How expensive are hospitalizations by Covid-19? evidence from Colombia

Objectives This study aimed to estimate the direct medical costs due to hospitalizations by COVID-19 in Colombia and to identify their cost drivers in Colombia. Methods This is a retrospective cost-of-illness study of COVID-19 in Colombia. We estimated direct medical costs using data from patients i...

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Autores:
ALVIS-ZAKZUK, NELSON J.
Flórez-Tanus, Álvaro
Díaz-Jiménez, Diana
Chaparro-Narváez, Pablo
Castañeda-Orjuela, Carlos
DE LA HOZ RESTREPO, FERNANDO
Dueñas-Castel, Carmelo
Alvis-Guzmán, Nelson
Tipo de recurso:
Article of journal
Fecha de publicación:
2022
Institución:
Corporación Universidad de la Costa
Repositorio:
REDICUC - Repositorio CUC
Idioma:
eng
OAI Identifier:
oai:repositorio.cuc.edu.co:11323/9371
Acceso en línea:
https://hdl.handle.net/11323/9371
https://doi.org/10.1016/j.vhri.2022.04.005
https://repositorio.cuc.edu.co/
Palabra clave:
Costs and cost analysis
COVID-19
Direct medical cost
Hospitalization
Rights
embargoedAccess
License
© 2022 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc.
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dc.title.eng.fl_str_mv How expensive are hospitalizations by Covid-19? evidence from Colombia
title How expensive are hospitalizations by Covid-19? evidence from Colombia
spellingShingle How expensive are hospitalizations by Covid-19? evidence from Colombia
Costs and cost analysis
COVID-19
Direct medical cost
Hospitalization
title_short How expensive are hospitalizations by Covid-19? evidence from Colombia
title_full How expensive are hospitalizations by Covid-19? evidence from Colombia
title_fullStr How expensive are hospitalizations by Covid-19? evidence from Colombia
title_full_unstemmed How expensive are hospitalizations by Covid-19? evidence from Colombia
title_sort How expensive are hospitalizations by Covid-19? evidence from Colombia
dc.creator.fl_str_mv ALVIS-ZAKZUK, NELSON J.
Flórez-Tanus, Álvaro
Díaz-Jiménez, Diana
Chaparro-Narváez, Pablo
Castañeda-Orjuela, Carlos
DE LA HOZ RESTREPO, FERNANDO
Dueñas-Castel, Carmelo
Alvis-Guzmán, Nelson
dc.contributor.author.spa.fl_str_mv ALVIS-ZAKZUK, NELSON J.
Flórez-Tanus, Álvaro
Díaz-Jiménez, Diana
Chaparro-Narváez, Pablo
Castañeda-Orjuela, Carlos
DE LA HOZ RESTREPO, FERNANDO
Dueñas-Castel, Carmelo
Alvis-Guzmán, Nelson
dc.subject.proposal.eng.fl_str_mv Costs and cost analysis
COVID-19
Direct medical cost
Hospitalization
topic Costs and cost analysis
COVID-19
Direct medical cost
Hospitalization
description Objectives This study aimed to estimate the direct medical costs due to hospitalizations by COVID-19 in Colombia and to identify their cost drivers in Colombia. Methods This is a retrospective cost-of-illness study of COVID-19 in Colombia. We estimated direct medical costs using data from patients insured to a Benefit Plan Administrator Company, between March 15, 2020 and May 29, 2020. Absolute and relative frequencies, averages, medians, and interquartile ranges (IQRs) were used to characterize the population and estimate the costs of hospitalized patients with COVID-19. We stratified the cost analysis by sex, age groups, comorbidities, and type of hospitalization (general ward and intensive care unit [ICU]). Cost drivers were calculated from a generalized linear model. Results We studied 113 confirmed patients, 51.3% men. On average, the hospital length of stay was 7.3 (± 6.2) days. A person hospitalized with COVID-19 reported median costs of $1688 (IQR 788-2523). In women, this cost was $1328 (IQR 463-2098); in men, this was 1.4 times greater. The median cost for ICU was $4118 (IQR 2069-5455), 3 times higher than those hospitalized only in the general ward. Admission to the ICU, having 1 comorbidity, length of stay, high blood pressure, having 5 comorbidities, and being treated in the city of Cartagena were statistically significant with direct medical costs. Conclusions Our study provides an idea of the magnitude of costs needed to hospitalize a COVID-19 case in Colombia. Other studies in Colombia have assessed the costs of hospitalization for infectious diseases such as influenza, costs significantly lower than those described here.
publishDate 2022
dc.date.accessioned.none.fl_str_mv 2022-07-14T19:48:12Z
dc.date.available.none.fl_str_mv 2022-07-14T19:48:12Z
2023
dc.date.issued.none.fl_str_mv 2022
dc.type.spa.fl_str_mv Artículo de revista
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dc.identifier.citation.spa.fl_str_mv Nelson J. Alvis-Zakzuk, Álvaro Flórez-Tanus, Diana Díaz-Jiménez, Pablo Chaparro-Narváez, Carlos Castañeda-Orjuela, Fernando De La Hoz-Restrepo, Carmelo Dueñas-Castel, Nelson R. Alvis-Guzmán, How Expensive Are Hospitalizations by COVID-19? Evidence From Colombia, Value in Health Regional Issues, Volume 31, 2022, Pages 127-133, ISSN 2212-1099, https://doi.org/10.1016/j.vhri.2022.04.005.
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dc.identifier.doi.spa.fl_str_mv 10.1016/j.vhri.2022.04.005
dc.identifier.eissn.spa.fl_str_mv 2212-1102
dc.identifier.instname.spa.fl_str_mv Corporación Universidad de la Costa
dc.identifier.reponame.spa.fl_str_mv REDICUC - Repositorio CUC
dc.identifier.repourl.spa.fl_str_mv https://repositorio.cuc.edu.co/
identifier_str_mv Nelson J. Alvis-Zakzuk, Álvaro Flórez-Tanus, Diana Díaz-Jiménez, Pablo Chaparro-Narváez, Carlos Castañeda-Orjuela, Fernando De La Hoz-Restrepo, Carmelo Dueñas-Castel, Nelson R. Alvis-Guzmán, How Expensive Are Hospitalizations by COVID-19? Evidence From Colombia, Value in Health Regional Issues, Volume 31, 2022, Pages 127-133, ISSN 2212-1099, https://doi.org/10.1016/j.vhri.2022.04.005.
2212-1099
10.1016/j.vhri.2022.04.005
2212-1102
Corporación Universidad de la Costa
REDICUC - Repositorio CUC
url https://hdl.handle.net/11323/9371
https://doi.org/10.1016/j.vhri.2022.04.005
https://repositorio.cuc.edu.co/
dc.language.iso.none.fl_str_mv eng
language eng
dc.relation.ispartofjournal.spa.fl_str_mv Value in Health Regional Issues
dc.relation.references.spa.fl_str_mv 1. Coronavirus disease (COVID-2019) situation reports–situation report - 87. World Health Organization. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports. Accessed June 30, 2020.
2. Wang Q, Su M. A preliminary assessment of the impact of COVID-19 on environment – a case study of China. Sci Total Environ. 2020;728:13 8915.
3. Suleyman G, Fadel RA, Malette KM, et al. Clinical characteristics and morbidity associated with coronavirus disease 2019 in a series of patients in metropolitan Detroit. JAMA Network Open. 2020;3(6):e2012270.
4. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223): 497–506.
5. Quah P, Li A, Phua J, Phua J. Mortality rates of patients with COVID-19 in the intensive care unit: a systematic review of the emerging literature. Crit Care. 2020;24(1):285.
6. Coronavirus Colombia. Instituto Nacional de Salud. https://www.ins.gov.co/Noticias/Paginas/Coronavirus.aspx. Accessed June 30, 2020.
7. Mahase E. Coronavirus covid-19 has killed more people than SARS and MERS combined, despite lower case fatality rate. BMJ. 2020;368: m641.
8. Guerrero R, Gallego AI, Becerril-Montekio, Vásquez J. Sistema de salud de Colombia. Salud Publ Mex. 2011;53(suppl 2):S144–S155.
9. Instituto Nacional de Salud. Observatorio nacional de salud. Acceso a servicios de salud en Colombia. DC: Décimo Prim. Inf Tecn Bogotá; 2019. http://www. ins.gov.co/Direcciones/ONS/Informes/11.%20Acceso%20a%20servicios%20de%20salud%20en%20Colombia2.pdf. Accessed May 31, 2022.
10. Tasa Representativa del Mercado (TRM - Peso por dólar). Banco de la República (banco central de Colombia). https://www.banrep.gov.co/es/estadisticas/trm. Accessed July 28, 2020.
11. Seguro obligatorio de accidentes de tránsito (SOAT). Manual tarifario. Consultorsalud. https://consultorsalud.com/manual-tarifario-soat-2019- facturacion-de-servicios-de-salud-pdf-consultorsalud/. Accessed July 28, 2020.
12. Barber J, Thompson S. Multiple regression of cost data: use of generalised linear models. J Health Serv Res Policy. 2004;9(4):197–204.
13. de la Hoz-Restrepo F, Alvis-Zakzuk NJ, De la Hoz-Gomez JF, De la HozGomez A, Del Corral LG, Alvis-Guzmán N. Is Colombia an example of successful containment of the COVID-19 2020 pandemic? A critical analysis of the epidemiological data, March to July 2020. Int J Infect Dis. 2020;99:522– 529.
14. Ji W, Huh K, Kang M, et al. Effect of underlying comorbidities on the infection and severity of COVID-19 in Korea: a nationwide case-control study. J Korean Med Sci. 2020;35(25):1–15.
15. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323(20): 2052–2059.
16. Chang R, Elhusseiny KM, Yeh Y-C, Sun W-Z. COVID-19 ICU and mechanical ventilation patient characteristics and outcomes—a systematic review and meta-analysis. PLoS One. 2021;16(2):e0246318.
17. Bartsch SM, Ferguson MC, McKinnell JA, et al. The potential health care costs and resource use associated with COVID-19 in the United States. Health Aff (Millwood). 2020;39(6):927–935.
18. Salcedo-Mejía F, Alvis-Zakzuk NJ, Carrasquilla-Sotomayor M, et al. Economic cost of severe acute respiratory infection associated to influenza in Colombian children: a single setting analysis. Value Heal Reg Issues. 2019;20:159–163.
19. Lineamientos para el manejo clínico de pacientes con infección por nuevo coronavirus COVID19. Ministerio de Salud y Protección Social. https://www.minsalud.gov.co/Ministerio/Institucional/Procesos%20y%20procedimientos/ PSSS03.pdf. Accessed August 2, 2020.
20. Cutler DM, Summers LH. The COVID-19 pandemic and the $16 trillion virus. JAMA. 2020;324(15):1495–1496.
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spelling ALVIS-ZAKZUK, NELSON J.Flórez-Tanus, ÁlvaroDíaz-Jiménez, DianaChaparro-Narváez, PabloCastañeda-Orjuela, CarlosDE LA HOZ RESTREPO, FERNANDODueñas-Castel, CarmeloAlvis-Guzmán, Nelson2022-07-14T19:48:12Z20232022-07-14T19:48:12Z2022Nelson J. Alvis-Zakzuk, Álvaro Flórez-Tanus, Diana Díaz-Jiménez, Pablo Chaparro-Narváez, Carlos Castañeda-Orjuela, Fernando De La Hoz-Restrepo, Carmelo Dueñas-Castel, Nelson R. Alvis-Guzmán, How Expensive Are Hospitalizations by COVID-19? Evidence From Colombia, Value in Health Regional Issues, Volume 31, 2022, Pages 127-133, ISSN 2212-1099, https://doi.org/10.1016/j.vhri.2022.04.005.2212-1099https://hdl.handle.net/11323/9371https://doi.org/10.1016/j.vhri.2022.04.00510.1016/j.vhri.2022.04.0052212-1102Corporación Universidad de la CostaREDICUC - Repositorio CUChttps://repositorio.cuc.edu.co/Objectives This study aimed to estimate the direct medical costs due to hospitalizations by COVID-19 in Colombia and to identify their cost drivers in Colombia. Methods This is a retrospective cost-of-illness study of COVID-19 in Colombia. We estimated direct medical costs using data from patients insured to a Benefit Plan Administrator Company, between March 15, 2020 and May 29, 2020. Absolute and relative frequencies, averages, medians, and interquartile ranges (IQRs) were used to characterize the population and estimate the costs of hospitalized patients with COVID-19. We stratified the cost analysis by sex, age groups, comorbidities, and type of hospitalization (general ward and intensive care unit [ICU]). Cost drivers were calculated from a generalized linear model. Results We studied 113 confirmed patients, 51.3% men. On average, the hospital length of stay was 7.3 (± 6.2) days. A person hospitalized with COVID-19 reported median costs of $1688 (IQR 788-2523). In women, this cost was $1328 (IQR 463-2098); in men, this was 1.4 times greater. The median cost for ICU was $4118 (IQR 2069-5455), 3 times higher than those hospitalized only in the general ward. Admission to the ICU, having 1 comorbidity, length of stay, high blood pressure, having 5 comorbidities, and being treated in the city of Cartagena were statistically significant with direct medical costs. Conclusions Our study provides an idea of the magnitude of costs needed to hospitalize a COVID-19 case in Colombia. Other studies in Colombia have assessed the costs of hospitalization for infectious diseases such as influenza, costs significantly lower than those described here.7 páginasapplication/pdfengElsevier USAUnited States© 2022 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc.Atribución-NoComercial-SinDerivadas 4.0 Internacional (CC BY-NC-ND 4.0)https://creativecommons.org/licenses/by-nc-nd/4.0/info:eu-repo/semantics/embargoedAccesshttp://purl.org/coar/access_right/c_f1cfHow expensive are hospitalizations by Covid-19? evidence from ColombiaArtículo de revistahttp://purl.org/coar/resource_type/c_6501http://purl.org/coar/resource_type/c_2df8fbb1Textinfo:eu-repo/semantics/articlehttp://purl.org/redcol/resource_type/ARThttp://purl.org/coar/version/c_970fb48d4fbd8a85https://www.sciencedirect.com/science/article/pii/S2212109922001121ColombiaValue in Health Regional Issues1. Coronavirus disease (COVID-2019) situation reports–situation report - 87. World Health Organization. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports. Accessed June 30, 2020.2. Wang Q, Su M. A preliminary assessment of the impact of COVID-19 on environment – a case study of China. Sci Total Environ. 2020;728:13 8915.3. Suleyman G, Fadel RA, Malette KM, et al. Clinical characteristics and morbidity associated with coronavirus disease 2019 in a series of patients in metropolitan Detroit. JAMA Network Open. 2020;3(6):e2012270.4. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223): 497–506.5. Quah P, Li A, Phua J, Phua J. Mortality rates of patients with COVID-19 in the intensive care unit: a systematic review of the emerging literature. Crit Care. 2020;24(1):285.6. Coronavirus Colombia. Instituto Nacional de Salud. https://www.ins.gov.co/Noticias/Paginas/Coronavirus.aspx. Accessed June 30, 2020.7. Mahase E. Coronavirus covid-19 has killed more people than SARS and MERS combined, despite lower case fatality rate. BMJ. 2020;368: m641.8. Guerrero R, Gallego AI, Becerril-Montekio, Vásquez J. Sistema de salud de Colombia. Salud Publ Mex. 2011;53(suppl 2):S144–S155.9. Instituto Nacional de Salud. Observatorio nacional de salud. Acceso a servicios de salud en Colombia. DC: Décimo Prim. Inf Tecn Bogotá; 2019. http://www. ins.gov.co/Direcciones/ONS/Informes/11.%20Acceso%20a%20servicios%20de%20salud%20en%20Colombia2.pdf. Accessed May 31, 2022.10. Tasa Representativa del Mercado (TRM - Peso por dólar). Banco de la República (banco central de Colombia). https://www.banrep.gov.co/es/estadisticas/trm. Accessed July 28, 2020.11. Seguro obligatorio de accidentes de tránsito (SOAT). Manual tarifario. Consultorsalud. https://consultorsalud.com/manual-tarifario-soat-2019- facturacion-de-servicios-de-salud-pdf-consultorsalud/. Accessed July 28, 2020.12. Barber J, Thompson S. Multiple regression of cost data: use of generalised linear models. J Health Serv Res Policy. 2004;9(4):197–204.13. de la Hoz-Restrepo F, Alvis-Zakzuk NJ, De la Hoz-Gomez JF, De la HozGomez A, Del Corral LG, Alvis-Guzmán N. Is Colombia an example of successful containment of the COVID-19 2020 pandemic? A critical analysis of the epidemiological data, March to July 2020. Int J Infect Dis. 2020;99:522– 529.14. Ji W, Huh K, Kang M, et al. Effect of underlying comorbidities on the infection and severity of COVID-19 in Korea: a nationwide case-control study. J Korean Med Sci. 2020;35(25):1–15.15. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323(20): 2052–2059.16. Chang R, Elhusseiny KM, Yeh Y-C, Sun W-Z. COVID-19 ICU and mechanical ventilation patient characteristics and outcomes—a systematic review and meta-analysis. PLoS One. 2021;16(2):e0246318.17. Bartsch SM, Ferguson MC, McKinnell JA, et al. The potential health care costs and resource use associated with COVID-19 in the United States. Health Aff (Millwood). 2020;39(6):927–935.18. Salcedo-Mejía F, Alvis-Zakzuk NJ, Carrasquilla-Sotomayor M, et al. Economic cost of severe acute respiratory infection associated to influenza in Colombian children: a single setting analysis. Value Heal Reg Issues. 2019;20:159–163.19. Lineamientos para el manejo clínico de pacientes con infección por nuevo coronavirus COVID19. Ministerio de Salud y Protección Social. https://www.minsalud.gov.co/Ministerio/Institucional/Procesos%20y%20procedimientos/ PSSS03.pdf. Accessed August 2, 2020.20. Cutler DM, Summers LH. The COVID-19 pandemic and the $16 trillion virus. JAMA. 2020;324(15):1495–1496.13312731Costs and cost analysisCOVID-19Direct medical costHospitalizationPublicationORIGINALHow Expensive Are Hospitalizations by COVID19 Evidence From Colombia.pdfHow Expensive Are Hospitalizations by COVID19 Evidence From Colombia.pdfapplication/pdf999197https://repositorio.cuc.edu.co/bitstreams/79c8d3c2-0208-42e1-a095-e94209179adf/download9cfc80e174cea9820a2df51f8aee4cb7MD51LICENSElicense.txtlicense.txttext/plain; charset=utf-83196https://repositorio.cuc.edu.co/bitstreams/e896423a-97e2-408c-b0b9-b2a5469b258f/downloade30e9215131d99561d40d6b0abbe9badMD52TEXTHow Expensive Are Hospitalizations by COVID19 Evidence From Colombia.pdf.txtHow Expensive Are Hospitalizations by COVID19 Evidence From Colombia.pdf.txttext/plain23668https://repositorio.cuc.edu.co/bitstreams/3863c6df-929a-4018-a3d4-f55a49f32b79/download3cc303d253a5d17cbded0c088444be15MD53THUMBNAILHow Expensive Are Hospitalizations by COVID19 Evidence From Colombia.pdf.jpgHow Expensive Are Hospitalizations by COVID19 Evidence From Colombia.pdf.jpgimage/jpeg15328https://repositorio.cuc.edu.co/bitstreams/c0bbbfaf-c48f-465f-9987-472e0053e74f/download95f665ece39e34d5af44c695422cc3afMD5411323/9371oai:repositorio.cuc.edu.co:11323/93712024-09-17 11:03:21.231https://creativecommons.org/licenses/by-nc-nd/4.0/© 2022 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc.open.accesshttps://repositorio.cuc.edu.coRepositorio de la Universidad de la Costa CUCrepdigital@cuc.edu.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