Effectiveness, safety and economic viability of daycare versus usual hospital care management of severe pneumonia with or without malnutrition in children using the existing health system of Bangladesh: a cluster randomised controlled trial

Nur H Alam; Abu S Faruque; Hasan Ashraf; Mohammod J Chisti; Tahmeed Ahmed; Marufa Sultana; Md Khalequzzaman; Shahjahan Ali; Shahnawaz Ahmed; Sabiha Nasrin; Md Tariqujjaman; K A T M Ehsanul Huq; Ruhul Amin; Abid Hossain Mollah; Lutful Kabir; Mohammod Shahidullah; Wahida Khanam; Khaleda Islam; Minjoon Kim; Maya Vandenent; Trevor Duke; Niklaus Gyr; George J Fuchs

doi:10.1016/j.eclinm.2023.102023

Effectiveness, safety and economic viability of daycare versus usual hospital care management of severe pneumonia with or without malnutrition in children using the existing health system of Bangladesh: a cluster randomised controlled trial

EClinicalMedicine. 2023 Jun 6:60:102023. doi: 10.1016/j.eclinm.2023.102023. eCollection 2023 Jun.

Authors

Nur H Alam¹, Abu S Faruque¹, Hasan Ashraf¹, Mohammod J Chisti¹, Tahmeed Ahmed¹, Marufa Sultana¹, Md Khalequzzaman², Shahjahan Ali¹, Shahnawaz Ahmed¹, Sabiha Nasrin¹, Md Tariqujjaman¹, K A T M Ehsanul Huq³, Ruhul Amin⁴, Abid Hossain Mollah⁵, Lutful Kabir⁶, Mohammod Shahidullah⁷, Wahida Khanam⁸, Khaleda Islam⁹, Minjoon Kim¹⁰, Maya Vandenent¹⁰, Trevor Duke¹¹, Niklaus Gyr¹², George J Fuchs¹³

Affiliations

¹ Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh.
² Infectious Diseases Division, icddr,b, Dhaka, Bangladesh.
³ Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan.
⁴ Dhaka Shishu Hospital, Dhaka, Bangladesh.
⁵ Dhaka Medical College Hospital, Dhaka, Bangladesh.
⁶ Sir Salimullah Medical College Hospital, Dhaka, Bangladesh.
⁷ Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
⁸ Institute of Child and Mother Health, Matuail, Dhaka, Bangladesh.
⁹ Primary Health Care, Ministry of Health and Family Planning, Government of Bangladesh, Bangladesh.
¹⁰ UNICEF Office, Dhaka, Bangladesh.
¹¹ Melbourne Children Hospital, Melbourne, Australia.
¹² University Hospital, Basel, Switzerland.
¹³ College of Medicine and College of Public Health, University of Kentucky, USA.

Abstract

Background: We aimed to define clinical and cost-effectiveness of a Day Care Approach (DCA) alternative to Usual Care (UC, comparison group) within the Bangladesh health system to manage severe childhood pneumonia.

Methods: This was a cluster randomised controlled trial in urban Dhaka and rural Bangladesh between November 1, 2015 and March 23, 2019. Children aged 2-59 months with severe pneumonia with or without malnutrition received DCA or UC. The DCA treatment settings comprised of urban primary health care clinics run by NGO under Dhaka South City Corporation and in rural Union health and family welfare centres under the Ministry of Health and Family welfare Services. The UC treatment settings were hospitals in these respective areas. Primary outcome was treatment failure (persistence of pneumonia symptoms, referral or death). We performed both intention-to-treat and per-protocol analysis for treatment failure. Registered at www.ClinicalTrials.gov, NCT02669654.

Findings: In total 3211 children were enrolled, 1739 in DCA and 1472 in UC; primary outcome data were available in 1682 and 1357 in DCA and UC, respectively. Treatment failure rate was 9.6% among children in DCA (167 of 1739) and 13.5% in the UC (198 of 1472) (group difference, -3.9 percentage point; 95% confidence interval (CI), -4.8 to -1.5, p = 0.165). Treatment success within the health care systems [DCA plus referral vs. UC plus referral, 1587/1739 (91.3%) vs. 1283/1472 (87.2%), group difference 4.1 percentage point, 95% CI, 3.7 to 4.1, p = 0.160)] was better in DCA. One child each in UC of both urban and rural sites died within day 6 after admission. Average cost of treatment per child was US$94.2 (95% CI, 92.2 to 96.3) and US$184.8 (95% CI, 178.6 to 190.9) for DCA and UC, respectively.

Interpretation: In our population of children with severe pneumonia with or without malnutrition, >90% were successfully treated at Day care Clinics at 50% lower cost. A modest investment to upgrade Day care facilities may provide a cost-effective, accessible alternative to hospital management.

Funding: UNICEF, Botnar Foundation, UBS Optimus Foundation, and EAGLE Foundation, Switzerland.

Keywords: Bangladesh; Cost-effectiveness; Daycare; Hospitalisation; Severe pneumonia.

Associated data

ClinicalTrials.gov/NCT02669654