Effectiveness of an electronic clinical decision support system in improving the management of childhood illness in primary care in rural Nigeria: an observational study

Abstract

ObjectivesTo evaluate the impact of ALgorithm for the MANAgement of CHildhood illness (‘ALMANACH’), a digital clinical decision support system (CDSS) based on the Integrated Management of Childhood Illness, on health and quality of care outcomes for sick children attending primary healthcare (PHC) facilities.DesignObservational study, comparing outcomes of children attending facilities implementing ALMANACH with control facilities not yet implementing ALMANACH.SettingPHC facilities in Adamawa State, North-Eastern Nigeria.ParticipantsChildren 2–59 months presenting with an acute illness. Children attending for routine care or nutrition visits (eg, immunisation, growth monitoring), physical trauma or mental health problems were excluded.InterventionsThe ALMANACH intervention package (CDSS implementation with training, mentorship and data feedback) was rolled out across Adamawa’s PHC facilities by the Adamawa State Primary Health Care Development Agency, in partnership with the International Committee of the Red Cross and the Swiss Tropical and Public Health Institute. Tablets were donated, but no additional support or incentives were provided. Intervention and control facilities received supportive supervision based on the national supervision protocol.Primary and secondary outcome measuresThe primary outcome was caregiver-reported recovery at day 7, collected over the phone. Secondary outcomes were antibiotic and antimalarial prescription, referral, and communication of diagnosis and follow-up advice, assessed at day 0 exit interview.ResultsWe recruited 1929 children, of which 1021 (53%) attended ALMANACH facilities, between March and September 2020. Caregiver-reported recovery was significantly higher among children attending ALMANACH facilities (adjusted OR=2·63, 95% CI 1·60 to 4·32). We observed higher parenteral and lower oral antimicrobial prescription rates (adjusted OR=2·42 (1·00 to 5·85) and adjusted OR=0·40 (0·22 to 0·73), respectively) in ALMANACH facilities as well as markedly higher rates for referral, communication of diagnosis, and follow-up advice.ConclusionImplementation of digital CDSS with training, mentorship and feedback in primary care can improve quality of care and recovery of sick children in resource-constrained settings, likely mediated by better guideline adherence. These findings support the use of CDSS for health systems strengthening to progress towards universal health coverage.

The Tools for Integrated Management of Childhood Illness (TIMCI) study protocol: a multi-country mixed-method evaluation of pulse oximetry and clinical decision support algorithms

“…Personally identifiable information (PII) is collected for follow-up, linking data and detecting possible duplicates. Caregiver-reported health status and care-seeking since Day 0 consultation are collected by phone on Day 7 (and 28 in the RCT only), in line with previous studies conducted by our group, and other large-scale pragmatic trials of primary care interventions [ 21 , 23 , 49 ]. Further attempts are made on at least 3 subsequent days if the initial attempt fails and the number is valid.…”

Antibiotic stewardship using ePOCT+, a digital health clinical decision support algorithm for paediatric outpatient care: results from the DYNAMIC Tanzania cluster randomized controlled trial

“…While previous CDSA studies were able to demonstrate signi cant reductions in clinical failure, the current trial was not powered to do so. 18,19,21 Nonetheless, the greatest bene t on clinical cure compared to usual care was observed in the subgroup of under 2 month olds, important results given that this population represents more than 50% of mortality in under 5 year olds. 37 Our study possesses several strengths that contribute to its robustness.…”

“…18,19,29 However, the results differ from other studies evaluating CDSAs implemented in routine health programs in Nigeria, Afghanistan, and Burkina Faso, which found little to no reduction in antibiotic prescription. [20][21][22]30 There are a number of differences that may explain the divergent results. First and foremost, the clinical algorithm of ePOCT + differs from other CDSAs.…”

“…18,19 However, many close to real-world studies have shown little to no reduction in antibiotic prescription. [20][21][22] In addition, many of the close to real-world studies have a number of methodological limitations as health facilities were not randomized, and/or safety was not evaluated, 16,22,23 emphasizing the need for more evidence on the impact of CDSAs on antibiotic prescription. Finally, poor uptake remains a challenge with previous and existing CDSAs.…”

Challenges Diagnosing and Treating Acute Febrile Children with Suspected Malaria at Healthcare Facilities in the Mwanza Region, Tanzania

“…Clinical decision algorithms on mobile systems (e.g., e-IMCI or ALMANACH) for the integrated managing childhood illnesses have the proven potential to reduce antibiotic prescriptions up to 80% by properly addressing the treatment of mRDT-negative cases [96][97][98][99]. Successful implementation of e-IMCI was documented in primary healthcare facilities in Nigeria, Vietnam, and Tanzania [100,101]. A randomized, controlled, non-inferiority trial conducted in Tanzania (2014-2016) enhanced e-IMCI by including POCT results: mRDTs, hemoglobin, C-reactive protein, procalcitonin and blood sugar levels [102].…”