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

Objectives: To evaluate the clinical outcomes and costs of managing pneumonia and severe malnutrition in a day clinic management (DC) model (outpatient) compared to hospital care (inpatient).

Methods: A randomized 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 randomization of variable length from 8-20 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: 470 children were randomly assigned to either DC or hospital care. Successful management was achieved for 184 of 235 (78.3%) by DC alone, compared to 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%) and 36/235 (15.3%) required

readmission to hospital in the DC and hospital care groups respectively [RR (95% CI) = 0.89 (0.67 – 1.18), p=0.21]. The average overall health care and societal cost was 34% lower in DC (US$ 188±11.7) compared to hospital (US$ 285±13.6) (p<0.001), and 33%

lower cost for households.

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 DC, and costs were substantially

lower than with hospital admission.