J Am Med Inform Assoc 18:150-155 doi:10.1136/jamia.2010.005520
  • Research and applications

Evaluation of computer-generated reminders to improve CD4 laboratory monitoring in sub-Saharan Africa: a prospective comparative study

  1. Burke W Mamlin1,2
  1. 1Indiana University School of Medicine, Indianapolis, Indiana, USA
  2. 2Regenstrief Institute, Indianapolis, Indiana, USA
  3. 3Moi University School of Medicine, Eldoret, Kenya
  4. 4USAID–AMPATH Partnership, Eldoret, Kenya
  1. Correspondence to Dr Martin C Were, Regenstrief Institute, and Indiana University School of Medicine, 410 West 10th Street, Suite 2000, Indianapolis, IN 46202-3012, USA; mwere{at}
  • Received 8 May 2010
  • Accepted 1 December 2010
  • Published Online First 20 January 2011


Objective Little evidence exists on effective interventions to integrate HIV-care guidelines into practices within developing countries. This study tested the hypothesis that clinical summaries with computer-generated reminders could improve clinicians' compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa.

Design A prospective comparative study of two randomly selected outpatient adult HIV clinics in western Kenya. Printed summaries with reminders for overdue CD4 tests were made available to clinicians in the intervention clinic but not in the control clinic.

Measurements Changes in order rates for overdue CD4 tests were compared between and within the two clinics.

Results The computerized reminder system identified 717 encounters (21%) with overdue CD4 tests. Analysis by study assignment (regardless of summaries being printed or not) revealed that with computer-generated reminders, CD4 order rates were significantly higher in the intervention clinic compared to the control clinic (53% vs 38%, OR=1.80, CI 1.34 to 2.42, p<0.0001). When comparison was restricted to encounters where summaries with reminders were printed, order rates in intervention clinic were even higher (63%). The intervention clinic increased CD4 ordering from 42% before reminders to 63% with reminders (50% increase, OR=2.32, CI 1.67 to 3.22, p<0.0001), compared to control clinic with only 8% increase from prestudy baseline (CI 0.83 to 1.46, p=0.51).

Limitations Evaluation was conducted at two clinics in a single institution.

Conclusions Clinical summaries with computer-generated reminders significantly improved clinician compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa. This technology can have broad applicability to improve quality of HIV care in these settings.


  • Funding This work was supported by a grant from the Abbott Fund, and in part by a grant to the USAID–AMPATH Partnership from the United States Agency for International Development as part of the President's Emergency Plan for AIDS Relief (PEPFAR).

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the Institutional Review Boards at Indiana University School of Medicine in Indianapolis, Indiana and the Institutional Review and Ethics Committee at Moi University School of Medicine in Eldoret, Kenya.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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