Clinical Decision Support Lowers CV Risk in Patients with Serious Mental Illness

Rebecca C. Rossom, MD, MS

New findings highlight the potential value of using a clinical decision support (CDS) system to prompt early primary care intervention for adults with serious mental illness, a collective term for schizophrenia, schizoaffective disorder, or bipolar disorder.

Data show the CDS intervention had a rate of change in total modifiable cardiovascular (CV) risk that was 4% lower among intervention patients compared to control at 12 months.

“Our finding of a 4% relative decrease in modifiable CV risk in intervention compared with control patients was modest yet clinically significant, particularly given the relatively low intensity of the intervention and the intention-to-treat analysis,” wrote study author Rebecca C. Rossom, MD, MS, Department of Research, HealthPartners Institute.

The randomized trial assessed whether an EHR-linked CDS system slowed increases in modifiable CV risk among adults with serious mental illness.

It was conducted from March 2016 - September 2018 at 76 primary care clinics in 3 Midwestern health care systems. The clinics were eligible after treating ≥20 patients with serious mental illness.

Eligible patients were adults aged 18 - 75 years who were not pregnant, had serious mental illness, and had ≥1 modifiable risk factor not at the goal set by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines.

The CDS system collected EHR data on demographics, vital signs, medications, comorbidities, allergies, and laboratory data. Primary outcomes were considered patient-level rate of change in total modifiable CV risk during the 12 months after index visit, with secondary outcomes considered the rate of change in individual modificable CV risk factors (blood pressure, lipid levels, HbA1c level, smoking, and BMI).

Investigators conducted statistical analysis on an intention-to-treat basis from January 2019 - December 2021.

A total of 80 clinics were randomized, but 4 clinics were excluded for having fewer than 20 eligible patients, leaving 42 intervention clinics and 34 control clinics in the study. In total, 8937 individuals with serious mental illness (4922 women, 55.1%; mean age, 48.4 years) made an index visit and had ≥1 follow-up visit.

From this population, 5901 participants (66.0%) had bipolar disorder, 1747 had schizoaffective disorder (19.5%), and 1289 had schizophrenia (14.4%).

Data show intervention patients had an estimated 1% decrease in total modifiable CV risk (rate ratio [RR], 0.99; 95% CI, 0.98 - 1.01) over 12 months, while control patients had an estimated 4% increase (RR, 1.04; 95% CI, 1.02 - 1.05). In total, a net 4% lower increase in total modifiable CV risk among patients in intervention clinics compared to control was observed (relative RR, 0.96; 95% CI, 0.94 - 0.98).

Further, the effectiveness of the intervention was found to vary by serious mental illness subtype, with the rate of change in intervention versus control patients 4% slower (RR, 0.96: 95% CI, 0.94 - 0.99) with bipolar disorder, 6% slower (RR, 0.94; 95% CI, 0.90 - 0.98) for patients with schizoaffective disorder, and 8% slower (RR, 0.92; 95% CI, 0.85 - 0.99) for patients with schizophrenia.

Additional data show the intervention favored patients who were 18 - 29 years of age (RR, 0.89; 95% CI, 0.81 - 0.98) or 50 - 59 years of age (RR, 0.93; 95% CI, 0.90 - 0.96), as well as Black (RR, 0.93; 95% CI, 0.88 - 0.98) or White (RR, 0.96; 95% CI, 0.94 - 0.98).

The study, “Effect of Clinical Decision Support on Cardiovascular Risk Among Adults With Bipolar Disorder, Schizoaffective Disorder, or Schizophrenia,” was published in JAMA Network Open.