i’mlooking for a question for a Master’s thesis,
Research design is a systematic review, meaning there will be NO participants. Question is to be answered by literature reviews only.
Requirements:
– Topic to be something about hospitals readiness during covid19 (if available)
– Question must be in the healthcare and administration fields
– Question MUST NOT be asked and answered before
– Must find between FIVE to EIGHT articles related to the question in hand (articles should be listed at the end)
– To write about a 100 words summary about the chosen question and the reason for choosing it
– To write a background paragraph about the question including an overview of the research question
(2022) 23:310
Aslanyan et al. BMC Primary Care
https://doi.org/10.1186/s12875-022-01923-4
BMC Primary Care
Open Access
RESEARCH
Primary healthcare providers challenged
during the COVID‑19 pandemic: a qualitative
study
Lusine Aslanyan*, Zaruhi Arakelyan, Astghik Atanyan, Arpine Abrahamyan, Manya Karapetyan and
Serine Sahakyan
Abstract
Background: Primary healthcare (PHC) providers are widely acknowledged for putting the most efficient and longlasting efforts for addressing community health issues and promoting health equity. This study aimed to explore PHC
providers’ experiences with coronavirus pandemic preparedness and response in Armenia.
Methods: We applied a qualitative study design using semi-structured in-depth interviews and structured observation checklists. Study participants were recruited using theoretical and convenience sampling techniques throughout
Armenia. Inductive conventional content analysis was utilized to analyze the in-depth interviews. Nineteen in-depth
interviews were conducted with 21 participants. Observations took place in 35 PHC facilities. The data collected during the observations was analyzed using the “SPSS22.0.0.0” software.
Results: Five main themes of primary healthcare providers’ experiences were drawn out based on the study findings:
1) the gap in providers’ risk communication skills; 2) uneven supply distributions; 3) difficulties in specimen collection
and testing processes; 4) providers challenged by home visits; 5) poor patient-provider relationships.
The results revealed that primary care providers were affected by uneven supply distribution throughout the country.
The lack of proper laboratory settings and issues with specimen collection were challenges shaping the providers’
experiences during the pandemic. The study highlighted the health systems’ unpreparedness to engage providers in
home visits for COVID-19 patients. The findings suggested that it was more challenging for healthcare providers to
gain the trust of their patients during the pandemic. The study results also underlined the need for trainings to help
primary care providers enhance their risk communication expertise or assign other responsible bodies to carry out risk
communication on PHC providers’ behalf.
Conclusion: The study discovered that PHC providers have a very important role in healthcare system’s preparedness
and response to handle public health emergencies such as the COVID-19 pandemic. Based on the findings the study
team recommends prioritizing rural PHC development, ensuring appropriate supply distributions, developing comprehensive protocols on safe home visits and specimen collection and testing processes, and trainings PHC providers
on risk communication, patient-centeredness, as well as proper use of personal protective equipment.
Keywords: Primary healthcare, COVID-19, Providers, Risk communication, Supply distribution, PPE, Specimen
collection, Home visits, Patients, Qualitative research
*Correspondence: laslanyan@aua.am
Turpanjian College of Health Sciences, American University of Armenia, 40
Marshal Baghramian Ave, 0019 Yerevan, Armenia
© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Aslanyan et al. BMC Primary Care
(2022) 23:310
Introduction
The coronavirus disease (COVID-19) [1] pandemic has
been defined as a global health crisis, causing major challenges for the health systems worldwide [2]. The World
Health Organization (WHO) expressed concerns, particularly for nations with underdeveloped healthcare
systems, highlighting the need of bolstering the health
systems’ front lines, particularly primary care [3]. Given
its capacity to lessen the burden on hospitals, serve as a
gateway for patients to secondary and tertiary care, and
significantly contribute to the achievement of health
equity and universal health coverage during the crisis,
primary healthcare (PHC) has played a determining role
during the COVID-19 pandemic [4–7].
Globally, since the onset of the COVID-19 pandemic,
PHC services have undergone a rapid shift to better serve
patients with and without COVID-19, with an emphasis on patient and healthcare worker safety [4–7]. The
involvement of PHC services in the detection, clinical
management, and follow-up of COVID-19 patients has
drastically altered the scope of operations, capacity, and
function of PHC services. PHC has also been the key
player in the delivery of mass vaccinations. In the meantime, changes in the management of non-COVID-19
patients, provision of essential health services, and methods of risk communication also took place in PHC facilities [6, 8, 9].
In several studies, the effects and difficulties of PHC
system reform during the COVID-19 pandemic were
examined in the context of the experiences of health
professionals. For instance, on-the-ground consultations in primary care were gradually partially replaced by
remote consultations using telephone calls and telemedicine[10–12]. Studies have documented both the advantages and disadvantages of this shift: while telemedicine
allowed for greater flexibility and patient-centered care, it
also increased the workload for PHC providers and created uncertainty in their decision-making regarding care
prioritization, which in some cases raised ethical questions [11–13]. During the first wave of the pandemic,
home visitation units were reduced in many countries
in order to minimize the danger of virus transmission,
restricting consultations to urgent care only [14–16].
However, home delivery of medications was also widely
practiced [11, 17]. A few studies emphasized the difficulties PHC professionals had faced as a result of adjustments made in reaction to the pandemic, including a
tremendous workload that was difficult to manage, an
increase in the burden of administrative duties, and low
job satisfaction [6, 16–19]. According to other studies,
PHC providers struggled to integrate to new workflows
because of lack of resources and training [20–22]. In
some limited resource settings, insufficient PHC facility
Page 2 of 10
preparedness and lack of equipment were also documented, causing poor working conditions which resulted
in reduced quality of care and increased risk for both
patients’ and health workers’ safety [14, 19, 21, 23].
Along with strengthening the PHC, effective risk communication to healthcare professionals and the general public is another crucial aspect of the pandemic
response. This includes messages on how to deal with
misinformation, deception, and the resulting psychological strain, as well as information on preventative actions
for harm reduction and preventing the spread of the disease [24, 25]. Previous studies have shown how crucial
it is for the government and healthcare organizations to
offer and disseminate accurate, timely, and educational
health risk information [26, 27].
In Armenia, national response to COVID-19 started in
March, 2020. On March 16, the government declared a
three-month state of emergency to control the spread of
infection in the country. The main measures against the
spread of COVID-19 included mask wearing, social distancing, quarantine and isolation, along with dissemination of health messages and risk communication to raise
the general public’s awareness on COVID-19 and its prevention. At the beginning of the outbreak, testing and
treatment services were available at designated hospitals and National Center for Disease Control laboratory.
Starting from May, 2020, testing (sample collection and
transportation to designated laboratories) and outpatient
care for patients with COVID-19 were expanded to PHC
facilities and private health facilties [28].
In Armenia, PHC sector involves 352 public and 148
private facilities and other PHC units that provide stateguaranteed health services to over 98% of the population
[29]. Services provided include immunizations; screening
and diagnostic services; specialist consultations; chronic
disease management; maternal and child health services; home visits and others [30–32]. PHC supply procurement is usually organized at the local level and only
medication is procured centrally by the national government. With the start of the pandemic a few changes were
made to the procurement procedures ensuring adequate
supply distribution throughout the PHC facilities. Legal
revisions were introduced to ensure accelerated supply
acquisition and distribution, as well as more funds were
allocated for supply purchasing [33].
In the light of the COVID-19, preparedness of the
health system for the future pandemics largely depends
on adequate and informed planning of operations.
Hence, knowledge of challenges and limitations in the
performance of health system and its infrastructures is of
utmost importance for informed decision-making. Additionally, since PHC physicians are often the initial point
of contact for patients visiting both private and public
Aslanyan et al. BMC Primary Care
(2022) 23:310
PHC facilities, they can provide the general public with
useful insights into “what works and what doesn’t”. Moreover, in many countries, including Armenia, PHC providers became responsible for specimen collection, testing,
and provision of initial care to COVID-19 patients [28].
Despite the large number of qualitative research on
the PHC preparedness for the COVID-19 pandemic, less
information is available on investigating the experiences
of primary care providers during the pandemic in terms
of response to COVID-19 in particular nations or areas.
Thus, the study team aimed to explore PHC providers
(general practitioners and family physicians) experiences
in the preparedness and response of PHC to COVID-19
pandemic in Armenia.
Methods
Study design
We applied a qualitative study design using semi-structured in-depth interviews and a structured observation
checklist to explore primary healthcare providers’ experiences during the pandemic. The rationale for conducting qualitative research was to address our study aim
of exploring healthcare providers’ experiences more
in-depth.
Study settings, participants and sampling
We recruited study participants by using theoretical [34]
and convenience [35] sampling throughout Armenia
including the capital city (Yerevan) and provinces (Ararat, Syunik, Tavush, Aragatsotn, Shirak, Armavir). The
theoretical sampling included analyzing data during the
data collection process to decide further types of professionals we might need to interview and what type of
additional data we should collect.
As part of the convenience sampling technique we
approached the PHC providers through the administration of the corresponding PHC facilities. The rest of the
participants were contacted directly through the social/
professional network of the research team. We recruited
PHC providers (general practitioners and family physicians) from public and private PHC facilities involved
in diagnosis and treatment of COVID-19 patients. In
Armenia, general practitioners and family physicians are
part of the PHC workforce. General practitioners usually
work in urban facilities and serve adult population only
and family physicians usually work in rural facilities [32].
We also recruited policy makers, PHC facility managers
as well as patients who had a COVID-19 diagnosis and
either received or did not receive services from PHC
facilities.
We conducted observations in PHC facilities of Armenia, both in the capital city and provincial facilities. Proportionate to size random sampling was implemented
Page 3 of 10
to select 36 urban PHC facilities in Yerevan (n = 13) and
provinces (n = 23). The study included only urban facilities for the observation purposes considering feasibility
issues.
Study instruments
The research team reviewed the local and international
scientific evidence, guidelines, standard operating procedures and recommendations on COVID-19 regulations in primary healthcare facilities to develop the
study instruments: the interview guides and observation
checklist. In-depth interview guides were developed specifically targeting each category of the study participants:
the PHC providers, patients and policy makers (Appendices 1, 2 and 3). The guides contained open-ended
questions on the main themes, each followed by probing questions to allow collection of in-depth information
from the study participants about their experiences with
providing/receiving PHC services during COVID-19.
The main domains of the interview guide used with the
PHC providers were risk communication (RC), availability of appropriate resources to ensure proper provision
of services, specimen collection, testing practices, and
case management. The guide targeting patients mainly
included questions regarding their experiences during
specimen collection and how they were managed during
their disease by their PHC providers or other healthcare
providers. The policy makers’ guide targeted questions
regarding PHC system’s preparedness and response to
the COVID-19 pandemic and areas for improvements.
The study team finalized the observation instrument
(Appendix 4) after discussion with an expert epidemiologist. It consisted of two sections: observation of the
facility common areas, including healthcare providers’
protective behavior, and a standardized checklist on supply availability and distribution of those in the facility.
The observation checklist and the interview guides
were initially developed in English, then translated into
Armenian. We piloted the observation checklist in one of
the PHC facilities. Based on the experiences of the pilot,
the research team improved the flow and the formulation
of the checklist items. The interview guides were continuously refined as part of the theoretical sampling.
Data collection, management and analysis
The research team conducted data collection activities from May to September 2021. We conducted
nineteen in-depth interviews with a total of 21 participants -9 PHC providers, 10 patients and 2 policy
makers. As part of the theoretical sampling technique
we continuously refined the interview guides during
the data collection process to cover newly developed
themes. Data collection stopped at meaning saturation
Aslanyan et al. BMC Primary Care
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[36, 37], which was identified through simultaneous
data collection and analysis, and data collection from
each category of respondents was stopped when further interviews were not able to generate any new
information.
Four independent researchers from the study team
conducted most of the in-depth interviews remotely
utilizing different virtual platforms such as Zoom. All
of the remote calls were video-assisted to foster rapport building. Following the participants’ priority,
seven interviews were conducted face-to-face, keeping social distance and using N95 respirators. Interviews were audio- recorded getting permission from
the study participants. If a study participant refused
to be audio recorded, the moderator only took notes
during the interview. The mean duration of in-depth
interviews was approximately 43 min, ranging from
30 to 69 min. The interviewers also collected information about the participants’ age, gender and place of
residence. They also asked the PHC providers if they
worked at a public or a private polyclinic.
The interviewers themselves transcribed and analyzed recordings and notes in the original language.
Then the representative quotes selected for the paper
were translated into English. We used inductive conventional content analysis [38] to analyze the transcripts. The collected data was coded by words and
meaningful sentences that were later grouped into several categories. The categories were further grouped
under subthemes. Some of the themes were developed
based on the discussions with interviewees that were
not incorporated in the instrument. All of the themes
explored wide range of differences from the perspective of urban and rural communities.
One of the researchers conducted the visits to all
chosen polyclinics for the observations through the
IPC standardized checklist. The observation took
place in 35 PHC facilities, out of which 3 were private
and 32 were public. The researcher conducted the
observation with a help of a tablet in the “Alchemer”
portal. The observation was conducted through interviews with the head of the PHC facility and two PHC
providers per facility as well as through observing the
behavior of the PHC providers and filling out the relevant checklist.
The data collected data during the observation was
exported from the “Alchemer” portal in SPSS format,
cleaned and analyzed through “SPSS 22.0.0.0” software.
The checklist gave an opportunity to compare the supply distributions from the perspective of the head of the
polyclinic and the perspective of the PHC providers. It
also allowed the research team to look at supply distributions in Yerevan versus the provinces.
Page 4 of 10
Study rigor
To build rapport between the interviewers and participants and to ensure credible responses, trained and
experienced researchers with relevant background conducted the interviews with each group of participants:
a healthcare provider with a public health background
interviewed the PHC providers and a social worker with
a public health background interviewed the patients, and
a public health specialist with the policy makers.
Frequent peer-briefing meetings took place to discuss
the data collection and analysis process improving the
trustworthiness [39] of the research. The interviewers
also conducted member checking to improve the rigor of
the research. Transcripts were sent back to participants
for member checking to remove inaccurate information.
Interviewers applied this technique for all in-depth interviews. The research team ensured the credibility [39] of
the study by conducting interviews in different regions
of Armenia, including both urban and rural areas, and
engaging three different groups of stakeholders with different perspectives in the study. We collected data through
several methods (in-depth interviews and observations),
which allowed methodological triangulation [40].
Results
Participant demographics
The recruited participants were from Yerevan (n = 7), as
well as Syunik (n = 5), Tavush (n = 3), Aragatsotn (n = 1),
Ararat (n = 3), Armavir (n = 1); and Shirak (n = 1) provinces. We had four male and 17 female participants. The
mean age of the participants was 47 years ranging from
23 to 64. The number of patients was 10. The number of
the PHC providers were nine eight of which worked at a
public polyclinic and one in a private (Table 1).
Themes
The data suggested five themes. The gap in providers’ risk communication skills theme explores PHC
providers’ involvement in the risk communication
management with the community, their satisfaction
regarding implemented strategies, and self-perception
and involvement in those activities. The uneven supply
distributions theme tells the level of preparedness with
the necessary equipment for personal protection combining findings from the interviews and observation.
The difficulties in specimen collection and testing processes theme presents results on the differences in challenges of assigning patients to testing laboratories for
COVID-19 in rural vs urban areas. The providers challenged by home visits theme investigates the challenges
related to home visits by the PHC providers given the
restricted resources and patient adherence to home
visits regulations. The final theme, patient-provider
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Page 5 of 10
Table 1 Characteristics of participants
Participant categories
Number of participants by gender (n)
Mean age
(years)
Primary healthcare facility
type
Number of
participants by
study site (n)
Private
Public
Urban
Rural
8
Male
Female
Total
PHC providers
1
8
9
53
1
4
5
COVID-19 patients
3
7
10
47
–
10
0
Policy makers
–
2
2
50
–
2
–
relationships, introduces dissimilarities of patient-provider relationships in urban and rural areas.
Gap in providers’ risk communication skills
The study results demonstrated providers’ limited perception of their own role and responsibility in risk communication with communities. Their perception of RC
entailed raising awareness among patients only when
they reached out and asked questions.
“It happens, we were not directly told [to spread
information], but the population visits us themselves [with the questions].” PHC provider, Female,
Province.
According to the interviewed physicians there was lack
of training and preparation on how to conduct effective
communication with public. Despite the fact that there
were online seminars regarding COVID-19, none of
these seminars covered how the information should be
delivered to the community and patients.
“…nobody involved us in it [in seminars regarding
RC], hence we couldn’t take part.” PHC provider,
Female, Yerevan.
The participants felt the need of the specific seminars
about proper information dissemination and sharing
skills development. Some of the providers noted that RC
shouldn’t be included in their responsibilities given their
overloaded schedules. They recommended that other
specialists should take charge of that.
“…for that purpose (RC) there should be a separate
specialist…. Obviously, there should be a program,
people who will get salary, will go and explain the
steps to those people (community members) and how
they (community members) should do it.” PHC provider, Female, Yerevan.
The most crucial difference observed in terms of RC
was the response of rural healthcare providers to the
needs of community. Overall, both the majority of rural
and urban participants did not see any specific actions
they could have undertaken in RC process, however
more commonly rural providers were ready to organize,
help and lead. A participant mentioned that they were
working closely with the local municipality and organizing awareness raising activities:
“In our [name of the medical center] we were implementing awareness raising strategies. The community was always in touch with us, as well as the
municipality employees, they also did a lot in terms
of spreading [information] from their end…” PHC
provider, Female, Province.
One of the PHC providers recruited a young woman
from her community to spread qualified and “evidencebased” information among the same community. As the
recruited woman was very “active” and “well known”
among the habitants, awareness level was increased
within the community.
Uneven supply distributions
Supply distribution was noted to be one of the challenges
in terms of providing quality healthcare services to the
community not only by the PHC providers but the policy
makers as well.
“The burden brought by COVID was huge [in terms
of supply distributions]. There were already problems before COVID, COVID made them worse.” Policy maker, Female, Yerevan.
One of the most noticeable differences was the presence of supply shortages in Yerevan’s public PHC facilities, whereas in rural areas the only challenge was the
delay of supply distribution. The supply shortages in
Yerevan were highly relevant during the beginning of the
pandemic, especially in the public facilities.
“We got nothing, they should have distributed, but
our facility did not provide us with anything. We
even bought our goggles ourselves; they are just now
starting to distribute something. Not even gloves.”
PHC provider, Female, Yerevan.
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The majority of healthcare providers from rural
areas mentioned that sometimes there were delays of
supply distribution because of which the healthcare
workers were buying the supplies themselves, but
eventually the PHC facility was equipped with the necessary supplies.
“We obtained [supplies] by ourselves, then we
received [from the government]. At some point we
realized very few is left, then we bought again…
it was more convenient for me that way, instead of
waiting until the government will obtain and send
to me, that would have been too late.” PHC provider,
Female, Province.
Besides minor delays of supply in rural settings, the
PHCs here were provided with appropriate supplies by
charitable organizations as well. Many were provided
with such type of supply even before the pandemic.
“[Names a charitable organization] also provided
us with coats, hats. We use them until now, they are
really good ones.” PHC provider, Female, Province.
According to additional file 1 the total percentage
of facilitates providing personal protective equipment
(PPE) to their healthcare providers from the perspective of the facility heads’ were the following for these
certain types of PPE: surgical masks – 100%, respirators—77%, gowns – 97%, gloves – 100%, goggles
– 97%, face shields – 100%. Respirators (54%) and goggles (77%) availability largely differed when considering the PHC providers’ perspective. When asked about
if the facilitates provide certain types of PPEs to the
PHC providers in sufficient quantities, the total percentages were the following according to the facility
heads: surgical masks – 86%, respirators – 67%, gowns
– 82%, gloves 86%, goggles – 91% and face shields –
100%. Notably, all these percentages are lower when
compared to the percentages of facilities providing
PPE (not necessarily in sufficient quantities) to the
healthcare workers. The total percentages of facilities
providing PPE in sufficient quantities were somewhat
different (either higher or lower) for certain types of
PPEs when considering the perspectives of PHC providers (Additional file 1).
There were a few notable differences when comparing
the percentages of facilities providing PPE to PHC providers in Yerevan vs the provinces. These numbers were
markedly different when considering the perspectives of
facility heads about respirators: 62% in Yerevan and 86%
in provinces. The percentages of facilities providing PPE
to PHC workers in sufficient quantities were also somewhat different for certain PPE supplies when looking at
the differences between Yerevan and provinces based
Page 6 of 10
on both facility heads’ and providers’ prospective (Additional file 1).
Another interesting finding from the observation that
confirmed the findings from the in-depth interviews was
the behavior of the observed PHC providers in terms of
wearing masks. During the observation, the mean percentage of observed PHC providers wearing masks in
Yerevan facilities was 52% with the highest percentage
being 80% and the lowest 19%. In provinces, the mean
percentage of PHC providers wearing masks was 36%
with the highest percentage being 100%. The lowest percentage was 0%, meaning in some facilitates healthcare
providers did not wear masks at all.
Difficulties in specimen collection and testing processes
A difference noted during discussions was the challenges
in rural areas compared to the urban regarding specimen
collection. In rural areas providers were sometimes unable to test patients due to small number of laboratories,
absence of laboratories in rural areas, absence of transport, shortage of fuel or low number of tests (transportation to the nearest laboratory was done only in case of
fixed number of specimens).
“There is such a problem here. We collect the specimen, but the laboratory is in Ijevan [Ijevan is the
province center and they live further from] do you
see that car? It was provided to us last year … no
fuel, nothing, if you can manage to make it work, do
it.” PHC provider, Male, Province.
In some cases, doctors did not have any other choice
then to ask the patient to take their own specimen to the
nearest laboratory.
“There is a problem with budget… why should the
member of my community take their specimen to Ijevan…., or some of them agree to take their specimens
together, so that it won’t be expensive for them.” PHC
provider, Male, Province.
In urban settings the only challenge regarding this topic
were waiting lines in the laboratories:
“Well obviously we did not wait in the polyclinic [to
get tested], as we did not trust them as much and it
was the season with the highest peak [of cases] with
enormous waiting lines…I went and paid to get
tested not to lose any time.” Patient, Male, Yerevan.
None of the urban PHC providers mentioned any challenges regarding testing process, some of the interviewed
participants even mentioned that they did not know the
process after specimen collection, as the nurse is generally taking care of it.
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(2022) 23:310
“We take it [the specimen], fill in everything, attach
everything and the nurse takes it.” PHC provider,
Female, Yerevan.
Providers challenged by home visits
This theme was discussed from different perspectives:
PHC providers, patients and policy makers. A major
gap was noticed during discussions with providers in
terms of differences of home visits in the urban vs rural
areas. In the rural areas most of the PHC facilities had
only one family physician, unlike the facilities in the cities. Hence if the only physician of the facility got infected
with COVID during the home visit, that could have had
enormous negative impact on the functionality of the
facility. Another common opinion regarding home visits
was voiced by 2 of the participants. They told that in rural
settings, the patient may ask for home visit but when the
physician got there, there was a chance that the patient
would be out doing their routine village work.
“In terms of home visits to COVID-19 confirmed
patients, if there is only one general practitioner in
that PHC facility or community, you should keep
that doctor safe, that is my personal opinion. If the
nurses are trained, they go, they check the temperature, and they check the overall well-being.” PHC
provider, Female, Province.
Throughout the discussions some of the participants
also mentioned that the habitants of rural settings very
often do not take into consideration that the working
day has finished and they may call for home visits even
at night.
“Usually, the concept of home visits is a little bit
out in the air. In practice it’s not the same. You go
to the home visit, the house owner [the patient)]
is in the garden [working], the house owner (the
patient) took the animals to pasture.” PHC provider, Male, Province.
Policy makers stressed about the importance of home
visits and that it was challenging to ensure proper and
“uninterrupted home visits”: They also reflected on the
organizational flow and the challenges to address technical issues such as transportation and proper PPE supply
for the PHC providers during home visits:
“[We couldn’t ensure] things like uninterrupted
availability of transportation, so that the team
[PHC providers] could go [do the home visits]. [We
couldn’t ensure] [PHC providers] to be protected, so
that everything would have been safe for them.” Policy maker, Female, Yerevan.
Page 7 of 10
Patient‑provider relationships
According to the findings there were two categories of
patients who “did not trust” their healthcare provider.
In one case, there was an absence of trust that the provider genuinely cared for patients’ interests, was honest,
practiced confidentiality, and had the competence to produce the best possible results. The participants said that
they faced difficulties in establishing good doctor-patient
communications, which made them find someone else
to monitor the whole treatment process. Patients sought
a quick resolution to their ailments by using their personal network and frequently calling several physicians to
obtain a satisfying answer.
“By the way, I am very dissatisfied with the attitude
of the doctor of that polyclinic. Well, as a pregnant
woman, at least they should have helped me in a
special way, right? At least they should have done an
X-ray, they should have been more careful as I am
pregnant. I did not see any such approach from them
at all. That’s why I went to a paid hospital.” Patient,
Female, Yerevan.
The second category of patients was from provinces.
They had good relationships with their healthcare providers or knew each other personally (regional communities
are very small) but patients perceived them as “less qualified” compared with healthcare providers of Yerevan.
Irrespective of their gratitude towards their providers
they still sought the advice of other qualified healthcare
providers from Yerevan and made their own decisions by
using mixed treatment approaches.
“I definitely obey the doctor of our polyclinic, but
since we also have acquaintances—doctors, nurses
among our close relatives and taking into account
all that I listen to their advices, they worked in the
ambulance during those crisis situations in our
Armenia. It’s very personal, especially if I have had
surgery.” Patient, Female, Province.
Discussion
Given the scarcity of studies investigating healthcare
providers’ experiences administering quality service
provision at the PHC level during COVID-19, our study
sought to fill this gap qualitatively exploring the factors
challenging PHC providers work during the pandemic.
The PHC preparedness and response to the COVID-19
pandemic was explored through the experiences of family physicians and general practitioners in both rural and
urban areas of Armenia.
The study identified five themes underlying PHC
providers’ experiences during the pandemic: gap in
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providers’ risk communication skills, uneven supply distributions, difficulties in specimen collection and testing processes, providers challenged by home visits and
patient-provider relationships.
Risk communication is an important aspect of public health and its role is even more important during
outbreak prevention and control [26]. Although RC has
initially not been part of PHC provision in Armenia,
considering its huge impact on PHC globally during the
pandemic [26, 41–43], we would like to discuss a few
significant discoveries concerning the PHC providers’
RC abilities. The providers’ comprehension of what RC
entails was limited. In some cases, they acknowledged
that their personal RC competence was insufficient and
emphasized the need for either trainings to help them
advance their RC knowledge and skills or for other
responsible entities to undertake risk communication
function on their behalf because of their busy schedules.
These findings were in line with studies from China and
Bangladesh [44, 45].
One of the important components of our study findings
was related to the unequal distribution of PPE supplies
throughout the country, despite the newly introduced
legal changes that were meant to accelerate the supply
procurement and distribution process [33]. This issue
was especially obvious when comparing the capital city
Yerevan and the provinces. While there were delays in
the delivery of goods to the provinces, Yerevan’s facilities frequently experienced a scarcity of materials. When
contrasting the views of PHC providers and facility managers regarding supply problems, an intriguing difference
was discovered. Compared to healthcare providers, the
facility managers had a more optimistic uptake regarding
the supplies in their facilities. When questioned about
the same materials, PHC providers generally believed
that they had fewer items and in smaller amounts than
the facility heads had stated. The greatest shortage was
reported about respiratory masks in all facilities we visited. These findings were consistent with previous studies
examining essential IPC and PPE supplies, particularly
facemasks crisis during the outbreak [46, 47].
Lack of adequate laboratory settings and other problems with specimen collection were explored through
the experiences of healthcare providers and patients.
The study findings revealed long waiting times in front
of specimen collection locations being one of the biggest
problems with laboratory testing in urban facilities. In
rural settings, the PHC providers collided with the issue
of appointing their patients’ specimens to laboratories
given the limited laboratory sites in their region [48, 49].
These findings can also be explained by the fact that in
Armenia before the pandemic, the laboratory facilities
were mainly located in urban areas [50]. At the beginning
Page 8 of 10
of the COVID-19 pandemic, the specimen collection and
testing processes in already existing laboratories were
gradually extended involving more human and technical
resources to respond to the pandemic [50]. However, the
main focus still remained on the urban areas, unintentionally leaving rural areas out of the focus.
The results of our study provided information about
providers’ perceptions of home visits for COVID-19
patients. The health system’s preparedness to conduct
home visits was noted to be insufficient. Providers were
reluctant to visit their patients at home as their facilities lacked the means to ensure proper and effective personal protection. At the same time, most PHC providers
avoided home visits based on their fear to get infected;
hence, they switched to calling the patients instead of
home visits [11, 21, 51]. The avoidance of home visits
resulted in enhanced application of telemedicine (using
telephones and other online platforms for patient care)
which according to the literature could potentially result
in higher flexibility but at the same time more workload
[11–13].
Patient-provider relationships were the last key component uncovered by the study results. The main conclusion
in relation to this issue was that patients found it difficult
to develop a relationship of trust with their healthcare
providers during the pandemic [52]. In Yerevan, the limited trust was mostly explained by the lack of communication skills of healthcare providers. Although patients in
the provinces had better ties with their PHC providers,
they still trusted more skilled specialists from Yerevan
regarding COVID-19 [53]. Patient-provider relationships
have generally been a core issue in the Armenian healthcare system. A study conducted to assess outpatient
tuberculosis care in Armenia confirmed our findings and
showed that education, psychiatric care, and family support should all be included in a more people-centered
treatment strategy in primary healthcare [54].
There were several limitations in this study. As the
study participants choose whether or not to participate,
there was a chance of self-selection bias. However, the
use of multiple data sources has minimized this bias.
Some study participants may also have provided more
socially desirable answers; hence, the real situation
might be worse than described. Although the study team
applied several measures (triangulation, member checking, collecting data through different methods and in
different geographical areas) to enhance the rigor of the
study. Researcher bias (related to correct interpretation
of the findings) might still have influenced the results. To
address this issue, frequent peer-briefing meetings took
place to decrease potential researcher bias. Finally, the
observation took place only in urban facilities due to feasibility limiting the generalizability of our findings.
Aslanyan et al. BMC Primary Care
(2022) 23:310
Conclusion
The study found that primary healthcare providers’ experiences were key to shape healthcare system preparedness in response to public health crisis situations such as
the COVID-19 pandemic. The results of this study could
help to come up with recommendations to improve the
overall experiences of healthcare providers working in
primary care settings during public health emergencies.
Moreover, considering that the characteristics discussed
as part of our study findings need to be addressed at the
baseline level, the study results might have a key impact
on an improved rapid response for future pandemics.
The study findings highlight the importance of developing a national comprehensive strategic plan for primary
healthcare preparedness and response to future pandemics, using an equity-based approach towards urban and
rural areas. The strategy will ensure prioritizing trainings among healthcare providers about the importance
of risk communication, proper use of personal protective
equipment, and patient-centered practices. The national
plan should also emphasize an exhaustive plan ensuring
proper supply distributions throughout the PHC facilitates across the country, improved access to specimen
collection and laboratory testing as well as protocols for
safe home visits.
Abbreviations
COVID-19: Coronavirus disease 2019; WHO: World Health Organization;
PHC: Primary healthcare; RC: Risk communication; PPE: Personal protective
equipment.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12875-022-01923-4.
Additional file 1.
Additional file 2.
Acknowledgements
Not applicable
Authors’ contributions
LA and SS (both researchers) were responsible for the conception and design
of the study, acquisition of data, analysis and interpretation of data, drafting the
manuscript writing and revising it critically for important intellectual content.
SS also collected the data from policy makers. ZA (researcher) collected, analyzed and interpreted the healthcare workers’ data regarding their own experiences and was a major contributor in writing the manuscript. MK (researcher)
collected, analyzed and interpreted the patients’ data regarding their experiences with the healthcare workers and the primary healthcare in general. AA
[1] (researcher) collected, analyzed and interpreted the observation data. AA
[2] (researcher) conducted the literature review and was a major contributor in
writing the manuscript. All authors read and approved the final manuscript.
Funding
The research reported here was supported by USAID within the “Support to
control COVID-19 and other infectious disease outbreaks” project. The funding
organization does not cover the costs of publication of the research.
Page 9 of 10
Availability of data and materials
The datasets used and/or analyzed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The Institutional Review Board #1 of the American University of Armenia
approved the study protocols (#AUA-2021–009) prior to onset of data collection. All participants were provided written informed consent. All methods
complied with relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 28 September 2022 Accepted: 21 November 2022
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www.nature.com/scientificreports
OPEN
Estimated cost of treating
hospitalized COVID‑19 patients
in Saudi Arabia
Abbas Al Mutair 1,2,3,4,5, Laila Layqah 6, Batool Alhassan 1, Saleh Alkhalifah 1,
Modhahir Almossabeh 1, Thanaa AlSaleh 1, Zuhair AlSulaiman 1, Zainab Alatiyyah 1,
Eman M. Almusalami 1,7*, Lamiaa H. Al‑Jamea 8, Alexander Woodman 8, Khalid Hajissa 9,
Saad Alhumaid 10 & Ali A. Rabaan 11,12,13
The economic impact of the COVID-19 pandemic on global health systems is a major concern. To plan
and allocate resources to treat COVID-19 patients and provide insights into the financial sustainability
of healthcare systems in fighting the future pandemic, measuring the costs to treat COVID-19
patients is deemed necessary. As such, we conducted a retrospective, real-world observational study
to measure the direct medical cost of treating COVID-19 patients at a tertiary care hospital in Saudi
Arabia. The analysis was conducted using primary data and a mixed methodology of micro and macrocosting. Between July 2020 and July 2021, 287 patients with confirmed COVID-19 were admitted and
their data were analyzed. COVID-19 infection was confirmed by RT-PCR or serologic tests in all the
included patients. There were 60 cases of mild to moderate disease, 148 cases of severe disease, and
79 critically ill patients. The cost per case for mild to moderate disease, severe disease, and critically
ill was 2003 USD, 14,545 USD, and 20,188 USD, respectively. There was a statistically significant
difference in the cost between patients with comorbidities and patients without comorbidities
(P-value 0.008). Across patients with and without comorbidities, there was a significant difference in
the cost of the bed, laboratory work, treatment medications, and non-pharmaceutical equipment.
The cost of treating COVID-19 patients is considered a burden for many countries. More studies from
different private and governmental hospitals are needed to compare different study findings for better
preparation for the current COVID-19 as well as future pandemics.
COVID-19 is an ongoing global pandemic that caused a huge disturbance in healthcare systems in most
countries1. In addition, it severely affected the global economy2. The number of COVID-19-infected patients
increased sharply at the beginning of the pandemic in which hospitals and healthcare systems faced great challenges to control the situation. The economic impact of the COVID-19 pandemic on global health systems is a
major concern; there was an urgent need for additional resources and financial i nvestments3. Financial challenges
related to the pandemic COVID-19 affect most hospitals and healthcare f acilities1.
Even though recovery signs from the COVID-19 pandemic starts to appear, efforts are needed for a full
restoration of the previous normal life1. COVID-19 is not likely to disappear shortly2. Therefore, to manage
the progression of the pandemic COVID-19 appropriately, healthcare systems should be aware of the required
resources and measures. These resources are needed for education, screening, testing, isolation, and treating
patients in general wards as well as in intensive care units (ICU)4.
1
Research Center, Almoosa Specialist Hospital, Al‑Ahsa, Saudi Arabia. 2School of Nursing, University of
Wollongong, Wollongong, Australia. 3Princess Norah Bint Abdulrahman University, Riyadh, Saudi Arabia. 4Nursing
Department, Prince Sultan Military College, Dhahran, Saudi Arabia. 5Nursing Department, Almoosa College of
Health Sciences, Al‑Ahsa, Saudi Arabia. 6Research Office, King Abdullah International Medical Research Center,
Riyadh, Saudi Arabia. 7King’s College London, Strand, London WC2R 2LS, UK. 8Vice Deanship of Postgraduate
Studies and Research, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia. 9Department of
Medical Microbiology and Parasitology, School of Medical Sciences, University Sains Malaysia, 16150 Kubang
Jerian, Kelantan, Malaysia. 10Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health,
Al‑Ahsa, Saudi Arabia. 11Molecular Diagnostics Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi
Arabia. 12College of Medicine, Alfaisal University, Riyadh, Saudi Arabia. 13Department of Public Health and
Nutrition, The University of Haripur, Haripur, Pakistan. *email: Almusalamieman@yahoo.com
Scientific Reports |
(2022) 12:21487
| https://doi.org/10.1038/s41598-022-26042-z
1
Vol.:(0123456789)
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Based on WHO, COVID-19 claimed more than six million lives5. According to the National Audit Office,
public spending on COVID-19-related measures was estimated to be £260 b
n6. Healthcare support was budgeted
at £84.3bn; accounting for 23% of the total which was the second largest area of spending after the spending for
business support6. Around £17.9bn was dedicated to the tests and trace program, £13.8bn for the procurement
of personal protective equipment, £7.8bn was spent by the NHS, and £1.8bn for vaccine and antibody supply7.
Furthermore, according to the International Monetary Fund World Economic Outlook Update, the estimated
cumulative output loss since the start of the pandemic through 2024 is estimated to be $13.8 trillion8. In addition,
the financial burden of the pandemic COVID-19 has many other different reasons. Europe reported that there
was an average of 7.4% reduction in the gross domestic product in 2020 varying between different European
countries9. Lockdown affects tourism especially for countries depending on tourism for their economy. Moreover,
a reduction in the employment rate resulted in some people do not have enough money to eat, pay the rent, and
live as pre-COVID-19 life. Additionally, people’s death including healthcare providers is associated with direct,
indirect, and tangible cost.
Mitigation measures affect the Saudi economy by decreasing oil demand and airline services, decreasing
manufacturing functions and supply chains, and disrupting religious tourism10. The Health system in Saudi
Arabia adopted many strategies to combat the pandemic COVID-19 with the least possible economic damage.
At the beginning of COVID-19, the Saudi government allocated an emergency budget of US$ 32 billion10. Early
intervention and application of national mitigation measures across the kingdom before the first COVID-19
case detection was the strongest strategy to avoid future collapse10. After that, Saudi MOH started quarantining
of epidemic areas, travel restrictions, expansion of serological screening, mask-wearing, and social distancing
along with disseminating information regarding the virus for awareness and educational p
urposes10. To advocate
for human values, Saudi Arabia’s Ministry of Health decided to provide medical treatment for all citizens and
residents infected with COVID-19 free without any c harge10.
Pandemics and epidemics will continue to occur leading to global challenges to lives, societies, and countries’
economies11. The resources used to support an emergency crisis such as Ebola, SARS, and COVID-19 have a
financial burden on the country’s government; affecting the way a country conducts its budget. Financial consideration is needed to be studied by the government for policy making to have a clear plan for emergencies.
This is to release the pressure on the government economy and reduce economic uncertainty. As a lesson learned
from the pandemic COVID-19, pandemic preparedness through engaging the stakeholders and policymakers
is deemed necessary to reduce unnecessary struggles associated with p
andemics12.
Understanding COVID-19-specific medical costs are critical, especially for healthcare providers, insurance
payers, and the Saudi healthcare system to provide the required information to plan and allocate resources to
treat COVID-19 p
atients12. Moreover, it gives insights into the financial sustainability of the Saudi healthcare
system in fighting the future pandemic13. There is only one study in Saudi Arabia that measured the average direct
medical cost for COVID-19 patients. Therefore, we conducted this study to measure the direct cost required to
treat COVID-19 patients with different disease severities and different clinical statuses.
Method
Study design. It is a retrospective, real-world observational study to measure the direct cost of treating
COVID-19 patients. The evaluation was conducted for all symptomatic patients with confirmed COVID-19
after being tested in inpatient setting. Data were collected from a private hospital in Saudi Arabia between July
2020 and July 2021. The Hospital is a 500-bed tertiary care center, serving a local catchment population of over
1.4 million people with all medical specialties available. Exclusion criteria were COVID-19 vaccinated patients,
and patients treated in an outpatient setting.
To calculate the minimum required sample size, Walters’s formula for non-normally distributed continuous
data were applied. In this calculation, a two-tailed 5% significance level, effect size (PNoether) of 0.51 (consistent
with those used in common association analyses), 80% power, and response rate of 80% was considered, which
gives the estimated number of subjects as 287.
2
2 Z1−α/ + Z1−β
2
n=
6(PNoether − 0.5)2
COVID‑19 severity classification.
According to the Saudi Ministry of Health Protocol for Patients Suspected of/Confirmed with COVID-19, (Version 3.6), April 14th, 20227, disease severity can be classified as follow:
1. Mild disease
Symptomatic patients meet the case definition for COVID-19 without evidence of viral pneumonia or
hypoxia.
2. Moderate disease/Pneumonia
Adult with clinical signs of pneumonia (fever, cough, dyspnea, fast breathing).
3. Severe disease/Severe pneumonia
Adult with clinical signs of pneumonia (fever, cough, dyspnea, fast breathing) plus one of the following
conditions: (i) respiratory rate > 30 breaths/min. (ii) severe respiratory distress; or oxygen saturation ≤ 93%
on room air. iii) ratio of partial pressure arterial oxygen and the fraction of inspired oxygen ≤ 300 mm Hg.
4. Critically ill
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Presence of any of the following conditions: (i) respiratory failure requiring mechanical ventilation. (ii) Shock.
(iii) another organ failure that requires monitoring and treatment in an intensive care unit (ICU).
Data collection. The analysis was conducted using primary data and a mixed methodology of micro and
macro-costing. The resources used by each patient were identified and quantified using electronic prescriptions,
and valued using hospital supply unit information to allow for the determination and description of individual
admission costs. Drugs, laboratory testing, radiologic exams, blood components, and feeding requirements were
all direct-cost subcategories of micro-costing for individual admission expenses. The direct costs of hospital supply inwards, emergency departments and ICUs, including general supplies and personal protective equipment
were considered macro-costing.
All patients were treated according to the updated Clinical Management Guideline for COVID-19 that was
developed and regularly updated by the Saudi Ministry of Health.
The variables extracted were age, sex, comorbidities, medications used, laboratory and imaging tests, medical
procedures, date of hospital admission, date of discharge from hospital, inpatient environment (ICU vs. General
Medical Ward (GMW)), and clinical outcome (death vs. discharge).
Input data and their associated quantities for each treatment pathway were estimated based on the classification criteria guidelines. The costs were recorded in Saudi Arabia Riyals (SAR) and converted into US dollars
(USD) using an exchange rate (as of 30th March 2021); 1 USD was worth an average of 3.75 SAR.
Ethical consideration. An ethical clearance to conduct the study was obtained from the Institutional
Review Board of Almoosa Specialist Hospital (IRB log Number: ARC-21.11.01). Informed consent was waived
by the Almoosa Specialist Hospital IRB as the study was retrospective, and the data were de-identified for the
use of this publication. All research procedures were performed in accordance with the Declaration of Helsinki.
Statistical analysis. Statistical analyses were conducted using the statistical software SPSS 24.0 (IBM Corp,
Armonk, NY). The continuous variables were expressed as mean with standard error (SE), and median with
interquartile range (IQR) for all sociodemographic and clinical subgroups. Categorical variables were expressed
as the number of cases and percentages. Shapiro–Wilk test was used to test the distribution of the data. The
non-parametric Mann–Whitney and Kruskal–Wallis tests were used to statistically compare the differences for
two, and more than two groupsdeviations, respectively. Descriptive analysis was conducted to compare the cost
stratified to different patient groupsthe a. A P-value less than 0.05 was considered significant.
Results
Between July 2020 and July 2021, 287 patients with confirmed COVID-19 were admitted. The average age for
the included subject was 59 years, and 55% of the participants were male. COVID-19 was confirmed by reverse
transcription–polymerase chain reaction (RT-PCR) or serologic tests in all the included patients. Only 58 (20%)
patients of the admitted patients had no comorbidities while the rest of the patients had one or more comorbidities. The most frequent comorbidities were diabetes mellitus (54%), followed by cardiac diseases (53%), then
renal disease (20%). Around half of the included patients were classified as having severe COVID-19 and 27.5%
of the included patients were admitted to ICU (Table 1).
The impact of age, gender, comorbidities, and severity of the disease on hospital costs are shown in Table 2.
The findings indicated that hospital cost was statistically significant among participants in different age groups
(P < 0.001). Moreover, the cost per case was significantly higher in critically ill patients compared to patients
with mild to moderate COVID-19 (P < 0.001). The mean cost for treating mild to moderate, severe, critically ill
COVID-19 patients was 2003 USD, 14,545 USD, and 20,188 USD, respectively. The total mean cost for clinical
management of COVID-19 according to the presence or absence of other underlying diseases was summarized
in Table 3.
The mean cost for bed accommodation, laboratory works, treatment medications, and non-pharmaceutical
equipment in ICU was significantly higher in patients with comorbidities than in patients without comorbidities (P < 0.05). However, the mean cost for the diagnostic radiology exams for both groups was not significantly
different (P 0.159). The mean cost of a bed was three times higher in patients with underlying diseases compared
to patients without underlying diseases; 315 USD, and 892 USD, respectively. Laboratory work’s mean cost was
655 USD for patients without underlying diseases while the mean cost was 2517 USD for patients with underlying diseases. Diagnostic radiology exams’ mean cost between the two groups was less than 100 USD difference.
While the mean cost of the treatment medications for patients with underlying comorbidities was 17,388 USD,
the mean cost for the medications used for patients without diseases was 1040 USD only. Nonpharmaceutical
devices and equipment mean cost was three times more in patients with the underlying disease compared to
patients without underlying diseases; 2246 USD, and 6950 USD, respectively. Table 4 presented the estimated
financial burden to the national health insurance for COVID-19 patients.
Discussion
The COVID-19 pandemic does not only cause a huge impact on the healthcare systems, but it is also a crisis that
affects the economy worldwide. In assessing the pandemic’s economic impact on the healthcare sector, it is essential to understand the cost of treating hospitalized COVID-19 patients. This helps with future risk preparedness,
response planning, and economic evaluation of global health e mergencies3. Pandemics disastrously impacted
healthcare spending and the global economy14. A study in the United States estimated the potential healthcare
costs associated with infected populations to be ranged between $163.4 billion to $654 b
illion15.
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Characteristic
Patients (n = 287) n (%)
Age, Mean ± SD
59.2 ± 15.9
Gender
Male
158 (55)
Female
129 (45)
Pre-existing disease*
None
58 (20.2)
Neurological Disease
18 (6.3)
Cardiovascular disease
153 (53.3)
GI disease
7 (2.4)
Renal disease
56 (19.5)
Respiratory disease
30 (10.5)
Malignancy disease
6 (2.1)
Endocrine disease
27 (9.4)
Diabetes mellitus
155 (54)
Hematological disease
14 (4.9)
*A patient could have more than one comorbidity
Disease severity
Mild–Moderate
60 (20.9)
Severe
148 (51.6)
Critically ill
79 (27.5)
Treatment medications*
Antiviral
207 (72.1)
Antibiotic
266 (92.7)
Antifungal
9 (3.1)
Immunomodulators
80 (27.9)
Anticoagulants
268 (93.4)
Steroid
119 (41.5)
Immunosuppressant
10 (3.5)
Tocilizimub
19 (6.6)
*A patient can receive more than one line of treatment
Median, IQR, 8 (9)
Length of Hospital stay
Mean (SE), (12.24 (0.77)
Clinical outcome
Alive
240 (83.6)
Died
47 (16.4)
Table 1. Demographic and clinical characteristics of patients.
Characteristics
Cost per case (USD, Mean ± SE)
Median (IQR)
P value
Sex
Male
12,512 (2062)
4438 (8045)
Female
14,658 (6970)
3806 (6148)
0.17
Age group (years)
18–34
2592 (789)
1770 (3123)
35–60
16,592 (7563)
4092 (7535)
> 60
12,787 (2221)
4971 (7507)
< 0.001
Comorbidities
Yes
20,662 (1534)
2760 (4409)
No
11,656 (1550)
4670 (7858)
0.006
Severity
2003 (266)
1493 (2059)
Severe
Mild–Moderate
14,545 (6230)
4021 (5066)
Critically ill
20,188 (2859)
10,750 (17,558)
< 0.001
Table 2. Cost for clinical management of COVID-19 patients stratified by various demographic and clinical
characteristics.
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Without underlying diseases
With underlying diseases
Classification
Cost Mean (SD) USD
Median (IQR)
Cost Mean (SD) USD
Median (IQR)
P-value
Accommodation (Bed cost)
315 (70)
134 (229)
892 (197)
200 (354)
0.028
Laboratory works
655 (169)
123 (707)
2517 (642)
312 (1354)
0.031
Diagnostic radiology exams
486 (321)
7.2 (107)
388 (55)
49 (287)
0.159
Treatment Medications
1040 (118)
429 (1143)
17,388 (1679)
208 (867)
The
Nonpharmaceutical (devices, fluid, Intubation, monitoring, and equipment in ICU) 2246 (533)
1218 (2844)
6950 (935)
2611 (5367)
0.002
Table 3. Comparative cost analysis for clinical management of COVID-19 cases with and without underlying
diseases.
Characteristics
Number of cases
Cost per case (USD)
Mild to moderate
60
2003
The total cost of COVID-19 cases (USD)
120,155
Sever
148
14,545
2,152,671
Critically ill
79
20,188
1,594,876
Total
287
13,476
3,867,701
Table 4. The estimated financial burden to the national health insurance for COVID-19 patients.
Our analysis showed that the average cost for treating patients infected with COVID-19 in Saudi Arabia
ranged from 2003 USD for mild to moderate cases to 20,188 USD for critically ill patients managed in intensive
and specialized hospital settings. Thus, the cost of COVID-19 treatment could increase up to 10-folds once a
patient’s condition needs critical care. This can be explained as critically ill patients are resource-intensive. They
need intensive care, expensive antiviral drugs, and oxygen support. In addition, they require more focused time
from health care professionals.
Patients with comorbidities are more likely to have more severe COVID-19 disease compared to COVID19-infected individuals without any comorbidities. Therefore, patients with comorbidities require more medications to stabilize their conditions and more intubation and monitoring procedures. Additionally, patients with
comorbidities need frequent lab investigations. Given the situation of deteriorating population lifestyle, treating
pandemics is going to be more costly, adding extra burden to the country’s health economics.
Only a limited number of published papers are available to measure the cost of treating COVID-19 patients,
including case management, which is the focus of this article. Additionally, it is difficult to compare the literature due to differences in the study methodology, population, cost of medications, and medical equipment. In
a previous study of 70 patients in China, the cost of treating COVID-19 patients was found to be 6827 USD per
treated episode16. Moreover, this study reported that the mean cost was higher for patients with pre-existing
diseases; supporting our finding. Interestingly, this study showed that the highest cost was spent on treatment
medications, accounting for 45.1% of the total cost. This finding also aligned with our finding as the highest cost
was observed with the treatment medications.
Association between cost and pre-existing health conditions has been reported in a study conducted in
Brazil12. An increasing trend was observed with the number of comorbidities. Comparing patients with no
comorbidities, having two or three comorbidities increased the average admission cost by 16% while having more
than three comorbidities increased the cost by 19%. In comparison with our finding, the mean cost for treatment
of patients with multiple comorbidities was 55% higher than patients without comorbidities.
In Saudi Arabia, the average direct medical cost per patient per day for patients with moderate-to-severe
COVID-19 symptoms admitted to the general medical ward was 42,704.49 SAR (11,387.864 USD), which was
lower than the average cost per patient per day for ICU patients (21,178.213 USD)17. The difference in the cost
for ICU patients between the previous study and our study is less than 1000 USD; supporting the accuracy of
our findings.
The cost of treating COVID-19 patients with different disease severities should be considered to have a clear
plan for resource allocation and an emergency budget for any upcoming pandemics or epidemics. In addition,
one important lesson that can be taken from the pandemic COVID-19 is that preventive measures should be
taken as early as possible to avoid the extra cost of treating patients which is a huge burden on the country’s
economy. Early preventive measures give time for researchers around the world to understand the pandemic and
try to get a solution. As in COVID-19, a vaccine developed and disease severity started to decrease; less money
was spent on treating patients.
The study covered only thirteen months of the pandemic. Therefore, we cannot capture the long-term economic effects of COVID-19. Future research is required to assess the long-term economic impact of COVID19 on the healthcare system. Moreover, these data were only from one hospital in Saudi Arabia; affecting the
generalizability of the findings. Furthermore, the number and salaries of labor, food services, and rehabilitation
services were not taken into account during calculating the cost in the study which is considered a limitation of
this study. However, the study aim was to measure the cost of treating COVID-19 patients as labor cost will be
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paid regardless of the presence of pandemic. Additionally, the private hospital where the study was conducted
did not have any additional employment nor salary increment during the study period. Changes in treatment
protocols and their possible impact on mortality and recovery rates were not considered in the study which is
another limitation of the study.
Conclusions
The cost of treating COVID-19 patients is considered a burden for many countries. As COVID-19 becomes
more severe, treating patients becomes more costly. In addition, the presence of comorbidities increased the cost
significantly compared to patients without comorbidities. More studies from different private and governmental
hospitals are needed for comparison with the study findings for better preparation for the current COVID-19
as well as future pandemics.
Received: 18 May 2022; Accepted: 8 December 2022
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Author contributions
A.A.: Conception, proposal development, ethical approval, data recruitment, formal analysis and manuscript
preparation, L.L.: Conception, proposal development, ethical approval, data recruitment, formal analysis and
manuscript preparation. B.A.: Data collection, proposal development, manuscript preparation, S.A., M.A., T.A.,
Z.A., Z.A.L.: data recruitment, LA: manuscript refinement, AW: manuscript refinement, A.R.: proposal development, manuscript refinement, E.A.: manuscript refinement, S.A. proposal development, manuscript refinement.
Competing interests
The authors declare no competing interests.
Additional information
Correspondence and requests for materials should be addressed to E.M.A.
Reprints and permissions information is available at www.nature.com/reprints.
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