No 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.

Purpose To investigate prevalence, independent associations, and variation over time of potentially inappropriate prescriptions in a population of older hospitalized patients. Methods A longitudinal study using a large dataset of hospital admissions of older patients (≥ 70 years) based on an electronic health records cohort including data from 2015 to 2019. Potentially inappropriate medication (PIM) and potential prescribing omission (PPO) prevalence during hospital stay were identified based on the Dutch STOPP/START criteria v2. Univariate and multivariate logistic regression were used for analyzing associations and trends over time. Results The data included 16,687 admissions. Of all admissions, 56% had ≥ 1 PIM and 58% had ≥ 1 PPO. Gender, age, number of medications, number of diagnoses, Charlson score, and length of stay were independently associated with both PIMs and PPOs. Additionally, number of departments and number of prescribing specialties were independently associated with PIMs. Over the years, the PIM prevalence did not change (OR = 1.00, p = .95), whereas PPO prevalence increased (OR = 1.08, p < .001). However, when corrected for changes in patient characteristics such as number of diagnoses, the PIM (aOR = 0.91, p < .001) and PPO prevalence (aOR = 0.94, p < .001) decreased over the years. Conclusion We found potentially inappropriate prescriptions in the majority of admissions of older patients. Prescribing relatively improved over time when considering complexity of the admissions. Nevertheless, the high prevalence shows a clear need to better address this issue in clinical practice. Studies seeking effective (re)prescribing interventions are warranted.