Stephanie E. Punt, PhD
Clinical Psychologist
UCLA Health Medical Psychological Assessment Center
UCLA Health Operation Mend
University of California, Los Angeles
Andrew J. Marra, MS
Clinical Psychology Doctoral Student
University of Missouri-Kansas City
Ilana Engel, PhD
Clinical Health Psychology Postdoctoral Fellow
Eastern Colorado VA Health Care System
Julia Russell, PhD
Clinical Psychology Doctoral Student
University of Kansas
Mariana Rincon Caicedo, MA
Clinical Psychology Doctoral Student
University of Kansas
Jessica Hamilton, PhD
Associate Professor
Psychiatry and Behavioral Sciences
University of Kansas Medical Center
Current Role of Pre-Surgical Psychological Evaluations for Medical Interventions
Prior to many major medical interventions, individuals are asked—or at times required—to undergo pre-surgical psychological evaluations (PSPE). Often misunderstood as barriers patients must overcome or “pass” to proceed to surgery, these evaluations are ultimately designed to assess the preparedness of the individual to engage with the intervention in a way that facilitates the greatest potential outcomes (Block, 2023; Diggins & Peterson, 2023). As a part of this process, patients are often linked with resources to help prepare them for positive outcomes (Benalcazar & Cascella, 2020; Block & Marek, 2020; Mechanick et al., 2013). Despite a relatively comprehensive establishment of PSPE guidelines (Mechanick, et al., 2013), there remains considerable variability in practical applications and uses of PSPEs (Liff & Bush, 2023).
The utility of empirically validated measures (such as standardized clinical interviews) when conducting PSPEs has elsewhere been emphasized (Marek, 2023; Rutledge et al., 2020), though there persists a dearth of research and consistency in standardized, empirically validated assessment procedures (Block, 2023). For transplant procedures, the Stanford Integrated Psychosocial Assessment for Transplants (SIPAT; Maldonado et al., 2012) is a standardized clinical interview used to measure individuals’ readiness for transplant in conjunction with a comprehensive assessment. The SIPAT covers the domains of readiness level, social support, psychological stability, and substance use. It is currently used for a variety of medical interventions beyond solid organ transplant, such as ventricular assist devices (e.g., Bui et al., 2019; Olt, et al., 2023) and bariatric surgeries (Punt et al., 2022), among others. The research base on the SIPAT in bariatric populations is small but emerging (Hamilton et al., 2019; Kurland et al., 2016). Building off this preliminary research, Punt and colleagues (2022) found the SIPAT to be predictive of whether bariatric surgery patients proceeded to surgery or not (though the cutoff score was found to be higher than what the SIPAT currently lists as clinically significant). Additionally, higher SIPAT Patient Readiness, indicating difficulty with adhering to health behaviors and a reduced understanding of bariatric surgery, and separately, higher SIPAT Social Support, indicating reduced social support access, were associated with elevated patient weight at 18-months follow up (Punt et al., 2024). We suggest adapting the SIPAT to contain broader, more inclusive language as a potential tool for improving upon the PSPE process such that the tool might be applicable to the PSPE process for a wide range of major medical interventions.
Adopting a Generic Language Version of the SIPAT for Medical Interventions at an Academic Medical Center
In order to better serve patient populations seeking medical interventions, adopting a generic language version of the SIPAT may be beneficial. Presently at a Midwest academic medical center, the SIPAT is used as part of a larger PSPE for patients seeking bariatric surgery, spinal cord stimulator surgery, and head and neck cancer treatment. Through using the generic language version of the SIPAT—adapting text referring to “transplant” to “medical intervention,” our clinical team is able to use the SIPAT as a template to structure the interview across multiple types of medical interventions. In its current form and for which it was originally developed, the SIPAT’s content is tailored to solid organ and cellular transplants. Maldonado and colleagues developed an integral tool for solid organ transplant, which may have promising utility beyond the population it was originally designed for. To date, one attempt at tailoring the SIPAT to a bariatric population (SIPABS), was introduced as an abstract by Kurland and colleagues. However, additional information related to how the SIPAT was adapted to bariatric surgery is unavailable from the authors and has not been published. Given the rapid evolution of medical interventions, adopting a generic language version of the SIPAT may be beneficial. Future research efforts could focus on validating a generic language version of the SIPAT across different medical interventions to determine medical intervention-specific cut-off scores.
At this Midwest institution, versions of this generic language form are already incorporated into the PSPE process for bariatric surgery, spinal cord surgery, and head and neck cancer treatment (i.e., at initiation of post-surgical radiation treatment within a recommended timeframe). In Table 1, we present our pilot data (N=653) reflecting the use of the generic language version of the SIPAT in bariatric surgery (n=379), spinal cord stimulator surgery (n=223), and head and neck cancer treatment (n=51). The SIPAT in its original form uses a cut-off score based on the SIPAT total score of 20 (Good and Excellent candidate), with individuals scoring ≥ 20 exhibiting fewer post-transplant complications, calculated from outcome data. As our pilot data is emerging, we calculated SIPAT total score cut-offs utilizing the 95% confidence interval (Sharma & Jain, 2014). Broadly, when comparing the cut-off score (21) used by the SIPAT in transplant populations, bariatric surgery (N=379; 24 cut-off), post-surgical radiation treatment initiation for head and neck cancer patients (N=223; 24 cut-off), and spinal cord stimulator surgery (N=51; 32 cut-off) demonstrate a higher cut-off threshold (indicating the presence of more psychosocial stressors) for proceeding with their respective medical interventions. It is possible that the medical interventions for which we are using the SIPAT allow for more variation in scores or a higher threshold for psychosocial stressors as compared with solid organ and cellular transplants. In terms of measurable outcomes across time, there is more variation across the medical interventions we present (e.g., weight, cancer treatment, and pain) whereas the transplant interventions tend to report compliance with anti-rejection medications. We also acknowledge the limitations of this pilot data. The majority of our samples, although small, include individuals who identify as White, Non-Hispanic, and individuals who reside in the rural Midwest, limiting generalization to individuals representing other backgrounds.
Conclusion and Call to Action
We propose the adoption of a generic language version of the SIPAT to the PSPE process that encourages generalizability across medical interventions. Preliminary data from this Midwest institution also suggests cut-off scores that are higher than the published cut-off (Total score = 21) for solid organ transplants (Maldonado et al., 2012). More studies will need to be performed to validate the use of this generic language version of the SIPAT across medical interventions. In addition to validation studies that also analyze medical intervention-specific cut-offs, there is also an increasing need for culturally responsive assessment and care for patients receiving PSPEs and specifically how this may need to be reflected in the SIPAT. Given the diversity of patient backgrounds who seek medical interventions each year, the majority of studies that investigate the use of PSPEs in patient populations have been predominantly patients who identify as middle-aged White, Non-Hispanic cisgender individuals. Similarly, the majority of studies investigating the SIPAT are predominantly White, Non-Hispanic individuals or do not report patient demographic characteristics. As such, studies have yet to thoroughly investigate the validity of these PSPEs within differing patient backgrounds and identities. As such, future studies will also need to assess the present scoring system of the SIPAT within different populations in order to adequately and appropriately determine whether patient-level and community-level factors impact SIPAT cut-offs. Perhaps, as similar to some cognitive screeners, score corrections will need to be incorporated to account for differences in patient background and lived context.
References
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