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CLINICAL SYNTHESIS   |    
Performance in Practice: Clinical Module for the Care of Patients With Posttraumatic Stress Disorder
Farifteh F. Duffy, Ph.D.; Laura J. Fochtmann, M.D.; Thomas Craig, M.D.; Joyce C. West, Ph.D., M.P.P.; Eve K. Mościcki, Sc.D., M.P.H.
FOCUS 2013;11:341-349. doi:10.1176/appi.focus.11.3.341
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Author Information and CME Disclosure

Farifteh F. Duffy, Ph.D., American Psychiatric Foundation, American Psychiatric Institute for Research and Education, Arlington VA

Laura J. Fochtmann, M.D., Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook NY

Thomas Craig, M.D., Springfield, VA

Joyce C. West, Ph.D., M.P.P., American Psychiatric Foundation, American Psychiatric Institute for Research and Education, Arlington VA

Eve K. Mościcki, Sc.D., M.P.H., American Psychiatric Foundation, American Psychiatric Institute for Research and Education, Arlington VA

All authors report no competing interests.

Adapted from Performance in Practice: Clinical Tools to Improve the Care of Patients with Posttraumatic Stress Disorder (Duffy FF, Craig T, Moscicki EK, West JC, Fochtmann LJ [Focus 2009; 7(2):186-191). This update includes DSM-5 changes in the diagnostic criteria for PTSD and the most recent evidence-based recommendations derived from practice guidelines.

This work was supported in part by the Department of Defense Concept Award #W81XWH-08-1-0399, the American Psychiatric Foundation Barriers to Care Grant, and by the American Psychiatric Association.

Address correspondence to Farifteh Duffy, Ph.D., American Psychiatric Institute for Research and Education, 1000 Wilson Blvd, Suite 1825, Arlington, Virginia, 22209; e-mail: fduffy@psych.org

The American Psychiatric Association’s (APA) Performance in Practice (PIP) clinical modules are designed to meet the requirements of the American Board of Medical Specialties (ABMS) and American Board of Psychiatry and Neurology (ABPN) Part IV of Maintenance of Certification (MOC), which will be in full effect by 2017. Part IV of the MOC, Practice Performance Assessment, is intended to assist in physicians’ evaluation of the quality of care provided in their practice, compared with peers and national benchmarks, and to facilitate practice improvements through the incorporation of best evidence or consensus recommendations to improve patient care. Physicians are required to complete one PIP unit every 3 years. There are two components for each PIP unit: the Clinical Module, consisting of chart reviews of at least five patients in a specific category; and the Feedback Module, requiring collection of feedback surveys from at least five peers and five patients. The chart review displayed below is designed as a Clinical Module to facilitate physician practice assessment. The peer and patient feedback modules are beyond the scope of this report.

There are three stages involved in each PIP unit [ABPN 2013 – (1)]:

  • STAGE A, the baseline retrospective chart review of at least 5 patients in a specified category, which is then compared with “published best practices, practice guidelines or peer-based standards”

  • STAGE B, the design and implementation of a clinical practice improvement plan

  • STAGE C, subsequent remeasurement via a second chart review of 5 patients within the same category within 2 years after the initial chart review. Although the MOC program requires the review of at least five patients as part of each PIP unit, it is important to note that larger samples, i.e. reviews of more than 5 charts, will provide more accurate estimates of quality within a practice.

The PIP module presented in Table 1 provides STAGE A, retrospective chart review for the assessment of care given to patients who meet DSM−5 criteria for posttraumatic stress disorder (PTSD) or other trauma and stressor-related disorders (2). The measures included in this module are based on recommendations of the 2004 APA Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder (3), the 2010 U.S. Departments of Veterans Affairs and Defense (VA/DoD) Clinical Practice Guideline for the Management of Post-Traumatic Stress Disorder (4), and the 2009 APA Guideline Watch for PTSD (5). The selected practice guideline recommendations that are endorsed with moderate-to-substantial levels of clinical confidence (3), and those endorsed at evidence-rating levels A and B (4) have been highlighted in this module.

The PIP module for PTSD has been designed to be relevant across clinical settings (e.g. inpatient, outpatient), straightforward and easy to complete, and usable in a pen-and-paper format to aid adoption. As with other retrospective chart reviews, some questions on the form relate to the initial assessment and treatment of patients, whereas others relate to subsequent care. In general, treatment options for newly diagnosed patients who are being treated for the first time should judiciously follow the first-line evidence-based treatment recommendations. On occasion, however, there may be appropriate clinical reasons for deviation from recommended care, including patient preferences, co-occurring psychiatric or medical conditions and therapeutic benefits or side effects of prior treatments.

American Psychiatric Association:  Diagnostic and Statistical Manual of Mental Disorders , 5th ed.  Washington, DC,  American Psychiatric Association, 2013
 
Ursano  RJ;  Bell  C;  Eth  S;  Friedman  M;  Norwood  A;  Pfefferbaum  B;  Pynoos  JD;  Zatzick  DF;  Benedek  DM;  McIntyre  JS;  Charles  SC;  Altshuler  K;  Cook  I;  Cross  CD;  Mellman  L;  Moench  LA;  Norquist  G;  Twemlow  SW;  Woods  S;  Yager  J; Work Group on ASD and PTSD; Steering Committee on Practice Guidelines:  Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder.  Am J Psychiatry 2004; 161(Suppl):3–31
[CrossRef] | [PubMed]
 
Management of PTSD Working Group: VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC, Departments of Veterans Affairs and Defense, 2010
 
Benedek  DM;  Friedman  MJ;  Zatzick  D;  Ursano  RJ:  Guideline Watch (Jan 2009): Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder.  Focus 2009; 7:204–213
 
Kilpatrick  DG;  Resnick  HS;  Friedman  MJ:  National Stressful Events Survey PTSD Short Scale   NSESSS-PTSD, 2010
 
Management of SUD Working Group: VA/DOD Clinical Practice Guideline Management for Substance Use Disorders (SUD). Washington, DC, Department of Veteran’s Affairs, Department of Defense, 2009http://www.healthquality.va.gov/Substance_Use_Disorder_SUD.asp
 
Helping Patients Who Drink Too Much: A Clinician’s Guide; U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, NIH Publication 07–3769 www.niaaa.nih.gov/guide Rockville, Md. 2005 edition, reprinted May 2007 http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
 
Gradus  JL;  Qin  P;  Lincoln  AK;  Miller  M;  Lawler  E;  Sørensen  HT;  Lash  TL:  Posttraumatic stress disorder and completed suicide.  Am J Epidemiol 2010; 171:721–727
[CrossRef] | [PubMed]
 
Ustün  TB;  Chatterji  S;  Kostanjsek  N;  Rehm  J;  Kennedy  C;  Epping-Jordan  J;  Saxena  S;  von Korff  M;  Pull  CWHO/NIH Joint Project:  Developing the World Health Organization Disability Assessment Schedule 2.0.  Bull World Health Organ 2010; 88:815–823
[CrossRef] | [PubMed]
 
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References

American Psychiatric Association:  Diagnostic and Statistical Manual of Mental Disorders , 5th ed.  Washington, DC,  American Psychiatric Association, 2013
 
Ursano  RJ;  Bell  C;  Eth  S;  Friedman  M;  Norwood  A;  Pfefferbaum  B;  Pynoos  JD;  Zatzick  DF;  Benedek  DM;  McIntyre  JS;  Charles  SC;  Altshuler  K;  Cook  I;  Cross  CD;  Mellman  L;  Moench  LA;  Norquist  G;  Twemlow  SW;  Woods  S;  Yager  J; Work Group on ASD and PTSD; Steering Committee on Practice Guidelines:  Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder.  Am J Psychiatry 2004; 161(Suppl):3–31
[CrossRef] | [PubMed]
 
Management of PTSD Working Group: VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC, Departments of Veterans Affairs and Defense, 2010
 
Benedek  DM;  Friedman  MJ;  Zatzick  D;  Ursano  RJ:  Guideline Watch (Jan 2009): Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder.  Focus 2009; 7:204–213
 
Kilpatrick  DG;  Resnick  HS;  Friedman  MJ:  National Stressful Events Survey PTSD Short Scale   NSESSS-PTSD, 2010
 
Management of SUD Working Group: VA/DOD Clinical Practice Guideline Management for Substance Use Disorders (SUD). Washington, DC, Department of Veteran’s Affairs, Department of Defense, 2009http://www.healthquality.va.gov/Substance_Use_Disorder_SUD.asp
 
Helping Patients Who Drink Too Much: A Clinician’s Guide; U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, NIH Publication 07–3769 www.niaaa.nih.gov/guide Rockville, Md. 2005 edition, reprinted May 2007 http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
 
Gradus  JL;  Qin  P;  Lincoln  AK;  Miller  M;  Lawler  E;  Sørensen  HT;  Lash  TL:  Posttraumatic stress disorder and completed suicide.  Am J Epidemiol 2010; 171:721–727
[CrossRef] | [PubMed]
 
Ustün  TB;  Chatterji  S;  Kostanjsek  N;  Rehm  J;  Kennedy  C;  Epping-Jordan  J;  Saxena  S;  von Korff  M;  Pull  CWHO/NIH Joint Project:  Developing the World Health Organization Disability Assessment Schedule 2.0.  Bull World Health Organ 2010; 88:815–823
[CrossRef] | [PubMed]
 
References Container
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