Do providers use computerized clinical decision support systems? A systematic review and meta-regression of clinical decision support uptake

Abstract

Background Computerized clinical decision support systems (CDSSs) are a promising knowledge translation tool, but often fail to meaningfully influence the outcomes they target. Low CDSS provider uptake is a potential contributor to this problem but has not been systematically studied. The objective of this systematic review and meta-regression was to determine reported CDSS uptake and identify which CDSS features may influence uptake. Methods Medline, Embase, CINAHL, and the Cochrane Database of Controlled Trials were searched from January 2000 to August 2020. Randomized, non-randomized, and quasi-experimental trials reporting CDSS uptake in any patient population or setting were included. The main outcome extracted was CDSS uptake, reported as a raw proportion, and representing the number of times the CDSS was used or accessed over the total number of times it could have been interacted with. We also extracted context, content, system, and implementation features that might influence uptake, for each CDSS. Overall weighted uptake was calculated using random-effects meta-analysis and determinants of uptake were investigated using multivariable meta-regression. Results Among 7995 citations screened, 55 studies involving 373,608 patients and 3607 providers met full inclusion criteria. Meta-analysis revealed that overall CDSS uptake was 34.2% (95% CI 23.2 to 47.1%). Uptake was only reported in 12.4% of studies that otherwise met inclusion criteria. Multivariable meta-regression revealed the following factors significantly associated with uptake: (1) formally evaluating the availability and quality of the patient data needed to inform CDSS advice; and (2) identifying and addressing other barriers to the behaviour change targeted by the CDSS. Conclusions and relevance System uptake was seldom reported in CDSS trials. When reported, uptake was low. This represents a major and potentially modifiable barrier to overall CDSS effectiveness. We found that features relating to CDSS context and implementation strategy best predicted uptake. Future studies should measure the impact of addressing these features as part of the CDSS implementation strategy. Uptake reporting must also become standard in future studies reporting CDSS intervention effects. Registration Pre-registered on PROSPERO, CRD42018092337

Use of an Electronic Medication Management Support System in Patients with Polypharmacy in General Practice: A Quantitative Process Evaluation of the AdAM Trial

“…The fact that the design of the AdAM study included an underlying process evaluation that had been planned and published beforehand, improves the methodological quality of the trial. Furthermore, this process evaluation addresses each step of the CDSS application process and responds to the urgent need for a deeper understanding of CDSS uptake reported in a recently published systematic review [40]. We could show that GPs attached more importance to severe alerts, and that alerts relating to medication dosage and kidney function were more frequently dealt with than those concerning e.g., drug-drug interactions or possible unsuitability due to a patient's age (Intervention Dose).…”

Barriers and enablers to implementing and using clinical decision support systems for chronic diseases: a qualitative systematic review and meta-aggregation

“…However, meta-analyses of CDS intervention studies show substantial heterogeneity in effect sizes [ 8 – 10 ]. Furthermore, widespread adoption of CDS systems has not been achieved [ 13 ], and access to CDS does not guarantee user uptake or acceptance in clinical settings [ 14 – 16 ]. For example, a review of 23 studies examining medication CDS systems found that between 46 and 96% of medication alerts were overridden by clinicians [ 15 ].…”

Design, effectiveness, and economic outcomes of contemporary chronic disease clinical decision support systems: a systematic review and meta-analysis

“… 159 , 160 In CDS studies, varying effect sizes can be due to inconsistent CDS uptake despite availability of the intervention. 161 …”