Cockburn Neil, Osborne Cristina, Withana Supun, Elsmore Amy, Nanjappa Ramya, South Matthew, Parry-Smith William, Taylor Beck, Chandan Joht Singh, Nirantharakumar Krishnarajah
Department of Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom.
Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom.
EClinicalMedicine. 2024 Sep 5;76:102822. doi: 10.1016/j.eclinm.2024.102822. eCollection 2024 Oct.
The use of Clinical Decision Support Systems (CDSS) is increasing throughout healthcare and may be able to improve safety and outcomes in maternity care, but maternity care has key differences to other disciplines that complicate the use of CDSS. We aimed to identify evaluated CDSS and synthesise evidence of their impact on maternity care.
We conducted a systematic review for articles published before 24th May 2024 that described i) CDSS that ii) investigated the impact of their use iii) in maternity settings. Medline, CINAHL, CENTRAL and HMIC were searched for articles relating to evaluations of CDSS in maternity settings, with forward- and backward-citation tracing conducted for included articles. Risk of bias was assessed using the Mixed Methods Assessment Tool, and CDSS were described according to the clinical problem, purpose, design, and technical environment. Quantitative results from articles reporting appropriate data were meta-analysed to estimate odds of a CDSS achieving its desired outcome using a multi-level random effects model, first by individual CDSS and then across all CDSS. PROSPERO ID: CRD42022348157.
We screened 12,039 papers and included 87 articles describing 47 unique CDSS. 24 articles (28%) described randomised controlled trials, 30 (34%) described non-randomised interventional studies, 10 (11%) described mixed methods studies, 10 (11%) described qualitative studies, 7 (8%) described quantitative descriptive studies, and 7 (8%) described economic evaluations. 49 (56%) were in High-Income Countries and 38 (44%) in Low- and Middle-Income countries, with no CDSS trialled in both income categories. Meta-analysis of 35 included studies found an odds ratio for improved outcomes of 1.69 (95% confidence interval 1.24-2.30). There was substantial variation in effects, aims, CDSS types, context, study designs, and outcomes.
Most CDSS evaluations showed improvements in outcomes, but there was heterogeneity in all aspects of design and evaluation of systems. CDSS are increasingly important in delivering healthcare, and Electronic Health Records and mHealth will increase their availability, but traditional epidemiological methods may be limited in guiding design and demonstrating effectiveness due to rapid CDSS development lifecycles and the complex systems in which they are embedded. Development methods that are attentive to context, such as Human Centred Design, will help to meet this need.
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临床决策支持系统（CDSS）在整个医疗保健领域的应用日益广泛，可能有助于提高产科护理的安全性和改善护理结果，但产科护理与其他学科存在关键差异，这使得CDSS的应用变得复杂。我们旨在识别经过评估的CDSS，并综合其对产科护理影响的证据。
我们对2024年5月24日前发表的文章进行了系统综述，这些文章描述了：i）CDSS；ii）调查了其使用的影响；iii）在产科环境中的应用。我们在Medline、CINAHL、CENTRAL和HMIC中搜索了与产科环境中CDSS评估相关的文章，并对纳入的文章进行了向前和向后的引文追踪。使用混合方法评估工具评估偏倚风险，并根据临床问题、目的、设计和技术环境对CDSS进行描述。对报告适当数据的文章的定量结果进行荟萃分析，以使用多层次随机效应模型估计CDSS实现其预期结果的几率，首先按单个CDSS进行，然后对所有CDSS进行汇总。PROSPERO注册号：CRD42022348157。
我们筛选了12039篇论文，纳入了87篇描述47个独特CDSS的文章。24篇文章（28%）描述了随机对照试验，30篇（34%）描述了非随机干预研究，10篇（11%）描述了混合方法研究，10篇（11%）描述了定性研究，7篇（8%）描述了定量描述性研究，7篇（8%）描述了经济评估。49篇（56%）来自高收入国家，38篇（44%）来自低收入和中等收入国家，没有CDSS在这两个收入类别中都进行过试验。对35项纳入研究的荟萃分析发现，改善结果的优势比为1.69（95%置信区间1.24 - 2.30）。在效果、目标、CDSS类型、背景、研究设计和结果方面存在很大差异。
大多数CDSS评估显示结果有所改善，但系统设计和评估的各个方面都存在异质性。CDSS在提供医疗保健方面越来越重要，电子健康记录和移动健康将增加其可用性，但由于CDSS快速的开发生命周期及其所嵌入的复杂系统，传统的流行病学方法在指导设计和证明有效性方面可能有限。关注背景的开发方法，如以人为本的设计，将有助于满足这一需求。
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