Regional Differences in COVID-19 Mortality Rates in the Kingdom of Saudi Arabia: A Simulation of the New Model of Care

Showcasing the Saudi e-referral system experience: the epidemiology and pattern of referrals utilising nationwide secondary data

Introduction

Referrals are an integral part of any healthcare system. In the Kingdom of Saudi Arabia (KSA) an electronic referral (e-referral) system known as the Saudi Medical Appointments and Referrals Centre (SMARC) began formally functioning in 2019. This study aims to showcase the Saudi experience of the e-referral system and explore the epidemiology of referrals nationally.

Methods

This retrospective descriptive study utilised secondary collected data between 2020 and 2021 from the SMARC system. Cross tabulations with significance testing and colour-coded maps were used to highlight the patterns across all regions.

Results

The study analysed over 600,000 referral requests. The mean age of patients was 40.70 ± 24.66 years. Males had a higher number of referrals (55.43%). Referrals in 2021 were higher than those in 2020 (56.21%). Both the Autumn and Winter seasons had the highest number of referrals (27.09% and 27.43%, respectively). The Surgical specialty followed by Medicine had the highest referrals (26.07% and 22.27%, respectively). Life-saving referrals in the Central region were more than double those in other regions (14.56%). Emergency referrals were also highest in the Southern regions (44.06%). The Central and Eastern regions had higher referrals due to unavailable sub-speciality (68.86% and 67.93%, respectively). The Southern regions had higher referrals due to both unavailable machine and unavailable beds (18.44% and 6.24%, respectively).

Conclusion

This study shows a unique system in which referrals are between secondary, tertiary, and specialised care. It also highlights areas of improvement for equitable resource allocation and specialised care in slightly problematic areas as well as the use of population density in future planning.

Assessing Medical Emergency E-referral Request Acceptance Patterns and Trends: A Comprehensive Analysis of Secondary Data From the Kingdom of Saudi Arabia

Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.

The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data

Background

Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health's Ada'a program.

Methods

Using a retrospective approach, the study examined data from the Ada'a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression.

Results

The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive.

Conclusion

Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.

Effectiveness of COVID-19 vaccines against ICU admission during Omicron surge in Saudi Arabia: a nationwide retrospective cohort study

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused significant economic damage and forced a slew of limitations to be placed by regulatory bodies worldwide. As the SARS-CoV-2 virus continuously mutates over time, it's crucial to understand how well the vaccines are effective against a new variant.

OBJECTIVES

To measure COVID-19 vaccine effectiveness against ICU admission with the Omicron variant in Saudi Arabia regions.

METHODS AND MATERIALS

A retrospective cohort study was conducted of vaccinated and non-vaccinated individuals who tested positive during Omicron dominant period (Jan 1, 2020- Jun 11, 2022). We used a Cox proportional hazards model based on calendar time to assess the vaccine's effectiveness while controlling for age and gender.

RESULTS

A total of 14103 individuals who were divided into fully vaccinated included 8388 (59.5%) individuals, partially vaccinated included 1851 (13.5%) individuals, and un-vaccinated included 3864 (27.4%) individuals. Higher age was associated with a higher risk of ICU admission (HR = 1.03, 95% CI: 1.02, 1.04). Three doses are associated with a lower risk of ICU admission compared to the single dose (HR = 0.09, 95% CI: 0.04, 0.20). By studying the distribution of Omicron infection among different regions, Al-Madinah Al-Monawarah had the highest proportion at 60.23 per 100,000 population (95% CI: 57.05, 63.53). In contrast, Al-jouf had the lowest proportion at 4.51 per 100,000 population (95%CI: 2.891, 6.713). The vaccination status was significantly different in different regions, as the highest proportion of fully vaccinated participants inhabited in Tabouk region, with 71.8% of its cases. Out of all regions, Najran had the highest proportion of ICU admission among Omicron cases with 20% (95% CI: 9.94%, 34.22%). While the lowest rates existed in Riyadh with 0.86% (95%CI: 0.61%, 1.17%).

CONCLUSION

We found that a booster significantly enhanced protection against severe COVID-19. The partially vaccinated and unvaccinated participants were at significantly higher risk of ICU admission when compared to the fully vaccinated participants. Furthermore, in future, it is worth investigating the effectiveness of a booster when other potential factors (e.g., region, comorbidities, etc.) are included, particularly among future variants of COVID-19.

COVID-19 and excess mortality in Russia: Regional estimates of life expectancy losses in 2020 and excess deaths in 2021

Accurately counting the human cost of the COVID-19 at both the national and regional level is a policy priority. The Russian Federation currently reports one of the higher COVID-19 mortality rates in the world; but estimates of mortality differ significantly. Using a statistical method accounting for changes in the population age structure, we present the first national and regional estimates of excess mortality for 2021; calculations of excess mortality by age, gender, and urban/rural status for 2020; and mean remaining years of life expectancy lost at the regional level. We estimate that there were 351,158 excess deaths in 2020 and 678,022 in 2021 in the Russian Federation; and, in 2020, around 2.0 years of life expectancy lost. While the Russian Federation exhibits very high levels of excess mortality compared to other countries, there is a wide degree of regional variation: in 2021, excess deaths expressed as a percentage of expected deaths at the regional level range from 27% to 52%. Life expectancy loss is generally greater for males; while excess mortality is greater in urban areas. For Russia as whole, an average person who died due to the pandemic in 2020 would have otherwise lived for a further 14 more years (and as high as 18 years in some regions), disproving the widely held view that excess mortality during the pandemic period was concentrated among those with few years of life remaining-especially for females. At a regional level, less densely populated, more remote regions, rural regions appear to have fared better regarding excess mortality and life expectancy loss-however, a part of this differential could be owing to measurement issues. The calculations demonstrate more clearly the true degree of the human cost of the pandemic in the Russian Federation.

Characteristics of Hospitalized COVID-19 Patients in the Four Southern Regions Under the Proposed Southern Business Unit of Saudi Arabia

Background

This is the first descriptive and comparative study conducted of COVID-19 inpatients from multi-centers in the four administrative southern regions and proposed Southern Business Unit (Jazan, Najran, Bisha, and Aseer) of the Kingdom of Saudi Arabia (KSA).

Methods

Participants were 809 randomly selected patients admitted to the eight sampled hospitals with confirmed COVID-19 between March 2020 and February 2021. We assessed and compared socio-demographics, clinical characteristics, and clinical outcomes of the four regions.

Results

Socio-demographic and clinical characteristics of the participants are a mean age of 60 ± 17.7 years, 70% Saudi male, the prevalence of diabetes (DM2) 58%, hypertension (HTN) 48%, obesity 43%, cardiac diseases 15%, and immunity or cancer diseases almost 1%. The prevalence of complications during admission were bacterial pneumonia 65%, acquired respiratory distress syndrome (ARDS) 32%, sepsis 20%, multi-organ failure 18%, acute kidney diseases 15%, and arrhythmia 4%. Clinical outcomes were: admitted to intensive care unit (ICU) 52%, mortality rate 25%, referred to other facilities 9%, and mean length of stay (LOS) was 11± 9.5 days. We observed statistically significant variation in many variables among the four regions. Najran and Aseer had a higher prevalence of risk factors for severity including age and comorbidities accompanied by higher rates of complications, ICU admissions, LOS, and mortality. Bisha and Jazan had lower prevalence of risk factors and LOS with lower rates of complications, ICU admissions, and mortality.

Conclusion

This study reveals that the geographic region in which the patient was cared for was related to the severity and outcome of COVID-19 infection. Policy makers should search for solutions to regional differences in underlying health conditions such as DM2, HTN, and obesity to plan for improvements in preventive care as well as resource distribution to ensure quality for all Saudi citizens. This study will serve as guidance to begin to form strategies for these improvements as envisioned in the future New Model of Care.