Damoiseaux-Volman Birgit A, van der Velde Nathalie, Ruige Sil G, Romijn Johannes A, Abu-Hanna Ameen, Medlock Stephanie
Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
JMIR Med Inform. 2021 Jul 16;9(7):e28023. doi: 10.2196/28023.
Clinical decision support systems (CDSSs) form an implementation strategy that can facilitate and support health care professionals in the care of older hospitalized patients.
Our study aims to systematically review the effects of CDSS interventions in older hospitalized patients. As a secondary aim, we aim to summarize the implementation and design factors described in effective and ineffective interventions and identify gaps in the current literature.
We conducted a systematic review with a search strategy combining the categories older patients, geriatric topic, hospital, CDSS, and intervention in the databases MEDLINE, Embase, and SCOPUS. We included controlled studies, extracted data of all reported outcomes, and potentially beneficial design and implementation factors. We structured these factors using the Grol and Wensing Implementation of Change model, the GUIDES (Guideline Implementation with Decision Support) checklist, and the two-stream model. The risk of bias of the included studies was assessed using the Cochrane Collaboration's Effective Practice and Organisation of Care risk of bias approach.
Our systematic review included 18 interventions, of which 13 (72%) were effective in improving care. Among these interventions, 8 (6 effective) focused on medication review, 8 (6 effective) on delirium, 7 (4 effective) on falls, 5 (4 effective) on functional decline, 4 (3 effective) on discharge or aftercare, and 2 (0 effective) on pressure ulcers. In 77% (10/13) effective interventions, the effect was based on process-related outcomes, in 15% (2/13) interventions on both process- and patient-related outcomes, and in 8% (1/13) interventions on patient-related outcomes. The following implementation and design factors were potentially associated with effectiveness: a priori problem or performance analyses (described in 9/13, 69% effective vs 0/5, 0% ineffective interventions), multifaceted interventions (8/13, 62% vs 1/5, 20%), and consideration of the workflow (9/13, 69% vs 1/5, 20%).
CDSS interventions can improve the hospital care of older patients, mostly on process-related outcomes. We identified 2 implementation factors and 1 design factor that were reported more frequently in articles on effective interventions. More studies with strong designs are needed to measure the effect of CDSS on relevant patient-related outcomes, investigate personalized (data-driven) interventions, and quantify the impact of implementation and design factors on CDSS effectiveness.
PROSPERO (International Prospective Register of Systematic Reviews): CRD42019124470; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=124470.
临床决策支持系统（CDSSs）构成了一种实施策略，可促进并支持医护人员对老年住院患者的护理。
我们的研究旨在系统评价CDSS干预措施对老年住院患者的影响。作为次要目的，我们旨在总结有效和无效干预措施中描述的实施和设计因素，并找出当前文献中的差距。
我们进行了一项系统评价，其检索策略是在MEDLINE、Embase和SCOPUS数据库中结合老年患者、老年医学主题、医院、CDSS和干预措施等类别进行检索。我们纳入了对照研究，提取了所有报告结局的数据以及潜在有益的设计和实施因素。我们使用Grol和Wensing变革实施模型、GUIDES（决策支持下的指南实施）清单和双流模型对这些因素进行构建。使用Cochrane协作网的有效实践和护理组织偏倚风险方法评估纳入研究的偏倚风险。
我们的系统评价纳入了18项干预措施，其中13项（72%）在改善护理方面有效。在这些干预措施中，8项（6项有效）侧重于药物审查，8项（6项有效）针对谵妄，7项（4项有效）针对跌倒，5项（4项有效）针对功能衰退，4项（3项有效）针对出院或后续护理，2项（0项有效）针对压疮。在77%（10/13）的有效干预措施中，效果基于与过程相关的结局，15%（2/13）的干预措施基于与过程和患者相关的结局，8%（1/13）的干预措施基于与患者相关的结局。以下实施和设计因素可能与有效性相关：先验问题或绩效分析（在9/13，69%有效干预措施中描述，而在0/5，0%无效干预措施中未描述）、多方面干预（8/13，62% vs 1/5，20%）以及对工作流程的考虑（9/13，69% vs 1/5，20%）。
CDSS干预措施可改善老年患者的医院护理，主要是在与过程相关的结局方面。我们确定了2个实施因素和1个设计因素，这些因素在有效干预措施的文章中报道更为频繁。需要更多设计严谨的研究来衡量CDSS对相关患者相关结局的影响，研究个性化（数据驱动）干预措施，并量化实施和设计因素对CDSS有效性影响。
PROSPERO（国际系统评价前瞻性注册库）：CRD42019124470；https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=124470 。
