Literature DB >> 35867684

Length of hospital stay and associated factors among heart failure patients admitted to the University Hospital in Northwest Ethiopia.

Masho Tigabe Tekle1, Abaynesh Fentahun Bekalu1, Yonas Getaye Tefera1.   

Abstract

BACKGROUND: A prolonged length of hospital stay during heart failure-related hospitalization results in frequent readmission and high mortality. The study was aimed to determine the length of hospital stays and associated factors among heart failure patients.
METHODS: A prospective hospital-based cross-sectional study was carried out to determine the length of hospital stay and associated factors among heart failure patients admitted to the medical ward of the University of Gondar Comprehensive Specialized Hospital from January 2019 to June 2020. Multiple linear regression was used to identify factors associated with length of hospital stay and reported with a 95% Confidence Interval (CI). P-value ≤ 0.05 was considered as statistically significant to declare the association. RESULT: A total of 263 heart failure patients (mean age: 51.08 ± 19.24 years) were included. The mean length of hospital stay was 17.29 ± 7.27 days. Number of comorbidities (B = 1.494, p < 0.001), admission respiratory rate (B = -0.242, p = 0.009), serum potassium (B = -1.525, p = 0.005), third heart sound (B = -4.118, p = 0.005), paroxysmal nocturnal dyspnea (B = 2.494, p = 0.004), causes of acute heart failure; hypertensive heart disease (B = -6.349, p = 0.005), and precipitating factors of acute heart failure; infection (B = 2.867, p = 0.037) were significantly associated with length of hospital stay. Number of comorbidities, paroxysmal nocturnal dyspnea, and precipitating factors of AHF specifically infection were associated with a prolonged length of hospital stay.
CONCLUSION: Heart failure patients admitted to the medical ward had prolonged hospital stays. Thus, clinicians would be aware of the clinical features contributing to the longer hospital stay and implementation of interventions or strategies that could reduce the heart failure patient's hospital stay is necessary.

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Mesh：

Year:  2022        PMID： 35867684      PMCID： PMC9307162          DOI： 10.1371/journal.pone.0270809

Source DB:  PubMed          Journal:  PLoS One        ISSN： 1932-6203            Impact factor:   3.752


Introduction

Heart Failure (HF) is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood [1]. It is the leading public health problem associated with frequent hospital admissions, prolonged length of hospital stays (LOS), increased health care costs, and mortality rates [2-4]. Acute Heart Failure (AHF) is the main reason for the hospitalization of HF patients as it is a life-threatening medical condition with a rapid development or change of signs and symptoms which requires urgent diagnosis and treatment [5]. Independent of the presence of co-morbidities and risk factors of cardiovascular diseases, a longer LOS during an initial HF hospitalization has been linked to poor clinical outcomes. This includes exposing patients to suffering from life-threatening medical complications, increased readmission, and high mortality [6-11]. Furthermore, prolonged LOS results in increased use of healthcare resources [9, 12–14]. Several studies described the LOS in HF-associated hospitalization is higher with an estimated median range of 7–21 days [4, 7, 13, 15–21]. The Sub-Saharan Africa Survey of Heart Failure which includes Ethiopian patients showed that the median LOS was 7 days [15]. There was variability in LOS reported by previous studies in Ethiopia with the median duration of hospitalization for HF patients being 11 days at St. Paul’s Hospital Millennium Medical College [20] and 4 days at Tikur Anbessa Specialized Hospital [22]. As to the several studies, time spent in the hospital among HF patients is affected by a variety of individual patient’s characteristics including socio-demographic variables, clinical presentation at admission, presence of comorbid illness, severity of a disease, in-hospital treatment, and the development of iatrogenic complications. According to these studies being female gender, New York Heart Association (NYHA) functional class, low left ventricular ejection fraction (LVEF), concurrent community-acquired infection, arrhythmias, cerebrovascular disease, dementia, hyponatremia, polypharmacy, pressure ulcers, chronic alcohol consumption, a higher number of comorbidities, peripheral edema, the development of renal impairment, the presence of social problems that need a particular intervention, and concomitant acute medical problems requiring specific treatment were associated with a prolonged LOS [2, 11–14, 21, 23, 24]. The ability to identify hospitalized HF patients at risk of prolonged LOS might be valued by the patients and health care providers. Risk stratification for LOS may help to bring good opportunities for patient care by identifying patients who need special attention and certain interventions such as education and initiation of specific therapies [23]. Nowadays health care professionals are striving to find interventions that help to improve clinical outcomes and reduce healthcare-associated costs. Reduction in the LOS for hospitalized patients has been considered as a primary strategy for efficient resource utilization [25-27]. Despite the growing burden and economic impact of HF in developing countries including Ethiopia, there is either a paucity or inconsistency of data regarding the LOS and associated factors among patients with HF. To the best of literature search, studies are lacking to describe the determinants of LOS for patients hospitalized with HF in Ethiopia. In providing an intervention to reduce the LOS of hospitalized heart failure patients identification and targeting of the individual heart failure patients’ factors which are identified as risk factors for a prolonged LOS is the starting point. In addition to the identification of these factors the finding of this study would provide data for clinicians on which factors they should target in reducing the LOS of their patients. Therefore, this study was conducted to determine the LOS and associated factors among hospitalized AHF patients in the medical ward of the University of Gondar Comprehensive Specialized Hospital (UOGCSH) in Ethiopia.

Materials and methods

Study setting and period

The study was conducted in the medical ward of UOGCSH from January 2019 to June 2020. It is located 738 km away from the capital city, Addis Ababa. Currently, it has four major departments namely pediatrics, internal medicine, surgery, gynecology, and obstetrics. Each department has an emergency, inpatient, and outpatient units. The internal medicine inpatient has two main subunits, ward C (serves for female patients) and ward D (serves for male patients). Hospitalized AHF patients are managed in either ward C or ward D. The internal medicine wards are run by nurses, residents, and interns under the supervision of senior physicians.

Study design

A prospective observational hospital-based cross-sectional study was carried out to determine the LOS and associated factors among hospitalized AHF patients admitted at the UOGCSH medical ward, Northwest Ethiopia.

Eligibility criteria

Inclusion criteria

Patients’ ≥ 18 years of age. Diagnosis of AHF. Admitted to and were discharged alive from the medical ward between January 2019 and June 2020.

Exclusion criteria

Patients with missing information regarding the number of days spent in the hospital, Patients with reported LOS < 1 day.

Sample size determination and sampling procedure

All patients with the diagnosis of AHF attending the medical ward of UOGCSH from January 2019 to June 2020 and those who fulfill the inclusion criteria were taken as the study sample. The study participants were selected by a convenient sampling technique.

Study variables

Dependent variable

Length of hospital stays (days) was described with both mean (±SD) and median (IQR).

Independent variables

The following patient demographic and clinical characteristics were used as independent variables. Socio-demographic variables: Sex, age. Causes of AHF: Ischemic heart disease (IHD), hypertension (HTN), atrial fibrillation (AF), stroke, dilated cardiomyopathy (DCMP), degenerative valvular heart disease (DVHD), chronic rheumatic valvular heart disease (CRHD), cor pulmonale, anemia, asthma, chronic obstructive pulmonary disease, thyroid disorder, and renal disease. Precipitating factors of AHF: DCMP, AF, HTN, IHD, non-adherence to medical regimen, infection (tuberculosis, community-acquired pneumonia), anemia, renal disease, and thyroid disorder. Co-morbidity: Human immune deficiency virus (HIV), IHD, AF, CRHD, DVHD, community-acquired pneumonia (CAP), chronic obstructive pulmonary disease, dyslipidemia, renal disease, cor pulmonale, diabetes mellitus, liver disease, stroke, thyroid disease, asthma, cancer, tuberculosis, anemia. The number of comorbidities. Clinical presentation at admission: NYHA class, paroxysmal nocturnal dyspnea (PND), AF, systolic blood pressure (SBP), diastolic blood pressure, respiratory rate, heart rate, temperature, LVEF, serum creatinine, hemoglobin, serum sodium, serum potassium, dyspnea at rest, dyspnea on exertion, easy fatigability, peripheral edema, elevated jugular venous pressure (JVP), cardiomegaly, third heart sound, orthopnea, neck vein distension, murmur. Cardiac medications: used for management of AHF during the hospital stay and at discharge. The number of medications during the hospital course. Mechanical ventilation: use of oxygen therapy during the hospital stay.

Data collection procedures

By using a pretested abstraction format (S1 Annex) data were collected by three trained nurses. Data abstraction format was prepared by reviewing similar studies [2, 8, 21, 23, 24, 28]. Data regarding demographic variables, medical history, clinical presentation on admission, echocardiographic and laboratory findings, and in-hospital treatment were collected through medical chart review and recorded on the data abstraction format.

Data quality control technique

To assure the completeness of the data abstraction format, a pre-test was conducted in the emergency medical in-patients and proper modification was employed to the format.

Data entry and statistical analysis

Data was edited; cleaned, coded, entered, and analyzed using Statistical Package for Social Sciences version 21. Descriptive, correlation, comparative, and regression analysis were conducted. Continuous variables were expressed as mean (±SD) when normally distributed or median (IQR) when not normally distributed. Additionally, categorical variables were summarized as frequency (percentage) of the total. Since the dependent variable LOS was a continuous variable which fulfill the normality distribution and linearity assumptions; multiple linear regression was used to identify factors associated with LOS. P-value ≤ 0.05 was considered as statistically significant to declare the association. In univariate analyses, Pearson and Spearman’s rank correlation coefficients were used to determine the correlation between variables. Multicollinearity was assessed using Pearson correlation coefficients. Comparative analysis was conducted on the LOS across different socio-demographic, clinical, and in-hospital treatment-related characteristics of patients using independent sample t-test and One-way Analysis of Variance (ANOVA) test. A skewness test was used for checking normality. In the study most of the independent variables were categorical variables which were categorized as Yes/No while few variables such as age, number of comorbidities, number of medications, were continuous. Additionally, during analysis categorical variables with more than two categories specifically precipitating factors of AHF and causes of AHF were analyzed by converting them in to dummy variables (Yes/No).

Operational definition

HF is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, and peripheral edema) caused by a structural and/or functional cardiac abnormality, resulting in reduced cardiac output and/ or elevated intracardiac pressures at rest or during stress [5]. AHF refers to the rapid onset or worsening of symptoms and/or signs of HF [5]. New-onset HF: AHF occurs in patients without a history of HF [5]. Acutely decompensated chronic heart failure (ADCHF): AHF occurs in patients with a history of chronic HF [5]. Length of hospital stays: was defined as the difference between the discharge and admission dates.

Ethics approval and consent to participate

Ethical clearance was obtained from the University of Gondar, College of Medicine and Health Sciences, School of Pharmacy Ethical Clearance Committee. Data was collected mainly through medical chart review and informed oral consent was obtained from each patient involved in the study. In addition, the study was done as per the declaration of Helsinki.

Result

Socio-demographic and clinical characteristics of patients

Between January 2019 and June 2020, a total of 290 HF patients were admitted to the medical ward of UOGCSH. Of these 263 HF patients who fulfill the inclusion criteria were included in this study. The mean (±SD) age was 51.08 (±19.24) years, 153 (58.2%) were females and 58.9% of patients had a new-onset type of HF. In the study, 88 (33.5%) of the patients were admitted with an undefined precipitating factor. Of the defined ones, CAP 79 (30%) and AF 52 (19.8%) were the leading precipitating factors for AHF. Among the ADCHF patients’, non-adherence to the medical regimen 33 (30.5%) was the leading precipitating factor followed by CAP 25 (23.1%). Fifty-one percent of patients had a prior history of CAP, 31.2% had IHD, 29.3% had AF, 27% had HTN, and 26.6% had CRHD. The mean (±SD) number of comorbidities was 3.34 (±1.42). The mean (±SD) LVEF was 46 (±20.55%) (Table 1).
Table 1

Socio-demographics and clinical characteristics of HF patients admitted at UOGCSH medical ward.

VariableFrequency (%)Mean (±SD)Median (IQR)
Age (years)51.08 (± 19.24)
Gender
Male110 (41.8)
Female153 (58.2)
Vital signs
SBP (mmHg)110 (100–130)
Diastolic blood pressure (mmHg)70 (60–80)
Heart rate (beats/minute)96 (88–110)
Respiratory rate (breaths/minute)24 (22–28)
Temperature (C0)36.60 ± 0.04
Laboratory findings
Serum creatinine (mg/dl)0.89 (0.71-.89)
Serum sodium (meq/L)139.1 (± 5.68)
Serum potassium (meq/L)3.84 (3.4–4.36)
Hemoglobin (g/dl)12.6 (0.71–1.3)
Comorbidities
CAP134 (51)
IHD82 (31.2)
AF77 (29.3)
HTN71 (27)
Anemia62 (23.6)
DVHD70 (26.6)
Cor pulmonale59 (22.4)
CRHD48 (18.3)

IHD, Ischemic Heart Disease; DVHD, Degenerative Valvular Heart Disease; CRHD, Chronic Rheumatic Heart Disease; CAP, Community-Acquired Pneumonia; HTN, Hypertension; AF, Atrial Fibrillation; SBP, Systolic Blood Pressure.

IHD, Ischemic Heart Disease; DVHD, Degenerative Valvular Heart Disease; CRHD, Chronic Rheumatic Heart Disease; CAP, Community-Acquired Pneumonia; HTN, Hypertension; AF, Atrial Fibrillation; SBP, Systolic Blood Pressure. On admission, 236 (89.7%), 225 (85.6%), 210 (79.8%), and 190 (72.2%) of patients were presented with dyspnea on exertion, dyspnea at rest, peripheral edema, and orthopnea, respectively (Fig 1). The result showed that IHD was the most common underlying cause of AHF (28.5%) which was followed by CRHD (19.4%) (Fig 2).
Fig 1

Clinical findings of HF patients admitted at UOGCSH medical ward, 2020 (N = 263).

Fig 2

Causes of AHF among HF patients admitted at UOGCSH medical ward, 2020 (N = 263).

In-hospital treatment of AHF and discharge medications

The median (IQR) number of medications taken during the hospital course was 3 (1–4). During hospitalization, almost all patients were treated with furosemide 260 (98.9%). Next to furosemide the most frequently prescribed medications were aspirin 98 (37.3%), atorvastatin 97 (36.95), and spironolactone 73 (27.8%). At discharge, furosemide, spironolactone, and enalapril were prescribed for 198 (75.3%), 80 (30.4%), and 63 (24.0%) patients, respectively (Fig 3). Additionally, mechanical ventilation via intranasal oxygen therapy was used in 90 (34.2%) of patients.
Fig 3

Medications received by AHF patients admitted at UOGCSH medical ward, 2020 (N = 263).

Length of hospital stay

The LOS data were normally distributed. The mean (±SD) and median (IQR) LOS were 17.29 (±7.27) days and 18 (12–23) days, respectively. There were 138 (52.5%) patients with LOS ≥ 18 days and 125 (47.5%) patients with LOS ≤ 17 days. Length of hospital stay showed a moderate positive association with the number of comorbidities (p < 0.001, Pearson’s r = 0.286). On the other hand, the number of prescribed medications during the hospital course (p = 0.004, Spearman’s r = -0.175) and presence of elevated JVP (p = 0.02, Spearman’s r = -0.143) at admission had a weak negative association with LOS (S1 Table). Patients hospitalized due to CRHD as a cause of AHF-related admission showed a higher mean (± SD) of 19.75 (±8.28) days of LOS than other causes (p = 0.005). Compared to other precipitating factors of HF, CAP showed higher mean ± (SD) 20.30 (±8.02) days (p < 0.001) of LOS (Table 2).
Table 2

Association of clinical factors with LOS among AHF patients admitted at UOGCSH medical ward.

CharacteristicsLength of hospital stay
Mean (±SD) P-value
Types of HFNew-onset17.58 (±7.18)0.437a
ADCHF16.87 (±7.41)
Causes of HF0.005b
IHD15.80 (±7.16)
Hypertensive heart disease11.18 (±6.4)
DCMP18.57 (±6.72)
DVHD16.65 (±7.72)
CRHD19.75 (±8.27)
Cor pulmonale18.09 (±6.280
Anemia18.11 (±5.13)
Comorbidities
DVHD0.046a
Yes18.77 (±8.45)
No16.75 (±6.74)
HIV0.003a
Yes24.33 (±8.82)
No17.04 (±7.11)
CRHD0.006a
Yes19.88 (±8.66)
No16.71 (±6.82)
CAP0.001a
Yes18.7 (±7.46)
No15.82 (±6.79)
Number of comorbidities< 0.001a
≤ 315.48 (±6.83)
≥ 419.65 (±7.19)
Clinical findings
Elevated JVP0.017a
Yes16.37 (±6.88)
No18.53 (±7.63)
PND0.007a
Yes16.23 (6.54)
No18.67 (7.94)
Third heart sound0.001a
Yes21.79 (±7.44)
No16.84 (±7.12)
Murmur0.016a
Yes18.21 (±7.53)
No16.03 (±6.73)
SBP (mmHg)0.003b
≤11917.77 (±7.20)
120–13917.80 (±6.85)
140–15916.86 (±7.58)
≥ 16010.43 (±5.85)
Laboratory values
Serum potassium< 0.001b
≤ 3.54919.94 (±7.14)
3.55–5.5516.42 (±6.95)
> 5.5512.27 (±7.84)
Medication
Enalapril0.076a
Yes15.44 (±6.51)
No17.63 (±7.37)
Atenolol0.019a
Yes20.86 (±7.96)
No16.98 (±7.14)
Dopamine0.022a
Yes21.31 (±8.88)
No17.03 (±7.09)
Atorvastatin0.007a
Yes15.71 (±6.89)
No18.21 (±7.35)
Number of medications0.012a
≤ 318.23 (±7.13)
≥ 415.95 (±7.29)

ADCHF, Acutely Decompensated Chronic Heart Failure; IHD, Ischemic Heart Disease; DCMP, Dilated Cardiomyopathy; DVHD, Degenerative Valvular Heart Disease; CRHD, Chronic Rheumatic Heart Disease; HIV, Human Immunodeficiency Virus; CAP, Community-Acquired Pneumonia; JVP, Jugular Venous Pressure; PND, HTN, Hypertension; AF, Atrial Fibrillation; Paroxysmal Nocturnal Dyspnea; SD, Standard Deviation; IQR, Inter Quartile Range.

a an Independent t-test

b Analysis of variance (ANOVA).

ADCHF, Acutely Decompensated Chronic Heart Failure; IHD, Ischemic Heart Disease; DCMP, Dilated Cardiomyopathy; DVHD, Degenerative Valvular Heart Disease; CRHD, Chronic Rheumatic Heart Disease; HIV, Human Immunodeficiency Virus; CAP, Community-Acquired Pneumonia; JVP, Jugular Venous Pressure; PND, HTN, Hypertension; AF, Atrial Fibrillation; Paroxysmal Nocturnal Dyspnea; SD, Standard Deviation; IQR, Inter Quartile Range. a an Independent t-test b Analysis of variance (ANOVA).

Predictors of length of hospital stay

The multiple linear regression indicated that number of comorbidities (B = 1.494, p < 0.001), admission respiratory rate (B = -0.242, p = 0.009), serum potassium (B = -1.525, p = 0.005), third heart sound (B = -4.118, p = 0.005), PND (B = 2.494, p = 0.004), causes of AHF specifically hypertensive heart disease (B = -6.349, p = 0.005), and precipitating factors of AHF specifically infection (B = 2.867, p = 0.037) were significantly associated with LOS. For every unit increase in the number of comorbidities, there is 1.494 increase in the LOS. Patients who were admitted with the presence of PND and the precipitating factors of AHF specifically infection had 2.494 and 2.867 times higher LOS, respectively, comparing to their counterparts. In contrast to this, the study showed that for every unit increase in the admission respiratory rate and serum potassium there is 0.242 and 1.525 decrease in the LOS, respectively. Comparing to patients who were admitted without third heart sound, patients presented with third heart sound had 4.118 times lower LOS. Additionally, comparing to other causes of AHF patients who were admitted because of hypertensive heart disease had 6.349 times lower LOS. The model analysis showed that the independent variables explain 35.9% of the variability of dependent variable LOS (R2 = 0.359, adjusted R square = 0.286) and the regression model was a good fit of the data, (F = 27,235) = 4.881, p < 0.001 (Table 3).
Table 3

Multiple linear regression for LOS of AHF patients admitted at UOGCSH medical ward.

VariablesBStandard errorßTP-value95%CI (upper, lower)
Age-0.0100.029-0.27-0.3540.723(-0.068,0.047)
Hypertensive heart disease -causes of AHF-6.3492.265-0.175-2.8030.005*(-10.811,1.886)
Dilated cardiomyopathy—causes of AHF-0.0161.483-0.001-0.0110.991(-2.938,2.906)
DVHD—causes of AHF-2.5052.066-0.098-1.2120.227(-6.577,1.566)
CRHD- causes of AHF0.0251.6350.0010.0150.988(-3.197,3.247)
Corpulmonale—causes of AHF-0.4141.453-0.022-0.2850.776(-3.277,2.448)
Anemia—causes of AHF-0.8272.475-0.021-0.3340.378(-5.703,4.048)
Others—causes of AHF-0.5972.256-0.016-0.2640.792(-5.040,3.847)
Atrial fibrillation–precipitating factor of AHF-0.6601.1175-0.036-0.5620.575(-2.975,1.655)
Non-compliance to medical regimen—precipitating factor of AHF0.4361.3250.0220.3290.743(-2.176,3.047)
Infection—precipitating factor of AHF2.8671.3670.1812.0980.037*(0.175,5.560)
DVHD1.0141.4220.0620.7130.477(-1.789,3.816)
HIV-4.2722.270-0.107-1.8820.061(-8.744,0.200)
CAP0.8571.1970.0590.7160.475(-1.501,3.215)
Number of comorbidities1.4940.3570.2914.1860.000**(0.791,2.196)
NYHA class3.0903.1010.0580.9960.320(-3.020,9.201)
SBP0.0620.0340.1911.7920.074(-0.006,0.129)
Diastolic blood pressure-0.0820.043-0.181-1.9120.057(-0.167,0.002)
Respiratory rate-0.2420.091-0.157-2.6500.009*(-.422,-0.062)
Serum potassium-1.5250.543-0.171-2.8070.005*(-2.596,-0.455)
Elevated JVP1.6040.8500.1091.8870.060(-0.070,3.279)
Third heart sound (S3gallop)-4.1181.466-0.163-2.8090.005*(-7.006,-1.230)
PND2.4940.8570.1702.9110.004*(0.806,4.181)
Murmur-1.0170.918-0.069-1.1080.269(-2.825,0.792)
Atenolol-0.8711.543-0.033-0.5640.573(-3.912,2.170)
Dopamine-2.1001.846-0.069-1.1380.256(-5.736,1.537)
Number of medications-0.4940.253-0.132-1.9520.052(-0.993,0.005)

AHF, Acute Heart failure, NYHA, New York Heart Association; SBP, Systolic Blood Pressure; DVHD, Degenerative Valvular Heart Disease; HIV, Human Immunodeficiency Virus; CAP, Community-Acquired Pneumonia; JVP, Jugular Venous Pressure; PND, Paroxysmal Nocturnal Dyspnea; B, Unstandardized Coefficients; ß, Standardized Coefficients; t, t-statistic.

*p-value ≤ 0.05

**p-value < 0.001.

AHF, Acute Heart failure, NYHA, New York Heart Association; SBP, Systolic Blood Pressure; DVHD, Degenerative Valvular Heart Disease; HIV, Human Immunodeficiency Virus; CAP, Community-Acquired Pneumonia; JVP, Jugular Venous Pressure; PND, Paroxysmal Nocturnal Dyspnea; B, Unstandardized Coefficients; ß, Standardized Coefficients; t, t-statistic. *p-value ≤ 0.05 **p-value < 0.001.

Discussion

The results of the present study showed that the mean (±SD) LOS was 17.29 (±7.27) days. According to the multiple linear regression increased number of comorbidities, PND, and precipitating factors of AHF specifically infection were significantly associated with a prolonged length of hospital stay. In the present study, the mean age of the participants was 51 years which was relatively lower compared to previous studies (71–73 years) [2, 8, 24]. The discrepancy might be explained by these studies were conducted in developed countries where the mean age of their adult population is relatively higher than the developing countries, but was comparable with the Sub-Saharan Africa Survey of Heart Failure [15] and other HF studies (47–53 years) conducted in Ethiopia [3, 20]. This study had shown that 58.2% of patients were females and similar to an observational study conducted at Tikur Anbessa Specialized Hospital (54.4%) [22]. According to the findings of this study, all patients were presented with either in NYHA class III (1.9%) or IV (98.1%). This is different from the proportion reported by a retrospective observational cohort study in Japan (NYHA class III = 35.4%, IV = 28.5%) [21] and a prospective study from Hospital Universitari de Bellvitge (NYHA Class III = 17%, IV = 76.9%) [12]. These differences could be explained as in the present study majority of patients were presented with more severe form of HF as documented with the presence of dyspnea on exertion (89.7%), dyspnea at rest (89.7%), peripheral edema (79.8%), and orthopnea (72.2%). The present study showed that a third of HF patients were admitted with an undefined precipitating factor. Of the defined ones, CAP (30%) and AF (19.8%) were the leading precipitating factors for AHF. Similarly, a study from St Paul’s Hospital Millennium Medical College in Ethiopia reported that 25.6% of patients were hospitalized without a definitive cause of precipitating factors of HF [20]. Additionally, CAP (28%), infective endocarditis (10.9%), and AF (8.7%) were the most frequent precipitating factors for AHF in this study [20]. Among the ADCHF, non-adherence to the medical regimen and CAP were the leading precipitating factors in nearly a third (30.5%) and a quarter (23.1%) of cases, respectively. Similarly, the Ugandan study identified that non-adherence to medical regimens and infection were the precipitating factors for HF decompensation in 31.7% and 26.7% of patients, respectively [29]. Furosemide was administered to almost all (98.9%) HF patients during hospitalization. This was consistent with a study done at Tikur Anbessa Specialized Hospital in Ethiopia which revealed that furosemide was prescribed to 95.9% of hospitalized HF patients [22]. Similarly, results from the Italian and Sub-Saharan Africa survey of heart failure showed that furosemide was used by 98.1% and 92.9% of patients, respectively [15, 17]. At hospitalization, aspirin was administered to 36.95% of patients. This is comparable to the Ugandan study in which aspirin was prescribed in 32.9% of patients [29]. Like that of aspirin, the rate of atorvastatin use during hospitalization was high (27.8%). In the HF-Turkey study, the rate of use of statin at admission was 24.7% which was comparable with the present study [30]. Generally, the frequent prescription of aspirin and atorvastatin in the current study might be due to the existence of IHD as a leading co-morbid condition since these medications are recommended as its treatment of choice [31, 32]. At discharge, furosemide (75.3%), spironolactone (30.4%), and enalapril (24.0%) were the most widely used medications. These findings are similar to previous studies which described furosemide, spironolactone, and enalapril as the most common discharge medications for HF patients [20, 21]. In the current study, the mean (±SD) LOS of the hospitalized HF patients was 17.29 (±7.27) days. This was in agreement with a retrospective cohort study carried out in Japan 19.5 (±12.5 days) [21], however, it was higher than a retrospective cohort study conducted in California 3.8 (± 4.8) days [8], Gulf Acute Heart Failure Registry 3 (±12.5) days [13], and Italian study 11.2 (± 6.7) days [17]. The median (IQR) length of hospitalization was 18 (12–23) days and comparable to the Japanese study which was 17 (11–25) days) [21] and West Tokyo Heart Failure registry was 15 (10–23) days [4]. However, it was higher than a cohort study conducted in New Zealand; 6 (4–9) days [2], Italian study; 10 (7–14) days [17], Sub-Saharan Africa Survey of Heart Failure registry; 7 (5–10) days [15] and the American Get With The Guidelines-HF registry; 4 (2–6) days [23].

Factors associated with length of hospital stay

In the current study, patients with prolonged LOS were more likely to be presented with a higher number of comorbidities. Similarly, the Get with the Guidelines-HF registry revealed that patients with LOS > 7 days have presented to the hospital with a greater number of comorbidities compared to those with < 7 days of LOS [23]. A cross-sectional study in the US also identified a higher number of comorbidities were associated with a longer LOS in AHF patients [14]. Additionally, this study showed that patients with prolonged LOS were more likely to be presented with a sign and symptoms of congestion specifically PND. A study done in New Zealand also showed that peripheral congestion was independently associated with longer (> 10 days) LOS [2]. Despite the simple linear regression demonstrating that CAP was associated with LOS, the multiple regression showed that CAP was not significantly associated with LOS. In contrast to this finding, a retrospective cohort study in Japan reported that pneumonia was strongly associated with prolonged LOS [21]. This might be attributed to a large number of AHF patients were included in the Japanese study. To the best of the authors’ literature search, this prospective study was the first to describe LOS and associated factors among hospitalized HF patients in Ethiopia. Despite its’ strength, it is not without limitations. Firstly, it involves a single population who were stratified by a specific disease criterion which was HF. However, the LOS among patients with the same disease may vary owing to complex factors related to the individual patient or organizational factors or divergences in the medical practice. Secondly, compared to the other studies the sample size in the present study was relatively small and significant associations could be missed out. Thirdly, this study was conducted in a single health facility. Fourthly, LOS might be influenced by the different health insurance systems, hospital capacity, patterns of clinical practice, and physicians however because of financial and time constraints we can’t include these factors. Thus, the generalizability of the results might be limited.

Conclusion

In conclusion, the present study revealed that HF patients admitted to the medical ward spent prolonged LOS. Patients who were presented with concurrent DVHD, increased number of comorbidities, presence of elevated JVP, and PND were associated with longer LOS. Thus, clinicians would be aware of the clinical features contributing to the longer hospital stays. Implementation of interventions or strategies that could reduce the time spent in hospital is necessary for HF patients. Additionally, these data may help health care providers in identifying patients who are more likely to spent prolonged LOS. Moreover, a study with larger sample size and multicenter approach will be required to further strengthen the current findings.

Correlations between patient characteristics and LOS among AHF patients.

(PDF) Click here for additional data file.

Data abstraction format of AHF patients.

(PDF) Click here for additional data file. 29 Jan 2021 PONE-D-21-01805 Length of hospital stay and associated factors among heart failure patients admitted to the medical ward of University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: A Cross-sectional study PLOS ONE Dear Dr. Tigabe, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please do English editing, title revision, and then re-submit. ​ Please submit your revised manuscript by Mar 12 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE Additional Editor Comments: 1. Please revise and shorten the Title to make it concise and informative. 2. Please do English editing first--too many English errors. Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please upload a copy of Supporting Information Table S1 and Annex S1 which you refer to in your text on page 28. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 24 Feb 2021 Rebuttal letter Dear editor, Thank you for your sincere comments. Please find our response to your concerns in the previously submitted manuscript in PLOS ONE Journal. 1. Please revise and shorten the Title to make it concise and informative. Dear editor, the title was revised and shortened from “Length of hospital stay and associated factors among heart failure patients admitted to the medical ward of University of Gondar Comprehensive specialized Hospital, Northwest Ethiopia: A Cross sectional study” to “Length of hospital stay and associated factors among heart failure patients admitted to the University Hospital in Northwest Ethiopia” 2. Please do English editing first--too many English errors. Dear editor, We have made English editing to the best of our capacity and please consider our revised manuscript to proceed in your esteemed journal. Submitted filename: Response to Reviewers.docx Click here for additional data file. 16 Mar 2021 PONE-D-21-01805R1 Length of hospital stay and associated factors among heart failure patients admitted to the University Hospital in Northwest Ethiopia PLOS ONE Dear Dr. Tigabe, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please revise accordingly. Please submit your revised manuscript by Apr 30 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. 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Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ********** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ********** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The Authors have adequately replied to previous editor comments. The paper is interesting, however it's not easy to read this manuscript, the intro is too long and also data presentation is complex with a lot of data and numbers. It's unclear why the use of diuretics, the type of underlying disease (i.e CAD, VHD or DCM), the time from symptom onset to hospital admission and finally the age, didn't enter in the multivariate analysis Reviewer #2: (No Response) ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: luciano agati Reviewer #2: Yes: Shady Abohashem, MD [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 25 Mar 2021 Response to reviewers Reviewer #1: The Authors have adequately replied to previous editor comments. The paper is interesting, however it's not easy to read this manuscript, the intro is too long and also data presentation is complex with a lot of data and numbers. It's unclear why the use of diuretics, the type of underlying disease (i.e CAD, VHD or DCM), the time from symptom onset to hospital admission and finally the age, didn't enter in the multivariate analysis Dear Reviewer: Thank you for your constructive comments. We have tried to address your concerns and we found most of them as helpful to the paper improvement. • With regard to length of the introduction section, we have reduced some sentences which are not much related with length of hospital stay of heart failure patients. • With data presentation and numbers, we understand it is appropriate concern having more numerical presentation may not be attractive to the reader. But we have kept them as it is since we believe reducing the data and numerical values may not give the full picture of the extent of association of variables with patients’ length of hospital stay. • Concerning the variables in the multivariate analysis, we included the missed variables as per your comments. Use of diuretics is not satisfied the requirement of the multivariate analysis since it has no significant association with length of hospital stay in the univariate analysis and was not considered for multivariate analysis. Age is already included in the multivariate analysis though it was not found to have significant association. The underlying diseases included to the multivariate analysis and we did not found association with length of hospital stay by themselves. But it affected slightly the extent of association of other variables with little numerical variation without change of direction of association. Thus, the table is amended considering the new variable added to the multivariable analysis. Submitted filename: Response to reviewers2.docx Click here for additional data file. 6 Apr 2021 PONE-D-21-01805R2 Length of hospital stay and associated factors among heart failure patients a dmitted to the University Hospital in Northwest Ethiopia PLOS ONE Dear Dr. Tigabe, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please address to the reviewers' concerns and revise accordingly. Please submit your revised manuscript by May 21 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #2: All comments have been addressed Reviewer #3: (No Response) ********** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #2: Yes Reviewer #3: (No Response) ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: I Don't Know Reviewer #3: (No Response) ********** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #2: Yes Reviewer #3: (No Response) ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #2: Yes Reviewer #3: (No Response) ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #2: (No Response) Reviewer #3: We have made a review for Manuscript Number PONE-D-21-01805R2; entitled: Length of hospital stay and associated factors among heart failure patients admitted to the University Hospital in Northwest Ethiopia. The current manuscript has critical points: 1- The very limited sample size of just 263 patients and the high number of variables incorporated in the analysis compared to the small sample size. This would greatly affect the confidence with the results. 2- The authors did not incorporate important variables of heart failure assessment in modern cardiology like Echocardiography parameters, natriuretic peptides level, etc... 3- Variables described by the authors like third heart sound, etc are considered diagnostic variables of decompensated heart failure. 4- Based on the prior comments, the clinical implications of the current manuscript will not be clear and practical. 5- Extensive editing is required. Kindest regards ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #2: Yes: Shady Abohashem Reviewer #3: Yes: Rami Riziq Yousef Abumuaileq [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 20 May 2021 Reviewer #3: We have made a review for Manuscript Number PONE-D-21-01805R2; entitled: Length of hospital stay and associated factors among heart failure patients admitted to the University Hospital in Northwest Ethiopia. The current manuscript has critical points: 1- The very limited sample size of just 263 patients and the high number of variables incorporated in the analysis compared to the small sample size. This would greatly affect the confidence with the results. 2- The authors did not incorporate important variables of heart failure assessment in modern cardiology like Echocardiography parameters, natriuretic peptides level, etc... 3- Variables described by the authors like third heart sound, etc are considered diagnostic variables of decompensated heart failure. 4- Based on the prior comments, the clinical implications of the current manuscript will not be clear and practical. 5- Extensive editing is required. Dear Reviewer: Thank you for your constructive comments and concerns. We appreciate for your concerns. Regarding the very limited sample size and the high number of variables incorporated in the analysis compared to the small sample size this might affect the confidence with the results. But we have tried to include all CHF patients during the study period. The prospective nature of the study design would increase the confidence of the results. Besides, we have disclosed the small size of the study may affect the generalization of the results. Thus, we have informed future researchers to consider the limitation of our study. Please note our concern was including the variables which are relevant to the length of hospital stay. However because of time and financial constraints we can’t include a large number of samples in our study. That is why these variables become large comparing to the small sample size. Regarding the incorporation of important variables of heart failure assessment in modern cardiology like Echocardiography parameters, natriuretic peptides level. The reason that these variables were not included in the study was such Echocardiographic parameters such as natriuretic peptides level were not done in the study setting. Concerning the variables like third heart sound, etc are considered diagnostic variables of decompensated heart failure. In the study, not only new onset acute heart failure patients but also those who were admitted with acutely decompensated chronic heart failure patients were included, The impact of the clinical features of these patients on length of hospital stay were assessed because these variables were included in the analysis. Regarding the clinical implications of the manuscript, we believe that the finding of study will have a role in clinical scenarios by providing data regarding the length of hospital stay and factors influencing length of hospital stay in patients with HF. Specifically, factors determine the current status of length of hospital stay and associated factors among hospitalized acute heart failure patients in the medical ward of the University of Gondar Comprehensive Specialized Hospital in Ethiopia were provided to the clinical practitioners and researchers. Moreover, clinicians would be aware of the clinical features contributing to the longer hospital stay and implementation of interventions or strategies that could reduce the heart failure patient’s hospital stay is necessary. Submitted filename: Response to Reviewerss.docx Click here for additional data file. 27 May 2021 PONE-D-21-01805R3 Length of hospital stay and associated factors among heart failure patients a dmitted to the University Hospital in Northwest Ethiopia PLOS ONE Dear Dr. Tigabe, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please address the issues and revise accordingly. Please submit your revised manuscript by Jul 11 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #4: (No Response) Reviewer #5: (No Response) ********** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #4: No Reviewer #5: No ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #4: No Reviewer #5: No ********** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #4: Yes Reviewer #5: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #4: No Reviewer #5: No ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #4: Dr Tekle MT et al. reported clinical factors associated with length of hospital stay in patients hospitalized for acute heart failure. Unfortunately, the manuscript was poorly written, and require adequate quality of English edition. My major concern is that length of hospital stay may be influenced by different health insurance system, hospital capacity, patterns of clinical practice and physicians. Therefore, generally, this topic may lack of generalization, and need to be explored in national database or multicenter cohorts. In this regard, the interpretation of their results may be challenging. For example, their results showed that factors precipitated to acute heart failure were associated with length of hospital stay; however, various types of precipitating factors (i.e., acute coronary syndrome, infection, non-adherence etc) exist and may influence length of hospital stay. Patients with acute heart failure precipitated by acute coronary syndrome were more likely to require a longer hospital stay than those precipitated by non-adherence since these patients need a cardiac catheterization during hospital stay. Please describe your findings more precisely. Furthermore, not surprisingly, their results showed that sicker patients with acute heart failure supported by more frequent comorbidities and/or more severe congestion were more likely to need hospital care longer. I am wondering about novel findings of the current study. If they use database from acute heart failure patients in Ethiopia as a representative of developing countries, which factor is specific for patients in developing countries. Other concerns were raised as follows: 1/ Overall, in introduction section, interpretation of some texts was confusing. Length of hospital is a result of a hospital care. Authors described “decreased LOS results in reduced risk of medication side effects and infection, lower mortality rates, increased hospital profit with more efficient bed management, and better treatment outcomes.” However, generally, low risk of medication side effects and infection may lead to a short hospital stay. 2/ I would disagree with author description showing that a longer hospital stay was associated with poor clinical outcomes. In some countries, patients are up-titrated to maximum tolerated doses of guideline recommended heart failure medications during their hospital stay, leading to favorable outcomes. Please comment on this issue. 3/ Acute heart failure is characterized by heterogenous phenotypes, and, sometimes, it is challenging to diagnose of this cardiac syndrome. Please describe detailed information about acute heart failure definition in the methods section, citing a relevant paper. 4/ Please explain heart failure medications in detailed. The term “number of medications” is confusing. Do “medications” indicate specific treatments for heart failure or general drugs such as proton pump inhibitor and antiplatelet therapy? In addition, do “number of medications” mean number of drug tablets? 5/ Spearman is not appropriate for looking at correlation between continuous variable and categorical variable. Please remove these results or analyze it with correct statistical approach. 6/ Please draw lines between rows or columns in each table. Additionally, in Table 1, some important variables are lacking. Please describe prevalence of comorbidities or precipitating factors, which may help reader understand overall patient characteristics in these patients with acute heart failure. 7/ Again, acute coronary syndrome is, generally, a high prevalence and important precipitating factor for acute heart failure patients. Why author do not include this factor in groups of precipitating factors? 8/ How did authors select variable associated with length of hospital stay in multivariable model? With backward or forward selection? 9/Presence of elevated jugular venous pressure and/or paroxysmal nocturnal dyspnea were associated with a longer hospital stay; however, presence of III heart sound or lower admission respiratory rate were associated with a shorter hospital stay. Although all variables may express the severity of congestion, why do authors have inconsistent results? 10/ All patients were hospitalized for acute heart failure, however, there was quite low number of patients having guideline-directed heart failure medications; for example, only <25% of patients were prescribed enalapril at discharge. Surprisingly, some patients (17.5%) took metoprolol at discharge, but none took other beta-blocker drugs such as carvedilol and bisoprolol, which have been proven to be superior to metoprolol and are used in routine clinical practice. I am convinced that the different management of hospitalized heart failure may limit generalization of their findings. 11/ How about length of hospital stay across heart failure phenotypes (i.e., reduced ejection fraction, mid-range ejection fraction and preserved ejection fraction) since different ejection fraction is not only a marker of systolic function, but also has different underlying causes, management and treatments, which might lead to different length of hospital stay. 12/ Please check number of percentages in Figure 1. 13/ Please revise the manuscript adequately for an English medical journal. Overall, this paper is not relevant; for example, length of introduction section, some redundant expressions. Reviewer #5: The authors' purpose is valuable and this should be emphasized to begin. Indeed, there are only few data available on heart failure and HF prognosis from Africa, and most are published by large, academic, universitary referal hospitals . What happens in smaller medical facilities or regional university hospitals is less known. The authors performed a large study that may be suitable for a broad readership. However there are major limitations to their study. 1 As acknowledged by the previous revievers, the manuscript is rather long, with only few,( and easy to shorten) results and conclusions. It's not easy to move from one Section to another, and to understand how relevant and useful for clinical practice are the results. Limiting the purpose to a description of the study population could be an alternate. It's interesting per se for a non African reader to know that hospital stay for acute HF may be as long as 17 days, especially in patients aged 51 years only. 2 The lack of echo and natriuretic peptides is easy to understand (BNP and NTproBNP are very expensive for low income countries). This is not a problem on my opinion. 3 The reference section may largely be improved. Data from Poland, Japan, China, Germany are not required, I believe. By contrast, the authors omitted a major study on HF from Subsaharan Africa , the Thesus-Hf study ( The sub-Saharan Africa Survey of Heart Failure (THESUS-HF) prospective cohort study). 4 I believe we should sustain and promote African studies especially from centers who make efforts to perform academic research. May be a way to make this submission suitable for publication would be to largely shorten it and to limit results to a description of the real world description of HF in their institution. ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #4: Yes: Masatake Kobayashi Reviewer #5: Yes: Jean-Jacques Monsuez [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 1 Jan 2022 Dear Reviewers thank you for your constructive comments. We have tried to address your concerns and we found most of them as helpful to the paper improvement. Submitted filename: Response to reviewers 4.docx Click here for additional data file. 17 Jan 2022
PONE-D-21-01805R4
Length of hospital stay and associated factors among heart failure patients a dmitted to the University Hospital in Northwest Ethiopia
PLOS ONE Dear Dr. Tigabe, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please revise and address the issues. Please submit your revised manuscript by Mar 03 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript:
A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #3: (No Response) Reviewer #4: (No Response) ********** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #3: (No Response) Reviewer #4: No ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: (No Response) Reviewer #4: Yes ********** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #3: (No Response) Reviewer #4: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #3: (No Response) Reviewer #4: No ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #3: (No Response) Reviewer #4: Unfortunately, my concerns were not addressed, and I cannot see what point authors modify or correct exactly in their revised version of manuscript. As authors can see in my comments, a variable, “precipitating factors”, was so confusing since clinical meaning and/or prognostic value varied greatly among precipitating factors including, acute coronary syndrome, infection, arrhythmia, and poor adherence. Even though this variable was statistically associated with length of hospital stay, I cannot interpret this result. Sadly, although authors tried to argue my concerns, they did not modify their manuscript and explain them in the “response to reviewers”. I am convinced that readers also have similar concerns, and these raised points should be addressed adequately, particularly, in the limitations section. Additionally, I am not sure whether the revised manuscript was edited by medical English editing. For example, their description in the results section entitled, “predictors of length of hospital stay” included many redundancies. Furthermore, in this study, heart failure was defined per the ESC guidelines; however, in their description table, authors did not show any findings of electrocardiogram, chest x-ray, and/or echocardiogram, or values of natriuretic peptide. Please present these variables. ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #3: Yes: Rami Riziq Yousef Abumuaileq Reviewer #4: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 23 Mar 2022 Dear Reviewer # 4 Thank you for your constructive comments and concerns. We have tried to address your concerns and we found most of them as helpful to the paper improvement. First of all, for the crucial comments that you have given to our paper, we would like to provide our deepest heart felt gratitude. Submitted filename: Response to reviewers 5.docx Click here for additional data file. 29 Mar 2022
PONE-D-21-01805R5
Length of hospital stay and associated factors among heart failure patients a dmitted to the University Hospital in Northwest Ethiopia
PLOS ONE Dear Dr. Tigabe, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.
Please revise. 
Please submit your revised manuscript by May 13 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript:
A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #3: (No Response) Reviewer #4: All comments have been addressed Reviewer #6: All comments have been addressed ********** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #3: (No Response) Reviewer #4: Yes Reviewer #6: Partly ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: (No Response) Reviewer #4: Yes Reviewer #6: No ********** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #3: (No Response) Reviewer #4: Yes Reviewer #6: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #3: (No Response) Reviewer #4: Yes Reviewer #6: Yes ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #3: (No Response) Reviewer #4: (No Response) Reviewer #6: A significant problem with the current version of the paper is the statistical analysis. First, the use of multivariate analysis is not properly mentioned in the Methods. Second, most of the variables in linear regression (see Table 3) are qualitative, which significantly affects its efficiency. It would be more logical to use other types of regression analysis, taking into account the type of input data. In any case, it is necessary to explain the reasons for choosing the multiple analysis method in Methods by discussing its limitations in the context of the peculiarities of the data. Moreover, very many indicators are included in the analysis with a fairly limited number of observations. I am not sure if presented results are correct. The principles of selection of indicators in the multivariate model, the modeling procedure need to be clarified and, most likely, corrected. It is unclear why the following phrases are given for a number of variables in Table 3: «causes of AHF» or « precipitating factor of AHF». Perhaps this should be reflected in the Methods when describing the data concept, or in the Discussion. ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #3: No Reviewer #4: No Reviewer #6: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 23 May 2022 Dear Reviewer # 6: thank you for your constructive comments and concerns which are helpful for our paper quality. based on your comments we have made modifications to our manuscript. Submitted filename: Response to reviewers 6.docx Click here for additional data file. 20 Jun 2022 Length of hospital stay and associated factors among heart failure patients a dmitted to the University Hospital in Northwest Ethiopia PONE-D-21-01805R6 Dear Dr. Tigabe, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #3: (No Response) Reviewer #6: All comments have been addressed ********** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #3: No Reviewer #6: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: No Reviewer #6: Yes ********** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #3: Yes Reviewer #6: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #3: No Reviewer #6: Yes ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #3: The authors have superficially addressed the previous comments, however the main defects are still present. The limited sample size, doubts regarding the diagnosis, management and proper follow up in a hospital without a specialized cardiology department. Kind regards Reviewer #6: Although I believe it is appropriate to perform multivariate data analysis using somewhat different methods, I agree with the authors' position, although their approach has a number of limitations. ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #3: Yes: Rami Riziq Yousef Abumuaileq Reviewer #6: No ********** 13 Jul 2022 PONE-D-21-01805R6 Length of hospital stay and associated factors among heart failure patients admitted to the University Hospital in Northwest Ethiopia Dear Dr. Tigabe Tekle: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Robert Jeenchen Chen Academic Editor PLOS ONE
  28 in total

1.  2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.

Authors:  Clyde W Yancy; Mariell Jessup; Biykem Bozkurt; Javed Butler; Donald E Casey; Mark H Drazner; Gregg C Fonarow; Stephen A Geraci; Tamara Horwich; James L Januzzi; Maryl R Johnson; Edward K Kasper; Wayne C Levy; Frederick A Masoudi; Patrick E McBride; John J V McMurray; Judith E Mitchell; Pamela N Peterson; Barbara Riegel; Flora Sam; Lynne W Stevenson; W H Wilson Tang; Emily J Tsai; Bruce L Wilkoff
Journal:  Circulation       Date:  2013-06-05       Impact factor: 29.690

2.  Characteristics of acute heart failure hospitalizations in a general medical ward in Southwestern Uganda.

Authors:  Samson Okello; Owori Rogers; Asaph Byamugisha; Joselyn Rwebembera; Andrew J Buda
Journal:  Int J Cardiol       Date:  2014-08-04       Impact factor: 4.164

3.  Length of stay and health outcome.

Authors:  K McPherson
Journal:  Br Med J (Clin Res Ed)       Date:  1984-06-23

4.  Factors influencing the length of hospital stay of patients with heart failure.

Authors:  S P Wright; D Verouhis; G Gamble; K Swedberg; N Sharpe; R N Doughty
Journal:  Eur J Heart Fail       Date:  2003-03       Impact factor: 15.534

5.  Clinical features and outcome in hospitalized heart failure in Japan (from the ATTEND Registry).

Authors:  Naoki Sato; Katsuya Kajimoto; Takehiko Keida; Masayuki Mizuno; Yuichiro Minami; Dai Yumino; Kuniya Asai; Koji Murai; Ryo Muanakata; Toshiyuki Aokage; Yasushi Sakata; Kyoichi Mizuno; Teruo Takano
Journal:  Circ J       Date:  2013-03-15       Impact factor: 2.993

6.  Demographics, Management, and In-Hospital Outcome of Hospitalized Acute Heart Failure Syndrome Patients in Contemporary Real Clinical Practice in Japan　- Observations From the Prospective, Multicenter Kyoto Congestive Heart Failure (KCHF) Registry.

Authors:  Hidenori Yaku; Neiko Ozasa; Takeshi Morimoto; Yasutaka Inuzuka; Yodo Tamaki; Erika Yamamoto; Yusuke Yoshikawa; Takeshi Kitai; Ryoji Taniguchi; Moritake Iguchi; Masashi Kato; Mamoru Takahashi; Toshikazu Jinnai; Tomoyuki Ikeda; Kazuya Nagao; Takafumi Kawai; Akihiro Komasa; Ryusuke Nishikawa; Yuichi Kawase; Takashi Morinaga; Kanae Su; Mitsunori Kawato; Kenichi Sasaki; Mamoru Toyofuku; Yutaka Furukawa; Yoshihisa Nakagawa; Kenji Ando; Kazushige Kadota; Satoshi Shizuta; Koh Ono; Yukihito Sato; Koichiro Kuwahara; Takao Kato; Takeshi Kimura
Journal:  Circ J       Date:  2018-09-26       Impact factor: 2.993

7.  The causes, treatment, and outcome of acute heart failure in 1006 Africans from 9 countries.

Authors:  Albertino Damasceno; Bongani M Mayosi; Mahmoud Sani; Okechukwu S Ogah; Charles Mondo; Dike Ojji; Anastase Dzudie; Charles Kouam Kouam; Ahmed Suliman; Neshaad Schrueder; Gerald Yonga; Serigne Abdou Ba; Fikru Maru; Bekele Alemayehu; Christopher Edwards; Beth A Davison; Gad Cotter; Karen Sliwa
Journal:  Arch Intern Med       Date:  2012-10-08

8.  The real-life data of hospitalized patients with heart failure: On behalf of the Journey HF-TR study investigators.

Authors:  Ümit Yaşar Sinan; Ahmet Ekmekçi; Benay Özbay; Filiz Akyıldız Akçay; Lütfü Bekar; Yavuzer Koza; İsmail Bolat; Umut Kocabaş; Mehdi Zoghi
Journal:  Anatol J Cardiol       Date:  2019-01       Impact factor: 1.596

9.  Association of gender and length of stay among Puerto Ricans hospitalized with decompensated heart failure.

Authors:  Mohammad A Alnajashi; Mohammed A Almasoud; Sami A Aldaham; Juan Manuel Acuña; Juan C Zevallos
Journal:  Medicine (Baltimore)       Date:  2016-07       Impact factor: 1.889

10.  2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: comments from the Dutch ACS working group.

Authors:  P Damman; A W van 't Hof; J M Ten Berg; J W Jukema; Y Appelman; A H Liem; R J de Winter
Journal:  Neth Heart J       Date:  2017-03       Impact factor: 2.380
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