加拿大多伦多大学Janice L Kwan团队分析了计算机临床决策支持系统与治疗绝对改善的相关性。2020年9月17日，该研究发表在《英国医学杂志》上。

为了报告临床决策支持系统对治疗的改善，并检查各种临床环境和干预目标在汇集效果方面的异质性，研究组在Medline数据库中检索截至2019年8月的文献，即根据临床决策支持系统推荐进行治疗，患者绝对改善数据完整的随机或半随机对照试验，并对这些试验进行系统回顾和荟萃分析。

研究组共筛选出108项研究，包括94项随机研究和14项半随机研究，共122项试验，涉及1203053名患者和10790名提供者，临床决策支持系统使接受期望治疗的患者比例增加了5.8%。这种汇集效果显示出很大的异质性，改善幅度10％到62％不等。在30个报告临床终点的试验中，临床决策支持系统将达到指南目标（例如，血压或血脂控制）的患者比例提高了0.3％。两项研究特征（低基线依从性和儿科环境）与更好的疗效显著相关。但将这些协变量包括在多元回归中并不能减少异质性。

总之，临床终点的微小变化来证实，临床决策支持系统的大多数干预措施似乎在针对性的治疗过程中实现了小到中等程度的改善。

附：英文原文

Title: Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials

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

Issue&Volume: 2020/09/17

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 1203053 patients and 10790 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.

DOI: 10.1136/bmj.m3216

Source: https://www.bmj.com/content/370/bmj.m3216