The Integration of Clinical Decision Support Systems Into Telemedicine for Patients With Multimorbidity in Primary Care Settings: Scoping Review

BACKGROUND

Multimorbidity, the presence of more than one condition in a single individual, is a global health issue in primary care. Multimorbid patients tend to have a poor quality of life and suffer from a complicated care process. Clinical decision support systems (CDSSs) and telemedicine are the common information and communication technologies that have been used to reduce the complexity of patient management. However, each element of telemedicine and CDSSs is often examined separately and with great variability. Telemedicine has been used for simple patient education as well as more complex consultations and case management. For CDSSs, there is variability in data inputs, intended users, and outputs. Thus, there are several gaps in knowledge about how to integrate CDSSs into telemedicine and to what extent these integrated technological interventions can help improve patient outcomes for those with multimorbidity.

OBJECTIVE

Our aims were to (1) broadly review system designs for CDSSs that have been integrated into each function of telemedicine for multimorbid patients in primary care, (2) summarize the effectiveness of the interventions, and (3) identify gaps in the literature.

METHODS

An online search for literature was conducted up to November 2021 on PubMed, Embase, CINAHL, and Cochrane. Searching from the reference lists was done to find additional potential studies. The eligibility criterion was that the study focused on the use of CDSSs in telemedicine for patients with multimorbidity in primary care. The system design for the CDSS was extracted based on its software and hardware, source of input, input, tasks, output, and users. Each component was grouped by telemedicine functions: telemonitoring, teleconsultation, tele-case management, and tele-education.

RESULTS

Seven experimental studies were included in this review: 3 randomized controlled trials (RCTs) and 4 non-RCTs. The interventions were designed to manage patients with diabetes mellitus, hypertension, polypharmacy, and gestational diabetes mellitus. CDSSs can be used for various telemedicine functions: telemonitoring (eg, feedback), teleconsultation (eg, guideline suggestions, advisory material provisions, and responses to simple queries), tele-case management (eg, sharing information across facilities and teams), and tele-education (eg, patient self-management). However, the structure of CDSSs, such as data input, tasks, output, and intended users or decision-makers, varied. With limited studies examining varying clinical outcomes, there was inconsistent evidence of the clinical effectiveness of the interventions.

CONCLUSIONS

Telemedicine and CDSSs have a role in supporting patients with multimorbidity. CDSSs can likely be integrated into telehealth services to improve the quality and accessibility of care. However, issues surrounding such interventions need to be further explored. These issues include expanding the spectrum of medical conditions examined; examining tasks of CDSSs, particularly for screening and diagnosis of multiple conditions; and exploring the role of the patient as the direct user of the CDSS.

Chronic Illnesses and Depressive Symptoms Among Older People: Functional Limitations as a Mediator and Self-Perceptions of Aging as a Moderator

OBJECTIVE

This research examined the mediation of functional limitations in the relationship between chronic illnesses and depressive symptoms among older Americans along with tests for the moderation of self-perceptions of aging.

METHOD

Data from the Health and Retirement Study (2008, 2010, and 2012) were used. Longitudinal mediation models were tested using a sample of 3,382 Americans who responded to psychosocial questions and were over 65 years old in 2008.

RESULTS

Functional limitations mediated the linkage between chronic illnesses and depressive symptoms. Negative self-perceptions of aging exacerbated the effects of chronic illnesses on depressive symptoms.

DISCUSSION

Health care professionals should be aware of depressive symptoms in older adults reporting chronic illnesses and particularly in those reporting functional limitations. To decrease the risk of depressive symptoms caused by chronic illnesses, negative self-perceptions of aging may need to be challenged.

Depression diagnosis and treatment amongst multimorbid patients: a thematic analysis

BACKGROUND

We explored experiences of depression diagnosis and treatment amongst multimorbid patients referred to a metropolitan multidisciplinary outpatient clinic to identify commonalities across this patient group.

METHODS

Patients with two or more chronic conditions and a diagnosis of depression participated in semi-structured interviews that were digitally recorded and transcribed. Thematic analysis was performed on the transcriptions.

RESULTS

Multimorbid patients attributed depressive symptoms to the loss of 'normal' roles and functionality and struggled to reconcile the depression diagnosis with their sense of identity. Beliefs about themselves and depression affected their receptivity to diagnosis and intervention strategies. These included prescribed interventions, such as psychotherapy or pharmacotherapy, and patient-developed strategies.

CONCLUSIONS

Functional and social role losses present a clear context in which GPs should raise the subject of mood, with the situational attribution of depression suggesting that psychotherapy, which is rarely offered, should be prioritised in these circumstances.

The identification of regions of significance in the effect of multimorbidity on depressive symptoms using longitudinal data: an application of the Johnson-Neyman technique

BACKGROUND

The investigation of multimorbidity and aging is complex and highly intertwined with aging-related changes in physical and cognitive capabilities, and mental health and is known to affect psychological distress and quality of life. Under these circumstances it is important to understand how the effects of chronic conditions evolve over time relative to aging-related and end-of-life changes. The identification of periods in time where multimorbidity impacts particular outcomes such as depressive symptoms, versus periods of time where this is not the case, reduces the complexity of the phenomenon.

OBJECTIVE

We present the Johnson-Neyman (J-N) technique in the context of a curvilinear longitudinal model with higher-order terms to probe moderators and to identify regions of statistical significance. In essence, the J-N technique allows one to identify conditions under which moderators impact an outcome from conditions where these effects are not significant.

METHODS

To illustrate the use of the J-N technique in a longitudinal sample, we used data from the Health and Retirement Study. Analyses were based on time-to-death models including participants who died within the study duration of 12 years.

RESULTS

Multimorbidity differentially affects rates of change in depression. For some periods in time the effects are statistically significant while in other periods the same effects are not statistically different from zero.

CONCLUSION

The J-N technique is useful to continuously probe moderating effects and to identify particular interactions with the model for time when certain effects are or are not statistically significant. In the context of multimorbidity this method is particularly useful for interpreting the complex interactions with differential change over time.