Is increasing complexity of algorithms the price for higher accuracy? virtual comparison of three algorithms for tertiary level management of chronic cough in people living with HIV in a low-income country

Data were collected at the University Hospital of Kigali (CHUK) in a total of 201 HIV-positive hospitalised patients with chronic cough. We simulated management of each patient following the three algorithms. The first was locally tailored by clinicians from CHUK, the second and third were drawn from publications by Médecins sans Frontières (MSF) and the World Health Organisation (WHO). Semantic analysis techniques known as Clinical Algorithm Nosology were used to compare them in terms of complexity and similarity. For each of them, we assessed the sensitivity, delay to diagnosis and hypothetical harm of false positives and false negatives.The principal diagnoses were tuberculosis (21%) and pneumocystosis (19%). Sensitivity, representing the proportion of correct diagnoses made by each algorithm, was 95.7%, 88% and 70% for CHUK, MSF and WHO, respectively. Mean time to appropriate management was 1.86 days for CHUK and 3.46 for the MSF algorithm. The CHUK algorithm was the most complex, followed by MSF and WHO. Total harm was by far the highest for the WHO algorithm, followed by MSF and CHUK.This study confirms our hypothesis that sensitivity and patient safety (i.e. less expected harm) are proportional to the complexity of algorithms, though increased complexity may make them difficult to use in practice.The algorithmic approach to guidelines has been introduced and promoted on a large scale since the 1970s. This flowchart representation of step-by-step clinical logic guides the management of a patient with symptoms, clinical signs, or results of technical examinations. The transition from one step to the next is mostly dichotomous, which means that only one out of two choices can be made at each step. Moreover, the logic is serial: only one pathway can be followed by a single patient.The original purpose of algorithmic guideline implementation was twofold. First, with continuing concern over the rising costs of health care, health policy makers have been impressed b