Use of a clinical decision support system was linked to significant reductions in cardiovascular disease risk among patients with schizophrenia, schizoaffective disorder, and bipolar disorder, according to research published in JAMA Network Open. The system prompts clinicians to provide individualized informational handouts about a patient’s cardiovascular risk and treatment recommendations.

“This landmark study is one of the first randomized controlled trials to improve cardiovascular health in a large US population of outpatients with SMI [severe mental illness]. Primary care practices serving patients with SMI now have a practical tool for addressing a major cause of these patients’ premature mortality,” said Susan T. Azrin, PhD, chief of the Premature Mortality in SMI Research Program at the National Institute of Mental Health.

Cardiovascular disease is a leading cause of death for people diagnosed with SMI. The higher rate of cardiovascular disease in this population are associated with higher rates of smoking, obesity, diabetes, and dyslipidemia. In addition, some medications for SMI can increase cause weight, insulin resistance, and lipid metabolism.


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The researchers conducted a cluster randomized clinical trial between March 2, 2016, and September 19, 2018, which included 76 primary care clinics that were part of 3 health care systems that provided care to patients in Minnesota, North Dakota, and Wisconsin. Health care sites were randomly assigned to an intervention (42 clinics) or a control (34 clinics) group. Participants at the control and intervention sites included nearly 9000 patients aged 18 to 75 years who were diagnosed with SMI and had at least 1 modifiable cardiovascular risk factor not in a healthy goal range.

Clinics in the intervention group used an electronic health record-linked clinical decision support system to print out and distribute shared decision-making handouts for patients and clinicians that included individualized information about patients’ cardiovascular risk and possible treatment considerations (Table). The researchers assessed modifiable cardiovascular risk factors during the 12 months following the initial patient visit.

Table. Elements of the Clinical Decisions Support System Clinician Handouts

• Summarized and prioritized patient’s blood pressure, lipid levels, glucose and HbA1c levels, smoking status, and BMI
• Estimated the patient’s 10-year ACC/AHA cardiovascular risk (for those aged 40-75 years) and/or 30-year risk (for those aged 18-59 years)
• Provided patient-specific treatment recommendations based on national guidelines

ACC, American College of Cardiology; AHA, American Heart Association; HbA1c, hemoglobin A1c

“The patient and clinician printouts were meant to become shared decision-making tools to help patients understand their risks and help clinicians quickly elicit patient preferences for addressing those risks,” said lead author Rebecca Rossom, MD. “We designed the shared decision-making tools to minimize any disruptions in clinic workflow and give primary care clinicians an overview of a patient’s cardiovascular risk and recommended actions at a glance.”   

The rate of change in total modifiable cardiovascular risk was 4% lower among patients at intervention sites compared with patients at control sites. A combination of changes across risk factors seemed to drive the reduction in total risk; no significant differences in individual modifiable risk factors were noted.

“While the difference in modifiable cardiovascular risk due to the intervention may seem small at 4%, it is clinically significant and translates to potentially preventing 3 heart attacks or strokes for every 1000 patients with SMI,” said Dr Rossom. “In my medical group alone, we have over 30,000 patients with SMI, so we could prevent as many as 90 heart attacks or strokes with this intervention. On top of that, we do not know the benefits that could be gained from continuing this intervention for longer than the 12 months that we studied it.” 

Changes in risk factors were most pronounced for those with bipolar disorder, followed by schizoaffective disorder, and schizophrenia. The intervention was equally effective among men and women, and was more effective among younger and middle-aged patients (aged 18–29 years and 50–59 years). The intervention was found to benefit patients self-identifying as either Black or White, but not in patients identifying as Asian, Native American, Hispanic, or those of other/unknown race.

The findings are based on data from 3 Midwestern integrated health care systems and the results may not be generalizable to other settings, the study authors noted. Also, patients with serious mental illness were identified from electronic health records and may have been misclassified.  

The findings suggest the use of a low-burden clinical decision support system to prompt the use of shared decision-making tools, such as the handouts used in this study, may result in treatment and lifestyle changes that affect long-term cardiovascular health in people with serious mental illness.

The study was supported through a cooperative agreement with the National Institutes of Health.

Sources

1. Rossom RC, Crain AL, O’Connor PJ, et al. Effect of clinical decision support on cardiovascular risk among adults with bipolar disorder, schizoaffective disorder, or schizophrenia: a cluster randomized clinical trial. JAMA Netw Open. 2022;5(3):e220202. doi:10.1001/jamanetworkopen.2022.020

2. National Institutes of Health. Clinical decision support system reduces cardiovascular risk in patients with serious mental illness. News Release. March 7, 2022. Accessed March 18, 2022. https://www.nih.gov/news-events/news-releases/clinical-decision-support-system-reduces-cardiovascular-risk-patients-serious-mental-illness