Electronic decision support and diarrhoeal disease guideline adherence (mHDM): a cluster randomised controlled trial
Ashraful Islam Khan, Jasmine A. Mack, M. Salim Uzzaman, Mazharul Islam Zion, Hasnat Sujon, Robyn L. Ball, Stace Maples, Md. Mahbubur Rashid, Mohammod Jobayer Chisti, Shafiqul Alam Sarker, Debashish Biswas, Raduan Hossin, Kevin Bardosh, Yasmin Ara Begum, Azimuddin Ahmed, Dane Pieri, Farhana Haque, Mahmudur Rahman, Adam C. Levine, Firdausi Qadri, Meerjady Sabrina Flora, Matthew J. Gurka, Eric J. Nelson
Abstract
Background Acute diarrhoeal disease management often requires rehydration alone without antibiotics. However, non-indicated antibiotics are frequently ordered and this is an important driver of antimicrobial resistance. The mHealth Diarrhoea Management (mHDM) trial aimed to establish whether electronic decision support improves rehydration and antibiotic guideline adherence in resource-limited settings. Methods A cluster randomised controlled trial was done at ten district hospitals in Bangladesh. Inclusion criteria were patients aged 2 months or older with uncomplicated acute diarrhoea. Admission orders were observed without intervention in the pre-intervention period, followed by randomisation to electronic (rehydration calculator) or paper formatted WHO guidelines for the intervention period. The primary outcome was rate of intravenous fluid ordered as a binary variable. Generalised linear mixed-effect models, accounting for hospital clustering, served as the analytical framework; the analysis was intention to treat. The trial is registered with ClinicalTrials.gov (NCT03154229) and is completed. Findings From March 11 to Sept 10, 2018, 4975 patients (75·6%) of 6577 screened patients were enrolled. The intervention effect for the primary outcome showed no significant differences in rates of intravenous fluids ordered as a function of decision-support type. Intravenous fluid orders decreased by 0·9 percentage points for paper electronic decision support and 4·2 percentage points for electronic decision support, with a 4·2-point difference between decision-support types in the intervention period (paper 98·7% [95% CI 91·8–99·8] vs electronic 94·5% [72·2–99·1]; p interaction =0·31). Adverse events such as complications and mortality events were uncommon and could not be statistically estimated. Interpretation Although 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. Funding US National Institutes of Health.