescription monitoring system on clinicians' prescribing behavior, knowledge of pharmacotherapy, attitudes toward computers, and the relationships between their attitudes and changes in their prescribing practices. The results document that surveillance systems can improve prescribing practices. The tangible feedback provided by the exception report, although in the form of a surveillance mechanism, also increased user acceptance to computer technology. However, the findings also suggest that user acceptance is not necessarily required to see positive effects, which in environments where clinical and fiscal accountability are paramount, may override some clinicians' concerns. Attention to human factors components may help to alleviate some negativism