Pragmatic trial design of an intervention to reduce cardiovascular risk in people with serious mental illness

Abstract

Background: Cardiovascular (CV) disease is the leading cause of death for people with serious mental illness (SMI), but clinicians are often slow to address this risk.

Methods/design: 78 Midwestern primary care clinics were randomized to receive or not receive access to a clinical decision support (CDS) tool. Between March 2016 and September 2018, primary care clinicians (PCPs) received CDS alerts during visits with adult patients with SMI who met minimal inclusion criteria and had at least one CV risk factor not at goal. The PCP CDS included a summary of six modifiable CV risk factors and patient-specific treatment recommendations. Psychiatrists received CDS alerts during their next visit with an eligible patient with SMI that alerted them to an elevated body mass index or recent weight gain and the presence of an obesogenic SMI medication. Study outcomes include total modifiable CV risk, six modifiable CV risk factors, and use of obesogenic SMI medications.

Discussion: This cluster-randomized pragmatic trial allowed PCPs and psychiatrists the opportunity to improve CV risk in a timely manner for patients with SMI. Effectiveness will be assessed using an intent-to-treat analysis, and outcomes will be assessed largely through electronic health record data harvested by the CDS tool itself. In total, 10,347 patients with SMI had an index primary care visit in a randomized clinic, and 8937 patients had at least one follow-up visit. Analyses are ongoing, and trial results are expected in mid-2020.

Trial registration: ClinicalTrials.gov Identifier: NCT02451670.

Keywords: Bipolar disorder; Cardiovascular disease; Clinical decision support; Primary care; Schizophrenia; Serious mental illness.

Copyright © 2020 Elsevier Inc. All rights reserved.

Figures

Figure 1.

Example PCP Interface.

Figure 2.

Example Patient Interface.

Figure 3.

Schematic Representation of CV Wizard Intervention: How Treatment Options are Identified, Prioritized, and Presented to Patients and Primary Care Providers (PCPs)