Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials [计算机化临床决策支持系统与医疗护理的绝对改善：对照性临床试验的meta分析]

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BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3216 (Published 17 September 2020)
Cite this as: BMJ 2020;370:m3216

Authors
Janice L Kwan, Lisha Lo, Jacob Ferguson, Hanna Goldberg, Juan Pablo Diaz-Martinez, George Tomlinson, Jeremy M Grimshaw, Kaveh G Shojania

Abstract
Objective To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets.

Design Systematic review and meta-analysis.

Data sources Medline up to August 2019.

Eligibility criteria for selecting studies and methods 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.

Results 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 (I2=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.

Conclusions 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.