Sickle-cell disease is the most frequent haemoglobin disorder in the world, mostly in sub-Saharan Africa where 75% of the 300, 000 babies are born each year with haemoglobin disorders live [
Brazzaville Teaching Hospital has a total of 4 pediatric departments: Intensive Care, Neonatology, Infant Care, and Toddler/Teenager care where a total of 5,657 children were admitted during the period of our study. This study was conducted from January 1 to December 31, 2014, in the Pediatric Intensive Care Unit (PICU) of Brazzaville Teaching Hospital. PICU manages all medical emergencies that involve immediate vital prognostic of children aged 1 month to 16 years old.
We enrolled in the study all pediatric patients that were developing severe acute SCD related complications. SCD children with no severe SCD related complications were not included in the study. We defined as severe acute complications all life threatening sickle-cell disease related acute complications. These are acute exacerbation of anemia due to acute splenic sequestration or acute hyperhemolysis; major acute pain syndromes; acute chest syndrome; stroke; mixed severe acute crisis that combines acute exacerbation of anemia and major pain syndromes; severe infection: in the context of functional asplenia, a temperature over 38, 5°C with or without a source is an emergency and considered as severe infection.
Thus, 94 sickle-cell disease children presenting one severe acute complication have been included in the study.
Costs generated correspond to the fees encountered for the diagnosis and treatment of acute complications and generating factors. The global cost was calculated by adding costs of medicines, hospitalization and diagnosis tests.
Hospitalization fees depend on the length of admission of the patient. Patients are charged XAF 25,000/USD 42.64 for the total of 5 days (first five days at the hospital) and then XAF 5,000/USD 11.72 for each day from the 6th day of hospitalization. Costs of medicines and diagnostic tests have been calculated from the fares displayed by the teaching hospital. The consumables, dressing, syringes, and infusion sets as well as the hospitalization or physician visits fees before the patient’s admission to the PICU, were not included.
Income of the family was interpreted based on the official lowest salary fixed by the government (XAF 90,000/USD 153.53). The income was low when it was lower than XAF 90,000/USD 153.53, middle when it was between XAF 90,000/USD 153.53 and XAF 500,000/USD 852.96, and high when it was above USD XAF 500,000/USD 852.96.
The data were computed on Microsoft Excel 2013 and processed and analyzed with the software STATA (version 12, Texas, USA). For the description of each quantitative variable, the mean/average value, median, and standard deviation were calculated. For the comparison of qualitative data, the ANOVA and Student tests were used. The tests were significantly significant when
1278 children were admitted in PICU during our study. Among them, 136 (10.64%) had sickle-cell disease and 94 (69.11%) had developed severe acute complications. These were 48 boys (51.1%) and 46 girls (48.9%) making a sex ratio of 1.04. the patients were aged from 6 to 192 months with an average age of
Characteristics of the population.
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Female | 46 (48.9) |
Male | 48 (51.1) |
Sex ratio | 1.04 |
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Mean ± Ecart type | 69.26 ± 50.40 |
Min–max | 6–192 |
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Teaching hospital’s departments | 12 (12.8) |
Primary and secondary public offices | 14 (14.9) |
Private offices | 10 (10.6) |
Home | 58 (61.7) |
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1-2 | 44 (46.8) |
3–8 | 34 (36.2) |
9–16 | 16 (17) |
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Low | 26 (27.7) |
Middle | 6 (6.4) |
High | 18 (19.1) |
Unknown | 44 (46.8) |
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Yes | 78 (83.0) |
No | 16 (17.0) |
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0–24 | 1 (12.5) |
25–60 | 0 (00) |
61–120 | 6 (37.5) |
>120 | 8 (50) |
The average length of hospitalization has been 5.5 days (extremes of 1 and 16 days) generating a median cost of XAF 30,000/USD 52.79 (range XAF 25,000/USD 42.64 and XAF 80,000/USD 136.47). Sixteen children (17%) died during their hospitalization. The mortality rate was significantly higher in the age group older than 120 months with no influence of referral origin of the patient (
The median global cost care of SCD related acute complications was XAF 65.460/USD 111.67 (range XAF 28,305/USD 49.81 and XAF 365,740/USD 643.69). Diagnostic tests, hospitalizations, and medicines represented, respectively, 16%, 38%, and 49% of the global cost (Table
Acute severe sickle-cell complications global treatment cost in XAF (USD).
Hospitalization cost | Diagnosis test cost | Medicines cost | Global cost care | |
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Mean | 33,085.1 (58.23) | 12,068.18 (21.23) | 53,647.67 (94.41) | 93,889.21 (165.24) |
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Ecart type | 16,535.4 (29.1) | 10,493.76 (18.46) | 59,461.21 (104.65) | 78,622.47 (138.37) |
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Median | 30,000 (52.79) | 10,500 (18.47) | 32,267.5 (56.79) | 65,460 (111.67) |
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Min–max | 25,000–80,000 (42.64–136.47) | 0–48,000 |
3,305–272,740 |
28,305–365,740 |
Bacterial infections were the most frequent acute complication associated with SCD related crisis with 50 cases (53.2%). Care of bacterial infections whatever the type of sickle-cell crisis they were triggering was the most expensive since the quotation for their care was the highest (range: XAF 62,800/USD 107.13 and XAF 135271.5/USD 230.76), followed by malaria (range: XAF 28.305/USD 48.28 and XAF 99,944/USD 170.49). Vascular complications were represented by acute chest syndrome and stroke with respective costs care of XAF 42,800/USD 73.01 and XAF 103,492/USD 176.55 (
Severe acute sickle-cell complications and its generated factors treatment cost.
Diagnostic |
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% | Global management care |
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Major acute pain + bacterial infections | 12 | 12.8 | 66,765 (117.50) | |
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Hyperhemolysis + bacterial infections | 18 | 19.2 | 103,492 (182.14) |
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Mixed severe acute crisis + bacterial infections | 28 | 29.8 | 135,271 (238.07) | |
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Major acute pain + malaria | 4 | 4.2 | 28,305 (49.82) | |
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Hyperhemolysis + malaria | 16 | 17,1 | 64,891.63 (114.21) | |
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Mixed severe acute crisis + malaria | 8 | 8.5 | 99,944 (175.90) | |
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Major acute pain + acute chest syndrome | 2 | 2.1 | 42,800 (75.33) | |
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Hyperhemolysis + acute chest syndrome | 2 | 2.1 | 62,800 (110.52) | |
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Mixed severe acute crisis + stroke | 4 | 4.2 | 130,333 (229.38) | |
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Total | 94 | 100 |
This first study has allowed estimating the cost of care of severe acute complications SCD related in pediatric population admitted in intensive care. The global cost borne by families is high since it is on average XAF 65,460/USD 111.67 per episode, representing 2/3 of the minimum wage salary in Congo officially set at XAF 90,000/USD 153.53. Our study has several limits. First, the analysis of these results does not take into account the fees generated by consumables (syringes, infusion sets, and dressings). They are also to be paid by the patient, as well as fees for preadmission physician visit or hospitalization in different hospitals or units that concerned 38.3% of our sample population. The second limitation is the care costs estimations. Estimated costs were calculated from the teaching hospital costing that has the lowest fees. Nevertheless, fees displayed by the teaching hospital do not allow a real cost recovery, limiting a sustainable procurement in reagents but also in medicines. Referring to a WHO study, availability of medicines is limited. Only 60% of essential medicines are available in public pharmacies [
Bacterial infections are the first cause of admission of sickle-cell disease children and adults in Africa [
Malaria represented the second cause of admission of sickle-cell disease children with a total of 29.8%. Malaria is widely considered a major cause of illness and death in SCD patients [
The additional costs of the prescription in our study come from the purchase of pain killers and labile blood products. Blood transfusion is a major therapeutic element in the treatment of sickle-cell disease crisis since it is performed on 47% of sickle-cell disease children [
This study has examined the cost of severe acute SCD related complications in intensive care. Severe acute SCD related complications remain worrisome not only due to their graveness, but mainly due to the expenses that families must bear for their care. This study is the first to examine the cost of all components of care for pediatrics population with SCD admitted in intensive care. It is an important input to SCD treatment strategies, health care planning, and research prioritization. This study has also shown that infections and malaria remain persistently high. Additional research is needed to better understand infectious pattern of children with SCD.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors are grateful to Dr. Lapnet Mustapha to his assistance in the translation.