Day clinic vs. hospital care of pneumonia and severe malnutrition in children under five: a randomised trial
Hasan Ashraf, Nur H Alam, Marufa Sultana, Selina A Jahan, Nurshad Begum, Sharmin Farzana, Mohammod J Chisti, Mohiuddin Kamal, Abu Shamsuzzaman, Tahmeed Ahmed, Jahangir A M Khan, George J Fuchs, Trevor Duke, Niklaus Gyr, Hasan Ashraf, Nur H Alam, Marufa Sultana, Selina A Jahan, Nurshad Begum, Sharmin Farzana, Mohammod J Chisti, Mohiuddin Kamal, Abu Shamsuzzaman, Tahmeed Ahmed, Jahangir A M Khan, George J Fuchs, Trevor Duke, Niklaus Gyr
Abstract
Objectives: To evaluate the clinical outcomes and costs of managing pneumonia and severe malnutrition in a day clinic (DC) management model (outpatient) vs. hospital care (inpatient).
Methods: Randomised clinical trial where children aged 2 months to 5 years with pneumonia and severe malnutrition were randomly allocated to DC or inpatient hospital care. We used block randomisation of variable length from 8 to 20 and produced computer-generated random numbers that were assigned to one of the two interventions. Successful management was defined as resolution of clinical signs of pneumonia and being discharged from the model of care (DC or hospital) without need for referral to a hospital (DC), or referral to another hospital. All the children in both DC and hospital received intramuscular ceftriaxone, daily nutrition support and micronutrients.
Results: Four hundred and seventy children were randomly assigned to either DC or hospital care. Successful management was achieved for 184 of 235 (78.3%) by DC alone, vs. 201 of 235 (85.5%) by hospital inpatient care [RR (95% CI) = 0.79 (0.65-0.97), P = 0.02]. During 6 months of follow-up, 30/235 (12.8%) in the DC group and 36/235 (15.3%) required readmission to hospital in the hospital care group [RR (95% CI) = 0.89 (0.67-1.18), P = 0.21]. The average overall healthcare and societal cost was 34% lower in DC (US$ 188 ± 11.7) than in hospital (US$ 285 ± 13.6) (P < 0.001), and costs for households were 33% lower.
Conclusions: There was a 7% greater probability of successful management of pneumonia and severe malnutrition when inpatient hospital care rather than the outpatient day clinic care was the initial method of care. However, where timely referral mechanisms were in place, 94% of children with pneumonia and severe malnutrition were successfully managed initially in a day clinic, and costs were substantially lower than with hospital admission.
Trial registration: ClinicalTrials.gov NCT00968370.
Keywords: Bangladesh; cost evaluation; enfants de moins de cinq ans; essai clinique randomisé; inpatient care; malnutrition; outpatient care; pneumonia; pneumonie; randomised clinical trial; soins ambulatoires; soins hospitaliers; under-fives; évaluation des coûts.
© 2019 John Wiley & Sons Ltd.
Source: PubMed