Economic Burden of Hospitalized COVID-19 Patients in Iran

Background: The outbreak of COVID -19 has had destructive inuences on social and economic systems as well as many aspects of human life. In this study, we aimed to estimate the economic effects of COVID-19 at the individual and societal levels during a scal year. Methods: This is an economic evaluation study conducted as cross-sectional. Data of the COVID-19 patients referred to the hospitals aliated to Bushehr University of Medical Sciences between March 2020 and 2021 were collected through the hospital information system (HIS). Cost of illness analysis was used to estimate the economic burden of COVID-19 for the province and Iran. The study methodology was based upon the human capital approach and bottom-up technic. Results: The COVID -19 pandemic has resulted in 9711 conrmed hospital cases and 767 deaths in Bushehr province during the study period. The direct medical costs were estimated to be 439,774,265,491 Rials ($ 27,893,839) in total with mean cost of 45,286,198 Rials ($ 2872) per patient. Hospitalization, drugs and ICU costs were the highest with 36.44, 30.80 and 26.88% of total direct costs respectively. Indirect costs, including income loss due to hospitalization, recovery period at home and premature death were 20,884,492,800 ($ 1,324,654), 62,058,707,200 ($ 3,936,237) and 854,181,793,653 ($ 54,178,726) Rials. Finally economic burden for the province and country was estimated to be 1,376,899,259,144 Rials ($ 87,333,455) and 83,957,271,899,024 Rials ($ 5,325,210,700). Conclusion: The results showed that the economic burden of this disease particularly premature deaths costs is remarkably high. In addition, direct costs could go beyond the health system capacity. Therefore, in order to increase the resiliency of the health system and the stability in services delivery, preventive-oriented strategies have to be more seriously considered by policymakers.

costs is remarkably high. In addition, direct costs could go beyond the health system capacity. Therefore, in order to increase the resiliency of the health system and the stability in services delivery, preventiveoriented strategies have to be more seriously considered by policymakers.

Background
Corona virus or simply COVID-19 is an infectious disease rstly found as an epidemic on December 31, 2019, in Wuhan, China [1,2].This disease quickly spread across the world as the world health organization (WHO) on March 11, 2020, declared it as a pandemic [3].the patients catching this virus manifest a various spectrum of symptoms from a mild fever to acute respiratory failure , also thromboembolic diseases, and dysfunction or failure of several organs [4]. People with underlying diseases like cardiovascular disease, diabetes, chronic respiratory disease and cancer are more likely to develop serious illnesses [5]. In rare cases, cardiac and cerebral problems have been reported in studies as well [6]. By October 29, 2021, this fatal disease has infected more than 245,373,039 million people and nearly 4,979,421 million have become the victim of this disease [7].
In Iran, the rst case of the disease was reported on February 19, 2020 [8]. since then, various measures have been implemented to prevent and control the disease [9]. Formulating health protocols for different job groups, insisting on social distancing, wearing a face mask, and temporary and classi ed closure of jobs with regard to the incidence rate of the disease in the affected geographic areas have been a number of these policy actions [10]. Among the organizations involved with Corona, hospitals as the front line of ghting against corona are considered to be the heart of the organizations that suffered the most from this highly contagious disease [11]. In addition to the direct costs imposed on hospitals due to COVID 19, most of the public hospitals were forced to cancel the routine elective surgeries to effectively cope with the invasion of this virus [12]. The economic burden of COVID -19 exceeds the direct medical costs and extends to the indirect costs, especially premature deaths costs and costs of absenteeism [13][14][15]. lost productivity araised from the premature death with regard to the fatality rate of COVID- 19 [16] and conducted studies about premature deaths rate [17] is estimated to be high.
The calculation of the economic burden of the disease has been studied in several studies [6,18,19]. But given the fact that different settings will have distinguished consequences, determining the economic burden of COVID-19 in the studied environment is of great importance.
According to the report of Iranian health authorities, there have been 125,223 COVID-19 deaths in Iran with more than 5,860,844 Con rmed cases until October 25, 2021 [20]. Bushehr province with 1,465,000 population [21] is located in the southwest of Iran and coincident with the COVID-19 outbreak has been subjected to this disease, but no study has been conducted to determine the economic burden of COVID-19 in this province yet. As a result, this study aimed to demonstrate a relatively comprehensive picture of costs imposed from the societal perspective in the province and such an estimation of its economic burden in Iran.

Study design and population
This is an applied and cross-sectional research conducted using a partial economic evaluation method on which cost outcomes are described.
The research population included all the patients hospitalized with COVID-19 who had referred to all hospitals a liated to Bushehr University of medical sciences from 20 March 2020 to 20 March 2021. No sampling was performed since all patients were included in the study.

Data source
The required data were collected through the hospital information system (HIS) database. The HIS is a large and comprehensive database at the hospital level in Iran encompassing all services and associated costs of patients admitted in hospitals. The information available in the HIS are qualitatively assured because they are based on records audited by representatives of different payers. Data elements included the patient's demographic information, hospital costs and discharge status (recovery or death).
Direct health-care costs per patient Data recorded in the HIS database were used to calculate direct medical costs. Data were categorized as follows: hospitalization cost, drugs cost, intensive care unit (ICU) cost and other (laboratory, imaging, nursing, visit…) costs.
In order to calculate the average direct cost per patient, the total incurred costs by hospitals were divided by the number of COVID-19 patients.
Cost per patient = total hospital costs/number of COVID-19 patients

Indirect costs per patient
To estimate indirect costs, human capital approach was used. Indirect costs were put into two main categories. The rst one included the cost of production lost due to hospitalization and rest at home and nally, absence at work, and the second one was lost productivity as a result of premature death at the ages of 15 to 65. Due to the fact that individuals under 15 and over 65 are not economically productive, their lost productivity was considered zero.
In order to calculate the average cost of hospitalization per patient in the hospital, the Average days of hospitalization was multiplied by the average daily wage of patients at ages 15-65 .in addition, to calculate the average cost owing to rest at home, days of home rehabilitation were determined based on experts' opinions (14 days) and then multiplied by the average wage of patients 15-65 years old. Considering that access to the average daily wage of patients was not possible, the minimum daily wage determined by Iran's labor o ce was replaced [22].
Furthermore, The Forgone Labor Output (FLO) equation was used to estimate the potentially lost productivity due to the premature deaths: In this equation w is the minimum wage lost per person per year, G is the annual growth rate, r is the discount rate, i is the number of years of life lost and p is the current value of the predicted future income per workforce [23].

Economic burden:
To estimate total economic burden of COVID-19 in the province, a bottom-up approach was used.
Accordingly: rstly, direct cost per patient was multiplied by the number of hospitalized patients. Secondly, the average indirect cost due to hospitalization in hospital and rest at home was multiplied by the number of patients 15 to 65 thirdly, the average indirect cost due to premature death per patient was multiplied by the number of dead patients 15 to 65 and nally, the obtained results were added together [24]. Accordingly, the economic burden will be estimated as follows: Where i x is the number of affected patients and p x is the unit cost at the patient level and C is the overall cost [24].
All costs were calculated in Iran's Rial at 2020 value and then converted to purchasing power parity (PPP) 2020, adjusted by, equivalent to 15,766 Rials per 1 dollar [25].

Statistical analyses
Descriptive statistics were utilized to summarize data and in this line demographic and hospitalization attributions such as insurance status, gender, age, place of residence, average length of stay, discharge Condition (death /recovery), average direct and indirect costs and total cost of major costing groups (ICU, drugs, hospitalization cost) were examined. Frequencies and percentages were reported for categorical variables and Continuous variables were summarized using means and standard deviations (SD).

Sensitivity analysis
Since indirect costs estimation was done based on the minimum daily wage and also full employment of 15-65 age group, a sensitivity analysis in the positive and negative range of (-20, +20) was performed to increase the robustness of the results.

Results
Demographic and hospitalization ndings of the study population 9711 hospitalized COVID-19 patients were identi ed from 20 March 2020 to 20 March 2021 using HIS database. Table 1 presents the demographic, and hospitalization characteristics of studied cases.
The mean age of the hospitalized COVID-19 patients was 49.7±18.50 years. 2.62 % of the patients were under 15 years old, 75% were 15-65 years old and 22.3% were 65 years or higher. On average, the length of stay (LOS) per patient was 4.71 days and the same indicator among the ICU patients was 9.88 days. ndings also showed that the largest share of direct costs belonged to the in-patient beds cost and drugs with 36.44% and 30.80% equivalent to $10,164,189 and & 8,590,578r respectively. fallowing that, ICU costs accounted for 26.88% of total direct costs. all in all, the three major cost groups mentioned above constituted approximately 95 % of total direct costs (table2).  . the current study highlighted 95 % of patients were insured which is nearly close to the reported percentage (4.5% in Di in Fusco et.al study [6]) but from the perspective of the hospital population served, the result was different as the proportion of the rural population in our study was higher (18 against 10.5%).
In-hospital mortality in the current study was 7%. This proportion among the admitted patients in ICU increased to 63%. The in-hospital mortality rate observed in this study to some extent was higher than what was reported in the Jin et.al study [27], but in comparison to Di Fusco et.al study [6], the mortality rate in our study was roughly 50% lower (13.6% against 7%).observed lower mortality rate could be attributed to the different treatment protocols and ease of access to treatments and also other appropriate strategies adopted by health ministry such as Equipping hospitals with oxygen generators and increased the hospital beds and canceling non-emergency surgeries.
Examining average LOS showed that this indicator for the whole patients was 4.71 days which is lower than the gures reported in Ghaffari 19]. This difference in costs could have resulted from underlying conditions of hospitalized patients, different clinical guidelines, physicians' discretion, and in turn the volume of delivered services, and nally, some differences in service unit cost. Drug cost groups along with hospitalization and ICU cost groups were three main components of hospital direct costs as almost 90% of hospital costs belonged to these three groups.
In addition to direct medical costs which are a proxy of the costs incurred by hospitals, the economic burden of the COVID-19 outbreak exceeds it and the societal cost of COVID-19 greatly outweighs the medical costs. Findings showed that only productivity losses due to premature death per patient were 2,612,176,739 Rials ($ 165,684) that in comparison with average direct medical costs is 58 times. The average indirect cost owing to premature death is nearly close to the estimated amount in another study conducted in Iran [19]. societal costs will exceed this amount when the lost productivity due to hospitalization and recovery course is considered as well.  [29] which in comparison with the results of another study undertaken in Iran is higher [19].
Since the estimated economic burden is in uenced by minimum daily wage and also the number of patients employed, therefore a sensitivity analysis was undertaken to enhance the power of the study. Accordingly, ndings indicate that economic consequences of COVID -19 disease at the least estimation are considerably high and increased prevalence will de nitely lead to the rise of a tremendous economic burden. Consequently, the health care system and society will be undergone more challenges.

Conclusion
Our study ndings provide a relatively comprehensive picture of hospitalized COVID-19 patients' characteristics and also offers valuable insights into hospital and non-hospital cost of COVID-19. Furthermore, considering budget constraints, ndings indicate that continuity of this trend would lead to the decreased capacity of the health care system in delivering routine services and in turn higher out-ofpocket payments and even more mortality and nally increased economic burden.in conclusion, to increase the resiliency of the health system against these kinds of unprecedented crises we need to put preventive measures in the priority which are dominantly more cost-effective strategies than therapeutic actions. Otherwise, health systems may face collapse.

Limitations
The ndings of this study should be interpreted in the contexts of several limitations. In the present study, due to the lack of access to patients' income, the minimum wage was used to calculate indirect costs. therefore, the economic burden may be underestimated. In addition, in this study only hospitals a liated to Bushehr University of Medical Sciences were included therefore, Generalizability should be done with caution.