Research Article| Volume 32, ISSUE 3, 106983, March 2023

Download started.


Predictors of inpatient admission likelihood and prolonged length of stay among cerebrovascular disease patients: A nationwide emergency department sample analysis



      To examine the hospital- and patient-related factors associated with increased likelihood of inpatient admission and extended hospitalization.


      We applied multivariate logistic regression to a subset of ED hospital and patient characteristics linearly extrapolated from the 2019 National Emergency Department Sample database (n=626,508). Patient characteristics with 10 or fewer ED visits after national extrapolation were not reported in the current study to maintain patient confidentiality, in accordance with the HCUP Data Use Agreement. All selected ED visits represented a primary diagnosis of CVD (ICD-10 codes 160-168). All reported hospital and patient characteristics were subject to adjustment for covariates. P-values < 0.05 were considered statistically significant.

      Main findings

      Medicare beneficiaries report higher inpatient admission rates than uninsured OR 0.81 (0.73-0.91) and privately insured OR 0.86 (0.79-0.94) individuals. Black and Native-American patients were 37% and 55% more likely to be hospitalized long (>75th percentile) (OR 1.37 [1.25-1.50], OR 1.55 [1.14-2.10]). Northeast emergency departments reported an increased odds of admission compared to the Midwest OR (0.40-0.62), South OR 0.79 (0.63-0.98) and West OR 0.52 (0.39-0.69). Patients with multiple comorbidities (mCCI = 3+) were 226% more likely to have a longer stay OR 3.26 (3.09-3.45) than patients presenting with zero or few comorbidities. Level I, II, and III trauma centers report distinctly high odds of inpatient admission (OR 3.54 [2.84-4.42], OR 2.68 [2.14-3.35], OR 1.51 [1.25-1.84]).

      Principal conclusions

      Likelihoods of inpatient admission and long hospital stays were observably stratified through multiple, independently acting hospital and patient characteristics. Significant associations were stratified by race/ethnicity, location, and clinical presentation, among others. Attention to the factors reported here may serve well to mitigate emergency department crowding and its sobering impact on United States healthcare systems and patients.



      Cerebrovascular disease (CVD), Coronary artery disease (CAD), Do-not-resuscitate (DNR), Emergency department (ED), Healthcare Cost and Utilization Project (HCUP), International Classification of Diseases (ICD), Modified Charlson Comorbidity Index (mCCI), National Emergency Department Sample (NEDS), Odds ratio (OR)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bihari S.
        • McElduff P.
        • Pearse J.
        • Cho O.
        • Pilcher D.
        Intensive care unit strain and mortality risk in patients admitted from the ward in Australia and New Zealand.
        J Crit Care. 2021; (00158-1Advance online publication): S0883-S9441
        • French G.
        • Hulse M.
        • Nguyen D.
        • Sobotka K.
        • Webster K.
        • Corman J.
        • Aboagye-Nyame B.
        • Dion M.
        • Johnson M.
        • Zalinger B.
        • Ewing M.
        Impact of hospital strain on excess deaths during the COVID-19 pandemic - United States, July 2020-July 2021.
        MMWR. Morbid Mortal Weekly Rep. 2021; 70: 1613-1616
        • Kokudo N.
        • Sugiyama H.
        Hospital capacity during the COVID-19 pandemic.
        Global Health Med. 2021; 3: 56-59
        • Hua M.
        • Halpern S.D.
        • Gabler N.B.
        • Wunsch H.
        Effect of ICU strain on timing of limitations in life-sustaining therapy and on death.
        Intensive Care Med. 2016; 42: 987-994
        • Reeves R.R.
        • Parker J.D.
        • Burke R.S.
        • Hart R.H.
        Inappropriate psychiatric admission of elderly patients with unrecognized delirium.
        South Med J. 2010; 103: 111-115
        • Rathlev N.K.
        • Bryson C.
        • Samra P.
        • Garreffi L.
        • Li H.
        • Geld B.
        • Wu R.Y.
        • Visintainer P.
        Reducing patient placement errors in emergency department admissions: right patient, right bed.
        Western J Emerg Med. 2014; 15: 687-692
        • Doctoroff L.
        • Hsu D.J.
        • Mukamal K.J.
        Trends in prolonged hospitalizations in the United States from 2001 to 2012: a longitudinal cohort study.
        Am J Med. 2017; 130: 483.e1-483.e7
        • Barba R.
        • Marco J.
        • Canora J.
        • Plaza S.
        • Juncos S.N.
        • Hinojosa J.
        • Bailon M.M.
        • Zapatero A.
        Prolonged length of stay in hospitalized internal medicine patients.
        Eur J Internal Med. 2015; 26: 772-775
        • Kim C.S.
        • Hart A.L.
        • Paretti R.F.
        • Kuhn L.
        • Dowling A.E.
        • Benkeser J.L.
        • Spahlinger D.A.
        Excess hospitalization days in an academic medical center: perceptions of hospitalists and discharge planners.
        Am J Manag Care. 2011; 17: e34-e42
        • Rogers C.M.
        • Busch C.M.
        • Cuoco J.A.
        • Elias Z.
        • Simonds G.R.
        Economic impact of hospitalization past maximal neurosurgical inpatient benefit.
        Cureus. 2018; 10: e3567
        • Ruangkriengsin D.
        • Phisalprapa P.
        Causes of prolonged hospitalization among general internal medicine patients of a tertiary care center.
        J Med Assoc Thai. 2014; 97 (Suppl): S206-S215
        • Bai A.D.
        • Dai C.
        • Srivastava S.
        • Smith C.A.
        • Gill S.S.
        Risk factors, costs and complications of delayed hospital discharge from internal medicine wards at a Canadian academic medical centre: retrospective cohort study.
        BMC Health Serv Res. 2019; 19: 935
        • Toh H.J.
        • Lim Z.Y.
        • Yap P.
        • Tang T.
        Factors associated with prolonged length of stay in older patients.
        Singapore Med J. 2017; 58: 134-138
        • Subramanian T.
        Impact of hospitalization on patients and their families.
        Indian J Public Health. 1998; 42: 15-16
        • Admi H.
        • Shadmi E.
        • Baruch H.
        • Zisberg A.
        From research to reality: minimizing the effects of hospitalization on older adults.
        Rambam Maimonides medical journal. 2015; 6: e0017
        • Park J.Y.
        • Kim M.H.
        • Bae E.J.
        • Kim S.
        • Kim D.K.
        • Joo K.W.
        • Kim Y.S.
        • Lee J.P.
        • Kim Y.H.
        • Lim C.S.
        Comorbidities can predict mortality of kidney transplant recipients: comparison with the charlson comorbidity index.
        Transplant Proc. 2018; 50: 1068-1073
        • Rattanasompattikul M.
        • Feroze U.
        • Molnar M.Z.
        • Dukkipati R.
        • Kovesdy C.P.
        • Nissenson A.R.
        • Norris K.C.
        • Kopple J.D.
        • Kalantar-Zadeh K.
        Charlson comorbidity score is a strong predictor of mortality in hemodialysis patients.
        Int Urol Nephrol. 2012; 44: 1813-1823
        • Wang H.Y.
        • Chew G.
        • Kung C.T.
        • Chung K.J.
        • Lee W.H.
        The use of Charlson comorbidity index for patients revisiting the emergency department within 72 hours.
        Chang Gung Med J. 2007; 30: 437-444
        • Voskuijl T.
        • Hageman M.
        • Ring D.
        Higher Charlson Comorbidity Index Scores are associated with readmission after orthopaedic surgery.
        Clin Orthop Relat Res. 2014; 472: 1638-1644
        • Sundararajan V.
        • Henderson T.
        • Perry C.
        • Muggivan A.
        • Quan H.
        • Ghali W.A.
        New ICD-10 version of the Charlson Comorbidity Index predicted in-hospital mortality. 2004; 57: 1289-1294
        • Bessaha M.L.
        • Shumway M.
        • Smith M.E.
        • Bright C.L.
        • Unick G.J.
        Predictors of hospital length and cost of stay in a national sample of adult patients with psychotic disorders.
        Psychiatr Serv. 2017; 68: 559-565
        • Akintoye E.
        • Briasoulis A.
        • Egbe A.
        • Adegbala O.
        • Sheikh M.
        • Singh M.
        • Alliu S.
        • Ahmed A.
        • Asleh R.
        • Kushwaha S.
        • Levine D.
        Regional variation in mortality, length of stay, cost, and discharge disposition among patients admitted for heart failure in the United States.
        Am J Cardiol. 2017; 120: 817-824
        • Smulowitz P.B.
        • O'Malley A.J.
        • McWilliams J.M.
        • Zaborski L.
        • Landon B.E.
        Variation in rates of hospital admission from the emergency department among medicare patients at the regional, hospital, and physician levels.
        Ann Emerg Med. 2021; 78: 474-483
        • Zhou R.A.
        • Baicker K.
        • Taubman S.
        • Finkelstein A.N.
        The uninsured do not use the emergency department more-they use other care less.
        Health Aff (Millwood). 2017; 36: 2115-2122
        • Pines J.M.
        • Russell Localio A.
        • Hollander J.E.
        Racial disparities in emergency department length of stay for admitted patients in the United States.
        Acad Emerg Med: Off J Soc Acad Emerg Med. 2009; 16: 403-410
        • Epstein A.M.
        • Stern R.S.
        • Tognetti J.
        • Begg C.B.
        • Hartley R.M.
        • Cumella Jr., E.
        • Ayanian J.Z.
        The association of patients' socioeconomic characteristics with the length of hospital stay and hospital charges within diagnosis-related groups.
        N Engl J Med. 1988; 318: 1579-1585
        • Ghosh A.K.
        • Geisler B.P.
        • Ibrahim S.
        Racial/ethnic and socioeconomic variations in hospital length of stay: a state-based analysis.
        Medicine (Baltimore). 2021; 100: e25976
        • Ehresman J.
        • Pennington Z.
        • Feghali J.
        • Schilling A.
        • Hersh A.
        • Hung B.
        • Lubelski D.
        • Sciubba D.M.
        Predicting nonroutine discharge in patients undergoing surgery for vertebral column tumors.
        J Neurosurg Spine. 2020; (Advance online publication): 1-10
        • Zeru A.B.
        • Muluneh M.A.
        Admission and inpatient mortality of hypertension complications in Addis Ababa.
        Integr Blood Pressure Control. 2020; 13: 103-110
        • Folmann N.B.
        • Bossen K.S.
        • Willaing I.
        • Sørensen J.
        • Andersen J.S.
        • Ladelund S.
        • Jørgensen T.
        Obesity, hospital services use and costs.
        Adv Health Econ Health Serv Res. 2007; 17: 319-332
        • Madsen T.
        • Bossart P.
        • Bledsoe J.
        • Bernhisel K.
        • Cheng M.
        • Mataoa T.
        • Bartlett J.
        • McKellar A.
        • Rivas W.
        • Quick N.
        Patients with coronary disease fail observation status at higher rates than patients without coronary disease.
        Am J Emerg Med. 2010; 28: 19-22
        • Prochaska J.J.
        • Gill P.
        • Hall S.M.
        Treatment of tobacco use in an inpatient psychiatric setting.
        Psychiatr Serv. 2004; 55: 1265-1270
        • Akbar D.H.
        • Al-Gamdi A.A
        Common causes of admission in diabetics.
        Saudi Med J. 2000; 21: 539-542
        • Arora S.
        • Panaich S.S.
        • Ainani N.
        • Kumar V.
        • Patel N.J.
        • Tripathi B.
        • Shah P.
        • Patel N.
        • Lahewala S.
        • Deshmukh A.
        • Badheka A.
        • Grines C.
        Comparison of in-hospital outcomes and readmission rates in acute pulmonary embolism between systemic and catheter-directed thrombolysis (from the national readmission database).
        Am J Cardiol. 2017; 120: 1653-1661
        • Caprio F.Z.
        • Sorond F.A.
        Cerebrovasc Dis. 2019; 103: 295-308
        • Newgard C.D.
        • Hedges J.R.
        • Diggs B.
        • Mullins R.J.
        Establishing the need for trauma center care: anatomic injury or resource use?.
        Prehospital Emerg Care: Off J Natl Assoc EMS Phys Natl Assoc State EMS Directors. 2008; 12: 451-458
        • Balogh Z.J.
        • Varga E.
        • Tomka J.
        • Süveges G.
        • Tóth L.
        • Simonka J.A.
        The new injury severity score is a better predictor of extended hospitalization and intensive care unit admission than the injury severity score in patients with multiple orthopaedic injuries.
        J Orthop Trauma. 2003; 17: 508-512
        • Madayag R.M.
        • Sercy E.
        • Berg G.M.
        • Banton K.L.
        • Carrick M.
        • Lieser M.
        • Tanner 2nd, A.
        • Bar-Or D.
        Are trauma research programs in academic and non-academic centers measured by equal standards? A survey of 137 level I trauma centers in the United States.
        Patient Saf Surg. 2021; 15: 34
        • Burke L.
        • Khullar D.
        • Orav E.J.
        • Zheng J.
        • Frakt A.
        • Jha A.K.
        Do Academic Medical Centers Disproportionately Benefit The Sickest Patients?.
        Health Aff (Millwood). 2018; 37: 864-872