A variety of clinical interventions focus on technologies that remind clinicians to order metabolic monitoring tests according to screening guidelines. One public mental health service in Queensland, Australia, created a standardized metabolic monitoring form to be uploaded to the electronic medical record. In their implementation study examining the efficacy of the metabolic monitoring form, they found that only 36% of the forms contained data. When data were recorded, there were significantly higher rates of documentation of measurements (weight, body mass index, blood pressure) rather than laboratory tests (including lipids and fasting blood glucose) [27].
Computerized reminder systems for metabolic monitoring have been studied in both outpatient and inpatient settings. Lai and colleagues studied the impact of a computerized reminder system on lab monitoring for metabolic parameters among outpatients with schizophrenia prescribed SGAs [42]. This intervention also included an educational component with discussion of metabolic monitoring for people prescribed SGAs at meetings with attending psychiatrists. Computer reminders were displayed when a provider failed to order fasting plasma glucose or lipids (cholesterol, triglyceride) for patients prescribed clozapine, olanzapine, quetiapine, or risperidone. The study found a statistically significant improvement in laboratory metabolic screening for patients prescribed SGAs after implementation, with the greatest impact 6-months post-intervention, though with subsequent decline in screening rates [42].
Psychiatric inpatient hospitalizations provide an opportunity to obtain testing at the time of treatment initiation and also for ongoing monitoring in a location where fasting laboratory tests may be more easily obtained given onsite phlebotomy. One intervention targeting psychiatric inpatients utilized a computerized physician order entry system with the goal to improve metabolic screening among patients prescribed SGAs. Set in a large academic medical setting, the study found inpatient metabolic monitoring rates did not change significantly after implementation of these pop-up computer alerts, comparing rates immediately and 4 years after implementation [46].
There has been increasing focus on integrating mental health and medical care in an effort to improve the health of people with mental illness [47]. Mangurian and colleagues found that the likelihood of diabetes mellitus screening doubled for people with severe mental illness who were seen for at least one primary care visit in addition to mental health treatment [48]. Haupt similarly found higher rates of metabolic screening among patients who had greater than one primary care visit [36]. Models of integration include both integration of medical services into mental health treatment as well as incorporation of mental health services into primary care. For people with SMI, integration efforts have largely focused on integrating primary care services into community mental health settings [49]. The Substance Abuse and Mental Health Service Administration’s (SAMHSA) Primary and Behavioral Health Care Integration (PBHCI) grants program and the Affordable Care Act’s Health Home Initiative are examples of federal incentive programs for improved integration between behavioral health and primary care [49]. In their evaluation of the PBHCI grant program, Scharf and colleagues presented findings that patients at 3 matched clinics with PCBHI grants showed improvement in some lipids, diastolic blood pressure, and fasting blood glucose, though not smoking or body mass index [50].
Conclusion
Several risk factors contribute to an increase in cardiometabolic risk for people with severe mental illness, including poor nutrition, sedentary lifestyle, social determinants of health, and prescribed antipsychotic medications. Metabolic monitoring aims to address these health disparities by screening for metabolic parameters and identifying abnormalities in order to target appropriate health interventions. Screening rates for metabolic parameters remain low for children, adolescents, and adults prescribed second-generation antipsychotics despite published guidelines and clinical interventions to improve screening. More system-wide interventions to improve collaboration between mental health and primary care are needed to enhance screening and prevent cardiovascular disease risk in this vulnerable population.
Corresponding author: Carrie Cunningham, MD, MPH, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Suite 7M, San Francisco, CA 94110, carrie.cunningham@ucsf.edu.
Funding/support: Dr. Cunningham was supported by the UCSF-Zuckerberg San Francisco General Public Psychiatry Fellowship. Mr. Riano was supported by the NIH Center Grant from the National Institute of Diabetes and Digestive and Kidney Diseases for The Health Delivery Systems-Center for Diabetes Translational Research (CDTR) (P30DK092924) and by the UCSF-San Francisco General Hospital Public Psychiatry Fellowship. Dr. Mangurian received support from a grant from the NIH National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (R03 DK101857), as well as NIH Career Development Award (K23MH093689).