gms | German Medical Science

Background: Clinical Decision Support Systems (CDSS) for medication management offer physicians and other involved professions targeted clinical knowledge, patient information, and further relevant health information to guide their decisions in the medication process of patients. CDSS are essential in augmenting drug safety and ultimately enhancing the quality of care. Several studies have assessed the short-, medium-, or long-term effects of medication management CDSS, while some have also evaluated the cost-effectiveness of these technologies. However, economic evaluations of CDSS often lack consideration of contextual information, variations in resource use or outcomes between different groups, and the potential impact on the relationship between resource use and outcomes. It is also argued that economic evaluations of CDSS are poorly generalizable and provide little information for implementers about the economic consequences of an intervention in their context of interest. Consequently, CDSS are not well implemented in routine care, despite their many benefits, impeding efficient medication management for patients and improvements in overall quality of care.

Objective: Therefore, we aimed to develop an economic program theory using a realist approach to gain a deeper understanding of the economic impact of CDSS used for medication management. Additionally, we aimed to analyze the contributions of a realist-informed economic program theory to evaluation planning compared to recent evaluations of CDSS.

Methods: We conducted a realist review based on a systematic review of reviews, given the large number of publications on the effects of CDSS in medication management. Based on the extracted data from the included reviews, we first created an initial program theory by formulating context-mechanism-outcome (CMO) configurations following the realist framework. The focus of the component outcomes was especially on costs or other economic effects. Using initial CMO configurations and through in-depth analysis of the included literature as well as primary studies from the reference lists, we refined the program theory and developed a hypothetical evaluation plan, which we compared to the contributions of recent economic literature on CDSS used for medication management.

Results: First we describe how we used the realist approach to capture the complex nature of our intervention and its context. In addition, we outline CMO configurations that allow us to identify what works, for whom, in which circumstances, why, and with what related resources and opportunity costs. Furthermore, we demonstrate how the results of this approach aid evaluation planning and inform the sustainability of health economic evaluations. Finally, we discuss the advantages and challenges encountered by applying realist methods in health economic evaluations.

Implication for research and/or (healthcare) practice: Accurately characterizing the complex relationship between resource use and outcomes allows for more thorough health economic evaluations, thereby improving appropriate guidance for decision-makers. Furthermore, integrating realist methods in constructing program theories guides the planning and implementation of study designs for health economic evaluations, which aligns with multiple stages advocated by the Medical Research Council.