In this study, the median length of hospital stay was 62 (IQR, 36to 100) days. Bedridden functional status, a pulmonary form of TB, and adverse drug effects were factors associated with prolonged hospital stays (≥ 62 days).
The length of hospital-stay also differed significantly between the hospitals, ranging from 39.5 days at Debremarkos referral hospital to 72.5 days at Bourmeda. The possible reasons might be the lack of consistent discharge criteria and professional expertise differences among hospitals. Also, the median length of hospital stay was explored per annum and differences were observed from a median of 94 days in 2012 to 60 days in 2015. The possible explanations might be better patient management experience in the later time, the use of new treatment approaches, and early case detection through active surveillance before critical conditions happened might contribute to cutting LOS [29].
The median length of hospital stay in this work was shorter than the WHO 2014 global TB report of 90 days [21], South Africa centralized hospital of 144 days [22], South Africa community-based sites of 143 days [22], and Canada Ontario of 82 days [30]. This might be due to differences in the health care system, the clinical condition of the patients like the severity of the disease, and the presence of co-morbidities, like HIV. However, the median length of hospital stay of this attempt was longer than that of a study conducted in San Francisco (14 days) [12]. The possible reasons might be differences in treatment approaches. In the San Francisco study, MDRTB treatment was provided through outpatient follow-ups, which decreased the length of hospital stays in the course of treatments.
Thus, patients who had the pulmonary form of tuberculosis associated with longer hospital stay compared to extra pulmonary cases. The pulmonary form of the disease is clinically more symptomatic and associated with severe illnesses which might be associated with longer hospital stays. Also, pulmonary TB is more public health concern for transmission of bacilli to others. Thus, pulmonary TB patients came from congregated settings like university dormitories and prisons usually stayed isolated in hospitals until the patient had two consecutive negative sputum culture result.
Moreover, the admissions of tuberculosis patients during the infectiousness period are highly important for isolation, especially for patients who come from congregated settings, such as university dormitories [31], prisons and refugee camps where the risk of transmission is high. Before the revision of DR-TB treatment protocol, smear and culture-positive pulmonary drug-resistant tuberculosis patients stayed admitted until their sputum result was converted to negative, perhaps contributing to longer hospital stays of a pulmonary form of TB sufferers [13, 27].
Similarly, Patients who had bedridden functional status at admission associated with three times higher odds of longer hospital stays compared to patients who had working functional status. This may be because patients with debilitating clinical conditions and altered functional status might have delayed clinical and treatment responses. Also, patients with low functional status have comorbidities, like HIV co-infection, which causes advanced diseases that require longer physician monitoring [14]. As shown on the table 3 the median length of hospital stay for working and bedridden functional status was 32 and 95 days, respectively, ultimately increased resource utilization and hospital bed occupancies.
Likewise, patients who reported having one or more adverse drug effects were two times more likely to stay longer at hospitals compared to those free form adverse drug effects. This finding is in line with those of studies conducted in Iran and Uzbekistan [32, 33]. Second-line anti-TB drugs are often more toxic and less effective and some of the adverse drug effects are life-threatening and occult to detect; hence, more frequent and close follow up is mandatory for early detection and prompt treatment. As shown on the table 3 adverse drug effects like neuropathy, ototoxicity, and electrolyte disturbance the median LOS was 78, 77.5, and 74 days respectively. These toxicities are life-threatening and require close monitoring and follow up until improvements. Early anticipation and detection of adverse drug effects could reduce unnecessary prolonged hospital stays and saves the cost of treatment [34].
This study has implications for patients, health care workers, public health experts, and health system administrators and national tuberculosis programs as well to design efficient drug-resistant tuberculosis treatment protocol. In addition, factors identified like bedridden functional status and adverse drug effects suggest the importance of early case detection and anticipated adverse events of SLD to reduce prolonged hospital stays that make health facilities more efficient. Furthermore, the findings of this study also helpful for evidence-based planning and resource allocation.
Limitation of the study
Since data from this retrospective review were collected from secondary sources, some important predictors, like adherence and health facility characteristics, which had significant associations with the length of hospital stay in other studies were missing in the treatment of patients at the centers. In addition, baseline sputum culture and treatment outcome of some of the patents had unknown status due to poor documentation and patient file keeping. There were consistent no discharge criteria for inpatient management of DRTB and standard cut off point for the length of hospital stay and might introduce misclassification of participants.