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.

Evaluation of Standard and Mobile Health–Supported Clinical Diagnostic Tools for Assessing Dehydration in Patients with Diarrhea in Rural Bangladesh

“…Recent studies using mobile technology have documented robust adherence to appropriate treatment of childhood cases of diarrhea, as well as medication and IV fluid recommendations in management of diarrhea in rural settings. 23,31 Our study investigates whether an mHealth application can improve the inter-rater reliability and usability of a clinical dehydration diagnostic tool among adults and pediatric patients with acute diarrhea.…”

“…The design of the user interface was based on previous experience, end user input, and study requirements. 23 With respect to the end user, the design requirements were accuracy, simplicity, and a pleasurable user experience that expedited assessment. The interface is coded to provide color-based nudges to notify the user of fields that were not entered.…”

“…21 A pilot study in rural Bangladesh demonstrated that a smartphone adaptation of the WHO diarrheal disease management guidelines improved adherence to guidelines. 23 In addition, results of a study conducted in Chakaria, Bangladesh, demonstrated that community members, community leaders, and health care providers were similarly enthusiastic about the use of mHealth services and expressed willingness to use mHealth in the future. 24 However, the use of mHealth technology to improve the clinical assessment of dehydration in adult and pediatric patients with diarrhea has not been examined previously.…”

The Effect of Text Message Reminders to Health Workers on Quality of Care for Malaria, Pneumonia, and Diarrhea in Malawi: A Cluster-Randomized, Controlled Trial

“…mHealth interventions using tablets or smartphones with programmed clinical algorithms that more directly guide case management practices might be more effective and have shown promising results in similar settings. 37,39 Even more promising might be electronically programmed clinical algorithms that integrate additional point-of-care tests, which have shown improved child health outcomes than electronic algorithms alone. 40 Other alternative strategies to consider for improving HW performance include adding a small financial incentive to the text message intervention for participation, which resulted in good participation rates in an SMS-based drug stock reporting system in Tanzania, 41 and more systematic supervision to reinforce case-management practices, with or without text messages.…”

Integrating evidence, models and maps to enhance Chagas disease vector surveillance

“…There are currently several apps for disease surveillance in resource limited settings, the most common being SMS-based apps (FrontlineSMS [38][39][40], RapidSMS [41,42], U-Report [43,44], Ushahidi [40,45], CycleTel [46,47], Geochat [48], among others [49]; see [50] for a thorough review of SMS apps for disease surveillance), and generic software and tool collections that offer mobile device-based data collection as their primary function, and some combination of basic data analysis, visualization and/or mapping as secondary functions (SAGES [51], Open data kit [52][53][54], Epicollect [54][55][56], eMOCHA [57,58], Medic mobile [59], Magpi [formerly Episurveyor, 60-62], DataWinners [63], and PhiCollect [64], among others [65][66][67][68][69]). A small number of apps have been developed for vector surveillance (Dengue Chat [70], CHAAK [71], eMO-CHA [72]), with the primary features being data collection based in social networking and community based surveillance [70], and data collection using electronic forms and/or SMS [71,72].…”