Effect of Interventions With a Clinical Decision Support System for Hospitalized Older Patients: Systematic Review Mapping Implementation and Design Factors

Abstract

Background Clinical decision support systems (CDSSs) form an implementation strategy that can facilitate and support health care professionals in the care of older hospitalized patients. Objective 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. Methods 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. Results 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%). Conclusions 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. Trial Registration PROSPERO (International Prospective Register of Systematic Reviews): CRD42019124470; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=124470.

Health and Wellbeing in Aging

“… The engagement of older adults with health technology (e-health), specifically the use of e-health tools during everyday life, has been reported in recent studies to be associated with better support regarding their healthcare needs [ 22 , 23 , 24 ], and in this context, the World Health Organization appealed to the development of strategies to improve digital literacy in older adults [ 25 ]. Better decision-making processes and decision-support systems for clinicians can improve the outcomes of hospitalized older adults, according to some studies [ 26 ]. Better pharmaceutical care should be provided for older adults through the identification of DRPs and improvements in patients’ literacy [ 27 ], with pharmacists having an essential role in patients’ wellbeing due to their proximity to the patients.…”

“…Better decision-making processes and decision-support systems for clinicians can improve the outcomes of hospitalized older adults, according to some studies [ 26 ].…”

Clinical validation of clinical decision support systems for medication review: A scoping review

“…CDSSs were mostly effective on process-related outcomes, but not yet on patient-related outcomes. 7,8 An intervention with a CDSS is complex and must address the needs and wishes of future users. The Two-Stream Model and the GUIDES checklist describe factors that contribute to the success of CDSSs.…”

“…Effectiveness of previous CDSS interventions supporting (part of) a medication review for hospitalized patients varied. CDSSs were mostly effective on process‐related outcomes, but not yet on patient‐related outcomes 7,8 …”

“…CDSSs were mostly effective on process‐related outcomes, but not yet on patient‐related outcomes. 7 , 8 …”