Department of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN.
Department of Surgery, University of Minnesota, Division of Acute Care Surgery, Minneapolis, MN.
Ann Surg. 2023 Mar 1;277(3):359-364. doi: 10.1097/SLA.0000000000005661. Epub 2022 Aug 9.
We critically evaluated the surgical literature to explore the prevalence and describe how equity assessments occur when using clinical decision support systems.
Clinical decision support (CDS) systems are increasingly used to facilitate surgical care delivery. Despite formal recommendations to do so, equity evaluations are not routinely performed on CDS systems and underrepresented populations are at risk of harm and further health disparities. We explored surgical literature to determine frequency and rigor of CDS equity assessments and offer recommendations to improve CDS equity by appending existing frameworks.
We performed a scoping review up to Augus 25, 2021 using PubMed and Google Scholar for the following search terms: clinical decision support, implementation, RE-AIM, Proctor, Proctor's framework, equity, trauma, surgery, surgical. We identified 1415 citations and 229 abstracts met criteria for review. A total of 84 underwent full review after 145 were excluded if they did not assess outcomes of an electronic CDS tool or have a surgical use case.
Only 6% (5/84) of surgical CDS systems reported equity analyses, suggesting that current methods for optimizing equity in surgical CDS are inadequate. We propose revising the RE-AIM framework to include an Equity element (RE 2 -AIM) specifying that CDS foundational analyses and algorithms are performed or trained on balanced datasets with sociodemographic characteristics that accurately represent the CDS target population and are assessed by sensitivity analyses focused on vulnerable subpopulations.
Current surgical CDS literature reports little with respect to equity. Revising the RE-AIM framework to include an Equity element (RE 2 -AIM) promotes the development and implementation of CDS systems that, at minimum, do not worsen healthcare disparities and possibly improve their generalizability.
我们批判性地评估了外科文献，以探讨使用临床决策支持系统时的普遍性，并描述如何进行公平性评估。
临床决策支持（CDS）系统越来越多地用于促进外科护理的提供。尽管有正式的建议，但CDS 系统并没有进行常规的公平性评估，代表性不足的人群面临着伤害和进一步的健康差距的风险。我们探讨了外科文献，以确定 CDS 公平性评估的频率和严谨性，并提出了通过附加现有框架来改善 CDS 公平性的建议。
我们使用 PubMed 和 Google Scholar 进行了范围界定审查，截至 2021 年 8 月 25 日，使用以下搜索词：临床决策支持、实施、RE-AIM、Proctor、Proctor 的框架、公平性、创伤、手术、外科。我们确定了 1415 条引文和 229 条摘要符合审查标准。在排除了 145 条未评估电子 CDS 工具的结果或没有外科使用案例的摘要后，共有 84 条摘要进行了全面审查。
只有 6%（5/84）的外科 CDS 系统报告了公平性分析，这表明目前优化外科 CDS 公平性的方法是不够的。我们建议修改 RE-AIM 框架，纳入一个公平性元素（RE 2 -AIM），规定 CDS 基础分析和算法是在具有准确代表 CDS 目标人群的社会人口特征的平衡数据上进行的，或者是在针对弱势群体的敏感性分析中进行训练的，并对这些数据进行评估。
目前的外科 CDS 文献很少涉及公平性问题。修改 RE-AIM 框架以纳入公平性元素（RE 2 -AIM），可以促进 CDS 系统的开发和实施，这些系统至少不会加剧医疗保健差距，并且可能会提高其通用性。
