Hospital length of stay for severe COVID-19: implications for Remdesivir's value

Remdesivir has been granted emergency use authorization for treatment of severe COVID-19. Remdesivir's pricing is based on a presumed reduction of hospital length of stay (LOS) by four days. But the Adaptive COVID-19 Treatment Trial (ACTT-1) that suggested this treatment benefit excluded patients who were expected to be discharged within 72 hours. Perhaps as a result, median time to recovery was unusually long in both arms of the study (15 days vs 11 days). Remdesivir requires a 5-day inpatient stay, so patients who would otherwise be discharged in fewer than 5 days may remain hospitalized to complete treatment while patients who would be discharged between 5 and 8 days, would only have potential reductions in their hospital LOS of 0-3 days. In a retrospective analysis of 1643 adults with severe COVID-19 admitted to Columbia University Medical Center and the Allen community hospital between March 9, 2020 and April 23, 2020, median hospital LOS was 7 (3-14) days. Five-hundred and eighty-six patients (36%) had a LOS of 1-4 days, 384 (23%) had a LOS of 5-8 days, and 673 (41%) were hospitalized for greater than or equal to 9 days. Remdesivir treatment may not provide the LOS reductions that the company relied on when pricing the therapy: 36% of the cohort would need to have LOS prolonged to receive a 5-day course, and only 41% of patients in our cohort had LOS of 9 days or more, meaning they could have their LOS shortened by 4 days and still receive a full Remdesivir course. Further investigation of shorter treatment courses and programs to facilitate outpatient intravenous Remdesivir administration are needed.