Can technology help improve diarrhoea management?
Authors: Zulfiqar A Bhutta
Journal: The Lancet Digital Health (2020)

Diarrhoeal diseases continue to account for a substantial proportion of deaths and morbidity in young children globally.1Liu L Oza S Hogan D et al.Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the Sustainable Development Goals.Lancet. 2016; 388: 3027-3035Summary Full Text Full Text PDF PubMed Scopus (1723) Google Scholar Despite vast knowledge around prevention and management, the burden remains high and, in particular, coverage rates of oral rehydration therapy remain stagnant at around 40% globally.2Khan AM Wright JE Bhutta ZA A half century of oral rehydration therapy in childhood gastroenteritis: toward increasing uptake and improving coverage.Dig Dis Sci. 2020; 65: 355-360Crossref PubMed Scopus (6) Google Scholar Despite adequate guidelines from WHO on appropriate management of dehydrated cases of diarrhoea in hospitals, there is concern that quality of care for childhood diarrhoea varies considerably and might contribute to persisting diarrhoea morbidity and mortality globally.3Gill CJ Young M Schroder K et al.Bottlenecks, barriers, and solutions: results from multicountry consultations focused on reduction of childhood pneumonia and diarrhoea deaths.Lancet. 2013; 381: 1487-1498Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar In The Lancet Digital Health, Ashraful Khan and colleagues4Khan AI Mack JA Salimuzzaman et al.Electronic decision support and diarrhoeal disease guideline adherence (mHDM): a cluster randomised controlled trial.Lancet Digital Health. 2020; 2: 240-258Summary Full Text Full Text PDF Scopus (14) Google Scholar randomly assigned ten district hospitals in Bangladesh for triage emergency room physicians to use different decision support tools for the WHO guidelines on diarrhoea management: electronic, in the form of a rehydration calculator on a hand-held device, or paper, in the form of a pocket card. The study included 2487 adults (≥20 years) and 2488 children and adolescents (a third of whom were aged 2–59 months) with uncomplicated acute diarrhoea. The authors found no statistical difference between electronic and paper decision support for rates of intravenous fluids ordered by physicians. The study had several limitations, including the small number of hospitals (clusters), insufficient power for age-stratified outcomes, seasonal differences in the pre-study and post-study analysis, and a relatively small group of physicians directly observed for practice and compliance. Notwithstanding these issues, the investigators report some interesting trends. They documented higher intravenous fluid volumes administered to children with severe dehydration with the use of the rehydration calculator (0·0620 L/kg vs 0·0475 L/kg using the pocket card); the ratio of ratios between the electronic and paper decision supports was 1·50 (95% CI 1·11–2·01). They also observed a 28·5-point decrease in non-indicated antibiotic use for patients younger than 5 years when using the rehydration calculator (97·2% to 68·7%) versus a 23·8-point increase when using the pocketcard (43·1% to 66·9%), although this particular analysis was not prespecified. Overall, the electronic decision-support tool was well accepted by hospital staff, an important consideration in introducing any new technology. The observation that antibiotic use rates went down during the intervention is an important finding and could have potential public health implications. Widespread use of inappropriate antibiotics is a well recognised risk factor for emergence of antimicrobial resistance among enteric pathogens5Alexandrova L Haque F Rodriguez P et al.Identification of widespread antibiotic exposure in patients with cholera correlates with clinically relevant microbiota changes.J Infect Dis. 2019; 220: 1655-1666Crossref PubMed Scopus (7) Google Scholar and adds to the cost of illness. Previous studies of the use of zinc for the treatment of diarrhoea in community settings in Bangladesh have also shown a reduction in antibiotic prescribing and use,6Baqui AH Black RE El Arifeen S et al.Zinc therapy for diarrhoea increased the use of oral rehydration therapy and reduced the use of antibiotics in Bangladeshi children.J Health Popul Nutr. 2004; 22: 440-442PubMed Google Scholar perhaps due to replacement. In the current study, Khan and colleagues4Khan AI Mack JA Salimuzzaman et al.Electronic decision support and diarrhoeal disease guideline adherence (mHDM): a cluster randomised controlled trial.Lancet Digital Health. 2020; 2: 240-258Summary Full Text Full Text PDF Scopus (14) Google Scholar also observed a non-significant increase (7 percentage points) in the prescription of zinc among children younger than 5 years in the paper decision-support group (compared with a 2-point decrease in the electronic decision-support group), which could have also contributed to reduced concomitant use of antibiotics. These data add useful information to the body of knowledge on the use of ancillary training aids to improve quality of care in health systems in low-income and middle-income countries. Poor quality of care within health systems has been shown to have accounted for at least 8 million amenable deaths in low-income and middle-income countries in 2015, costing at least US$6 trillion in economic losses.7Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1007) Google Scholar A major component of this poor quality in health systems relates to staff training, workload, and motivation. Thus, strategies to improve their knowledge, skills, and performance are a crucial piece in addressing the quality gap. Several methods have been applied to address this issue with variable impact. These include traditional system of audits and feedback, use of checklists, and increasingly, the use of technology for immediate as well as regular feedback. In a large effectiveness trial across 60 paired facilities in 24 districts of Utter Pradesh (India), the use of a fairly intensive 8 months of coaching-based clinical support using a WHO Safe Childbirth Checklist was seen to improve adherence to essential birth practices, but did not affect perinatal or maternal mortality.8Semrau KEA Hirschhorn LR Marx Delaney M et al.Outcomes of a coaching-based WHO Safe Childbirth Checklist program in India.N Engl J Med. 2017; 377: 2313-2324Crossref PubMed Scopus (149) Google Scholar By contrast, a clinical information network of 13 hospitals in Kenya with regular data collection, central processing, reporting back every 2–3 months, and biannual meetings led to a significant improvement in the paediatric admission quality-of-care score for children with diarrhoea and dehydration.9Akech S Ayieko P Irimu G Stepniewska K English M Clinical Information Network authorsMagnitude and pattern of improvement in processes of care for hospitalised children with diarrhoea and dehydration in Kenyan hospitals participating in a clinical network.Trop Med Int Health. 2019; 24: 73-80Crossref PubMed Scopus (6) Google Scholar There is thus a continued need for developing strategies for improving quality of care and the use of technology, particularly applications on daily-use devices such as mobile phones and tablets. Such technologies are clearly important in helping the world to face many new challenges; in this case, they might allow us to make preventable diarrhoea deaths history.10Kickbusch I Agrawal A Jack A Lee N Horton R Governing health futures 2030: growing up in a digital world—a joint The Lancet and Financial Times Commission.Lancet. 2019; 3941309Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar I declare no competing interests. Electronic decision support and diarrhoeal disease guideline adherence (mHDM): a cluster randomised controlled trialAlthough intravenous fluid orders did not change, electronic decision support was associated with increases in the volume of intravenous fluid ordered and decreases in antibiotics ordered, which are consistent with WHO guidelines. Full-Text PDF Open Access