So Much to Do: Expected Duration of Initial Consultations for Sick Children in Low- and Middle-income Countries Using the Integrated Management of Childhood Illness Clinical Algorithm

Abstract

AbstractBackgroundFew studies have examined the time required for primary care consultations; none have focused on sick child visits in LMICs. This paper begins to fill that gap by providing evidence-based estimates of the time needed for initial visits with under-five infants and children at public or not-for-profit facilities in low- and middle-income countries that have adopted the Integrated Management of Childhood Illness (IMCI) clinical algorithm.MethodEstimates of the mean expected duration of IMCI consultations are based on (a) classification profiles, i.e., tabulations of the health issues presented by patients less than 5 years old; (b) lists of the tasks included in applicable versions of the IMCI algorithm and the conditions that elicit them, and (c) an estimate of the time needed to perform tasks with no pre-defined minimum duration. The latter requires, in addition to classification profiles, information on rates of task performance and the mean observed duration of consultations. I found such information by searching MEDLINE, the database of the International Network for Rational Use of Medicines, the websites of the WHO and its regional offices, GOOGLE, and GOOGLE SCHOLAR using search terms such as ‘Integrated Management of Childhood Illness’, ‘observational’, ‘prospective’, ‘classification’, ‘clinical signs’, ‘health facility survey’, and ‘validity’. I also reviewed studies that cited a qualified study and, conversely, material included in the bibliographies of qualified studies.ResultsI have found or constructed classification profiles for 38 patient populations in 22 countries. The mean expected duration of consultations ranges from 16.3 to 18.7 minutes in the infant populations and from 15.9 to 26.3 minutes in the child populations. Largely because of mandatory tasks, the distributions of expected consultation durations are left-truncated. The shortest consultations range from 14.9 to 16.7 minutes in the infant populations and from 10.4 to 16.8 minutes in the child populations. One in 50 patients requires a consultation that, depending on the mix of cases in the patient population, exceeds the mean duration by 13.2 to 32.1 percent.ConclusionsIMCI consultations with infants and children presenting for the first time with a new concern require considerably more time than previously recognized. This confirms that the quality of most IMCI consultations is low and that the personnel costs of providing appropriate IMCI services are substantial. The steps required to produce estimates of the expected duration of IMCI consultations suggest that surveys designed to measure the effects of IMCI training must include tabulations of the gold standard classifications found in the patient populations.