The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A New Tool for the Psychosocial Evaluation of Pre-Transplant Candidates

Psychosomatics 2012:53:123–132

© 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Original Research Reports The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A New Tool for the Psychosocial Evaluation of Pre-Transplant Candidates José R Maldonado, M.D., Holly C. Dubois, M.D., Evonne E. David, L.C.S.W., Yelizaveta Sher, M.D., Sermsak Lolak, M.D., Jameson Dyal, B.A., Daniela Witten, Ph.D.

Background: While medical criteria have been well established for each end-organ system, psychosocial listing criteria are less standardized. To address this limitation, we developed and tested a new assessment tool: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT). Methods: The SIPAT was developed from a comprehensive review of the literature on the psychosocial factors that impact transplant outcomes. Five examiners blindly applied the SIPAT to 102 randomly selected transplant cases, including liver, heart, and lung patients. After all subject’s files had been rated by the examiners, the respective transplant teams provided the research team with the patient’s outcome data. Results: Univariate logistic regression models were fit in order to predict the transplant psychosocial outcome (positive or negative) using each rater’s SIPAT scores. These results show that SIPAT scores are

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ecause donated organs are a severely limited resource, the best potential recipients should be identified. The probability of a good outcome must be highly emphasized to achieve the maximum benefit for all transplants.” (From: OPTN/UNOS Ethics Committee General Considerations in Assessment for Transplant Candidacy White Paper–2010).1 Even though the number of transplant surgeries in the USA has continued to rise over the last 18 years, it has not kept pace with the number of patients on the transplant list.2 In fact, the transplant wait list has increased 7-fold during the last 20 years.2– 4 As a result, the number of deaths while on the waiting list has steadily increased and is now over 7100 Psychosomatics 53:2, March-April 2012

highly predictive of the transplant psychosocial outcome (P ⬍ 0.0001). The instrument has excellent inter-rater reliability (Pearson’s correlation coefficient ⫽ 0.853), even among novice raters. Conclusions: The SIPAT is a comprehensive screening tool to assist in the psychosocial assessment of organ transplant candidates. Its strengths includes the standardization of the evaluation process and its ability to identify subjects who are at risk for negative outcomes after the transplant, in order to allow for the development of interventions directed at improving the patient’s candidacy. Our goal is that the SIPAT, in addition to a set of agreed upon minimal psychosocial listing criteria, would be used in combination with organ-specific medical listing criteria in order to establish standardized criteria for the selection of transplant recipients. (Psychosomatics 2012; 53:123–132)

deaths a year.4 Parallel to this, the number of living donors has tripled, from 1829 in 1988 to 6561 in 2010.4,5 The inReceived April 3, 2011; revised December 25, 2011; accepted December 27, 2011. From Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine (JRM, HCD, YS, SL); Department of Social Work & Case Management, Stanford Hospital and Clinics Stanford University, Stanford, CA (ED); Department of Human Biology, School of Humanities and Sciences, Stanford University, Stanford, CA (JD); Department of Biostatistics, University of Washington, Seattle, WA (DW). Send correspondence and reprint requests to José R, Maldonado, M.D., Associate Professor of Psychiatry, Medicine, Surgery, and Law, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stanford, CA 94305; e-mail: [email protected] © 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

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SIPAT: Tool for Psychosocial Evaluation of Transplant Candidates creased use of living donors has added a new dimension and set of complexities to the ethical debate with respect to recipient selection as the potential for harm (to the donor) makes graft failure due to non-adherence or other psychosocial factors a more painful reality. Despite the advances in surgical techniques and immunosuppression, there has been little change in the method by which transplant selection committees evaluate psychosocial risk in potential transplant recipients. The selection process should be considered a continuum from (1) the determination that a patient suffers from end-stage organ disease; (2) to an assessment for indications for transplantation; (3) to a parallel screening for both medical and psychosocial fitness and/or contraindications to transplantation; (4) to being wait-listed for the specific organ transplant, (5) to transplantation (see Figure 1). Previously Existing Tools for Psychosocial Assessment of Transplant Patients When we started this project, there were three tools already available. The Psychosocial Assessment of CanFIGURE 1.

Road to Transplantation.

didates for Transplantation (PACT) consists of eight items, each rated on a 5-point scale, plus the rater’s overall impressions.6 The Psychosocial Levels System (PLS) assesses patients on three gradations of intensity, taking into account seven psychosocial variables, suggesting it was “the first stage in developing a system to reliably identify high-risk BMT patients at the onset of medical treatment,”7 The Transplant Evaluation Rating Scale (TERS), a revision of the PLS, consists of 10 items rated on a 3-point scale and provides a single summary score that indicates a patient’s current level of functioning as well as a weighted score for each variable, suggesting it “can become a valuable instrument enabling consultants to organ transplant programs to predict patients’ psychosocial adjustment.”8 Each scale has different interpretative characteristics. After the original paper, nothing further has been published using the PLS, which seems to have been replaced by the TERS. One study compared the PACT vs. TERS on candidates for bone marrow transplant (BMT) and found comparable inter-rater reliability, although the authors suggest that “the 5-point scaling of PACT items allows more leeway in making ratings.”9 In addition, the PACT allows for a clinician’s subjective experience (via the “final rating”) to overcome the total items score thus defeating the attempt at objectivity.9 A more recent study explored the association of the PACT subscales and the final rating with 16 post-transplant medical outcomes and found significant relationships (P ⱕ 0.05) between PACT subscales and several medical outcomes, yet the final rating score and medical outcomes were not significantly correlated.10 There is no data regarding how widespread their use is. Rationale for the Development of a Standardized Approach The main issue in the assessment of any patient being considered as a potential transplant recipient resides in whether the patient meets medical and psychosocial listing criteria. Minimal medical listing criteria have been relatively well established by the United Network for Organ Sharing (UNOS), and more specifically defined for each end organ system (see Table 1).11–15 On the other hand, psychosocial listing criteria are less standardized, both regarding tools and techniques used. Unfortunately, OPTN/UNOS guidelines regarding the psychosocial evaluation process are too broad and provide little direction: “All transplant programs should identify appropriately trained individuals who are designated members of the transplant team and have primary responsi-

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Maldonado et al.

TABLE 1. End Organ Liver

Heart

Lung Kidney

Pancreas

U.S. Transplantation Medical Criteria Medical Criteria Model for endstage liver disease (MELD) New York Heart Association (NYHA) functional classification Lung allocation system (LAS) Kidney allocation score (KAS) Pancreas allocation system (PAS)

Developing Entity

Reference

Mayo Clinic

(11)

NYHA

(12)

OPTN/UNOS

(13)

UNOS

(14)

OPTN/UNOS Pancreas Transplantation Committee

(15)

NYHA ⫽ New York Heart Association; OPTN ⫽ National Organ Procurement and Transplantation Network; UNOS ⫽ United Network for Organ Sharing.

bility for coordinating the psychosocial needs of transplant candidates, recipients, living donors and families (OPTN Evaluation Plan, page IV-6).”16 The OPTN/UNOS Ethics Committee recognized that “the concept of non-medical transplant candidate criteria is an area of great concern. Most transplant programs in the United States use some type of non-medical evaluation of patients for transplantation. . . There is general agreement that non-medical transplant candidate criteria need to be evaluated. The legitimate substance of such an evaluation could cover a very wide range of topics.”17 Published and anecdotal data reveal that transplant programs and psychosocial evaluators (i.e., transplant social workers) and expert consultants (e.g., transplant psychiatrists and psychologists) utilize different techniques and psychosocial eligibility criteria to evaluate prospective transplant candidates.18,19 Furthermore, several literature reviews have demonstrated that there is a relative absence of evidence-based guidelines for pre-transplant psychosocial and behavioral screening.20,21 In fact, a 20-year qualitative review demonstrated that psychosocial assessments differ in content and application to candidate selection depending on the transplant program.22 A survey of transplant psychosocial experts provided evidence for the need of expanding routine screening and support services to candidates for and recipients of transplants.18 Even though there are no national standards or psychosocial minimal Psychosomatics 53:2, March-April 2012

listing criteria, a survey of transplant programs found there were certain conditions (i.e., current addictive drug use, active schizophrenia, current heavy alcohol use, history of multiple suicide attempts, current suicide ideation, dementia) which were endorsed as “absolute contraindication to transplantation” by 70% of responders.23 Despite the lack of psychosocial criteria standardization, psychosocial consultants positively contribute to the ultimate transplant success by enhancing the assessment of patients being considered for transplantation.21,23–26 This can most effectively be done by focusing on risk factors that are associated with poor adherence/compliance and ultimate medical and psychosocial transplant success.27–33 The psychosocial evaluation should serve to identify patient’s level of social, neuropsychiatric and cognitive functioning, assist in the development of a psychosocial treatment plan to address current social and psychiatric problems and help minimize preventable problems, and implement appropriate treatments in order to reduce harm, mitigate risk and optimize graft survival and the patient’s level of functioning and quality of life post-transplantation (see Table 2). Data suggest that there is not only a strong association between pre-transplant psychosocial vulnerability markers and post-transplant psychosocial outcome,34 but also between specific psychosocial factors and ultimate transplant success or failure.22,23,26, 28,32,35– 48 In fact, one study demonstrated that many pre-transplant psychosocial problems continued after transplantation; and that psychiatric problems after transplantation led to a higher risk of infection, hospital readmissions, and higher medical costs.49 Others have demonstrated that the global psychosocial risk was associated with the number of rejection episodes and medication adherence after transplantation.50 Another study TABLE 2.

● ● ●

●

Goals of a Psychosocial Pre-Transplant Evaluation [Source: (40)]

Promoting fairness and equal access to care Maximizing optimal outcomes and wisely use scarce resources Ensuring that the potential for benefits outweigh surgical risks to the patient by identifying potential risk factors (i.e., substance abuse, compliance issues, serious psychopathology) that may result in increased risk of postoperative non-compliance & morbidity Providing information to develop treatment planning for individuals at high risk: – Identifying patient’s level of neuropsychiatric and cognitive functioning – Developing a psychiatric treatment plan to address current psychiatric problems and help minimize preventable problems – Implementing appropriate treatments that reduce harm and mitigate risk

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SIPAT: Tool for Psychosocial Evaluation of Transplant Candidates found that increasing psychiatric risk classification (i.e., high risk versus acceptable versus good candidates) was associated with a greater hazard of post-transplant mortality.33 A total of five psychosocial variables (i.e., previous suicide attempts, poor adherence to medical recommendations, past history of substance abuse, and depression) were significantly associated with shortened post-transplant survival and/or greater risk for post-transplant infection.33 In fact, differences among risk groups emerged early in the post-transplant process, with patients in the High Risk group experiencing greater mortality shortly after transplant, compared with the Acceptable and Good groups.33 More recently, a prospective study demonstrated that selected pre-transplant psychosocial factors predicted both post-transplant non-adherence to treatment and poor clinical outcome (i.e., non-adherence to immunosuppressant medications, late acute rejection, graft loss, and resource utilization), after controlling for medical predictors of poor outcome.29

Development of the SIPAT When we reviewed the psychosocial evaluation process of the various transplant programs within our institution, we discovered we were assessing dozens of psychological and social factors (i.e., a comprehensive psychiatric examination, plus various pieces of social demographical information). At that point the question was whether the current process was useful (i.e., predictive of transplant outcome) and whether there was a better way to do it. So we began to scrutinize what we were doing and looked into the published literature for those psychosocial variables that are supported by evidence-based data for treatment adherence, quality of life, and graft survival.40 We concluded that in order to minimize potential selection bias a tool that attempted to objectively assess complex psychosocial data would be desirable. We started with our own old screening questionnaire and added and deleted items based on our extensive review of the literature. The result was a new comprehensive pre-transplant organ evaluation instrument: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) (see Appendix 1 for the SIPAT tool and scoring instructions. The extended questionnaire used for all transplant evaluations is available at the Stanford’s Psychosomatic Medicine Website ⬍http://psychiatry.stanford.edu/Psychosomatic⬎). The SIPAT intends to assess the psychosocial factors that appear to better predict patients’ adherence and graft survival. We divided these 18 identified risk factors into four domains, 126

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including patients’ readiness, social support, psychological stability, and substance abuse (see Table 3).40 Based on the assessment of these factors, the SIPAT provides an overall risk severity score for psychosocial variables important in predicting post-transplant behavior, psychosocial support viability and effectiveness, treatment adherence, substance abuse, and recidivism and mental health. Studies have shown that the psychosocial and behavioral characteristics were comparable among solid organ, pre-transplant candidates.37 Thus instead of performing the pre-transplant psychosocial screening in an organ-specific fashion, we recommend a more general screening protocol. In fact, studies have confirmed that the transplant psychiatrist’s global rating of risk for post-transplant psychosocial problems that affect management (a measure that among other items incorporated ratings of coping and social support) was strongly associated with post-transplant non-adherence and the number of rejection episodes.51 Our review of the evidence suggested that some of the measured factors are more predictive of treatment nonadherence and clinical outcomes than others. Therefore, the SIPAT items scoring system is weighted more heavily to compensate for this reality. When administering the SIPAT, it is important that whenever possible, psychosocial consultants utilize sources of collateral information to verify the facts provided, particularly in patients suffering from end-stage organ failure or encephalopathy. Also, developing good collaborative relationship with the patient’s medical providers and family members can provide a wealth of useful and corroborating (or conflicting) information, which may be beneficial for the evaluation process. MATERIALS AND METHODS Recognizing that some patients may wait years for a transplant once they have been listed, we viewed a prospective study as an unrealistic method for the initial assessment of the tool’s efficacy. Therefore, we chose to apply the scale retrospectively with the outcomes blinded to the examiners. After obtaining Institutional Review Board (IRB) approval (Protocol #15041), five examiners blindly applied the SIPAT to 102 transplant cases (via retrospective chart review), including liver (n ⫽ 52), heart (n ⫽ 25), and lung patients (n ⫽ 25) randomly selected and provided by the respective transplant teams. The examiners were divided into two teams based on their level of expertise (i.e., expert Psychosomatics 53:2, March-April 2012

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TABLE 3.

Psychosocial Domains and Factors Measured by the SIPAT

(A) PATIENT’S READINESS LEVEL and ILLNESS MANAGEMENT (5 items) Item 1: Knowledge and understanding of medical illness process (that caused specific organ failure) Item 2: Knowledge and understanding of the process of transplantation Item 3: Willingness/desire for treatment (transplant) Item 4: History of treatment adherence/compliance (pertinent to medical issues) Item 5: Lifestyle factors (including diet, exercise, fluid restrictions, and habits according to organ system) (B) SOCIAL SUPPORT SYSTEM LEVEL OF READINESS (3 items) Item 6: Availability of social support system Item 7: Functionality of social support system Item 8: Appropriateness of physical living space and environment (C) PSYCHOLOGICAL STABILITY AND PSYCHOPATHOLOGY (5 items) Item 9: Presence of psychopathology (other than personality disorders and organic psychopathology) Item 10: History of organic psychopathology or neurocognitive impairment (i.e., illness or medication-induced psychopathology) Item 11: Influence of personality traits vs. disorder Item 12: Effect of truthfulness vs. deceptive behavior Item 13: Overall risk for psychopathology (D) LIFESTYLE AND EFFECT OF SUBSTANCE USE (5 items) Item 14: Alcohol use, abuse, and dependence Item 15: Alcohol abuse - risk for recidivism Item 16: Illicit substance, abuse and dependence Item 17: Illicit substance abuse - risk for recidivism Item 18: Nicotine use, abuse, and dependence

and novice). The expert team consisted of three seasoned transplant clinicians (two psychiatrists and an advanced licensed clinical social worker). The novice team consisted of two trainees (two psychiatric residents) with some knowledge of the pre-transplant evaluation process but who were new to the use of the SIPAT. Although all patients in this study had already undergone transplantation, the five examiners conducting the ratings were blind to the patients’ names, identifying information, and transplant outcomes. The examiners applied the SIPAT to the patient’s clinical chart available to the team at the time of transplant selection, including medical evaluation, transplant social worker’s evaluation, and psychiatric report, if available. After all subject’s files had been rated by the examiners, the research assistant blind to the SIPAT score obtained the patient’s outcome data (as defined above) from two independent sources: documentation in the Transchart/EPIC data system (which contains detailed information regarding the information in question entered in real time by all members of the transplant team) and by interviewing the corresponding nurse coordinators and social workers to corroborate chart findings and provide any additional information. A standardized questionnaire to elicit medical and psychosocial outcomes was used in both cases. Transplant coordinators and social workers were asked to rate in each case, whether the transplant had been successful (i.e., positive or negative outcomes) Psychosomatics 53:2, March-April 2012

based on specific post-transplant psychosocial criteria, including issues with adherence, stability of the psychosocial support system, recidivism of substances of abuse, or the development/relapse of psychiatric problems. A negative outcome was defined as meeting one or more of the following conditions: difficulty with treatment adherence, unstable psychosocial support system, substance use recidivism, the development of (or relapse) psychiatric problems, or graft failure. A positive outcome was defined by the absence of these complications. The predictions made by the use of the SIPAT were compared against these actual outcomes. For each case, a SIPAT score was obtained. In addition, each examiner also conducted a PACT and the results were compared with the SIPAT. After rating each case using both scales, we fit univariate logistic regression models in order to predict actual transplant psychosocial outcome (positive or negative) using the SIPAT and PACT scores determined by each rater. We reported the coefficients for the SIPAT and PACT scores in the regressions, as well as the corresponding P values. The reproducibility of the SIPAT scores was assessed by computing Pearson’s correlation coefficient for the scores assigned by each pair of raters. The reproducibility of PACT was similarly assessed. We also computed the correlation coefficient between the SIPAT and PACT scores for each rater in order to determine whether SIPAT and PACT scores tend to agree with each other. www.psychosomaticsjournal.org

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TABLE 4.

Novice 1 Novice 2 Expert 1 Expert 2

Inter-Rater Reliability Based on SIPAT Scores (Pearson’s Correlation Coefficient) Novice 2

Expert 1

Expert 2

Expert 3

0.864

0.866 0.829

0.873 0.823 0.853

0.872 0.773 0.806 0.874

TABLE 6. Rater

Tables 4 and 5 show the inter-rater reliability of SIPAT and PACT scores, respectively. Using the SIPAT score, the median agreement between experts was 0.853. Using the PACT score, the median agreement between experts was 0.753. The median agreement between experts and novices was 0.847 using SIPAT and 0.769 using PACT. Each of the 10 pair comparisons between the raters was higher for the SIPAT scores than for the PACT scores. It may be important to note that the “novice” team was given equal time training for the SIPAT and the PACT; thus, the increased accuracy and reliability when using the SIPAT suggests this tool is easier to use, implement, and reproduce. For each rater, the correlation between the SIPAT and PACT scores was computed (Table 6). The median correlation between the scores was ⫺0.906. (The negative sign is due to the fact that a high score on one scale corresponds to a low score on the other scale.) This indicates strong intra-user consistency between the two scales. Univariate logistic regression models were fit in order to predict the transplant psychosocial outcome (positive or negative) using each rater’s SIPAT scores. Given that this was a retrospective study, we decided to limit the assessment of potential predictive value to one organ in order to limit confounding factors and kept our subjects relatively homogenous. The liver data contain the largest sample size and the most even split of positive and negative outcomes (23 positive and 29 negative outcomes); therefore, only the Inter-Rater Reliability Based on PACT Scores (Pearson’s Correlation Coefficient) Novice 2

Expert 1

Expert 2

Expert 3

0.828

0.784 0.778

0.732 0.722 0.717

0.822 0.761 0.753 0.781

PACT ⫽ Psychosocial Assessment of Candidates for Transplantation.

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0.916 0.895 0.935 0.868 0.906

liver transplant data was used in this analysis. Table 7 contains the coefficients and P values for the logistic regressions performed on the liver data. Note that the SIPAT coefficients are negative because a high SIPAT score correlates with a negative outcome. These results show that SIPAT scores are highly predictive of the transplant psychosocial outcome. DISCUSSION The data available to date confirms that in addition to typical medical factors, psychosocial and behavioral issues may affect the ultimate success of the transplantation process. Accordingly, most guidelines suggest that the pretransplant screening process must include both a comprehensive medical evaluation and a thorough psychological assessment.20, 52, 53 Furthermore, there is data to suggest that pre-transplant psychiatric history can predict psychological outcomes after transplant, and that post-transplant psychosocial outcomes may predict physical morbidity and mortality.22 In an attempt to provide a standardized, objective, and evidence-based psychosocial evaluation, we have developed and tested a new tool, the SIPAT, which we propose will assist in the assessment of transplant candidates from a psychosocial point of view. In our study, SIPAT scores TABLE 7.

Novice 1 Novice 2 Expert 1 Expert 2

Negative Correlation

Novice 1 Novice 2 Expert 1 Expert 2 Expert 3

The negative sign is due to the fact that a high score on one scale corresponds to a low score on the other scale. This indicates strong intra-user consistency between the two scales.

RESULTS

TABLE 5.

Agreement Between SIPAT and PACT Scores

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Rater Novice 1 Novice 2 Expert 1 Expert 2 Expert 3

Prediction of Outcome Using SIPAT Scores for Liver Data (Univariate Logistic Regression) Coefficient

P value

⫺0.0167 ⫺0.0228 ⫺0.0252 ⫺0.0155 ⫺0.0249

⬍0.0001 ⬍0.0001 0 ⬍0.0001 ⬍0.0001

Note that the SIPAT coefficients are negative because a high SIPAT score correlates with a negative outcome.

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Maldonado et al. were highly predictive of transplant psychosocial outcome. These findings are consistent with a previous prospective study assessing patients before and 6, 12, and 24 months after transplantation and demonstrating that the mental health of patients with poor pre-transplant mental health continues to deteriorate after transplantation.34 One of the strengths of the SIPAT is that it standardizes the psychosocial assessment evaluation process so all transplant candidates undergo the same rigorous psychosocial scrutiny helping identify areas of strength that can be built upon, and areas of weakness needing assistance or further consultation and treatment. This process helps transplant teams know as much as they need about the factors that may influence transplant outcomes. The function of psychosocial consultants should not be to make a determination regarding the patient’s worthiness as a candidate, but to assist the transplant selection committee in making the best clinical decision based on current available data.40 The use of assessment tools, such as the SIPAT, not only assists clinicians in eliminating the emotional factor from the decision-making process, but also in presenting the facts during the selection process. We believe the SIPAT compares favorably with the PACT, but it has some significant advantages, including detailed descriptions regarding social support, substance abuse, use, and recidivism risk, knowledge regarding illness and transplantation process, the effects of psychopathology, and other cognitive organic factors. Our study was able to demonstrate excellent inter-rater reliability and a robust association between SIPAT scores and post-transplant psychosocial problems. SIPAT scores appear to be more reproducible than PACT scores between different raters. Moreover, SIPAT scores appear to be consistent between novice and expert raters. The SIPAT may not only help to improve the selection process of transplant candidates, but it may also serve to identify a patient’s level of social, neuropsychiatric, and cognitive functioning. Clinicians may use the SIPAT to complement and standardize the psychosocial evaluation process, although it should not be used as the sole determinant of eligibility for transplantation. Instead, the content items of the SIPAT may enhance the selection process by identifying risk factors that may be amenable to clinical intervention before the transplant, or that may require extra attention after transplantation. This will assist in developing a comprehensive psychosocial treatment plan for each individual patient with the ultimate goal of minimizing preventable problems, mitigating risk, and optimizing graft survival and patient’s functioning and quality Psychosomatics 53:2, March-April 2012

of life. In fact, we believe the major strength of the tool is not only its accuracy in identifying and predicting those patients who may do poorly after transplantation, but its ability to screen for areas of a candidate’s weaknesses in order to allow for the development of interventions directed at improving the patient’s candidacy, thus turning marginal patients into acceptable transplant recipients. Although we recognize that many factors go into determining eventual transplant success (e.g., even with perfect adherence, some organs will be rejected), we predict that enhanced psychosocial selection criteria will translate into lower morbidity, lower rejection rates, enhanced graft survival, and better quality of life for transplanted patients. Limitations and Future Steps/Research Because we wanted to be able to test the potential value of our assessment tool, we elected to apply it retrospectively to patients already transplanted, even though the tool was designed to be used during the prospective assessment of transplant candidates. This allowed us to assess the tool’s usefulness without having to wait years of waiting while the patients are in the transplant list awaiting transplantation and eventual outcomes. Because of the retrospective nature of the study, examiners had to apply the instruments to historical data contained in the patient’s chart rather than being able to perform an exam on a live patient. This may have limited the examiner’s ability to ask questions, which may have increased the accuracy. Likewise, because the cases were selected blindly, the retrospective application of the SIPAT could not take into consideration whether the ultimate outcome was affected by the application of corrective measures or lack thereof. For example, a patient who received a high SIPAT score may have been identified at the time as being high risk by the team, and an appropriate treatment plan may have corrected the identified psychosocial problems, eventually making the patient a better transplant candidate. Given that we only applied the measures to the initial evaluation process, we could not take the effects of those interventions into account. Also, because of the number of subjects and differences among the members of various transplant teams, we decided to limit the analysis of predictive outcomes to a single organ in order to limit confounders, and kept the sample relatively homogenous. Our next step is to conduct a prospective study to look at the ability of this instrument to predict medical treatment outcomes. We predict that in order to prove an www.psychosomaticsjournal.org

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SIPAT: Tool for Psychosocial Evaluation of Transplant Candidates association between the SIPAT and medical outcome (i.e., morbidity, mortality, graft survival and quality of life), a larger data set would be needed. Also, it may be required that the SIPAT is used to reassess the patient’s candidacy after psychosocial interventions have taken place, or if the patient’s psychosocial situation deteriorates, as either scenario may affect the ultimate score and eventual outcome. Similarly, future studies should also assess issues of how psychosocial factors affect quality of life after transplantation. CONCLUSION The SIPAT is a comprehensive screening tool designed to enhance the psychosocial assessment of organ transplant candidates. Its strengths include the standardization of the evaluation process and its ability to identify subjects who are at risk for negative outcomes after the transplant, in order to allow for the development of interventions directed at improving the patient’s candidacy. SIPAT scores were found to be highly predictive of the transplant psychosocial outcome. The instrument has excellent inter-rater reliability, even among novice raters, and is highly correlated with PACT scores. Our goal is that the SIPAT, in addition to a set of agreed upon minimal psychosocial listing criteria, would be used along organ-specific medical listing criteria in order to establish standardized criteria for the selection of solid organ transplant recipients in a way that

promotes fairness, allows for the identification and timely management of potential problems, and maximizes graft survival and quality of life. For practitioners wanting the benefit of a more extended, guided interview, there is an associated psychosocial questionnaire (the SIPAT Long Form, available at the Stanford’s Psychosomatic Medicine Program website), which can be used for the evaluation of transplant patients and contains all the elements of the SIPAT tool. Further information regarding the rationale for the inclusion of the specific items in the SIPAT, an administration manual, and the SIPAT-Interview Long Form can be found in the Stanford University, Department of Psychiatry, Psychosomatic Medicine Program website found at ⬍http://psychiatry. stanford.edu/Psychosomatic⬎.

The authors thank all of the dedicated and hardworking solid organ transplant social workers who conducted all subject interviews. In particular, the authors thank those who helped provide the necessary medical records and outcome data. They also thank Rodney Plante, RSW, for his participation during the very early stages of this project. The authors also thank all the patients who participated in this endeavor. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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APPENDIX 1 The SIPAT Tool is available online at www.psychosomaticsjournal.org

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