Lambert C M, Hurst N P, Forbes J F, Lochhead A, Macleod M, Nuki G
Department of Medicine, University of Edinburgh, Western General Hospital.
BMJ. 1998 Mar 28;316(7136):965-9. doi: 10.1136/bmj.316.7136.965.
To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis.
Randomised controlled clinical trial with integrated cost minimisation economic evaluation.
Rheumatic diseases unit at a teaching hospital between 1994 and 1996.
118 consecutive patients with active rheumatoid arthritis randomised to receive either day care or inpatient care.
Clinical assessments recorded on admission, discharge, and follow up at 12 months comprised: the health assessment questionnaire, Ritchie articular index, erythrocyte sedimentation rate, hospital anxiety and depression scale, and Steinbrocker functional class. Resource estimates were of the direct and indirect costs relating to treatment for rheumatoid arthritis. Secondary outcome measures (health utility) were ascertained by time trade off and with the quality of well being scale.
Both groups had improvement in scores on the health assessment questionnaire and Ritchie index and erythrocyte sedimentation rate after hospital treatment (P < 0.0001) but clinical outcome did not differ significantly between the groups either at discharge or follow up. The mean hospital cost per patient for day care, 798 Pounds (95% confidence interval 705 Pounds to 888 Pounds), was lower than for inpatient care, 1253 Pounds (1155 Pounds to 1370 Pounds), but this difference was offset by higher community, travel, and readmission costs. The difference in total cost per patient between day care and inpatient care was small (1789 Pounds (1539 Pounds to 2027 Pounds) v 2021 Pounds (1834 Pounds to 2230 Pounds)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (374 Pounds; 639 Pounds to 109 Pounds).
Day care and inpatient care for patients with uncomplicated active rheumatoid arthritis have equivalent clinical outcome with a small difference in overall resource cost in favour of day care. The choice of management strategy may depend increasingly on convenience, satisfaction, or more comprehensive health measures reflecting the preferences of patients, providers, and service commissioners.
比较日间护理与住院护理对活动期类风湿关节炎患者的临床等效性及资源消耗情况。
随机对照临床试验，并结合成本最小化经济评估。
1994年至1996年间，某教学医院的风湿科。
118例连续入选的活动期类风湿关节炎患者，随机分为日间护理组或住院护理组。
入院、出院及12个月随访时记录的临床评估指标包括：健康评估问卷、里奇关节指数、红细胞沉降率、医院焦虑抑郁量表及斯坦布鲁克功能分级。资源评估包括类风湿关节炎治疗的直接和间接成本。次要观察指标（健康效用）通过时间权衡法和幸福感量表确定。
两组患者经住院治疗后，健康评估问卷、里奇指数及红细胞沉降率评分均有改善（P < 0.0001），但出院时及随访时两组间临床结局无显著差异。日间护理组每位患者的平均住院费用为798英镑（95%置信区间705英镑至888英镑），低于住院护理组的1253英镑（1155英镑至1370英镑），但这一差异被社区、交通及再入院的较高费用所抵消。日间护理组与住院护理组每位患者的总成本差异较小（1789英镑（1539英镑至2027英镑）对2021英镑（1834英镑至2230英镑））。分位数回归分析显示，直至第50百分位数，日间护理的成本差异为374英镑（639英镑至109英镑），有利于日间护理。
对于无并发症的活动期类风湿关节炎患者，日间护理与住院护理具有等效的临床结局，总体资源成本差异较小，日间护理更具优势。管理策略的选择可能越来越取决于便利性、满意度或更全面的健康指标，这些指标反映了患者、提供者和服务专员的偏好。
