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

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, pound 798 (95% confidence interval pound 705 to pound 888), was lower than for inpatient care, pound 1253 (pound 1155 to pound 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 (pound 1789 (pound 1539 to pound 2027) v pound 2021 (pound 1834 to pound 2230)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (pound 374; pound 639 to pound 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.