title: Evaluation of a Smartphone Decision-Support Tool for Diarrheal Disease Management in a Resource-Limited Setting.
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.
authors.affiliation: Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh.|Infectious Diseases Division (IDD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Farhana
authors.initials: F
authors.lastname: Haque
authors.affiliation: Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California, United States of America.
authors.forename: Robyn L
authors.initials: RL
authors.lastname: Ball
authors.affiliation: Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh.
authors.forename: Selina
authors.initials: S
authors.lastname: Khatun
authors.affiliation: Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh.
authors.forename: Mujaddeed
authors.initials: M
authors.lastname: Ahmed
authors.affiliation: Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America.
authors.forename: Saraswati
authors.initials: S
authors.lastname: Kache
authors.affiliation: Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Mohammod Jobayer
authors.initials: MJ
authors.lastname: Chisti
authors.affiliation: Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Shafiqul Alam
authors.initials: SA
authors.lastname: Sarker
authors.affiliation: Geospatial Center, Stanford University Libraries, Stanford, California, United States of America.
authors.forename: Stace D
authors.initials: SD
authors.lastname: Maples
authors.affiliation: Independent Technology Developer, San Francisco, California, United States of America.
authors.forename: Dane
authors.initials: D
authors.lastname: Pieri
authors.affiliation: BeeHyv Software Solutions Pvt. Ltd., Hyderabad, India.
authors.forename: Teja
authors.initials: T
authors.lastname: Vardhan Korrapati
authors.affiliation: Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America.
authors.forename: Clea
authors.initials: C
authors.lastname: Sarnquist
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America.
authors.forename: Nancy
authors.initials: N
authors.lastname: Federspiel
authors.affiliation: Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh.|Infectious Diseases Division (IDD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Muhammad Waliur
authors.initials: MW
authors.lastname: Rahman
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America.
authors.forename: Jason R
authors.initials: JR
authors.lastname: Andrews
authors.affiliation: Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh.
authors.forename: Mahmudur
authors.initials: M
authors.lastname: Rahman
authors.affiliation: Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America.
authors.forename: Eric Jorge
authors.initials: EJ
authors.lastname: Nelson
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D017963:Azithromycin / Q000008:administration & dosage; D001459:Bangladesh; D002648:Child; D002675:Child, Preschool; D003681:Dehydration; D003967:Diarrhea / Q000188:drug therapy* / Q000523:psychology; D005260:Female; D019983:Guideline Adherence; D006295:Health Resources; D006801:Humans; D007223:Infant; D008297:Male; D010865:Pilot Projects; D000068997:Smartphone / Q000706:statistics & numerical data*; D015032:Zinc / Q000008:administration & dosage
chemical_list: D000900:Anti-Bacterial Agents; D017963:Azithromycin; D015032:Zinc