Volume 4, Issue 15 (Autumn 2018)                   Caspian.J.Neurol.Sci 2018, 4(15): 169-177 | Back to browse issues page


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Majidi Shad M, Saberi A, Shakiba M, Rezamasouleh S. Research Paper : Evaluating the Duration of Hospitalization and Its Related Factors Among Stroke Patients. Caspian.J.Neurol.Sci. 2018; 4 (15) :169-177
URL: http://cjns.gums.ac.ir/article-1-250-en.html
1- Student of Medicine, Student Research Committee of Neurosciences Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
2- Professor of Neurology, Neurosciences Research Center, Neurology Department, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
3- Assistant Professor of Epidemiology, Road Trauma Research Center, School of Health, Guilan University of Medical Sciences, Rasht, Iran
4- Lecturer in Nursing, Department of Medical Surgical Nursing, Shahid Beheshti School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
Keywords: Length of stay, Stroke
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Introduction
Stroke is defined as the onset of focal neurological symptoms or decreased consciousness which takes more than 24 hours or could be fatal [1]. Stroke is the fifth cause of death after heart disease, cancer, chronic respiratory illnesses, and unpredictable injuries; it is also one of the most important causes of disability in the world [2]. Annually about 16 million new strokes occur in the world. Two-thirds of these cases occur in poor countries or in a modest economic situation [3]. Around 125000 people in the UK suffer from stroke and 40000 of them die [4]. Although stroke does not necessarily end in death, it can lead to severe neurological defects for the patient and generates a lot of expenses for treatment and rehabilitation [5].
Stroke recovery starts from the earliest days and lasts for a long time. Caring for patients with stroke has a significant financial burden [6]. Increasing the length of hospitalization can lead to increased hospital care costs, increased hospitalization complications, and higher mortality rate and adverse outcomes [7]. The desired outcome depends on the diagnosis and treatment in the acute phase, therapeutic interventions for the prevention of stroke recurrence, rehabilitation during initial stroke phase and scheduled discharge. Hospital costs for stroke patients account for a large portion of total costs over the first 12 months after stroke [8]. Therapeutic interventions are planned to reduce the Length of Stay (LOS) of the patients and reduction of the costs [9].
It is necessary to identify the factors affecting LOS in stroke patients, in order to select the appropriate rehabilitation targets and planning for discharge [8]. The average LOS may be predicted by some parameters such as demographic characteristics, severity of stroke, and associated diseases [10]. According to Martin and Smith’s study, patient’s demographic characteristics and hospital features are two main determinants of hospitalization [11]. In terms of demographic characteristics, patients’ LOS in a hospital varies according to patient’s age and type of disease [12]. Among the hospital characteristics, the hospital care service can affect the LOS of the patients [13]. Patients and their families, health care workers, hospital managers, and health care systems are increasingly interested in predicting the length of hospitalization to obtain useful information about patient’s prognosis [6].
Of course, the relationship between the LOS and the quality of health care is not straight forward. Longer hospitalization is not necessarily associated with better quality care. Both quality and non-quality health care services may have the same length of stay. It is more likely that the duration of hospitalization with the quality of health care will have a “U” shape association. LOS, longer or shorter than the optimum, can reduce the quality of care. The suitable length of hospitalization in the particular circumstances has a range that depends on supply and demand factors, such as needs of each patient or the availability of related social services. 
Community-based care in industrial societies has reduced the role of the hospital. The duration of hospitalization should not be reduced without considering the appropriate care and treatment pattern. Guaranteeing appropriate care and treatment patterns for the quality of health care is very important [13]. This study was conducted to identify the effective factors on LOS in stroke patients.

Materials and Methods
This is a descriptive-analytic study and The study population were stroke patients admitted to a teaching hospital affiliated with GUMS during 2016-2017. The study inclusion criteria were confirmation of patients’ stroke based on the diagnosis of neurologist and neuro-imaging specialist and the completeness of their medical records in terms of the main variables of the study. Exclusion criteria were considered as patients’ deaths or their personal consent for discharge.
According to a Hashemifard study [14], with standard deviation of 2.6, a precision of 0.4, and an error of 0.05, the sample size was determined as 103 patients. Considering 5 people for each of the 18 primers, the final sample size was 253 patients. A researcher-made questionnaire was used to collect information after getting informed consent from patients or their legal relatives. After reviewing the literatures, the relevant research questions were set up as a data collection form.
Variables included the length of stay and the individual-social factors of the patient such as age, gender, marital status, occupation, smoking, alcohol consumption, drug use, history of previous stroke, and underlying illness, as well as factors associated with illness and admission such as type of stroke, severity of stroke, location of ischemia, location of bleeding, lesion size, type of insurance, their physician, admission to ICU, infectious side effects, and lesion side. The severity of stroke was classified into three classes: mild (1-5), moderate (6-13), and severe (14-42) based on the score obtained from the NIHSS (National Institutes of Health Stroke Scale score) [15].
After collecting data, the information was organized and entered into SPSS 21. Normality of quantitative variables was confirmed by Kolmogorov–Smirnov test. The obtained data were described and analyzed by descriptive statistics (mean and standard deviation, percentage and frequency and related tables) and analytical statistics with t test and ANOVA. Linear regression model was used to determine the adjusted estimation of each risk factor in the prediction of hospitalization time. The significance level was considered as less than 0.05. The confidentiality of collected information and respect for trustworthiness and integrity in the use of information based on research ethical considerations were respected at all stages.

Results
In this research, the medical records of 253 patients with stroke were studied. The mean age of patients was 69 years (range 41-94 years). The Mean±SD of their LOS was 5.6±2.1 days (minimum 2 and maximum 12 days). The frequency of other demographic variables and risk factors for stroke is listed in Table 1. There was no statistically significant relationship between duration of hospitalization and variables of demographic characteristics, stroke risk factors, and past medical history (Table 1). In this study, of 253 patients suffering from stroke, the most frequent cases were arterial ischemic stroke. There was a significant correlation between type of stroke and LOS (P=0.0001). 
Most strokes had moderate severity and volume. The variables of brain lesion volume and severity of stroke showed a significant relationship with the duration of hospitalization (P=0.0001). The deep arteries and basal ganglia were the most frequent site of involvement in ischemic stroke and hemorrhagic stroke, respectively. There was a significant relationship between ischemic location and duration of hospitalization (P=0.0001). LOS was significantly longer in cases of ischemic lesion in Middle Cerebral Artery (MCA) territory than other arterial territory except Posterior Cerebral Artery (PCA) artery. Involvement of PCA territory was significantly higher than deep arteries and did not differ from other types. Three percent of the patients were admitted to the ICU. There was a significant relationship between admission in ICU and LOS (P=0.0001).
In general, 25% of the patients developed infectious complications. A significant relationship between infectious complications and duration of hospitalization was observed (P=0.0001). Also, the duration of hospitalization had a significant relationship with their physicians (P=0.0001) (Table 2). A multivariate linear regression model was used to determine the predictive factors of hospitalization time and estimate the adjusted coefficients of the variables studied in the prediction of hospitalization time. The variables that had a significant level of less than 0.1 in single-variable analyzes entered the model.
The ischemic stroke location variable due to the strong linear correlation with other variables and the ICU variable because of its low frequency and the long hospitalization time that caused an uncommon increase in LOS were not included in the regression model. In the multivariate regression model, job, severity and volume of lesion, physician and infectious complications were independently associated with the duration of hospitalization. In terms of occupation, the length of admission of unemployed persons increased by an average of 0.68 day compared to those who were self-employed.
With the increase in stroke severity, according to the NIHSS index, the duration of hospitalization also increased.  LOS in severe stroke was on average 1.5 days more than mild stroke. Also, the increase in stroke volume increased LOS. Regarding the responsible therapist, the physician number 2 and 3, compared to physician number 1, increased the hospitalization to 1.71 and 0.75 days, respectively. The length of hospitalization of patients with physician number 4 did not differ significantly with physician number 1. The presence of infectious complications increased LOS by 1.91 days (Table 3).


 

 

 


 


 
Discussion
The prediction of LOS in patients with stroke is a complex subject in the healthcare profession [16]. In this study, the Mean±SD duration of hospitalization in patients with stroke was 5.6±2.1 days. Unemployed patients with hemorrhagic stroke, severe stroke, large lesion volume, infectious complications, and certain physician were associated with longer LOS. Also the type, severity, volume of stroke, infectious complications, as well as the physician, were the most powerful predictors of hospitalization time of stroke patients.
A study by GÖz et al. in Turkey reported an average length of hospitalization of 7 days [16]. In Saxena et al. study in India, the Mean±SD duration of hospitalization was 5.6±4.3 days [3]. The average length of hospitalization in Kim et al. study in South Korea was 18.6 days [5]. Likewise, in studies in Denmark and Taiwan this time was 13 and 11 days, respectively [17, 18]. However, in our study, the mean length of stay for stroke patients was shorter than other studies. Such variation in the period of hospitalization in different countries may be due to differences in the inclusion and exclusion criteria, different diseases, the compensation system and so on [5]. It seems that in the present study, we can mention the lack of hospital space and the occupancy rate of hospital beds, which can have a significant effect on the reduction of the mean LOS.
In our study, consistent with another research, no significant correlation was found between the age of the patients and LOS which contradicts the findings reported by Lee et al. [3, 19]. Perhaps the reason for this discrepancy is the difference in the rest of the patient’s variables, such as stroke severity or the infectious disease complications. The relationship between gender and LOS for stroke patients remains unclear, and various results have been reported in various studies [16, 17]. In our study, although female subjects had longer hospital stay, there was no significant relationship between sex and duration of hospitalization. It is likely that this lack of association can be also attributed to the difference in the rest of the patient variables.
In some studies, marital status is considered as another factor affecting the average LOS in the hospital, with the duration of staying of married patients reported less than single individuals. It is probably due to the fact that married people have family support and care more than single patients [20, 21]. But in the study of Liu et al., single subjects had less hospitalization time [22]. However, in this study, the marital status did not have a significant relationship with the LOS. According to the results of some studies, there was no significant correlation between the socioeconomic status and the duration of hospitalization [3, 23]. Nonetheless, other studies suggest that housewives had a shorter stay than other occupations [24]. Our study indicate that unemployment can be associated with longer LOS. Such an outcome is likely to be attributed to the increased acceptance of the treatment process and the monitoring of this category of patients.
In some studies, alcohol and smoking could increase the risk of hospitalization and prolong LOS [25, 26]. Our study indicate that the history of drug use, alcohol and smoking did not have a significant relationship with LOS. Similar results were also observed in other study [27]. In the present study, there was no association between history of stroke and length of hospitalization. It is worth noting that similar studies in this area are few. Other disease-related features and hospitalization seem to be effective in this result. In some studies, the type of stroke was effective in predicting the duration of hospitalization [28]. In the present study, like the study of Lim et al., patients with hemorrhagic stroke had longer hospitalization than other patients [10]. However, in another study no significant relationship was found between the type of stroke and LOS [3].
In our study, patients with longer hospitalization time had greater severity of stroke than other patients. Similarly, a direct relationship was reported in a study by George et al. and Koton et al [29, 30]. It is evident that the greater severity of stroke and its association with severe neurological symptoms and disability in patients requires more hospitalization time. In addition, these patients develop more complications such as infection, bed sore, and so on, and thus increase their length of hospital stay. In the present study, in line with the study by Saxena et al., no correlation was found between the side of the stroke and the length of stay in the hospital [3]. In this study, similar to some other studies, there was a significant direct correlation between stroke location and LOS [19, 31].
In Arboix et al. study, the lacunar infarction was the only subtype that was inversely related to the LOS [27]. In another study, it has been concluded that lacunar infarcts are associated with shorter LOS but anterior or posterior circulatory infarcts with more days of hospitalization [3]. In our study, it was found that in the ischemic stroke, the location of the lesion had a significant relationship with the duration of hospitalization and the presence of a lesion in the MCA and PCA territories was accompanied by more days of hospitalization. It can be due to the feeding of wider areas of brain tissue by these arteries and more neurological manifestations, resulting in the need for more time to cure the symptoms. Moreover, the involvement of these areas in some cases is associated with a decrease in the level of consciousness and the severity of the stroke, with more disability, which requires longer LOS.
In the present study, the location of hemorrhage was not associated with the LOS, while in some studies the presence of hemorrhage in the cortical area was significantly associated with the duration of the patient’s stay in the hospital [27]. The reason for such a difference in results can be due to the low proportion of hemorrhagic stroke samples studied or to other accompanying features in these patients. In our study, no association was found between underlying diseases such as hyperlipidemia, hypertension, diabetes mellitus, or cardiac disease with duration of hospitalization. Saxena et al. and Curtain et al. also did not report such a relationship [3, 32]. But in studies conducted by Spurt et al. as well as Lee et al., diabetes mellitus and hypertension were the determinants for increasing LOS [7, 19]. In some studies, the presence of underlying heart disease, such as heart failure and valvular heart disease was associated with an increase in the LOS [27, 33].
In the present study, it was determined that the physician can be considered as factors influencing the LOS. Similar studies in this area are few. The present study, in line with the study by GÖz et al. and Arboix et al. indicate that LOS is associated with the occurrence of infectious complications [16, 27]. It seems that the cause and effect relationship in this case can be bilateral and creates a defective loop. Acute stroke can make patients susceptible to complications such as pneumonia, urinary tract infections, and bed sore [19]. On the other hand, the length of hospitalization can be shortened by reducing the infectious complications [34]. Early-care, patients’ monitoring, and encouraging the patients to start moving can prevent a lot of these complications.
Some studies have indicated that the type of patient’s insurance has a significant relationship with the average LOS in the hospital [5, 24]. While in our study, the type of insurance did not correlate with LOS. It seems that the implementation of the national plan for health system reform and the benefit of all patients from public health insurance can contribute in this finding.

Conclusion
Stroke management is an interdisciplinary expertise and no sacrifice in treatment quality is accepted.  Assessing the length of hospitalization and identifying its potential predictors can be useful in proper use of the resources and discharge of patients with stroke. Certain demographic and clinical characteristics of stroke patients associated with longer LOS were identified. These findings could improve planning, organizing, and reducing the cost of care.

Ethical Considerations
Compliance with ethical guidelines

This study approved by the Ethics Committee of Guilan University of Medical Sciences (GUMS) (ethical code: IR.GUMS.REC.1396.162).

Funding
This article is based on the results of the thesis of Maedeh Majidi Shad on General Medicine (registered thesis number:2067) sponsored by Guilan University of Medical Sciences.

Authors contributions
All authors contributed in preparing this article.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgements
We would like to thank the staff of the Neuroscience Research Center of Guilan University of Medical Sciences for their valuable efforts.




References
  1. World Health Organization. STEPS-Stroke manual (version 1.2): The WHO STEPwise approach to stroke surveillance. Geneva: World Health Organization; 2013.
  2. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics—2016 update: A report from the American Heart Association. Circulation. 2016; 133(4):e38-e360. h [DOI:10.1161/CIR.0000000000000366] [PMID]
  3. Saxena A, Prasad R, Verma K, Saxena S. Factors predicting length of hospital stay in acute stroke patients admitted in a rural tertiary care hospital. J Gerontol Geriatr Res S. 2016; 5:2. [DOI:10.4172/2167-7182.S5-003]
  4. Morris S, Hunter RM, Ramsay AI, Boaden R, McKevitt C, Perry C, et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: Difference-in-differences analysis. BMJ. 2014; 349:g4757. [DOI:10.1136/bmj.g4757] [PMID] [PMCID]
  5. Kim SM, Hwang SW, Oh EH, Kang JK. Determinants of the length of stay in stroke patients. Osong Public Health Res Perspect. 2013; 4(6):329-41. [DOI:10.1016/j.phrp.2013.10.008] [PMID] [PMCID]
  6. Kwok C, Clark A, Musgrave S, Potter J, Dalton G, Day D, et al. The SOAR stroke score predicts hospital length of stay in acute stroke: an external validation study. Int J Clin Pract Suppl. 2015; 69(6):659-65. [DOI:10.1111/ijcp.12577] [PMID]
  7. Spratt N, Wang Y, Levi C, Ng K, Evans M, Fisher J. A prospective study of predictors of prolonged hospital stay and disability after stroke. J Clin Neurosci. 2003; 10(6):665-9. [DOI:10.1016/j.jocn.2002.12.001] [PMID]
  8. Somerford PJ, Lee AH, Yau KK. Ischemic stroke hospital stay and discharge destination. Ann Epidemiol. 2004; 14(10):773-7. [DOI:10.1016/j.annepidem.2004.02.003] [PMID]
  9. Seet RC, Lim EC, Chan Y, Chan BP, Quek AM, Ong BK. Can demographic and admission laboratory variables be useful to identify long-stay patients with acute ischemic stroke? A hospital-based cohort study in Singapore. Neurol Sci. 2009; 30(4):275-80. [DOI:10.1007/s10072-009-0084-0] [PMID]
  10. Lim JH, Cheon SH. Analysis of variation in length of stay (LOS) after ischemic and hemorrhagic stroke using the Charlson Comorbidity Index (CCI). J Phys Ther Sci. 2015; 27(3):799-803. [DOI:10.1589/jpts.27.799] [PMID] [PMCID]
  11. Martin S, Smith P. Explaining variations in inpatient length of stay in the National Health Service.J Health Econ. 1996; 15(3):279-304. [DOI:10.1016/0167-6296(96)00003-3]
  12. McMullan R, Silke B, Bennett K, Callachand S. Resource utilisation, length of hospital stay, and pattern of investigation during acute medical hospital admission. Postgrad Med J. 2004; 80(939):23-6. [DOI:10.1136/pmj.2003.007500] [PMID] [PMCID]
  13. Clarke A. Length of in-hospital stay and its relationship to quality of care. BMJ Qual Saf. 2002; 11(3):209-10. [DOI:10.1136/qhc.11.3.209] [PMCID]
  14. Hashemi-Fard A, Saffari S, Adnan R. [Analysis of hospitalization length for cerebrovascular accident patients in Sabzevar Vaseyee hospital using count regression models (Persian)]. Daneshvar Med. 2014; 21(109):17-24. 
  15. Kang JH, Bae HJ, Choi YA, Lee SH, Shin HI. Length of hospital stay after stroke: A Korean nationwide study. Ann Rehabil Med. 2016; 40(4):675-81.
  16. Göz E, Kahraman T, Genc A, Kaya Ö, Öztürk V, Kutluk K. [Factors affecting hospital length of stay among patients with acute stroke (Turkish)]. J Neurol Sci. 2017; 34(2):143-52.
  17. Chang KC, Tseng MC. Costs of acute care of first-ever ischemic stroke in Taiwan. Stroke. 2003; 34(11):e219-e21. [DOI:10.1161/01.STR.0000095565.12945.18] [PMID]
  18. Svendsen ML, Ehlers LH, Andersen G, Johnsen SP. Quality of care and length of hospital stay among patients with stroke. Med Care. 2009; 47(5):575-82. [DOI:10.1097/MLR.0b013e318195f852] [PMID]
  19. Lee HC, Chang KC, Lan CF, Hong CT, Huang YC, Chang ML. Factors associated with prolonged hospital stay for acute stroke in Taiwan. Acta Neurol Taiwan. 2008; 17(1):17-25. [PMID]
  20. Adler R, MacRitchie K, Engel GL. Psychologic processes and ischemic stroke (occlusive cerebrovascular disease): I. observations on 32 men with 35 Strokes. Psychosom Med. 1971; 33(1):1-30. [DOI:10.1097/00006842-197101000-00001] [PMID]
  21. Meer J, Rosen HS. Insurance and the utilization of medical services. Soc Sci Med. 2004; 58(9):1623-32. [DOI:10.1016/S0277-9536(03)00394-0]
  22. Liu Y, Phillips M, Codde J. Factors influencing patients’ length of stay. Aust Health Rev. 2001; 24(2):63-70. [DOI:10.1071/AH010063] [PMID]
  23. Lang PO, Zekry D, Michel JP, Drame M, Novella JL, Jolly D, et al. Early markers of prolonged hospital stay in demented inpatients: A multicentre and prospective study. J Nutr Health Aging. 2010; 14(2):141-7. [DOI:10.1007/s12603-009-0182-y]
  24. Arab M, Zarei A, Rahimi A, Rezaiean F, Akbari F. [Analysis of factors affecting length of stay in public hospitals in Lorestan province, Iran (Persian)]. Hakim Res J. 2010; 12(4):27-32.
  25. Akbari Sari A, Rezaei S, Arab M, Karami Matin B, Majdzadeh R. Does smoking status affect cost of hospitalization? Evidence from three main diseases associated with smoking in Iran. Med J Islam Repub Iran. 2017; 31(1):363-7. [DOI:10.14196/mjiri.31.63] [PMID] [PMCID]
  26. Hvidtfeldt UA, Rasmussen S, Gronbaek M, Becker U, Tolstrup JS. Influence of smoking and alcohol consumption on admissions and duration of hospitalization. Eur J Public Health. 2010; 20(4):376-82. [DOI:10.1093/eurpub/ckp153] [PMID]
  27. Arboix A, Massons J, García-Eroles L, Targa C, Oliveres M, Comes E. Clinical predictors of prolonged hospital stay after acute stroke: Relevance of medical complications. Int J Clin Med. 2012; 3(6):Article:24547. [DOI:10.4236/ijcm.2012.36090]
  28. Li Y, Liu H, Wang J, Li Y, Yu GP, Ma XM, et al. Variable lengths of stay among ischemic stroke subtypes in Chinese general teaching hospitals. PLoS One. 2012; 7(9):e45101. [DOI:10.1371/journal.pone.0045101] [PMID] [PMCID]
  29. George AJ, Boehme AK, Siegler JE, Monlezun D, Fowler BD, Shaban A, et al. Hospital-acquired infection underlies poor functional outcome in patients with prolonged length of stay. ISRN stroke. 2013; 2013.
  30. Koton S, Bornstein N, Tsabari R, Tanne D, Investigators N. Derivation and validation of the prolonged length of stay score in acute stroke patients. Neurology. 2010; 74(19):1511-6. [DOI:10.1212/WNL.0b013e3181dd4dc5] [PMID]
  31. Kwok CS, Clark A, Ford GA, Durairaj R, Dixit AK, Davis J, et al. Association between prestroke disability and inpatient mortality and length of acute hospital stay after acute stroke. J Am Geriatr Soc. 2012; 60(4):726-32. [DOI:10.1111/j.1532-5415.2011.03889.x] [PMID]
  32. Curtain JP, Yu M, Clark AB, Gollop ND, Bettencourt-Silva JH, Metcalf AK, et al. Determinants of length of stay following total anterior circulatory stroke. Geriatrics. 2017; 2(3):26. [DOI:10.3390/geriatrics2030026]
  33. Qureshi AI, Adil MM, Zacharatos H, Suri MFK. Factors associated with length of hospitalization in patients admitted with transient ischemic attack in United States. Stroke. 2013; 44(6):1601-5. [DOI:10.1161/STROKEAHA.111.000590] [PMID]
  34. Huang YC, Hu CJ, Lee TH, Yang JT, Weng HH, Lin LC, et al. The impact factors on the cost and length of stay among acute ischemic stroke. J Stroke Cerebrovasc Dis. 2013; 22(7):e152-e8. [DOI:10.1016/j.jstrokecerebrovasdis.2012.10.014] [PMID]
Type of Study: Research | Subject: Special
Received: 2018/03/13 | Accepted: 2018/08/23 | Published: 2018/10/1

References
1. d Health Organization. STEPS-Stroke manual (version 1.2): The WHO STEPwise approach to stroke surveillance. Geneva: World Health Organization; 2013.
2. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics—2016 update: A report from the American Heart Association. Circulation. 2016; 133(4):e38-e360. h [DOI:10.1161/CIR.0000000000000366] [PMID] [DOI:10.1161/CIR.0000000000000366]
3. Saxena A, Prasad R, Verma K, Saxena S. Factors predicting length of hospital stay in acute stroke patients admitted in a rural tertiary care hospital. J Gerontol Geriatr Res S. 2016; 5:2. [DOI:10.4172/2167-7182.S5-003] [DOI:10.4172/2167-7182.S5-003]
4. Morris S, Hunter RM, Ramsay AI, Boaden R, McKevitt C, Perry C, et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: Difference-in-differences analysis. BMJ. 2014; 349:g4757. [DOI:10.1136/bmj.g4757] [PMID] [PMCID] [DOI:10.1136/bmj.g4757]
5. Kim SM, Hwang SW, Oh EH, Kang JK. Determinants of the length of stay in stroke patients. Osong Public Health Res Perspect. 2013; 4(6):329-41. [DOI:10.1016/j.phrp.2013.10.008] [PMID] [PMCID] [DOI:10.1016/j.phrp.2013.10.008]
6. Kwok C, Clark A, Musgrave S, Potter J, Dalton G, Day D, et al. The SOAR stroke score predicts hospital length of stay in acute stroke: an external validation study. Int J Clin Pract Suppl. 2015; 69(6):659-65. [DOI:10.1111/ijcp.12577] [PMID] [DOI:10.1111/ijcp.12577]
7. Spratt N, Wang Y, Levi C, Ng K, Evans M, Fisher J. A prospective study of predictors of prolonged hospital stay and disability after stroke. J Clin Neurosci. 2003; 10(6):665-9. [DOI:10.1016/j.jocn.2002.12.001] [PMID] [DOI:10.1016/j.jocn.2002.12.001]
8. Somerford PJ, Lee AH, Yau KK. Ischemic stroke hospital stay and discharge destination. Ann Epidemiol. 2004; 14(10):773-7. [DOI:10.1016/j.annepidem.2004.02.003] [PMID] [DOI:10.1016/j.annepidem.2004.02.003]
9. Seet RC, Lim EC, Chan Y, Chan BP, Quek AM, Ong BK. Can demographic and admission laboratory variables be useful to identify long-stay patients with acute ischemic stroke? A hospital-based cohort study in Singapore. Neurol Sci. 2009; 30(4):275-80. [DOI:10.1007/s10072-009-0084-0] [PMID] [DOI:10.1007/s10072-009-0084-0]
10. Lim JH, Cheon SH. Analysis of variation in length of stay (LOS) after ischemic and hemorrhagic stroke using the Charlson Comorbidity Index (CCI). J Phys Ther Sci. 2015; 27(3):799-803. [DOI:10.1589/jpts.27.799] [PMID] [PMCID] [DOI:10.1589/jpts.27.799]
11. Martin S, Smith P. Explaining variations in inpatient length of stay in the National Health Service.J Health Econ. 1996; 15(3):279-304. [DOI:10.1016/0167-6296(96)00003-3] [DOI:10.1016/0167-6296(96)00003-3]
12. McMullan R, Silke B, Bennett K, Callachand S. Resource utilisation, length of hospital stay, and pattern of investigation during acute medical hospital admission. Postgrad Med J. 2004; 80(939):23-6. [DOI:10.1136/pmj.2003.007500] [PMID] [PMCID] [DOI:10.1136/pmj.2003.007500]
13. Clarke A. Length of in-hospital stay and its relationship to quality of care. BMJ Qual Saf. 2002; 11(3):209-10. [DOI:10.1136/qhc.11.3.209] [PMCID] [DOI:10.1136/qhc.11.3.209]
14. Hashemi-Fard A, Saffari S, Adnan R. [Analysis of hospitalization length for cerebrovascular accident patients in Sabzevar Vaseyee hospital using count regression models (Persian)]. Daneshvar Med. 2014; 21(109):17-24.
15. Kang JH, Bae HJ, Choi YA, Lee SH, Shin HI. Length of hospital stay after stroke: A Korean nationwide study. Ann Rehabil Med. 2016; 40(4):675-81. [DOI:10.5535/arm.2016.40.4.675] [PMID] [PMCID]
16. Göz E, Kahraman T, Genc A, Kaya Ö, Öztürk V, Kutluk K. [Factors affecting hospital length of stay among patients with acute stroke (Turkish)]. J Neurol Sci. 2017; 34(2):143-52.
17. Chang KC, Tseng MC. Costs of acute care of first-ever ischemic stroke in Taiwan. Stroke. 2003; 34(11):e219-e21. [DOI:10.1161/01.STR.0000095565.12945.18] [PMID] [DOI:10.1161/01.STR.0000095565.12945.18]
18. Svendsen ML, Ehlers LH, Andersen G, Johnsen SP. Quality of care and length of hospital stay among patients with stroke. Med Care. 2009; 47(5):575-82. [DOI:10.1097/MLR.0b013e318195f852] [PMID] [DOI:10.1097/MLR.0b013e318195f852]
19. Lee HC, Chang KC, Lan CF, Hong CT, Huang YC, Chang ML. Factors associated with prolonged hospital stay for acute stroke in Taiwan. Acta Neurol Taiwan. 2008; 17(1):17-25. [PMID] [PMID]
20. Adler R, MacRitchie K, Engel GL. Psychologic processes and ischemic stroke (occlusive cerebrovascular disease): I. observations on 32 men with 35 Strokes. Psychosom Med. 1971; 33(1):1-30. [DOI:10.1097/00006842-197101000-00001] [PMID] [DOI:10.1097/00006842-197101000-00001]
21. Meer J, Rosen HS. Insurance and the utilization of medical services. Soc Sci Med. 2004; 58(9):1623-32. [DOI:10.1016/S0277-9536(03)00394-0] [DOI:10.1016/S0277-9536(03)00394-0]
22. Liu Y, Phillips M, Codde J. Factors influencing patients' length of stay. Aust Health Rev. 2001; 24(2):63-70. [DOI:10.1071/AH010063] [PMID] [DOI:10.1071/AH010063]
23. Lang PO, Zekry D, Michel JP, Drame M, Novella JL, Jolly D, et al. Early markers of prolonged hospital stay in demented inpatients: A multicentre and prospective study. J Nutr Health Aging. 2010; 14(2):141-7. [DOI:10.1007/s12603-009-0182-y] [DOI:10.1007/s12603-009-0182-y]
24. Arab M, Zarei A, Rahimi A, Rezaiean F, Akbari F. [Analysis of factors affecting length of stay in public hospitals in Lorestan province, Iran (Persian)]. Hakim Res J. 2010; 12(4):27-32.
25. Akbari Sari A, Rezaei S, Arab M, Karami Matin B, Majdzadeh R. Does smoking status affect cost of hospitalization? Evidence from three main diseases associated with smoking in Iran. Med J Islam Repub Iran. 2017; 31(1):363-7. [DOI:10.14196/mjiri.31.63] [PMID] [PMCID] [DOI:10.14196/mjiri.31.63]
26. Hvidtfeldt UA, Rasmussen S, Gronbaek M, Becker U, Tolstrup JS. Influence of smoking and alcohol consumption on admissions and duration of hospitalization. Eur J Public Health. 2010; 20(4):376-82. [DOI:10.1093/eurpub/ckp153] [PMID] [DOI:10.1093/eurpub/ckp153]
27. Arboix A, Massons J, García-Eroles L, Targa C, Oliveres M, Comes E. Clinical predictors of prolonged hospital stay after acute stroke: Relevance of medical complications. Int J Clin Med. 2012; 3(6):Article:24547. [DOI:10.4236/ijcm.2012.36090] [DOI:10.4236/ijcm.2012.36090]
28. Li Y, Liu H, Wang J, Li Y, Yu GP, Ma XM, et al. Variable lengths of stay among ischemic stroke subtypes in Chinese general teaching hospitals. PLoS One. 2012; 7(9):e45101. [DOI:10.1371/journal.pone.0045101] [PMID] [PMCID] [DOI:10.1371/journal.pone.0045101]
29. George AJ, Boehme AK, Siegler JE, Monlezun D, Fowler BD, Shaban A, et al. Hospital-acquired infection underlies poor functional outcome in patients with prolonged length of stay. ISRN stroke. 2013; 2013.
30. Koton S, Bornstein N, Tsabari R, Tanne D, Investigators N. Derivation and validation of the prolonged length of stay score in acute stroke patients. Neurology. 2010; 74(19):1511-6. [DOI:10.1212/WNL.0b013e3181dd4dc5] [PMID] [DOI:10.1212/WNL.0b013e3181dd4dc5]
31. Kwok CS, Clark A, Ford GA, Durairaj R, Dixit AK, Davis J, et al. Association between prestroke disability and inpatient mortality and length of acute hospital stay after acute stroke. J Am Geriatr Soc. 2012; 60(4):726-32. [DOI:10.1111/j.1532-5415.2011.03889.x] [PMID] [DOI:10.1111/j.1532-5415.2011.03889.x]
32. Curtain JP, Yu M, Clark AB, Gollop ND, Bettencourt-Silva JH, Metcalf AK, et al. Determinants of length of stay following total anterior circulatory stroke. Geriatrics. 2017; 2(3):26. [DOI:10.3390/geriatrics2030026] [DOI:10.3390/geriatrics2030026]
33. Qureshi AI, Adil MM, Zacharatos H, Suri MFK. Factors associated with length of hospitalization in patients admitted with transient ischemic attack in United States. Stroke. 2013; 44(6):1601-5. [DOI:10.1161/STROKEAHA.111.000590] [PMID] [DOI:10.1161/STROKEAHA.111.000590]
34. Huang YC, Hu CJ, Lee TH, Yang JT, Weng HH, Lin LC, et al. The impact factors on the cost and length of stay among acute ischemic stroke. J Stroke Cerebrovasc Dis. 2013; 22(7):e152-e8. [DOI:10.1016/j.jstrokecerebrovasdis.2012.10.014] [PMID] [DOI:10.1016/j.jstrokecerebrovasdis.2012.10.014]

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