An Electronic Clinical Decision Support System for the Assessment and Management of Suicidality in Primary Care: Protocol for a Mixed-Methods Study

Background Suicide is a global public health concern, but it is preventable. Increased contact with primary care before the suicide or attempted suicide raises opportunities for intervention and prevention. However, suicide assessment and management are areas that many general practitioners (GPs) find particularly challenging. Previous research has indicated significant variability in how GPs understand, operationalize, and assess suicide risk, which subsequently has an impact on clinical decision making. Clinical decision support systems (CDSS) have been widely implemented across different health care settings, including primary care to support practitioners in clinical decision making. A CDSS may reduce inconsistencies in the identification, assessment, and management of suicide risk by GPs by guiding them through the consultation and generating a risk assessment plan that can be shared with a service user or with specialized mental health services. Objective Our aim is to co-develop and test with end users (eg, GPs, primary care attendees, mental health professionals) an electronic clinical decision support system (e-CDSS) to support GPs in the identification, assessment, and management of suicidality in primary care. Methods Ours is an ongoing embedded mixed-methods study with four phases: (1) qualitative interviews with GPs to explore their views on the content, format, and use of the e-CDSS, as well as consultation with two service-user advisory groups (people aged ≤25 and people aged ≥25) to inform the content of the e-CDSS including phrasing of items and clarity; (2) participatory co-production workshops with GPs, service users, and clinical experts in suicidality to determine the content and format of the e-CDDS; gain consensus of the relevance of items; establish content validity and identify pathways to implementation, using the Consolidated Framework for Implementation Research; (3) building the e-CDSS so that it guides the GP through a consultation; and (4) usability testing of the e-CDSS with GPs and service users in one primary care practice involving a nonlive and a live stage. Results The study was funded for four years, to take place between 2015 and 2019, and is currently completing phase 4 data collection. The first results are expected to be submitted for publication in June 2019. The findings will enable us to evaluate the feasibility, acceptability, and usability of a suicide-specific, electronic, guided decision support system in primary care. Conclusions This study will be the first to explore the feasibility, acceptability, and usability of an electronic, guided decision support system for use in primary care consultations for the improved assessment and management of suicidality. International Registered Report Identifier (IRRID) RR1-10.2196/11135

Involve co-production between researchers and those expected to use or benefit from the findings In the current application there is no PPI involvement although if funded the application mentions that the public will be involved at a number of levels.
Are likely to be implemented by CLAHRC EM Partners Unsure Address important issues on chronic disease and public health Yes Be led by experienced research teams with a strong track record of delivery in applied health research One of the applicants has a reasonable track record in research publications.
The project represents excellent value-for money.

No
Have an impact on patient outcomes within 3-5 years Deliver significant reductions in service demand, improved service quality and/or efficiency gains Reduce disparities in health between socially Unlikely to have an impact in such a short period of time. There are major concerns regarding this proposal. One of the concerns is the huge amount being charged by PRIMIS as I am aware of other studies being conducted by PRIMIS at much lower costs. The background of the application gives rationale for conducting this study with a number of references. However a reference list has not been included. The references that they have cited do not in fact refer to studies that have developed computerised screening tools for risk of suicide.
The key aim of the study is to develop an electronic suicide screening tool. Although methodologically it is clear that the applicants are not developing a new tool. For the development of a new tool one would need to have an outcome of suicide or indeed some validity of the primary outcome. Analysis plan would include development of risk score using ROC methodology which again is not included in the application. The authors state that they will work with PRIMIS to develop a computerised risk assessment tool. However one could develop a risk assessment tool using the CPRD database which I am not aware has been attempted previously.

Reviewer No2
Project Name: The development and evaluation of an electronic suicide risk screening tool for use in primary care.

Criteria
Comments Likely to bring benefits to patients and the public Yesfits with the national strategy 2012 and local suicide prevention plan (City CCG).
Have strong interest and engagement from services and commissioners across the East Midlands Identifies 'county CCG' this is an out of date term, therefore cannot identify which CCG is involved or if multiple CCGs. Includes local NHS providers, mental health.
Involve co-production between researchers and those expected to use or benefit from the findings Focus solely on identification through GP using a risk profile. As 30% known/make contact with GP (research identify 2002 date as 45%) numbers of suicides increasing. Are likely to be implemented by CLAHRC EM Partners Address important issues on chronic disease and public health Fits with national strategy and local plans. Identified as a priority and in patient safety collaboration.
Be led by experienced research teams with a strong track record of delivery in applied health research Cannot comment re GP involvement and experience but supported by experienced researchers.
The project represents excellent value-for money.
50% costs relate to salary costs. Matched funding £2,700 from CCG.
Have an impact on patient outcomes within 3-5 years Deliver significant reductions in service demand, improved service quality and/or efficiency gains Reduce disparities in health between socially Will lead to further research therefore impact may not be seen until 5 years plus. However education ,ay improve.
The tool is to be tested, the approach not proven in England; however Primary Care identified as a focus.
Suicide is linked to disparities in health and social groups. A screening tool is one approach but not yet tested in this area. May lead to additional benefits of increased awareness and education locally. Essentially will require further, large scale, research. PSC, identified as a key priority. Would increase profile of locality.

Reviewer 3
Project Name: The development and evaluation of an electronic suicide risk screening tool for use in in primary care

Criteria
Comments Likely to bring benefits to patients and the public Project is likely to bring benefits to public and patients by development of new electronic tool for assessment of risk of suicide in primary care. Have strong interest and engagement from services and commissioners across the East Midlands The topic selected for this piece of research will attract strong interest from service users and commissioners Involve co-production between researchers and those expected to use or benefit from the findings The proposed plan to involve co-production is robust Are likely to be implemented by CLAHRC EM Partners Yes, it's likely to be implemented by partners of EM CLAHRC Address important issues on chronic disease and public health Correct identification of suicide risk is important issue and the proposed project aim to address this.
Be led by experienced research teams with a strong track record of delivery in applied health research The given profile of research team fits nicely in to feasibility of this project The project represents excellent value-for money.

Yes
Have an impact on patient outcomes within 3-5 years Deliver significant reductions in service demand, improved service quality and/or efficiency gains Reduce disparities in health between socially Given research proposal will definitely have impact on clinical practice in primary care in identifying the suicide risk in vulnerable patient correctly and referring patient in time but at the same time reducing the improper referrals to secondary care on suspicion of suicide risk. The proposal has plans for adoption of findings in collaboration with EM AHSN and also has a potential to lead to development of capacity to conduct applied health research. The chosen topic is quite relevant to our day to day clinical practice and will attract service users and commissioners. As rightly described, majority of work on risk estimation for suicide is done outside of UK and there is need to produce local evidence to direct our clinical practice.