The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A New Scale for the...

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Original Research Reports

The Stanford Integrated Psychosocial Assessment forTransplantation (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 wellestablished for each end-organ system, psychosociallisting criteria are less standardized. To address thislimitation, we developed and tested a new assessmenttool: the Stanford Integrated Psychosocial Assessmentfor Transplantation (SIPAT). Methods: The SIPAT wasdeveloped from a comprehensive review of the literatureon the psychosocial factors that impact transplant out-comes. Five examiners blindly applied the SIPAT to 102randomly selected transplant cases, including liver,heart, and lung patients. After all subject’s files hadbeen rated by the examiners, the respective transplantteams provided the research team with the patient’s out-come data. Results: Univariate logistic regression mod-els were fit in order to predict the transplant psychoso-cial outcome (positive or negative) using each rater’sSIPAT scores. These results show that SIPAT scores are

highly predictive of the transplant psychosocial outcome(P � 0.0001). The instrument has excellent inter-raterreliability (Pearson’s correlation coefficient � 0.853),even among novice raters. Conclusions: The SIPAT is acomprehensive screening tool to assist in the psychoso-cial assessment of organ transplant candidates. Itsstrengths includes the standardization of the evaluationprocess and its ability to identify subjects who are atrisk for negative outcomes after the transplant, in orderto allow for the development of interventions directed atimproving the patient’s candidacy. Our goal is that theSIPAT, in addition to a set of agreed upon minimal psy-chosocial listing criteria, would be used in combinationwith organ-specific medical listing criteria in order toestablish standardized criteria for the selection of trans-plant recipients.

(Psychosomatics 2012; 53:123–132)

“Because donated organs are a severely limited re-source, the best potential recipients should be iden-

tified. The probability of a good outcome must be highlyemphasized to achieve the maximum benefit for all trans-plants.” (From: OPTN/UNOS Ethics Committee GeneralConsiderations in Assessment for Transplant CandidacyWhite Paper–2010).1

Even though the number of transplant surgeries in theUSA has continued to rise over the last 18 years, it has notkept pace with the number of patients on the transplant list.2

In fact, the transplant wait list has increased 7-fold during thelast 20 years.2–4 As a result, the number of deaths while onthe waiting list has steadily increased and is now over 7100

deaths a year.4 Parallel to this, the number of living donorshas tripled, from 1829 in 1988 to 6561 in 2010.4,5 The in-

Received April 3, 2011; revised December 25, 2011; accepted December 27,2011. From Department of Psychiatry and Behavioral Sciences, StanfordUniversity School of Medicine (JRM, HCD, YS, SL); Department ofSocial Work & Case Management, Stanford Hospital and Clinics Stan-ford 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, Maldo-nado, M.D., Associate Professor of Psychiatry, Medicine, Surgery, andLaw, Stanford University School of Medicine, 401 Quarry Road, Suite2317, Stanford, CA 94305; e-mail: [email protected]

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

Psychosomatics 2012:53:123–132 © 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

123Psychosomatics 53:2, March-April 2012 www.psychosomaticsjournal.org


creased use of living donors has added a new dimension andset of complexities to the ethical debate with respect to re-cipient selection as the potential for harm (to the donor)makes graft failure due to non-adherence or other psychos-ocial factors a more painful reality.

Despite the advances in surgical techniques and im-munosuppression, there has been little change in themethod by which transplant selection committees evaluatepsychosocial risk in potential transplant recipients. Theselection process should be considered a continuum from(1) the determination that a patient suffers from end-stageorgan disease; (2) to an assessment for indications fortransplantation; (3) to a parallel screening for both medicaland psychosocial fitness and/or contraindications to trans-plantation; (4) to being wait-listed for the specific organtransplant, (5) to transplantation (see Figure 1).

Previously Existing Tools for Psychosocial Assessmentof Transplant Patients

When we started this project, there were three toolsalready available. The Psychosocial Assessment of Can-

didates for Transplantation (PACT) consists of eightitems, each rated on a 5-point scale, plus the rater’s overallimpressions.6 The Psychosocial Levels System (PLS) as-sesses patients on three gradations of intensity, taking intoaccount seven psychosocial variables, suggesting it was“the first stage in developing a system to reliably identifyhigh-risk BMT patients at the onset of medical treat-ment,”7 The Transplant Evaluation Rating Scale (TERS),a revision of the PLS, consists of 10 items rated on a3-point scale and provides a single summary score thatindicates a patient’s current level of functioning as well asa weighted score for each variable, suggesting it “canbecome a valuable instrument enabling consultants to or-gan transplant programs to predict patients’ psychosocialadjustment.”8 Each scale has different interpretative char-acteristics. After the original paper, nothing further hasbeen published using the PLS, which seems to have beenreplaced by the TERS. One study compared the PACT vs.TERS on candidates for bone marrow transplant (BMT)and found comparable inter-rater reliability, although theauthors suggest that “the 5-point scaling of PACT itemsallows more leeway in making ratings.”9 In addition, thePACT allows for a clinician’s subjective experience (viathe “final rating”) to overcome the total items score thusdefeating the attempt at objectivity.9 A more recent studyexplored the association of the PACT subscales and thefinal rating with 16 post-transplant medical outcomes andfound significant relationships (P � 0.05) between PACTsubscales and several medical outcomes, yet the final rat-ing score and medical outcomes were not significantlycorrelated.10 There is no data regarding how widespreadtheir use is.

Rationale for the Development of a StandardizedApproach

The main issue in the assessment of any patient beingconsidered as a potential transplant recipient resides inwhether the patient meets medical and psychosocial listingcriteria. Minimal medical listing criteria have been relativelywell established by the United Network for Organ Sharing(UNOS), and more specifically defined for each end organsystem (see Table 1).11–15 On the other hand, psychosociallisting criteria are less standardized, both regarding tools andtechniques used. Unfortunately, OPTN/UNOS guidelines re-garding the psychosocial evaluation process are too broadand provide little direction: “All transplant programs shouldidentify appropriately trained individuals who are designatedmembers of the transplant team and have primary responsi-

FIGURE 1. Road to Transplantation.

SIPAT: Tool for Psychosocial Evaluation of Transplant Candidates

124 www.psychosomaticsjournal.org Psychosomatics 53:2, March-April 2012


bility for coordinating the psychosocial needs of transplantcandidates, recipients, living donors and families (OPTNEvaluation Plan, page IV-6).”16 The OPTN/UNOS EthicsCommittee recognized that “the concept of non-medicaltransplant candidate criteria is an area of great concern. Mosttransplant programs in the United States use some type ofnon-medical evaluation of patients for transplantation. . .There is general agreement that non-medical transplant can-didate criteria need to be evaluated. The legitimate substanceof such an evaluation could cover a very wide range oftopics.”17

Published and anecdotal data reveal that transplantprograms and psychosocial evaluators (i.e., transplant so-cial workers) and expert consultants (e.g., transplant psy-chiatrists and psychologists) utilize different techniquesand psychosocial eligibility criteria to evaluate prospectivetransplant candidates.18,19 Furthermore, several literaturereviews have demonstrated that there is a relative absenceof evidence-based guidelines for pre-transplant psychoso-cial and behavioral screening.20,21 In fact, a 20-year qual-itative review demonstrated that psychosocial assessmentsdiffer in content and application to candidate selectiondepending on the transplant program.22 A survey of trans-plant psychosocial experts provided evidence for the needof expanding routine screening and support services tocandidates for and recipients of transplants.18 Even thoughthere are no national standards or psychosocial minimal

listing criteria, a survey of transplant programs found therewere certain conditions (i.e., current addictive drug use,active schizophrenia, current heavy alcohol use, history ofmultiple suicide attempts, current suicide ideation, demen-tia) which were endorsed as “absolute contraindication totransplantation” by 70% of responders.23

Despite the lack of psychosocial criteria standardization,psychosocial consultants positively contribute to the ultimatetransplant success by enhancing the assessment of patientsbeing considered for transplantation.21,23–26 This can mosteffectively be done by focusing on risk factors that are asso-ciated with poor adherence/compliance and ultimate medicaland psychosocial transplant success.27–33 The psychosocialevaluation should serve to identify patient’s level of social,neuropsychiatric and cognitive functioning, assist in the de-velopment of a psychosocial treatment plan to address cur-rent social and psychiatric problems and help minimize pre-ventable problems, and implement appropriate treatments inorder to reduce harm, mitigate risk and optimize graft sur-vival and the patient’s level of functioning and quality of lifepost-transplantation (see Table 2).

Data suggest that there is not only a strong associationbetween pre-transplant psychosocial vulnerability markersand post-transplant psychosocial outcome,34 but also be-tween specific psychosocial factors and ultimate transplantsuccess or failure.22,23,26, 28,32,35–48 In fact, one study dem-onstrated that many pre-transplant psychosocial problemscontinued after transplantation; and that psychiatric prob-lems after transplantation led to a higher risk of infection,hospital readmissions, and higher medical costs.49 Othershave demonstrated that the global psychosocial risk wasassociated with the number of rejection episodes and med-ication adherence after transplantation.50 Another study

TABLE 1. U.S. Transplantation Medical Criteria

End OrganMedicalCriteria

DevelopingEntity

Reference

Liver Model for end-stage liverdisease(MELD)

Mayo Clinic (11)

Heart New York HeartAssociation(NYHA)functionalclassification

NYHA (12)

Lung Lung allocationsystem (LAS)

OPTN/UNOS (13)

Kidney Kidneyallocationscore (KAS)

UNOS (14)

Pancreas Pancreasallocationsystem (PAS)

OPTN/UNOSPancreasTransplantationCommittee

(15)

NYHA � New York Heart Association; OPTN � National OrganProcurement and Transplantation Network; UNOS � United Net-work for Organ Sharing.

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., substanceabuse, compliance issues, serious psychopathology) that mayresult in increased risk of postoperative non-compliance &morbidity

● Providing information to develop treatment planning forindividuals at high risk:– Identifying patient’s level of neuropsychiatric and cognitivefunctioning– Developing a psychiatric treatment plan to address currentpsychiatric problems and help minimize preventable problems– Implementing appropriate treatments that reduce harm andmitigate risk

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found that increasing psychiatric risk classification (i.e.,high risk versus acceptable versus good candidates) wasassociated with a greater hazard of post-transplant mortal-ity.33 A total of five psychosocial variables (i.e., previoussuicide attempts, poor adherence to medical recommenda-tions, past history of substance abuse, and depression)were significantly associated with shortened post-trans-plant survival and/or greater risk for post-transplant infec-tion.33 In fact, differences among risk groups emergedearly in the post-transplant process, with patients in theHigh Risk group experiencing greater mortality shortlyafter transplant, compared with the Acceptable and Goodgroups.33 More recently, a prospective study demonstratedthat selected pre-transplant psychosocial factors predictedboth post-transplant non-adherence to treatment and poorclinical outcome (i.e., non-adherence to immunosuppres-sant medications, late acute rejection, graft loss, and re-source utilization), after controlling for medical predictorsof poor outcome.29

Development of the SIPAT

When we reviewed the psychosocial evaluation processof the various transplant programs within our institution, wediscovered we were assessing dozens of psychological andsocial factors (i.e., a comprehensive psychiatric examination,plus various pieces of social demographical information). Atthat point the question was whether the current process wasuseful (i.e., predictive of transplant outcome) and whetherthere was a better way to do it. So we began to scrutinizewhat we were doing and looked into the published literaturefor those psychosocial variables that are supported by evi-dence-based data for treatment adherence, quality of life, andgraft survival.40 We concluded that in order to minimizepotential selection bias a tool that attempted to objectivelyassess complex psychosocial data would be desirable. Westarted with our own old screening questionnaire and addedand deleted items based on our extensive review of the liter-ature. The result was a new comprehensive pre-transplantorgan evaluation instrument: the Stanford Integrated Psycho-social Assessment for Transplantation (SIPAT) (see Appen-dix 1 for the SIPAT tool and scoring instructions. The ex-tended questionnaire used for all transplant evaluations isavailable at the Stanford’s Psychosomatic Medicine Website�http://psychiatry.stanford.edu/Psychosomatic�). The SIPATintends to assess the psychosocial factors that appear tobetter predict patients’ adherence and graft survival. Wedivided these 18 identified risk factors into four domains,

including patients’ readiness, social support, psychologi-cal stability, and substance abuse (see Table 3).40

Based on the assessment of these factors, theSIPAT provides an overall risk severity score for psy-chosocial variables important in predicting post-trans-plant behavior, psychosocial support viability and ef-fectiveness, treatment adherence, substance abuse, andrecidivism and mental health. Studies have shown thatthe psychosocial and behavioral characteristics werecomparable among solid organ, pre-transplant candi-dates.37 Thus instead of performing the pre-transplantpsychosocial screening in an organ-specific fashion, werecommend a more general screening protocol. In fact,studies have confirmed that the transplant psychiatrist’sglobal rating of risk for post-transplant psychosocialproblems that affect management (a measure thatamong other items incorporated ratings of coping andsocial support) was strongly associated with post-trans-plant non-adherence and the number of rejection epi-sodes.51

Our review of the evidence suggested that some of themeasured factors are more predictive of treatment non-adherence and clinical outcomes than others. Therefore,the SIPAT items scoring system is weighted more heavilyto compensate for this reality. When administering theSIPAT, it is important that whenever possible, psycho-social consultants utilize sources of collateral informa-tion to verify the facts provided, particularly in patientssuffering from end-stage organ failure or encephalopa-thy. Also, developing good collaborative relationshipwith the patient’s medical providers and family mem-bers can provide a wealth of useful and corroborating(or conflicting) information, which may be beneficialfor the evaluation process.

MATERIALS AND METHODS

Recognizing that some patients may wait years for a trans-plant once they have been listed, we viewed a prospectivestudy as an unrealistic method for the initial assessment ofthe tool’s efficacy. Therefore, we chose to apply the scaleretrospectively with the outcomes blinded to the examin-ers. After obtaining Institutional Review Board (IRB) ap-proval (Protocol #15041), five examiners blindly appliedthe SIPAT to 102 transplant cases (via retrospective chartreview), including liver (n � 52), heart (n � 25), and lungpatients (n � 25) randomly selected and provided by therespective transplant teams. The examiners were dividedinto two teams based on their level of expertise (i.e., expert




and novice). The expert team consisted of three seasonedtransplant clinicians (two psychiatrists and an advancedlicensed clinical social worker). The novice team consistedof two trainees (two psychiatric residents) with someknowledge of the pre-transplant evaluation process butwho were new to the use of the SIPAT.

Although all patients in this study had already under-gone transplantation, the five examiners conducting theratings were blind to the patients’ names, identifying in-formation, and transplant outcomes. The examiners ap-plied the SIPAT to the patient’s clinical chart available tothe team at the time of transplant selection, includingmedical evaluation, transplant social worker’s evaluation,and psychiatric report, if available.

After all subject’s files had been rated by the ex-aminers, the research assistant blind to the SIPAT scoreobtained the patient’s outcome data (as defined above)from two independent sources: documentation in theTranschart/EPIC data system (which contains detailedinformation regarding the information in question en-tered in real time by all members of the transplant team)and by interviewing the corresponding nurse coordinatorsand social workers to corroborate chart findings and provideany additional information. A standardized questionnaire toelicit medical and psychosocial outcomes was used in bothcases. Transplant coordinators and social workers wereasked to rate in each case, whether the transplant hadbeen successful (i.e., positive or negative outcomes)

based on specific post-transplant psychosocial criteria,including issues with adherence, stability of the psycho-social support system, recidivism of substances ofabuse, or the development/relapse of psychiatric prob-lems. A negative outcome was defined as meeting oneor more of the following conditions: difficulty withtreatment adherence, unstable psychosocial support sys-tem, substance use recidivism, the development of (orrelapse) psychiatric problems, or graft failure. A posi-tive outcome was defined by the absence of these com-plications. The predictions made by the use of the SIPATwere compared against these actual outcomes.

For each case, a SIPAT score was obtained. In addi-tion, each examiner also conducted a PACT and the resultswere compared with the SIPAT. After rating each caseusing both scales, we fit univariate logistic regressionmodels in order to predict actual transplant psychosocialoutcome (positive or negative) using the SIPAT andPACT scores determined by each rater. We reported thecoefficients for the SIPAT and PACT scores in the regres-sions, as well as the corresponding P values.

The reproducibility of the SIPAT scores was assessed bycomputing Pearson’s correlation coefficient for the scoresassigned by each pair of raters. The reproducibility of PACTwas similarly assessed. We also computed the correlationcoefficient between the SIPAT and PACT scores for eachrater in order to determine whether SIPAT and PACT scorestend to agree with each other.

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 transplantationItem 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 systemItem 7: Functionality of social support systemItem 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. disorderItem 12: Effect of truthfulness vs. deceptive behaviorItem 13: Overall risk for psychopathology(D) LIFESTYLE AND EFFECT OF SUBSTANCE USE (5 items)Item 14: Alcohol use, abuse, and dependenceItem 15: Alcohol abuse - risk for recidivismItem 16: Illicit substance, abuse and dependenceItem 17: Illicit substance abuse - risk for recidivismItem 18: Nicotine use, abuse, and dependence

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RESULTS

Tables 4 and 5 show the inter-rater reliability of SIPATand PACT scores, respectively. Using the SIPAT score,the median agreement between experts was 0.853. Usingthe PACT score, the median agreement between expertswas 0.753. The median agreement between experts andnovices was 0.847 using SIPAT and 0.769 using PACT.Each of the 10 pair comparisons between the raters washigher for the SIPAT scores than for the PACT scores. Itmay be important to note that the “novice” team was givenequal time training for the SIPAT and the PACT; thus, theincreased accuracy and reliability when using the SIPATsuggests this tool is easier to use, implement, and repro-duce.

For each rater, the correlation between the SIPATand PACT scores was computed (Table 6). The mediancorrelation between the scores was �0.906. (The neg-ative sign is due to the fact that a high score on onescale corresponds to a low score on the other scale.)This indicates strong intra-user consistency between thetwo scales.

Univariate logistic regression models were fit in orderto predict the transplant psychosocial outcome (positive ornegative) using each rater’s SIPAT scores. Given that thiswas a retrospective study, we decided to limit the assess-ment of potential predictive value to one organ in order tolimit confounding factors and kept our subjects relativelyhomogenous. The liver data contain the largest sample sizeand the most even split of positive and negative outcomes(23 positive and 29 negative outcomes); therefore, only the

liver transplant data was used in this analysis. Table 7contains the coefficients and P values for the logistic re-gressions performed on the liver data. Note that the SIPATcoefficients are negative because a high SIPAT score cor-relates with a negative outcome. These results show thatSIPAT scores are highly predictive of the transplant psy-chosocial outcome.

DISCUSSION

The data available to date confirms that in addition totypical medical factors, psychosocial and behavioral issuesmay affect the ultimate success of the transplantation pro-cess. Accordingly, most guidelines suggest that the pre-transplant screening process must include both a compre-hensive medical evaluation and a thorough psychologicalassessment.20, 52, 53 Furthermore, there is data to suggestthat pre-transplant psychiatric history can predict psycho-logical outcomes after transplant, and that post-transplantpsychosocial outcomes may predict physical morbidityand mortality.22

In an attempt to provide a standardized, objective, andevidence-based psychosocial evaluation, we have devel-oped and tested a new tool, the SIPAT, which we proposewill assist in the assessment of transplant candidates froma psychosocial point of view. In our study, SIPAT scores

TABLE 4. Inter-Rater Reliability Based on SIPAT Scores(Pearson’s Correlation Coefficient)

Novice 2 Expert 1 Expert 2 Expert 3

Novice 1 0.864 0.866 0.873 0.872Novice 2 0.829 0.823 0.773Expert 1 0.853 0.806Expert 2 0.874

TABLE 5. Inter-Rater Reliability Based on PACT Scores(Pearson’s Correlation Coefficient)

Novice 2 Expert 1 Expert 2 Expert 3

Novice 1 0.828 0.784 0.732 0.822Novice 2 0.778 0.722 0.761Expert 1 0.717 0.753Expert 2 0.781

PACT � Psychosocial Assessment of Candidates for Transplan-tation.

TABLE 6. Agreement Between SIPAT and PACT Scores

Rater Negative Correlation

Novice 1 0.916Novice 2 0.895Expert 1 0.935Expert 2 0.868Expert 3 0.906

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

TABLE 7. Prediction of Outcome Using SIPAT Scores forLiver Data (Univariate Logistic Regression)

Rater Coefficient P value

Novice 1 �0.0167 �0.0001Novice 2 �0.0228 �0.0001Expert 1 �0.0252 0Expert 2 �0.0155 �0.0001Expert 3 �0.0249 �0.0001

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




were highly predictive of transplant psychosocial out-come. These findings are consistent with a previous pro-spective study assessing patients before and 6, 12, and 24months after transplantation and demonstrating that themental health of patients with poor pre-transplant mentalhealth continues to deteriorate after transplantation.34

One of the strengths of the SIPAT is that it standard-izes the psychosocial assessment evaluation process so alltransplant candidates undergo the same rigorous psycho-social scrutiny helping identify areas of strength that canbe built upon, and areas of weakness needing assistance orfurther consultation and treatment. This process helpstransplant teams know as much as they need about thefactors that may influence transplant outcomes. The func-tion of psychosocial consultants should not be to make adetermination regarding the patient’s worthiness as a can-didate, but to assist the transplant selection committee inmaking the best clinical decision based on current avail-able data.40 The use of assessment tools, such as theSIPAT, not only assists clinicians in eliminating the emo-tional factor from the decision-making process, but also inpresenting the facts during the selection process.

We believe the SIPAT compares favorably with thePACT, but it has some significant advantages, includingdetailed descriptions regarding social support, substanceabuse, use, and recidivism risk, knowledge regarding ill-ness and transplantation process, the effects of psycho-pathology, and other cognitive organic factors. Our studywas able to demonstrate excellent inter-rater reliability anda robust association between SIPAT scores and post-trans-plant psychosocial problems. SIPAT scores appear to bemore reproducible than PACT scores between differentraters. Moreover, SIPAT scores appear to be consistentbetween novice and expert raters.

The SIPAT may not only help to improve the selec-tion process of transplant candidates, but it may also serveto identify a patient’s level of social, neuropsychiatric, andcognitive functioning. Clinicians may use the SIPAT tocomplement and standardize the psychosocial evaluationprocess, although it should not be used as the sole deter-minant of eligibility for transplantation. Instead, the con-tent items of the SIPAT may enhance the selection processby identifying risk factors that may be amenable to clinicalintervention before the transplant, or that may requireextra attention after transplantation. This will assist indeveloping a comprehensive psychosocial treatment planfor each individual patient with the ultimate goal of min-imizing preventable problems, mitigating risk, and opti-mizing graft survival and patient’s functioning and quality

of life. In fact, we believe the major strength of the tool isnot only its accuracy in identifying and predicting thosepatients who may do poorly after transplantation, but itsability to screen for areas of a candidate’s weaknesses inorder to allow for the development of interventions di-rected at improving the patient’s candidacy, thus turn-ing marginal patients into acceptable transplant recipi-ents. Although we recognize that many factors go intodetermining eventual transplant success (e.g., even withperfect adherence, some organs will be rejected), wepredict that enhanced psychosocial selection criteriawill translate into lower morbidity, lower rejectionrates, enhanced graft survival, and better quality of lifefor transplanted patients.

Limitations and Future Steps/Research

Because we wanted to be able to test the potentialvalue of our assessment tool, we elected to apply it retro-spectively to patients already transplanted, even thoughthe tool was designed to be used during the prospectiveassessment of transplant candidates. This allowed us toassess the tool’s usefulness without having to wait years ofwaiting while the patients are in the transplant list awaitingtransplantation and eventual outcomes. Because of theretrospective nature of the study, examiners had to applythe instruments to historical data contained in the patient’schart rather than being able to perform an exam on a livepatient. This may have limited the examiner’s ability toask questions, which may have increased the accuracy.Likewise, because the cases were selected blindly, theretrospective application of the SIPAT could not take intoconsideration whether the ultimate outcome was affectedby the application of corrective measures or lack thereof.For example, a patient who received a high SIPAT scoremay have been identified at the time as being high risk bythe team, and an appropriate treatment plan may havecorrected the identified psychosocial problems, eventuallymaking the patient a better transplant candidate. Given thatwe only applied the measures to the initial evaluationprocess, we could not take the effects of those interven-tions into account. Also, because of the number of subjectsand differences among the members of various transplantteams, we decided to limit the analysis of predictive out-comes to a single organ in order to limit confounders, andkept the sample relatively homogenous.

Our next step is to conduct a prospective study to lookat the ability of this instrument to predict medical treat-ment outcomes. We predict that in order to prove an

Maldonado et al.



association between the SIPAT and medical outcome (i.e.,morbidity, mortality, graft survival and quality of life), alarger data set would be needed. Also, it may be requiredthat the SIPAT is used to reassess the patient’s candidacyafter psychosocial interventions have taken place, or if thepatient’s psychosocial situation deteriorates, as either sce-nario may affect the ultimate score and eventual outcome.Similarly, future studies should also assess issues of howpsychosocial factors affect quality of life after transplan-tation.

CONCLUSION

The SIPAT is a comprehensive screening tool designed toenhance the psychosocial assessment of organ transplantcandidates. Its strengths include the standardization of theevaluation process and its ability to identify subjects whoare at risk for negative outcomes after the transplant, inorder to allow for the development of interventions directedat improving the patient’s candidacy. SIPAT scores werefound to be highly predictive of the transplant psychosocialoutcome. The instrument has excellent inter-rater reliabil-ity, even among novice raters, and is highly correlatedwith PACT scores. Our goal is that the SIPAT, in additionto a set of agreed upon minimal psychosocial listing cri-teria, would be used along organ-specific medical listingcriteria in order to establish standardized criteria for theselection of solid organ transplant recipients in a way that

promotes fairness, allows for the identification and timelymanagement of potential problems, and maximizes graftsurvival and quality of life.

For practitioners wanting the benefit of a more ex-tended, guided interview, there is an associated psycho-social questionnaire (the SIPAT Long Form, available atthe Stanford’s Psychosomatic Medicine Program website),which can be used for the evaluation of transplant patientsand contains all the elements of the SIPAT tool. Furtherinformation regarding the rationale for the inclusion of thespecific items in the SIPAT, an administration manual, andthe SIPAT-Interview Long Form can be found in the Stan-ford University, Department of Psychiatry, PsychosomaticMedicine Program website found at �http://psychiatry.stanford.edu/Psychosomatic�.

The authors thank all of the dedicated and hardwork-ing solid organ transplant social workers who conductedall subject interviews. In particular, the authors thankthose who helped provide the necessary medical recordsand outcome data. They also thank Rodney Plante, RSW,for his participation during the very early stages of thisproject. The authors also thank all the patients who par-ticipated in this endeavor.

Disclosure: The authors disclosed no proprietary orcommercial interest in any product mentioned or conceptdiscussed in this article.

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APPENDIX 1

The SIPAT Tool is available online at www.psychoso-maticsjournal.org



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