T97. REAL WORLD IMPLEMENTATION OF A TRANSDIAGNOSTIC RISK CALCULATOR FOR THE AUTOMATIC DETECTION OF INDIVIDUALS AT RISK OF PSYCHOSIS IN CLINICAL ROUTINE
Authors: Oliver Dominic , Spada Giulia , Patel Rashmi , Stewart Robert , Dobson Richard , McGuire Philip , Fusar-Poli Paolo 
Published: May 2020

Abstract

Background
Detection of individuals at-risk for psychosis is the rate-limiting step of primary indicated prevention. Improvement is imperative to improving clinical outcomes; to mitigate this, our group has developed a transdiagnostic, clinically-based, individualised risk calculator. The risk calculator uses simple predictors (age, gender, ethnicity, ICD-10 diagnosis and age*gender interaction) selected a priori and recorded as part of clinical routine. While there are numerous examples of prognostic tools in psychiatry that have been externally validated, there are none that have been implemented into clinical practice. This is the first study assessing the implementation of a prognostic tool in psychiatry.

Methods
A feasibility study was composed of both an initial in-vitro phase, aiming to successfully integrate the risk calculator into the local electronic case register, as well as an in-vivo phase to investigate the feasibility of real world implementation of the calculator in clinical routine. The in-vitro phase involved development of the risk calculator prototype, addressing of feasibility problems associated with its implementation in clinical practice, and conducting clinician engagement work prior to initiating in-vivo piloting. In the in-vivo phase, the risk calculator was implemented into the local electronic health records. Clinicians were not required to enter any new variables as predictors were recorded as part of clinical routine. All patients over the age of 14 receiving a non-organic, non-psychotic primary index diagnosis were automatically assessed for psychosis risk, with responsible clinicians being contacted if their patient was considered to be above 5% risk within 2 years. The primary outcome was adherence of clinicians to the use of the transdiagnostic risk calculator, as measured by the proportion of clinicians who responded to prompts sent on the recommendation of the calculator.

Results
Of the 88 patients included in the final sample, mean (SD) age was 39.05 (18.27) and 33 (37.5%) were male. The calculator was successfully integrated into the local electronic case register, running automatically to estimate psychosis risk on all new cases in our mental health trust. Clinician adherence was high (84%), providing evidence of successful implementation of the risk calculator in clinical routine. 55% of clinicians who responded also referred their patient for a refined psychosis risk assessment, highlighting the applicability of the calculator.

Discussion
This implementation study provides the rationale for a prospective effectiveness study for our transdiagnostic, clinically-based, individualised risk calculator. This risk calculator has the potential to significantly improve the identification of individuals at-risk for psychosis and has been shown to be feasible to use in clinical routine. Additionally, this highlights the absence of implementation research in psychiatry, in spite of the prolific publishing of prognostically accurate models.