临床决策支持工具能否提高心血管疾病一级预防的医疗质量:系统回顾与荟萃分析

IF 4.3 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS American journal of preventive cardiology Pub Date : 2024-09-20 DOI:10.1016/j.ajpc.2024.100855
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引用次数: 0

摘要

目的评估临床决策支持工具(CDST)在提高初级心血管疾病(CVD)预防护理质量方面的有效性。方法根据 PRISMA 指南进行系统性综述,包括在 Ovid Medline、Ovid Embase、CINAHL 和 Scopus 中进行检索。符合条件的研究均为2013年后发表的随机对照试验,这些试验针对有心血管疾病风险和未确诊心血管疾病的患者,在各种初级医疗机构的电子健康系统(EHS/EHR)中使用了包含数字通知的CDST。两位审稿人使用 Cochrane RoB-2 工具独立评估了偏倚风险。采用限制最大似然随机效应荟萃分析法对临床目标的实现情况进行分析。由于研究和结果指标存在异质性,因此对其他相关结果进行了叙述性综合分析。31,-1.10)和舒张压目标的实现(MSD=0.34,95 %CI=-0.24,-0.92),但对血脂(MSD=0.01;95 %CI=-0.10,0.11)或血糖目标的实现(MSD=-0.19,95 %CI=-0.66,0.28)没有显著影响。有主动提示的 CDSTs 增加了他汀类药物的使用率,并提高了患者遵守临床预约的依从性,但对其他药物治疗和提高服药依从性的效果甚微。该研究旨在评估临床决策支持工具(CDST)如何影响初级心血管疾病(CVD)管理的医疗质量。临床决策支持工具旨在通过在护理点(即电子健康系统中的数字通知)及时提供相关信息,支持医疗保健专业人员为患者提供最佳护理。虽然 CDST 旨在提高医疗保健结果的质量,但目前有关其有效性的证据并不一致。因此,我们进行了一项系统性回顾和荟萃分析,以量化 CDST 的有效性。研究对象为具有心血管疾病风险因素但未确诊心血管疾病的患者。荟萃分析发现,CDST 对收缩压和舒张压目标的实现有改善作用,但对血脂或血糖目标的实现没有显著影响。具体而言,CDST 在增加他汀类药物的处方量方面显示出有效性,但在增加降压药或抗糖尿病药的处方量方面没有显示出有效性。旨在增加筛查计划的 CDST 干预措施对肾病患者和高危患者有效,但对糖尿病患者或青少年高血压患者无效。警报能有效改善患者遵守临床预约的情况,但不能改善遵守用药的情况。这项研究表明,在心血管疾病一级预防中,CDST能有效提高有限的几项护理质量,但未来的研究还需要探索可能阻碍心血管健康成果充分实现的多重障碍的机制和背景。
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Do clinical decision support tools improve quality of care outcomes in the primary prevention of cardiovascular disease: A systematic review and meta-analysis

Aim

To assess the effectiveness of Clinical Decision Support Tools (CDSTs) in enhancing the quality of care outcomes in primary cardiovascular disease (CVD) prevention.

Methods

A systematic review was undertaken in accordance with PRISMA guidelines, and included searches in Ovid Medline, Ovid Embase, CINAHL, and Scopus. Eligible studies were randomized controlled trials of CDSTs comprising digital notifications in electronic health systems (EHS/EHR) in various primary healthcare settings, published post-2013, in patients with CVD risks and without established CVD. Two reviewers independently assessed risk of bias using the Cochrane RoB-2 tool. Attainment of clinical targets was analysed using a Restricted Maximum Likelihood random effects meta-analysis. Other relevant outcomes were narratively synthesised due to heterogeneity of studies and outcome metrics.

Results

Meta-analysis revealed CDSTs showed improvement in systolic (Mean Standardised Difference (MSD)=0.39, 95 %CI=-0.31, -1.10) and diastolic blood pressure target achievement (MSD=0.34, 95 %CI=-0.24, -0.92), but had no significant impact on lipid (MSD=0.01; 95 %CI=-0.10, 0.11) or glucose target attainment (MSD=-0.19, 95 %CI=-0.66, 0.28). The CDSTs with active prompts increased statin initiation and improved patients’ adherence to clinical appointments but had minimal effect on other medications and on enhancing adherence to medication.

Conclusion

CDSTs were found to be effective in improving blood pressure clinical target attainments. However, the presence of multi-layered barriers affecting the uptake, longer-term use and active engagement from both clinicians and patients may hinder the full potential for achieving other quality of care outcomes.

Lay Summary

The study aimed to evaluate how Clinical Decision Support Tools (CDSTs) impact the quality of care for primary cardiovascular disease (CVD) management. CDSTs are tools designed to support healthcare professionals in delivering the best possible care to patients by providing timely and relevant information at the point of care (ie. digital notifications in electronic health systems). Although CDST are designed to improve the quality of healthcare outcomes, the current evidence of their effectiveness is inconsistent. Therefore, we conducted a systematic review with meta-analysis, to quantify the effectiveness of CDSTs. The eligibility criteria targeted patients with CVD risk factors, but without diagnosed CVD. The meta-analysis found that CDSTs showed improvement in systolic and diastolic blood pressure target achievement but did not significantly impact lipid or glucose target attainment. Specifically, CDSTs showed effectiveness in increasing statin prescribing but not antihypertensives or antidiabetics prescribing. Interventions with CDSTs aimed at increasing screening programmes were effective for patients with kidney diseases and high-risk patients, but not for patients with diabetes or teenage patients with hypertension. Alerts were effective in improving patients' adherence to clinical appointments but not in medication adherence. This study suggests CDSTs are effective in enhancing a limited number of quality of care outcomes in primary CVD prevention, but there is need for future research to explore the mechanisms and context of multiple barriers that may hinder the full potential for cardiovascular health outcomes to be achieved.
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来源期刊
American journal of preventive cardiology
American journal of preventive cardiology Cardiology and Cardiovascular Medicine
CiteScore
6.60
自引率
0.00%
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0
审稿时长
76 days
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