Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 1  |  Page : 18-23

Determinants of hospital length of stay among skin cancer patients in a teaching hospital in north-central, Nigeria


1 Department of Surgery, College of Health Sciences, Benue State University and Benue State University Teaching Hospital, Makurdi, Nigeria
2 Department of Epidemiology and Community Health, College of Health Sciences, Benue State University and Benue State University Teaching Hospital, Makurdi, Nigeria
3 Department of Surgery, Benue State University Teaching Hospital, Makurdi, Nigeria
4 Department of Haematology and Blood Transfusion, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria

Date of Web Publication16-Aug-2017

Correspondence Address:
Chukwukadibia N Ahachi
Department of Surgery, College of Health Sciences, Benue State University & Benue State University Teaching Hospital, Makurdi
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_8_17

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  Abstract 

Objective: To study the determinants of hospital length of stay among skin cancer patients in a teaching hospital in North-Central, Nigeria.
Patients and Methods: A 3-year retrospective study of patients with histologically confirmed skin cancers presenting to our institution from April 1, 2012 to March 31, 2015 was conducted. Relevant data were extracted from the patients’ records and subjected to statistical analysis (frequencies, cross tabulation and χ2 tests).
Results: Records were available for 43 patients with a mean age of 46 ± 18 years. There were 21 males and 22 females with a M:F ratio of approximately 1:1. The length of hospital stay (LOS) ranged from 0 to 63 days with a mean of 14 ± 15 days. Most (51.2%) patients spent <8 days in hospital with the 20–29 years age group spending the least time. Married patients had longer LOS than unmarried patients. Patients who are human immunodeficiency virus (HIV)-positive, artisans and students along with patients with facial and multifocal lesions had shorter LOS. Patients who delayed their presentation, underwent major surgery, had complications and had melanomas had longer LOS.
Conclusion: The study found the patients’ marital status, occupation, location of the lesion, type of surgery performed, histologic diagnosis and complications were significant factors in determining the patients’ LOS.

Keywords: Determinants, length of stay, skin cancer


How to cite this article:
Ahachi CN, Akaa PD, Audu O, Elachi IC, Omeh JD, Okpara CO. Determinants of hospital length of stay among skin cancer patients in a teaching hospital in north-central, Nigeria. Nigerian J Plast Surg 2017;13:18-23

How to cite this URL:
Ahachi CN, Akaa PD, Audu O, Elachi IC, Omeh JD, Okpara CO. Determinants of hospital length of stay among skin cancer patients in a teaching hospital in north-central, Nigeria. Nigerian J Plast Surg [serial online] 2017 [cited 2017 Sep 22];13:18-23. Available from: http://www.njps.org/text.asp?2017/13/1/18/213032


  Introduction Top


Skin cancers are the most common malignancies worldwide.[1],[2],[3] They are less common in Nigeria than that in some other parts of the world but are still a very important cause of morbidity and, to a lesser extent, mortality especially among albinos here.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] It is estimated that there are 65,258 new cases of skin cancer in Nigeria annually giving a projected annual incidence of 52 in 100,000.[17] This creates a significant burden on health care systems and the length of hospital stay (LOS) contributes to this.[14],[16],[18] The LOS is an important component of the cost of treating most diseases especially for patients who undergo surgery.[18],[19],[20] It is a common measure of the efficiency of health systems.[21],[22],[23] The determinants of LOS are important in planning due to their influence on cost and allocation of resources.[19],[20],[21],[22]

We have observed a fairly high incidence of skin cancers in our practice and have set out to study the determinants of LOS among patients with skin cancer seen at our institution.


  Patients and methods Top


A retrospective study was conducted to review the records of patients presenting at the Benue State University Teaching Hospital (BSUTH), Makurdi, Nigeria over a three-year period: April 1, 2012 to March 31, 2015.

Patients

All patients who met the following criteria:
  1. Patients who presented with skin lesions histologically confirmed to be malignant following a biopsy.
  2. Patients whose records were adequate to meet the objectives of the study.


Data collection

Having sought and received ethical approval, records of patients who met the inclusion criteria were retrieved and relevant data including age, sex, occupation, duration of symptoms (DOS), LOS, histological diagnosis, surgery performed, complications was extracted. At the end of the study, the data were subjected to simple statistical analysis (frequencies, cross tabulation and χ2 tests) using the Statistical Package for the Social Sciences version 21 software (IBM Corp, Armonk, NY).


  Results Top


Demographics

A total of 43 patients met the inclusion criteria for the study. There were 21 males and 22 females, giving a male:female ratio of approximately 1:1. The ages ranged from 20 to 78 years with a mean (± standard deviation) of 46 ± 18 years. The median age was 43 years. The 20–29 years group constituted the highest proportion of patients (10 patients, 23.3%), followed by the 40–49 years group whose nine patients constituted 20.9% of total [Table 1]. Farmers (37.2%) were more commonly affected than others and most patients were of the Tiv ethnic group, reflecting the ethnic demographics of the state and its position as an agrarian state. The DOS before presentation ranged from 1 to 168 months with a mean value of 28 ± 33 months.
Table 1: Length of stay variables

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Length of hospital stay

The average LOS was 14 ± 15 days. The range was 0–63 days and the median LOS was 14 days. Fifty-one percent of the patients spent <8 days in hospital, while 32.6% spent >21 days [Table 2]. The 20–29 year age group spent the least time in hospital while the 70–79 year group spent the most time [Table 1]. The P value was 0.016 (significant value, P < 0.005). The sex distribution was roughly equal with a P value of 0.948.
Table 2: Frequency

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Married patients had longer LOS with 12 (44.4%) of them spending 22 days or more in hospital [Table 1]. Single patients had LOS of 0–7 days (12 patients, 92.3%) or 8–14 days (1 patient, 7.7%). Marital status had a P value of 0.000.

Most artisans (90%) and all the students had LOS of 0–7 days while 68.8% of the farmers spent 22 days or more in hospital. Occupation had a P value of 0.000. The patients’ religion and ethnicity, with P values of 0.514 and 0.477 respectively, did not appear significant.

Patients with facial and multifocal lesions spent the least time in hospital with 88.9 and 100% spending 0–7 days in hospital respectively. Patients with lower limb and trunk lesions were associated with increased LOS [Table 1]. With P < 0.000, this is statistically significant.

Fourteen patients (32.6%) had no history of psychoactive substance use and 28.6% of them had LOS ≥22 days. Alcohol was most commonly used (22 patients, 51.2%) and 36.6% of alcohol-only users had LOS ≥22 days. The P value was 0.870.

Seventeen patients (39.5%) had viral infections. However, the largest proportion of patients with prolonged LOS was in the non-infected group [Table 1]. The patients who are human immunodeficiency virus (HIV)-positive mostly had LOS of 0–7 days. The P value was 0.056.

Fifty-eight percent of the patients whose DOS before presentation was 0–12 months spent 0–7 days in hospital, 10.5% each spent 8–14 days and 15–21 days respectively, while 21.1% had LOS ≥21 days [Table 1]. Seventy-five percent of the patients with DOS of 13–24 months had LOS of 0–7 days, 16.7% had LOS of 15–21 days and 8.3% had LOS ≥21 days. In the DOS 25–36 months and >36 months groups, 55.7 and 77.8% respectively had LOS of ≥21 days. The P value was 0.011.

Patients with and without metastasis had similar LOS distribution patterns [Table 1]. The P value was 0.993.

Eighty-three percent of the 12 patients who had incisional biopsies had LOS of 0–7 days while 16.7% had LOS ≥21 days [Table 1]. Sixty-four percent of the 14 patients who underwent split-skin grafting spent ≥21 days in hospital while 7.1 and 28.6% had LOS of 8–14 days and 15–21 days respectively. The two patients who underwent groin dissection had LOS ≥21 days. The P value was 0.000.

Patients with basal cell carcinoma all had LOS of 0–7 days along with 91% of the patients with Kaposi’s sarcoma [Table 1]. Patients with melanoma had relatively long LOS with 36.4 and 54.5% spending 15–21 days and ≥21 days respectively. Fifty-three percent of the patients with squamous cell carcinoma spent 0–7 days in hospital while 36.8% spent ≥21 days. The P value was 0.001.

All the patients who had complications had LOS >14 days and most ≥21 days [Table 1]. The P value was 0.000.


  Discussion Top


Thirteen factors were assessed in our study but only six were found to be statistically significant with P < 0.005. They are marital status, occupation, location of the lesion, type of surgery performed, histologic diagnosis, and complications. Age, sex, religion, ethnicity, psychoactive substance use, viral infections, presence of metastases, and DOS were not statistically significant. Our literature search did not reveal any studies of length of stay in patients with skin cancer. This limited the comparative analysis performed though we did look at similar studies conducted on population of patients with other pathologies. In addition to this, our small sample size made multiple regression analysis difficult to use.

Married and widowed patients spent more time in hospital than the single patients (only one of whom spent >7 days in hospital). It is noteworthy that single patients constituted 31% of the study population, and none had a melanoma. In our society, most people who have never been married are usually young people. In a study of LOS correlates among psychiatric patients conducted by Adegunloye et al. in Ilorin and another of determinants of LOS in patients with colorectal cancer who underwent elective or emergency surgical resection performed by Kelly et al. in Ireland, unmarried patients were found to have longer LOS than married patients.[23],[24] This contrasted with our own findings.

Farmers spent more time in hospital than others. Students and professionals spent the least time followed by artisans. This would have been adduced to late presentation and youth but our study found neither age nor DOS before presentation to be statistically significant. Khosravizadeh et al. found LOS to be lowest among students in Iranian teaching hospitals.[25] Another study of LOS in road trauma patients found blue-collar workers had the longest LOS.[26]

Lower limb and trunk lesions attracted the longest LOS while others had relatively short LOS. Due to the poorer perfusion of the lower limb, wounds in that part of the body heal more slowly than in other parts of the body. There is also a little or no room for covering excisional wounds there without skin grafts or flaps. Literature search did not yield similar studies for comparison.

The LOS reflected the extensiveness of the surgery performed. The patients who had groin dissection in addition to other procedures stayed longest in hospital. This finding is in keeping with those of Gümüs et al. and Khosravizadeh et al. which also looked at the relationship between LOS and the type of surgery performed on the patient.[19],[25]

Patients with melanoma had the longest LOS while the patients with basal cell carcinoma and patients with Kaposi’s sarcoma spent the least period of time. All the melanomas were on the lower limb which was another determinant of LOS found in our study The histological type also influenced the choice of treatment, another determinant of LOS.

The presence of complications also prolonged the LOS in our study. Patients who had no complications spent the least time in hospital while those with complications almost had prolonged hospital stay. The presence of complications has been shown to prolong the duration of treatment and many studies of LOS in various pathologies had findings similar to ours.[20],[27],[28],[29],[30]

Our study did not agree with other studies which found age to be a determinant of length of stay.[20],[24],[28],[31] Most found LOS to increase with the age of the patients including Khosravizadeh et al. who found that patients older than 40 years of age have increased LOS.[25] The patients’ gender was not significant in our study. This agreed with the findings of Khosravizadeh et al. but not with those of Singh and Ladusingh.[25],[32] Shayne et al. also found gender to be a determinant of LOS along with ethnicity which was also not significant in our study.[30] Psychoactive substance use, DOS before presentation, and the presence of HIV and hepatitis B and C viral infections were found to be insignificant in our study. A number of patients had lesions (Kaposi’s sarcoma) which had been attributed to the presence of HIV infection but this was not statistically significant along with the hepatitis B and C viral infections which were found in some patients. The presence of metastasis was not found to be significant in this population of patients. Gümüs et al.’s study of postsurgical LOS in breast cancer patients performed in Turkey found a relationship between metastasis and LOS.[19]


  Conclusion Top


Our study of the determinants of length of stay in patients with skin cancer seen at our hospital produced results which agreed with or contrasted with some similar studies. Some of the findings were unexpected though we had no similar studies in patients with skin cancer to compare with. A study of a larger population of patients is desirable as that will allow multiple regression analysis and take more variables into cognizance.

The patients’ marital status, occupation, location of the lesion, histologic diagnosis, type of surgery performed, and complications are the most important factors that determined the LOS of our patients. Only the last two determinants can be influenced by the healthcare providers. Thus a lot of emphasis must be placed on making the right treatment choices and preventing complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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