Sinai Health System, Department of Medicine, 600 University Avenue, Toronto, ON M5G 1X5, Canada
Department of Medicine, University of Toronto, Toronto, ON, Canada.
BMJ. 2020 Sep 17;370:m3216. doi: 10.1136/bmj.m3216.
To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets.
Systematic review and meta-analysis.
Medline up to August 2019.
Randomised or quasi-randomised controlled trials reporting absolute improvements in the percentage of patients receiving care recommended by clinical decision support systems. Multilevel meta-analysis accounted for within study clustering. Meta-regression was used to assess the degree to which the features of clinical decision support systems and study characteristics reduced heterogeneity in effect sizes. Where reported, clinical endpoints were also captured.
In 108 studies (94 randomised, 14 quasi-randomised), reporting 122 trials that provided analysable data from 1 203 053 patients and 10 790 providers, clinical decision support systems increased the proportion of patients receiving desired care by 5.8% (95% confidence interval 4.0% to 7.6%). This pooled effect exhibited substantial heterogeneity (I=76%), with the top quartile of reported improvements ranging from 10% to 62%. In 30 trials reporting clinical endpoints, clinical decision support systems increased the proportion of patients achieving guideline based targets (eg, blood pressure or lipid control) by a median of 0.3% (interquartile range -0.7% to 1.9%). Two study characteristics (low baseline adherence and paediatric settings) were associated with significantly larger effects. Inclusion of these covariates in the multivariable meta-regression, however, did not reduce heterogeneity.
Most interventions with clinical decision support systems appear to achieve small to moderate improvements in targeted processes of care, a finding confirmed by the small changes in clinical endpoints found in studies that reported them. A minority of studies achieved substantial increases in the delivery of recommended care, but predictors of these more meaningful improvements remain undefined.
报告临床决策支持系统取得的改进，并考察在不同临床环境和干预目标下汇总效应的异质性。
系统评价和荟萃分析。
截至 2019 年 8 月的 Medline。
报告临床决策支持系统推荐的护理百分比绝对提高的随机或准随机对照试验。多水平荟萃分析考虑了研究内聚类。采用元回归评估临床决策支持系统的特征和研究特征在多大程度上降低了效应大小的异质性。在有报告的情况下，还捕获了临床终点。
在 108 项研究（94 项随机，14 项准随机）中，报告了 122 项试验，共纳入 1 203 053 名患者和 10 790 名提供者，临床决策支持系统使接受所需护理的患者比例增加了 5.8%（95%置信区间 4.0%至 7.6%）。该汇总效应表现出显著的异质性（I=76%），报告的改善幅度最高的四分位数范围为 10%至 62%。在 30 项报告临床终点的试验中，临床决策支持系统使达到基于指南目标（如血压或血脂控制）的患者比例中位数增加了 0.3%（四分位距-0.7%至 1.9%）。两项研究特征（低基线依从性和儿科环境）与更大的效应显著相关。然而，在多变量荟萃回归中纳入这些协变量并没有降低异质性。
大多数具有临床决策支持系统的干预措施似乎在有针对性的护理过程中取得了较小到中等程度的改善，这一发现得到了报告这些改善的研究中临床终点微小变化的证实。少数研究实现了推荐护理的实质性增加，但这些更有意义的改善的预测因素仍未确定。
