Effectiveness of a clinical decision support algorithm (ePOCT+) in improving quality of care for sick children in primary health facilities in Tanzania (DYNAMIC project): results from a cluster randomized trial

Abstract

Introduction

The Integrated Management of Childhood Illness (IMCI) chartbook for managing sick children under five years improves quality of care and reduces childhood mortality. However, compliance to IMCI remains a challenge. Electronic clinical decision support algorithms (eCDSAs) are a promising solution to improve IMCI compliance. We performed a cross-sectional study to evaluate whether an eCDSA based on IMCI improves quality of care compared to usual care in Tanzanian primary health facilities.

Methods

18 health facilities (9 intervention and 9 control, randomized 1:1) were sampled from the main cluster randomized trial. Children aged 2-59 months with an acute illness were enrolled and consultations were observed by an independent researcher. The intervention consists of the use of an electronic point of care tool (ePOCT+) and clinical mentorship. The primary outcome measure was the mean score of major IMCI symptoms and signs assessed.

Results

450 consultations (225 in each arm) were observed. The mean score of major IMCI symptoms and signs was 42% (95% CI: 39% - 44%) in intervention facilities and 23% (95% CI: 22% - 25%) in control facilities (p<0.001). The use of ePOCT+ significantly increased the proportion of assessment of convulsions (33% vs 7%) and nutrition status assessment (60% vs 2%) compared to routine care clusters (p<0.001). There were however no significant differences between the intervention and control arms for other measures such as fever assessment (91% vs 87%; p=0.148) and height measurement (1.3% vs 0.4%; p=0.315).

Discussion

Clinical skills and adherence to the guidelines among healthcare workers are among the major challenges in primary healthcare facilities. ePOCT+ CDSA improves adherence to IMCI, quality of clinical assessment and disease management by Improving history taking, prompting and guiding healthcare workers to assess the danger signs and improving the quality of physical examination. ePOCT+ CDSA can be an invaluable tool to improve the quality of care, clinical outcome and reduce mortality in resource-limited settings.

Conclusion

ePOCT+ significantly improves quality of care for sick children in primary health facilities in Tanzania.