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A Comparative Study of the Management Decisions by IMNCI Algorithm and by Pediatricians of a Teaching Hospital for
Agnihotri Bhattacharyya1, Chitra Chatterjee, Sukanta Chatterjee
1Department of Community Medicine, Calcutta National Medical College, Kolkata, India.
Insights
The Integrated Management of Neonatal and Childhood Illness (IMNCI) algorithm shows low agreement with pediatrician decisions in India, with frequent overdiagnosis of fever as malaria. The algorithm appropriately considers multiple symptoms, similar to expert pediatricians.
Area of Science:
- Pediatric Health
- Clinical Decision Support Systems
- Public Health Interventions
Background:
- The Integrated Management of Neonatal and Childhood Illness (IMNCI) strategy is widely implemented in India.
- Limited studies have evaluated the validity and reliability of IMNCI compared to pediatricians' clinical judgments within the Indian context.
Purpose of the Study:
- To compare diagnostic decisions made by the IMNCI algorithm with those of pediatricians for sick children.
- To assess the significance of multiple presenting symptoms within the IMNCI decision-making algorithm.
Main Methods:
- A comparative study involving sick children aged 2 months to 5 years was conducted.
- IMNCI algorithm outputs were compared against pediatrician diagnoses using percent agreement, Kappa, and weighted Kappa statistics.
Main Results:
- Overall diagnostic agreement between IMNCI and pediatricians was low at 36.64% (Kappa=0.16).
- The IMNCI algorithm demonstrated a tendency towards overdiagnosis (51.15%) and underdiagnosis (12.21%).
- Both IMNCI and pediatricians recognized the increased severity associated with multiple presenting symptoms, with statistically significant findings (P<0.0001 for IMNCI, P=0.018 for pediatricians).
Conclusions:
- Significant diagnostic discordance exists between the IMNCI algorithm and pediatricians, particularly in fever cases often overdiagnosed as malaria.
- The IMNCI algorithm's consideration of comorbidities aligns with pediatricians' clinical assessments.
Background:
Integrated management of neonatal and childhood illness (IMNCI) is already operational in many states of India, but there are very few studies in Indian scenario comparing its validity and reliability with the pediatricians' decisions.
Objectives:
1) To compare the IMNCI decision with the decision of pediatricians; 2) to assess the significance of multiple presenting symptoms in the IMNCI algorithm.
Materials And Methods:
The study was conducted among the sick children between 2 months to 5 years presented in pediatric department from January to March 2009. The IMNCI decision was compared with pediatrician's decisions by percent agreement, Kappa and weighted Kappa with the aids of SPSS version 10.
Results:
The overall diagnostic agreement between IMNCI algorithm and pediatrician's decisions was 36.64%, (Kappa 0.16 and weighted Kappa 0.29) with 51.15% over diagnosis and 12.21% under diagnosis. The importance given by IMNCI algorithm in cases of multiple presenting symptoms was also reflected as it was evident that 37.50% children presented with three symptoms were categorized as red, whereas it was 28.57% and 11.67% for those presented with two and one symptom, respectively, (P < 0.0001). Pediatricians also gave importance for presence of multiple symptoms by considering 50% as admissible in the group presented with three symptoms, 30.16% in the group presented with two symptoms, and 16.67% in the group presented with only one symptom. The association was also statistically significant (P = 0.018).
Conclusion:
Diagnostic discordance is seen mainly due to over diagnosis of all fever cases as malaria. Importance of presence of comorbidities was also reflected.
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