Effectiveness of an Electronic Clinical Decision Support System in Improving the Management of Childhood Illness in Primary Care in Rural Nigeria: A Prospective Observational Study

Abstract

Background and Rationale: Digital interventions can support health systems strengthening in resource-constrained settings. Clinical decision support systems (CDSS) provide evidence-based recommendations to health workers, tailored to individual patients, using clinical algorithms. Recent studies suggest that CDSS hold promise for the management of childhood illness in primary care, but evidence on effectiveness at scale is limited. We evaluated the impact of ‘ALMANACH’, a CDSS based on the Integrated Management of Childhood Illness (IMCI), on health and quality of care outcomes for children attending primary care facilities in north-eastern Nigeria. Methods In this prospective observational study, we compared caregiver-reported recovery of children (age 2-59 months) with acute illness in 45 facilities implementing ALMANACH with 44 facilities using paper-based IMCI. We collected sociodemographic and clinical information from caregivers and clinical records on Day 0, and recovery data from Day 7 phone follow-up. We calculated risk ratios and odds ratios for primary and secondary outcomes, and derived adjusted effect estimates using mixed-effects regressions. Findings We recruited 1,929 children of which 1,021 (53%) attended facilities implementing ALMANACH, in March and between July-September 2020. Caregiver-reported recovery was significantly higher among children attending ALMANACH facilities (adjusted OR=2·63, 95% CI: 1·60-4·32). We observed an increase in parenteral antimicrobial prescriptions (adjusted OR=2·42 (1·00-5·85)), and a decrease in oral antimicrobials (adjusted OR=0·40 (0·22-0·73)) in ALMANACH facilities, as well as marked increases in referral, communication of diagnosis, and follow-up advice. Interpretation Implementation of digital CDSS in primary care can improve quality of care and recovery of sick children in resource-constrained settings. The effect is likely mediated by better guideline adherence by health workers supported step-by-step through evidence-based recommendations on clinical assessment, diagnosis, treatment and referral. These findings support the use of CDSS for health systems strengthening to progress towards universal health coverage. Funding International Committee of the Red Cross. Declaration of Interest: All authors declare no competing interest. Ethical Approval: The study obtained ethical approval from the Health Research Ethics Committee of Adamawa, Nigeria (ADHREC 8/02/2020/003) and the Ethics Committee Northwest and Central Switzerland (Req-2020-00082).