Evidence-based commissioning o tlarcourt Brace and Company Ltd 1998

The only financial savings from a shift to day care for rheumatoid arthritis results from cost transfer to patients and families

)MMENTAR~

Lambert C M, Hurst N P, Forbes J F, Lochead A, Macleod M, Nuki G. Is day care equivalent to hzpatient care for active rheunzatoid arthritis? Randomised controlled clinical and economic evahtation. Br Med J 1998; 316:965-969

Background

It has been common to admit patients with rheumatoid arthritis to hospital for investigation, stabilization and initiation of treatment. The alternative of day care stabilization is a matter of debate.

Objective

To compare the clinical and resource consequences of day care and inpatient care for active rheumatoid arthritis.

Setting

Edinburgh, UK.

Method

I 18 consecutive patients with active rheumatoid arthritis were randomized to receive either day care or inpatient care.

Li terature review

No explicit strategy; 27 references.

Outcomes

Outcomes assessed at admission, discharge and at 12 months included:

1. Health assessment questionnaire 2. Validated specialized assessment for

rheumatoid arthritis 3. Erythrocyte sedimentation r a t e - blood

test to measure disease activity 4. Anxiety and depression 5. Functional ability 6. Direct costs 7. Indirect costs 8. Health utility, the patient's perspective of

value, was assessed using two validated

method: time trade-off and a quality of well-being scale.

Results

Clinical outcome did not differ significantly between the two groups, either at the time of discharge or 12 months later. The health care cost for day care was £798 (95% confidence intervals [CI] £705-888), compared with inpatient care which cost £1253 (95% CI £1155-1370) but this difference was offset by higher community travel and readmission costs. The difference in total cost was small (£1789 [95% CI £1539-2027] compared with £2021 [95% CI £1834-2230]).

Authors ' conclusions

Several randomized trials have shown the benefit of multidisciplinary inpatient care for active rheumatoid arthritis and one of these trials found that inpatient care was more cost-effective than outpatient care, supposedly because more intensive treatment could be given as an inpatient.

The authors conclude that day care is only 'slightly more cost-effective than inpatient care,' and that it is unlikely that cash would be released by developing day care because the resources used for inpatient care would have to be transferred to the Day Care Unit. Furthermore, their study shows that any increase in cost-effectiveness from the perspective of the health care system results from cost shifting to patients and families. They also emphasise that the benefit from intensive management of active rheumatoid arthritis, whether inpatient or day care, is limited, and that other approaches must be developed to ensure that benefits attained from intensive management are sustained.

Given that clinical outcomes for inpatient vs day care t reatment for rheumatoid arthritis are the same, intuit ively commissioners would expect to favor day-case t reatment as the more cost-effective option. Taken at face value, inpatient costs at £1253 are much higher than day care costs of £798 p.er patient to the hospital. However, when true costs, including those fall ing on the patient such as transport and community costs were considered, differences were much narrower at £1789 for day case vs £2021 for inpatient care. The authors were concerned that in the case of day care much of the cost fell on chronically ill patients and therefore potential ly economically disadvantaged patients, although interestingly 62% of the day patients and 42% of the inpatients preferred to receive day patient t reatment in future (52% overall).

What are the implications for commissioners? Given the authors findings, how should ,:ornmissioners respond? There seems to be litt le compelling reason for radical change. Inpatient facilities will certainly need to be retained as 60 of the 200 patients eligible for the study were unable to travel and a further 22 had medical complications. Addit ionally, 11 of the 59 patients randomized to day care transferred to inpatient care, five due to travell ing difficulties, two for clinical reasons, two for domestic reasons and two out of preference. Whilst there are no compelling economic arguments to drive commissioners down the day care route, given that 52% of patients prefer it, there does seem to be a good case for encouraging rheumatologists to develop this option.

A potential bonus for commissioners and acute Trusts, given the current political pressure to clear wait ing lists, is that a small number of beds might be freed up for elective surgery.

One area of future research in v iew of the development of Primary Care Groups of 100 000, is the possibility of developing community day care, perhaps supervised by rheumatologists but delivered by multidisciplinary teams including GPs wi th hospital rheumatology experience. Research would need to ensure no adverse impact on outcomes.

Dr Rod Smith and Dr Judith James Balmore Park Surgery

Reading, UK

SEPTEMBER 1998 EVIDENCE-BASED IIEALTH POLICY AND MANAGEMENT 71