In this study, the median length of hospital stay was 62 (IQR, 36 to 100) days. Bedridden functional status, the pulmonary form of TB, and adverse drug effects were factors associated with prolonged hospital stays (≥ 62 days). The length hospital stays 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. This shows high resource consumption, which makes hospitals less efficient, especially for facilities with limited beds and spaces.
The median length of hospital stay also explored over time, and differences 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 [30].
The median length of hospital stay in this work was shorter than the WHO 2014 global TB report of 90 days [22], South Africa centralized hospital of 144 days [23], South Africa community-based sites of 143 days [23], and Canada Ontario of 82 days [31]. Health care system differences, the clinical condition of the patients like the severity of the disease, and the presence of co-morbidities, like HIV and DM, might be responsible for the observed discrepancies. However, this attempt's median length of hospital stay was longer than that of a study conducted in San Francisco, finding 14 days [13]. The possible reasons might be differences in treatment approaches; in the San Francisco study, MDR-TB treatment was provided through outpatient follow-ups, which decreased the length of hospital stays during treatments.
Thus, patients with the pulmonary form of tuberculosis associated with more extended hospital stay than extrapulmonary cases. The pulmonary form of the disease is clinically more symptomatic and associated with severe disease conditions, which might be related to more extended hospital stays. Also, pulmonary TB is more public health concern to the transmission of the bacilli to others. Thus, pulmonary TB patients came from congregated settings like university dormitories and prisons usually stay isolated in the hospitals until the patient had two consecutive negative sputum culture results. Moreover, the admissions of tuberculosis patients during the period of infectiousness are crucial for isolation, especially when patients came from congregated settings, like university dormitories [32], 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, which could contribute to extended hospital stays among pulmonary TB sufferers [14, 28].
Similarly, bedridden patients at admission had three times higher odds of more extended hospital stays than patients who had working functional status. These might be due to the reasons patients with debilitating clinical conditions and altered functional states might have delayed clinical and treatment responses. Also, patients with low functional status have co-morbidities, like HIV co-infection, which causes advanced diseases that require more prolonged physician monitoring [15]. As shown in Table 3, the median length of hospital stay for working and bedridden functional status was 32 and 95 days, respectively, ultimately increasing resource utilization and hospital bed occupancies. Bedridden patients are highly dependent and are unable to self-care that could affect treatment follow-up.
Likewise, patients who reported having one or more adverse drug effects were two times more likely to stay longer at hospitals than those free form adverse drug effects. This finding is in line with studies conducted in Iran and Uzbekistan [33, 34]. Second-line anti-TB drugs are often more toxic and less effective. 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 in the table, three 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 [35].
This study has implications for patients, healthcare workers, public health experts, health system administrators, and national tuberculosis programs to design efficient drug-resistant tuberculosis treatment protocol. Also, 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 this retrospective review was collected from secondary sources, some essential 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. Besides, 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 in-patient management of DRTB and standard cut off point for the length of hospital stay and might introduce participants' misclassification.