在孟加拉国现有卫生系统下，日托与常规医院护理管理对伴有或不伴有营养不良的儿童重症肺炎的有效性、安全性和经济可行性：一项整群随机对照试验。

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.

作者信息

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

机构信息

Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh.

Infectious Diseases Division, icddr,b, Dhaka, Bangladesh.

出版信息

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

DOI:10.1016/j.eclinm.2023.102023

PMID:37304498

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10250158/

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.

摘要

背景

我们旨在确定在孟加拉国卫生系统中，日间护理模式（DCA）替代常规护理（UC，对照组）来管理儿童重症肺炎的临床效果和成本效益。

方法

这是一项于2015年11月1日至2019年3月23日在达卡市区和孟加拉国农村地区进行的整群随机对照试验。年龄在2至59个月、患有或未患有营养不良的重症肺炎儿童接受DCA或UC治疗。DCA的治疗场所包括由达卡南城公司下属非政府组织运营的城市初级卫生保健诊所，以及卫生和家庭福利部下属农村联合卫生和家庭福利中心。UC的治疗场所是这些地区的医院。主要结局是治疗失败（肺炎症状持续、转诊或死亡）。我们对治疗失败进行了意向性分析和符合方案分析。在www.ClinicalTrials.gov注册，注册号为NCT02669654。

结果

共纳入3211名儿童，1739名接受DCA治疗，1472名接受UC治疗；DCA组和UC组分别有1682名和1357名儿童有主要结局数据。DCA组儿童的治疗失败率为9.6%（1739名中的167名），UC组为13.5%（1472名中的198名）（组间差异为-3.9个百分点；95%置信区间（CI）为-4.8至-1.5，p = 0.165）。卫生保健系统内的治疗成功率[DCA加转诊与UC加转诊，1587/1739（91.3%）对1283/1472（87.2%），组间差异4.1个百分点，95%CI为3.7至4.1，p = 0.160]在DCA组更高。城市和农村地区UC组各有一名儿童在入院后第6天内死亡。DCA组和UC组每名儿童的平均治疗费用分别为94.2美元（95%CI为92.2至96.3）和184.8美元（95%CI为178.6至190.9）。