Variations in length of stay of inpatients with COVID-19: A nationwide test of the new model of care under vision 2030 in Saudi Arabia

Abstract

Objective The coronavirus disease 2019 (COVID-19) has impacted the Kingdom of Saudi Arabia (KSA) as it has other nations. However, length of stay (LOS), as a healthcare quality indicator, has not been examined across the healthcare regions in the KSA. Therefore, this study aimed to examine factors associated with LOS to better understand the Saudi Health System's performance in response to the COVID-19 pandemic in the newly suggested five Saudi regional business units (BUs). Methods A retrospective study was conducted using Ministry of Health (MOH) data on hospital LOS during the period from March to mid-July 2020. Participants were adult inpatients (18 years or older) with confirmed COVID-19 (n=1743 patients). The 13 regions of the KSA were united into the defined five regional BUs during the reorganization of the health system. Covariates included demographics such as age and sex, comorbidities, and complications of COVID-19. A multiple linear regression with stepwise forward selection was used to model LOS for other explanatory variables associated with LOS, including demographic, comorbidities, and complications. Results The mean LOS was 11.85 days which differed significantly across the BUs, ranging from 9.3 days to 13.3 days (p value < 0.001). BUs differed significantly in LOS for transferred patients but not for patients in the intensive care unit (ICU) or those who died in-hospital. The multiple regression analysis revealed that the LOS for inpatients admitted in the Eastern and Southern BUs was significantly shorter than for those in the Central BU. (p value < 0.001). Admission to the ICU was associated with lengthier stays (p value <.0001). Factors significantly associated with shorter stays (compared to the reference), were being Saudi, death during admission, and patients referred to another hospital (p value < 0.05). Conclusion The LOS for patients with COVID-19 differed across the proposed regional healthcare BUs, suggesting regional differences in quality of care under the reorganization of the national health system. Since patient and disease characteristics did not explain these findings, differences in staffing and other resources need to be examined to develop interventions.

Characteristics of Hospitalized COVID-19 Patients in the Four Southern Regions Under the Proposed Southern Business Unit of Saudi Arabia

“…The explanation of our findings in regard to outcome is consistent with several studies that reported the association of mortality with comorbidities, especially the risk factors of HTN, obesity, DM2, renal disease, and cardiovascular disease. 8 , 16 , 17 , 28–33 This study is also consistent with national studies that reported the association of complications of COVID-19, with mortality rate, ICU admission, and LOS 8 , 16 , 17 and our data is consistent with international studies that found significantly higher risk of death in COVID-19 inpatients with pre-existing obesity and complications of sepsis and multi-organ failure. 34 , 35 Other studies have found risk factors that have an impact on the severity of COVID-19 including certain demographics such as being male or of advanced age along with comorbidities such as DM2, HTN, cardiac diseases, asthma, chronic obstructive pulmonary disease (COPD), tuberculosis, pneumonia, ARDS, renal disease, and hepatic disease, along with behaviors such as smoking.…”

“…Clinical course and outcome may be used as quality indicators during admission. 8 , 16 , 17 Aseer and Najran were almost identical, and had the highest prevalence among inpatients in rates of ICU admission, length of stay, and referrals to other facilities. The mortality rate had the highest prevalence in Najran followed in order by Aseer, Jazan, and Bisha.…”

“…15 The pandemic has disrupted the healthcare system just as the transition of the healthcare system under Vision 2030 has begun, providing an opportunity to measure many quality factors using this rare occurrence. 8 , 16 …”

Hospital Length of Stay and Related Factors for COVID-19 Inpatients Among the Four Southern Regions Under the Proposed Southern Business Unit of Saudi Arabia

“…After adjusting for known demographic and disease severity characteristics that may have affected the LoS among patients with COVID-19 our study revealed a mean LoS for the total sample of just over 10 days which is shorter than that observed by most international studies, 7 , 9 , 13 but similar to a recent study of all regions in the KSA. 15 Linear regression analysis revealed a statistically significant association between region and LoS and compared to Bisha (reference) at just over seven days, Jazan had just over 10 days (34% longer), Najran had 15 days (62% longer) and Aseer had 13 days (40% longer) ( Tables 3 and 4 ).…”

“… 7–9 , 13 , 14 A study in the KSA of cases during a four-month period from mid-March to mid-July 2020 observed a mean LoS of 11.85 days with a range of 9.3–13.3 days depending on the region. 15 Several factors have been identified as having an association with LoS. Comorbidities have an impact on LoS, ICU admission, and mortality; for example, several international studies observed increased LoS in patients with uncontrolled DM2 14 , 16–18 although one study in Iran did not find DM2 by itself to be statistically significant in affecting LoS.…”