Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials
Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials
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DOI：
10.1136/bmj.m3216
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发表时间：
2020-09-17
影响因子：
105.7
通讯作者：
Shojania, Kaveh G.
中科院分区：
文献类型：
--
作者：
Kwan, Janice L.;Lo, Lisha;Shojania, Kaveh G.
目的：报告临床决策支持系统所取得的进步，并检查不同临床环境和干预目标之间汇集效应的异质性。方法：系统综述和荟萃分析。数据来源Medline截至2019年8月。选择研究和方法的资格标准随机或准随机随机对照试验报告了接受临床决策支持系统推荐的护理的患者百分比的绝对改善。多水平荟萃分析解释了研究聚类。荟萃回归用于评估临床决策支持系统和研究特征降低效应量异质性的程度。在108项研究（94项随机研究，14项半随机研究）中，报告了122项试验，提供了来自1203053名患者和10790名提供者的可分析数据，临床决策支持系统使接受期望护理的患者比例增加了5.8%（95%置信区间为4.0%至7.6%）。这种合并效应表现出显著异质性（I-2 =76%），报告的改善的前四分位数范围为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实现基于指南的目标（例如血压或血脂控制）的患者比例增加了中位数0.3%（四分位数间距-0.7%至1.9%）。两个研究特征（低基线依从性和儿科环境）与显著更大的影响相关。纳入这些协变量的多变量荟萃回归，但是，并没有减少heterogeneity.CONCLUSIONSMost干预与临床决策支持系统似乎实现小到中度的改善，有针对性的护理过程中，一个发现证实了小的变化，发现在临床终点的研究，报告他们。少数研究在提供推荐的护理方面取得了实质性的增长，但这些更有意义的改善的预测因素仍然不确定。
OBJECTIVETo report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets.DESIGNSystematic review and meta-analysis.DATA SOURCESMedline up to August 2019.ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODSRandomised 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.RESULTSIn 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-2 =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.CONCLUSIONSMost 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.