Figure 1
Recruitment schema of the participants.
Note: 178 patients were clinically diagnosed to have acute decompensated heart failure. Those who were readmitted during the study period were excluded from the study to avoid recounting. Since the cost of treatment significantly varied between the public wing and the private wing of MTRH, the two patients who received care through the private wing were excluded. ADHF, acute decompensated heart failure; MTRH, Moi Teaching and Referral Hospital.
Table 1
Baseline characteristics of the participants.
| BASELINE CHARACTERISTICS | (n, %) | |
|---|---|---|
| Gender | Male | 69 (48.59) |
| Female | 73 (51.41) | |
| Age (years) (mean (SD) | Median (IQR)1 | 54.0 (20.0) | 60 (37.3, 70) | |
| Marital Status | Married | 92 (64.8) |
| Single | 25 (17.6) | |
| Divorced/Separated | 7 (4.93) | |
| Widowed | 18 (12.7) | |
| Level of Education | Primary | 85 (59.9) |
| Secondary | 36 (25.4) | |
| Tertiary | 21 (14.8) | |
| Occupation | Unskilled | 105 (73.9) |
| Students | 11 (7.7) | |
| Skilled | 15 (10.6) | |
| Professional | 8 (5.6) | |
| Retired | 3 (2.1) | |
| Mode of Payment | NHIF2 | 75 (52.8) |
| OOP | 67 (47.2) | |
| LOS (mean (SD)| median (IQR))1 | 10.1 (7.1) | 8 (5, 12.8) | |
| Ward | General ward | 73 (51.4) |
| CCU | 69 (48.6) | |
| Discharge Status | Alive | 115 (81.0) |
| Dead | 27 (19.0) | |
| HF History | De novo HF | 68 (47.9) |
| ADCHF | 74 (52.11) | |
| Comorbidities | HIV | 8 (5.6) |
| HTN | 45 (31.7) | |
| DM | 17 (12.0) | |
| Anaemia | 37 (26.1) | |
| Chronic Lung Disease3 | 41 (28.9) | |
| Liver Disease | 47 (33.1) | |
| Renal Insufficiency | 97 (68.3) | |
| Thyroid Dysfunction | 26 (18.3) | |
| Dyslipidaemia | 87 (61.3) | |
| Cancers | 6 (4.2) | |
| NYHA Stage | II | 2 (1.4) |
| III | 87 (61.2) | |
| IV | 53 (37.3) | |
| ECG/ECHO summary | HR (bpm)1,4 | 105 (29) | 102 (85, 121) |
| Sinus | 110 (77.5) | |
| Atrial fibrillation | 32 (22.5) | |
| Reduced | 70 (49.3) | |
| Mildly reduced | 18 (12.7) | |
| Preserved | 54 (38.0) | |
| RVSP1 | 60 (20) | 56 (45, 75) | |
| TAPSE1 | 1.5 (0.5) | 1.3 (1, 1.9) | |
| Medications5 | Diuretics | 131 (92.3) |
| MRAs | 83 (58.5) | |
| ACEIs/ARBs | 74 (52.1) | |
| SGLT2 Inhibitors | 35 (24.7) | |
| Vasopressors | 32 (22.5) | |
| B-Blockers | 30 (21.1) | |
| Digoxin | 29 (20.4) | |
| Amiodarone | 27 (19.0) | |
| CCBs | 19 (13.4) | |
[i] Note: 1Values are both mean (SD) and median (IQR), respectively. 2NHIF was the main public health insurance cover in Kenya at the time of this study. 3Chronic lung diseases (CLDs) included chronic obstructive lung disease (19, 46.3% of the CLDs), pulmonary hypertension excluding pulmonary embolism (10, 24.4%), post-TB lung disease and bronchiectasis (7, 17.1%), lung masses (3, 7.3%), and pulmonary embolism and chronic thromboembolic pulmonary hypertension (2, 4.9%). 4Heart rate was measured during admission. 5The list of the medications that the patients received during admission, and the list is not mutually exclusive. ACEIs, Angiotensin-converting enzyme inhibitors; ADCHF, acute decompensation of chronic heart failure; ARBs, Angiotensin receptor blockers; CCB, calcium channel blockers; CCU, cardiac care unit; DM, diabetes mellitus; HIV, human immunodeficiency virus; HR, heart rate; IQR, interquartile range; MRAs, mineralocorticoids; NHIF, National Health Insurance Fund; OOP, out-of-pocket payment; RVSP, right ventricular systolic pressure; SD, standard deviation; SGLT2, sodium glucose transporter-2; TAPSE, transannular plane systolic excursion.
Figure 2
Primary causes of heart failure.
Note: The values are presented as percentages, with 95% confidence intervals in round brackets. CM, cardiomyopathy; CP, cor pulmonale; HHD, hypertensive heart disease; IHD, ischemic heart disease; PD, pericardial heart disease; RHD, rheumatic heart disease.
Table 2
Direct medical cost of heart failure hospitalization.
| ITEM LINE | OVERALL COST | % OF OVERALL | OVERALL COST BY WARD | ||
|---|---|---|---|---|---|
| GENERAL WARD | CCU | ||||
| Inpatient Fees | KES USD | 18091.72 (20861.32) [147.46 (170.03)] | 17.4 | 7919.78 (4856.96) [64.55 (39.59)] | 28853.34 (25471.93) [235.17 (207.61)] |
| Lab Investigations | KES USD | 22733.39 (14135.5) [185.29 (115.21)] | 21.8 | 20953.01 (11167.76) [170.78 (91.02)] | 24619.99 (16590.92) [200.67 (135.23)] |
| Imaging | KES USD | 5139.44 (4928.71) [41.89 (40.17)] | 4.9 | 6434.25 (5814.52) [52.44 (47.39)] | 3769.57 (3296.85) [30.72 (26.87)] |
| Medications | KES USD | 36694.92 (42403.40) [299.08 (345.61)] | 35.2 | 18833.61 (19719.78) [153.50 (160.73)] | 55591.67 (51105.17) [453.10 (416.53)] |
| Oxygen | KES USD | 10044.44 (9743.60) [81.87 (79.42)] | 9.6 | 7960.53 (6530.91) [64.88 (53.23)] | 12373.53 (12076.73) [100.85 (98.43)] |
| Other Utilities | KES USD | 11427.48 (12925.69) [93.14 (105.35)] | 11.0 | 7505.31 (4583.15) [61.17 (37.36)] | 15577.02 (17035.38) [126.96 (138.85)] |
| Total cost/patient (KES) | 99065.65 (76339.71) | 65775.94 (36922.10) | 134285.20 (90510.95) | ||
| Total cost/patient [USD] | [807.44 (622.21)] | [536.11 (300.94)] | [1094.50 (737.71)] | ||
| LOS (days) | 10.1 (7.1) | 10.0 (6.6) | 10.3 (7.7) | ||
| Cost/patient/day (KES) | 11470.94 (8289.57) | 7687.57 (3783.92) | 15473.63 (9782.79) | ||
| Cost/patient/day [USD] | [93.49 (67.56)] | [62.66 (30.84)] | [126.12 (79.74)] | ||
[i] Note: The values are in Kenyan Shillings (KES) but also converted to United States of America Dollars (USD) in the square brackets. LOS, length of hospital stay; SD, standard deviation.
Figure 3
Drivers of the overall direct medical cost of HF hospitalization.
Note: The β-regression coefficients were derived using generalized linear models with gamma distribution and log link function and reflect the unit change in the overall cost per unit change in the cost of medications, inpatient fees, labs (laboratory investigations), utilities, O2 (oxygen therapy), and imaging. The units were standardized for the purpose of ranking. CI, confidence interval.
Table 3
Direct medical cost per patient per day per primary cause of HF.
| PRIMARY CAUSE OF HF | OVERALL COST | OVERALL COST: GENERAL WARD | OVERALL COST: CCU |
|---|---|---|---|
| CM | 12268.08 (7816.12) [99.99 (63.71)] | 7145.15 (2825.26) [58.24 (23.03)] | 16171.26 (8184.52) [131.80 (66.71)] |
| CP | 9696.38 (5646.20) [79.03 (46.02)] | 7471.55 (3292.20) [60.90 (26.83)] | 14488.33 (6741.84) [118.09 (54.95)] |
| HHD | 8934.33 (3757.89) [72.82 (30.63)] | 8719.35 (3914.86) [71.07 (31.91)] | 9579.26 (3490.76) [78.08 (28.45)] |
| IHD | 12966.47 (6656.49) [105.68 54.25)] | 0.00 | 12966.47 (6656.49) [105.68 (54.25)] |
| PD | 5968.67 (1542.23) [48.65 (12.57)] | 6166.27 (2126.65) [50.26 (17.33)] | 5573.44 [45.43 (45.43)] |
| RHD | 15299.08 (13196.88) [124.70 (107.56)] | 7598.44 (6359.84) [61.93 (51.84)] | 18946.76 (14126.75) [154.43 (115.14)] |
[i] Note: The costs are presented as mean and corresponding standard deviation in round brackets. They are also stratified as overall costs (both general ward and CCU) and by ward (general ward vs. CCU). The units are in Kenyan shillings (KES) but also converted to US dollars (USD) in the square brackets. CCU, cardiac care unit; CM, cardiomyopathy; CP, cor pulmonale; HHD, hypertensive heart disease; IHD, ischemic heart disease; PD, pericardial disease; RHD, rheumatic heart disease.
Figure 4
Stratified direct medical costs by the primary cause of HF.
Note: The figure shows the overall direct medical cost of heart failure hospitalization per patient per day, presented in Kenyan shillings (KES) on the left vertical axis and US dollars (USD) on the right vertical axis for ease of international comparison. The percentages in the bars represent the proportion of the overall cost incurred by each primary cause of heart failure. CM, cardiomyopathy; CP, cor pulmonale; HHD, hypertensive heart disease; PD, pericardial disease; RHD, rheumatic heart disease.
Table 4
Primary causes of HF of in Sub-Saharan Africa: Comparison of the current study and prior studies.
| AUTHOR | N | STUDY DESIGN | Country | HHD | CM | RHD | CP | IHD | PD |
|---|---|---|---|---|---|---|---|---|---|
| Amoah & Kallen, 2000 | 572 | Prospective | Ghana | 21.3 | 16.8 | 20.1 | 9.8 | 7.7 | |
| Ismail et al., 2007 | 65 | Prospective | Uganda | 47.7 | 35.4 | 4.6 | 4.6 | 1.5 | |
| Sliwa et al., 2008 | 4162 | Prospective | South Africa | 35.0 | 28.0 | 8.0 | 27.0 | 9.0 | |
| Damasceno et al., 2012 | 1009 | Prospective, multicentre | 9 African countries | 45.4 | 18.8 | 14.3 | 7.7 | 6.8 | |
| Owusu & Adu-Boakye, 2013 | 398 | Cross-sectional | Ghana | 45.0 | 15.0 | 23.0 | 1.2 | 2.3 | 2.2 |
| Kwan et al., 2013 | 138 | Prospective | Rwanda | 8.0 | 54.0 | 25.0 | |||
| Ogah et al., 2014 | 452 | Prospective | Nigeria | 78.5 | 7.5 | 2.4 | 4.4 | 0.4 | 3.3 |
| Abebe et al., 2016 | 311 | Retrospective | Ethiopia | 16.0 | 12.5 | 40.1 | 4.5 | 15.8 | |
| Makubi et al., 2016 | 411 | Prospective, matched | Tanzania & Sweden | 47.0 | 23.0 | 3.0 | 10.0 | ||
| Kingery et al., 2017 | 145 | Prospective | Tanzania | 42.8 | 19.3 | 16.6 | 7.6 | 6.2 | |
| Eberly et al., 2018 | 451 | Prospective | Rwanda | 13.1 | 39.7 | 26.8 | |||
| Karaye et al., 2021 | 1294 | Prospective, multicentre | 5 African countries | 35.0 | 15.9 | 7.2 | 20.0 | ||
| Oyoo & Ogola, 1999 | 91 | Cross-sectional | Kenya, KNH | 17.6 | 25.2 | 32.0 | 2.2 | 13.2 | |
| Ogeng’o et al., 2014 | 116 | Prospective | Kenya, KNH | 15.5 | 18.1 | 12.9 | 9.5 | ||
| Current study | 142 | Prospective | Kenya, MTRH | 16.9 9.2–25.9 | 26.1 18.3–35 | 19.7 12–28.7 | 28.9 21.1–37.7 | 6.3 0–15.3 | 2.1 0–11.1 |
[i] Note: CM, cardiomyopathy; CP, cor pulmonale; HHD, hypertensive heart disease; IHD, ischemic heart disease; KNH, Kenyatta National Hospital; MTRH, Moi Teaching and Referral Hospital; PD, pericardial disease.
Table 5
Comparison of cost of HF treatment in different countries by GDP-PPP.
| A | B | C | D | E | F | G | H | I |
|---|---|---|---|---|---|---|---|---|
| STUDY | COUNTRY | YEAR OF STUDY | COST BY YEAR OF STUDY (USD) | GDP-PPP BY YEAR OF STUDY | STANDARDIZED COST PER GDP-PPP | MEASURE | COST AS | PERSPECTIVE |
| Current study | Kenya | 2023 | 93.49 | 6,307.20 | 0.01 | Mean | Per patient per day | Payer’s |
| Current study | Kenya | 2023 | 807.44 | 6,307.20 | 0.13 | Mean | Per patient per hospitalization | Payer’s |
| Appiah et al. | Ghana | 2023 | 182 | 7,543.00 | 0.02 | Median | Per hospitalization | Payer’s |
| Ong et al. | Malaysia | 2022 | 1473 | 34,366.20 | 0.04 | Mean | Per patient per year | Payer’s |
| Alghamdi et al. | Saudi Arabia | 2021 | 9563 | 55,768.20 | 0.17 | Mean | Per patient per year | Payer’s |
| Ogah et al. | Nigeria | 2014 | 2128 | 5,252.20 | 0.41 | Mean | Per patient per year | Societal |
| Zaour et al. | Canada | 2015 | 10123 | 44,669.50 | 0.23 | Mean | Per patient per hospitalization | Payer’s |
| Kwok et al. | US | 2021 | 11845 | 71,318.30 | 0.17 | Mean | Per patient per hospitalization | Payer’s |
[i] Note: GDP-PPP, gross domestic product by purchasing power parity; USD, United States dollars.
GDP-PPP refers to the GDP of a given country converted into international dollars using the country’s relative purchasing power parity (40). It considers varying pricing levels and economies in different countries. GDP-PPP by year of study represents the GDP-PPP of the country in the year in which the study was published. Standardized cost per GDP-PPP (column F) was derived by dividing the cost of heart failure (column D) by the GDP-PPP of the respective country by the year of the study (column E), with the lower the value, the cheaper the cost relative to the country’s economy.