Evaluation of a Smartphone Decision-Support Tool for Diarrheal Disease Management in a Resource-Limited Setting.

Farhana Haque,Nancy Federspiel,Shafiqul Alam Sarker,Dane Pieri,Eric Jorge Nelson,Selina Khatun,Saraswati Kache,Stace D Maples,Mujaddeed Ahmed,Jason R Andrews,Teja Vardhan Korrapati,Robyn L Ball,Mahmudur Rahman,Mohammod Jobayer Chisti,Clea Sarnquist,Muhammad Waliur Rahman,Andrew S Azman

doi:10.1371/journal.pntd.0005290

Abstract

The emergence of mobile technology offers new opportunities to improve clinical guideline adherence in resource-limited settings. We conducted a clinical pilot study in rural Bangladesh to evaluate the impact of a smartphone adaptation of the World Health Organization (WHO) diarrheal disease management guidelines, including a modality for age-based weight estimation. Software development was guided by end-user input and evaluated in a resource-limited district and sub-district hospital during the fall 2015 cholera season; both hospitals lacked scales which necessitated weight estimation. The study consisted of a 6 week pre-intervention and 6 week intervention period with a 10-day post-discharge follow-up. Standard of care was maintained throughout the study with the exception that admitting clinicians used the tool during the intervention. Inclusion criteria were patients two months of age and older with uncomplicated diarrheal disease. The primary outcome was adherence to guidelines for prescriptions of intravenous (IV) fluids, antibiotics and zinc. A total of 841 patients were enrolled (325 pre-intervention; 516 intervention). During the intervention, the proportion of prescriptions for IV fluids decreased at the district and sub-district hospitals (both p < 0.001) with risk ratios (RRs) of 0.5 and 0.2, respectively. However, when IV fluids were prescribed, the volume better adhered to recommendations. The proportion of prescriptions for the recommended antibiotic azithromycin increased (p < 0.001 district; p = 0.035 sub-district) with RRs of 6.9 (district) and 1.6 (sub-district) while prescriptions for other antibiotics decreased; zinc adherence increased. Limitations included an absence of a concurrent control group and no independent dehydration assessment during the pre-intervention. Despite limitations, opportunities were identified to improve clinical care, including better assessment, weight estimation, and fluid/ antibiotic selection. These findings demonstrate that a smartphone-based tool can improve guideline adherence. This study should serve as a catalyst for a randomized controlled trial to expand on the findings and address limitations.

Highlights

The provision of high-quality clinical care in resource-limited settings is challenged by logistical, educational, and temporal constraints that are exacerbated by a high volume of patients
Innovative interventions to address gaps in the clinical care of these patients are lacking, yet will likely reduce the morbidity and mortality from diarrheal diseases. The objective of this pilot study was to take a technology-enabled approach to improve guideline adherence, including antibiotic selection for diarrheal disease management in a resource-limited setting. To do this we adapted World Health Organization (WHO) guidelines to a smartphone platform and evaluated the approach in Bangladesh at two rural hospitals
The results suggest that the decision-support tool was associated with a decrease in intravenous fluid use while maintaining safety, an increase in use of the recommended antibiotic, and a decrease in use of medications not recommended

Summary

Introduction

The provision of high-quality clinical care in resource-limited settings is challenged by logistical, educational, and temporal constraints that are exacerbated by a high volume of patients. While outpatient decision-support tools like the paper-based World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) have improved community efforts despite limitations [4,5,6,7,8], inpatient references like the WHO Pocketbook of Hospital Care for Children are often scarce or anecdotally don’t meet providers needs in highvolume situations [9]. These collective challenges manifest in poor guideline adherence and exacerbate the ongoing struggle to improve care for patients with diarrheal disease, especially during large-scale outbreaks. High rates of post-discharge mortality suggest that improved in-hospital efforts might decrease overall morbidity and mortality [17]

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Discussion

Conclusion