Day clinic vs. hospital care of pneumonia and severe malnutrition in children under five: a randomised trial

Abstract

Summary 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.

Clinical Characteristics and Underlying Factors Related to Recovery from Severe Pneumonia in Under-Five Children with or without Malnutrition Treated at Health Care Facilities in Bangladesh

“…We analyzed the data by using SPSS for Windows (version 21.0; SPSS Inc., Chicago, IL, USA) and Epi Info (version 7.0, USD, Stone Mountain, GA, USA). On the basis of previous study findings [ 23 , 24 , 25 ], we assumed the clinical outcome of day-cares and hospitals would be similar, and therefore, we analyzed the data together to compare the malnourished and well-nourished children, and we did not compare the outcome of clinical features among day-cares versus hospitals in our study. As day-cares and hospitals were used for the same protocols for the management/treatment of children with severe pneumonia, we did not consider it as a variable, and for that reason, it was not analyzed.…”

“…Earlier efficacy trials have reported primary health care facilities equipped with oxygen, pulse oximeter, suction machine, and nebulizer facilities can provide efficient care for severe pneumonia irrespective of the nutritional status of the children on a day-care basis if staff were provided with quality clinical management training [ 23 , 24 , 25 ]. Such facilities provided care and treatment to the children on an outpatient basis, during daytime hours, and sent the children home with advice to return the following day until an outcome (recovery or referral to the hospital) was achieved [ 23 , 24 , 25 ].…”

Tinjauan Literatur Malnutrisi Didapat di Rumah Sakit: Karakteristik Anak dan Alat Skrining yang Digunakan

“…Penyakit lain seperti pneumonia menyumbang kematian pada anak dengan malnutrisi hingga 23% atau 15 kali lebih besar (7) . Penyakit infeksi lainnya sebanyak 68,5% juga mengambil bagian penyebab peningkatan kejadian malnutrisi didapat di rumah sakit (8) .…”

“…Malnutrisi didapat di rumah sakit memiliki kelebihan dan kekurangan dalam hal penanganan dan manajemen pemberian terapi. Salah satu kelebihannya adalah 86% asuhan manajemen nutrisi yang diberikan oleh profesional ahli di rumah sakit tertangani dengan baik dibandingkan klinik mulai dari penanganan triase, pengawasan dan pemantauan status nutrisi yang tepat serta rujukan bila diperlukan (7) . Namun adanya infeksi nosokomial di rumah sakit akibat lama rawat anak selama masa hospitalisasi akan memperburuk kondisi anak.…”

“…Salah satu penyebab adanya kejadian malnutrisi di rumah sakit adalah adanya beberapa penyakit penyerta diantaranya penyakit infeksi sebesar 13,5%, penyakit non infeksi sebanyak 17,9% dan pembedahan sebanyak 7,7%. Penyakit infeksi yang diteliti disalah satu rumah sakit di Bangladesh mendapat data pneumonia berat sebanyak 30 anak, pneumonia berat disertai hipoksemia sebanyak 17 anak, diare dan dehidrasi sebanyak 8 anak dari 470 anak (7) . Selain penyakit infeksi, penelitian lain juga mengatakan penyakit neurologi, penyakit jantung, penyakit gastrointestinal, penyakit genito-urinari dan penyakit respiratori juga penyumbang terbesar pada kasus kejadian malnutrisi di rumah sakit (21) .…”