The first study aimed at assessing and quantifying the impact of Covid-19 on mortality, hospital utilisation and expenditure in the South African private sector has been published in the PLOS ONE journal.

Conducted by Dr Geetesh Solanki and colleagues at the South African Medical Research Council’s Health Systems Research Unit (HSRU), the cross-sectional analytic study was based on the analysis of the medical records of more than 188 000 members of Discovery Medical Scheme who tested positive for Covid-19 from 1 March 2020 to 28 February 2021, and their hospitalisation data until 30 June 2021.

All the data was provided in a de-identified format and aggregated at an individual level and the research team had no access to information that would enable the identification of any individual.

Hospitalisation and mortality risk

The study found that in this population, 18.8% of those who tested positive landed up in hospital while the mortality risk was 3.3%.  Individuals who were aged 65+ years, had three or more comorbidities, and males had the highest hospitalisation and mortality risks and the longest and costliest hospital stays. It was found that hospitalisation and mortality risks were higher in the second wave compared to the first.

Hospital and mortality risks varied across provinces, even after controlling for important predictors. Furthermore, hospitalisation and mortality risks were the highest for diabetes alone or in combination with hypertension, hypercholesterolaemia and ischaemic heart disease.

Hospitalisation utilisation

The overall median length of hospital stay (LoS) for COVID-19 positive individuals was 6 days,  increasing with age.  Those older than 65 years had a two-fold increased LoS compared with those less than 18 years.

Hospitalisation expenditure

The overall median hospitalisation cost per COVID-19 positive case was R49 836 with costs ranging from R28 500 to more than R107 000.  After adjustment for all other factors, there was an increasing hospitalisation cost with each age category and those over age 65 years incurred a 172% increased cost of hospitalisation compared to individuals under age 18 years.  The cost of hospitalisation for males was 18% higher than that for females and increased for each additional comorbidity. Those with more than three comorbidities had 28% higher hospitalisation costs compared with individuals with no comorbidities.

Hospital group  and provincial outcome variations indicating private sector inefficiencies

Provincial variation in all four outcome measures were found, even after adjustment for all other factors.

“This reflects differences in clinical practice between private hospitals which may not necessarily adhere to national Department of Health COVID-19 protocols. There may also be underlying differences in health seeking behaviour across provinces and different thresholds applied by general practitioners regarding when to admit patients to hospital,” the researchers write.

Hospital costs in Gauteng was almost 12% more expensive compared to the Western Cape, which could be attributed to the reduced plan costs for coastal versus inland hospitals under the DH plan options. There were also differences in cost across hospital networks after adjusting for all other covariates with the cost of some hospital networks significantly less than others.

“The finding of provincial and hospital group variation on outcomes after adjusting for other risk factors is in line with the findings of the Competition Commission’s Health Market Inquiry which identified this variation as a major source of private sector inefficiency in South Africa,” the researchers note.

“The results highlight the difficulties related to efforts to contain health system costs, with complex dynamics between independent clinician judgment, hospital groups, and insurance plan types in a system with few mechanisms for standardisation, and even built-in efficiency impediments–for example health insurance providers are by law required to negotiate separately with individual hospital groups. They also highlight the need to identify and minimise unwarranted variation through the implementation of protocols which are evidence based, effective and cost-effective across the private sector.

“In addition, the analysis provides a basis for determining the cost effectiveness of different treatment and preventative interventions–an understanding of the expected cost and mortality risk in the South African context for different patient populations following a COVID-19 diagnosis enables realistic estimations about how best limited resources can be used in developing clinical guidelines and protocols,” the researchers write.

According to Dr Solanki, this paper is the first to present COVID-19 outcomes amongst a private health insured population in Africa and will contribute to addressing the gap in the knowledge base on the actual observed COVID-19 risks and subsequent hospitalisation using real world data.

 He concluded that this would enable targeted patient management strategies and risk stratification, identification of opportunities for provider quality and efficiency improvements and will generate information to assess the cost and cost effectiveness of preventative and treatment interventions for patients with COVID-19. 

Reference: Solanki G, et al. COVID-19 hospitalization and mortality and hospitalization-related utilization and expenditure: Analysis of a South African private health insured population. PLOS ONE. Published 5 May 2022. . https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0268025#sec020