George Fuchs, M.D., professor in the Department of Pediatrics in the University of Kentucky College of Medicine and pediatric gastroenterologist for Kentucky Children's Hospital, recently published a report in the journal eClinicalMedicine, one of the Lancet family of journals. The report is the result of a multiyear study about opportunities to improve clinical care for children in lower and middle-income nations around the world. Fuchs was the senior investigator among the team of collaborators from International Centre for Diarrhoeal Disease Research in Bangladesh, University of Basel, and the Ministry of Health and Family Planning in Bangladesh, Melbourne Children Hospital, Hiroshima University and UNICEF.
The report, "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 randomized controlled trial," studied an outpatient day care clinic treatment approach in Bangladesh compared to traditional inpatient/hospitalized management and that showed not only no difference in treatment outcomes, but the cost of treating a patient at a day care center is significantly less, easing logistical and financial burdens for local governments, health care providers and patient families.
"Pneumonia is the single largest cause of death for children under 5 years old in the world," said Fuchs. "In 2017, over 800,000 children died, mostly in low- and middle-income countries. Significant barriers to treatment exist, especially when there just aren't enough hospitals and hospital beds."
The World Health Organization (WHO) recommends children with severe pneumonia be treated in hospitals for supportive care including oxygen therapy, airway suction and antibiotics. Hospitals in countries such as Bangladesh do not have the capacity or resources to admit the large number of children with pneumonia. There are roughly three hospital beds per 10,000 children in Bangladesh, compared to 63 per 10,000 in Europe. In the largest pediatric hospital in Bangladesh, one in four patients who require hospitalization are unable to access inpatient care and 22% of those children denied admission have pneumonia.
In addition to the dearth of available beds, hospitals mandate that the child's parent, usually the mother, remain with the patient for the entirety of the inpatient stay. Families face the added challenge of transportation costs, long distances between the hospital and home and lack of child care for the other children at home. These added burdens can force families to forgo treatment entirely.
From 2014 to 2019, Fuchs and his research team conducted a study that included 3,211 children in both rural and urban areas of Bangladesh. With more than $5 million in funding from UNICEF, the Botnar Foundation, UBS Foundation and EAGLE Foundation, the team worked within the local health care system of three rural and two urban slum areas to establish day care clinics to treat children with pneumonia, a number of whom also had other comorbidities such as malnutrition.
Children with pneumonia who did not respond to at-home treatment, or whose conditions either deteriorated or presented as severe were enrolled in the day care clinic. From 8:30 a.m. until late afternoon, in clinics with four beds, two nurses, equipment and medication, children were treated with WHO-directed treatment protocols including supplemental oxygen, antibiotics, suction, nebulizer and temperature monitoring. Patients who were malnourished or had diarrhea received therapeutic feeds and rehydration solutions. At the end of the day, patients were reevaluated, and those who needed additional treatment returned the next day. After discharge, patients were assessed monthly for potential relapse.
"The ultimate outcome was that there was no difference between the outcomes of those treated in the day care clinics compared to the control group of children treated in hospital," said Fuchs. "The resources needed to establish these day cares are really modest and, especially considering the cost savings of the day care approach, very much within reach of lower- and middle-income countries that don't have unlimited money to spend on health care."
Since 1992, Fuchs has conducted studies and managed programs in Thailand and Bangladesh focusing on clinical as well as public health and community-based trials. He directed operations research for the Bangladesh Integrated Nutrition Program, funded by the World Bank. Over a period of two years, Fuchs, using his connections within the Bangladesh government, including the Secretary of Health as well as nongovernmental organizations that operate clinics and hospitals, personally worked with local governments, global health foundations and research organizations for funding and logistical support.
"Getting these people on board, showing that it's not going to disrupt their activities, takes a little persuasion," Fuchs said. "We held a workshop and symposium before we started to review the topic and set the research priorities including the new treatment models. It took quite a bit of groundwork, but everyone was invested in this."
In addition to the health impact, Fuchs' team included a medical anthropologist to ensure this model of care fit within the culture's expectations and abilities. Health economists were also involved in measuring the financial logistics.
"The bottom line is to have an impact, and governments understandably aren't going to implement something that's not cost-effective or doesn't take into account cultural perceptions and biases," said Fuchs.
In low-income countries such as Bangladesh, families often must liquidate property or take out loans to afford medical treatment. In hospitals, even if the child is admitted, parents are responsible for purchasing medication at nearby pharmacies. At the day care clinics, medication and treatment are provided at no cost to the family. Combined with the convenient location and the fact that the child would be well-cared for while the parents worked, the study showed day care clinics were the preferred care option by families.
The study demonstrated that 90% of children with severe pneumonia were successfully treated in day care clinics but at a much lower cost than hospital-based treatment in both rural and urban settings. With a modest and affordable investment in day care clinics and upgrading facilities and patient capacities, Fuchs projects the model will be effective and practical at treating childhood pneumonia if widely implemented.
"Even with additional resources, it would still be cheaper for the health care system and for families," said Fuchs. "This is already starting to be further scaled up. It's obviously beneficial in terms of cost, so my expectation is that this will be considered as a protocol globally."
