Papers

Is day care equivalent to inpatient care for active rheumatoid arthritis? Randomised controlled clinical and economic evaluation

C Michael Lambert, consultant rheumatologist, ^a Nigel P Hurst, consultant rheumatologist, ^a John F Forbes, senior lecturer in health economics, ^b Alison Lochhead, research assistant, ^a Mary Macleod, clinical metrologist, ^a George Nuki, professor of rheumatology. ^a

^a Rheumatic Diseases Unit, Department of Medicine, University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU, ^b Department of Public Health Sciences, Medical School, University of Edinburgh, Edinburgh EH8 9AG

Correspondence to: Dr Lambert

Objective: To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis.
Design: Randomised controlled clinical trial with integrated cost minimisation economic evaluation.
Setting: Rheumatic diseases unit at a teaching hospital between 1994 and 1996. 
Subjects: 118 consecutive patients with active rheumatoid arthritis randomised to receive either day care or inpatient care.
Main outcome measures: 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.
Results: 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 (95% confidence interval £705 to £888), was lower than for inpatient care, £1253 (£1155 to £1370), 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 (£1539 to £2027) v £2021 (£1834 to £2230)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (£374; £639 to £109).
Conclusions: 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.