Hospital Utilization for Coronary Artery Disease, 1997–2014 : Journal of Cardiovascular Nursing

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Hospital Utilization for Coronary Artery Disease, 1997–2014

Shakya, Shamatree MGS, RN; Cary, Michael P. PhD, RN, FAAN

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The Journal of Cardiovascular Nursing ():10.1097/JCN.0000000000000965, December 30, 2022. | DOI: 10.1097/JCN.0000000000000965
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Coronary artery disease (CAD) involves inflammatory changes and the building of plaques in the coronary arteries, eventually compromising blood supply to the heart.1 Coronary artery disease is linked with adverse cardiovascular events such as myocardial infarction, cerebral infarction,2,3 cognitive impairment, dementia,4 premature mortality,5 and postoperative complications, including prolonged ventilation and intensive care unit stays, atrial fibrillation, and cerebrovascular accidents.6 Approximately 15.5 million adults (≥20 years old) in the United States are inflicted by CAD.7 Coronary artery disease is one of the most common conditions for emergency department visits in the United States.8 The care related to CAD is costly, and it ascribes to $219-billion healthcare cost annually due to either the use of healthcare services or the loss of productivity.9 The burden on the healthcare system incurred due to CAD is projected to increase with the rapid growth of the aging population.8

In the United States, nationwide public health programs and agendas such as Healthy People 2000 and 2010 were formulated and implemented from the beginning of the 1990s10 to promote cardiovascular health and curb cardiovascular disease at the population level. At the same time, several payment reforms were initiated in the late 1990s to curtail acute hospital expenditure and promote the use of cost-effective postacute services. In addition, the Affordable Healthcare Act enacted in 2010 expanded healthcare coverage for various chronic conditions, including cardiovascular diseases, to promote cardiovascular health and disease prevention.11–13 These national policies and strategies can influence the healthcare utilization among patients with CAD.11

Previous studies have shown that the national trends of the emergency department use are decreasing in patients with CAD.11 Wide disparities have been documented in terms of the services and quality of care provided to patients with CAD.14 However, information on the trends of inpatient hospital utilization among patients with CAD is lacking. Therefore, there is a need to examine the trends of inpatient hospital care utilization for CAD stratified by gender, age group, insurance status, hospital ownership, and geographical location to infer the impact of policy and payment reforms.

This study aims to address this gap and investigate the trends of inpatient hospital use including length of hospital stays, mean hospital charges, and discharge outcomes for CAD and the variation in the inpatient hospital use by gender, age, insurance status, hospital ownership, and geographical location. In this study, the National Inpatient Sample (NIS), a large national data set of inpatient hospital stays, was used to examine trends in hospital utilization for CAD between 1997 and 2014 post public health and payment reforms. This study aims to answer these research questions: (a) how did the trends of inpatient hospital use related to CAD change over 17 years, and (b) how did the trends of costs and discharge outcomes associated with CAD change over 17 years?


This is a retrospective longitudinal study. The data for this study came from the NIS, which is funded by the Agency for Healthcare Research and Quality. The NIS is part of the Healthcare Utilization Project (HCUPnet) databases and is publicly available containing information on regional and national inpatient utilization, access, charges, quality, and outcomes based on the billing data presented by hospitals and statewide data organizations across the United States.15,16 The NIS is nationally representative of all community hospitals, and it includes all the patients from each hospital, irrespective of their insurance payment status.17 The inclusion criteria for this study are admission to inpatient hospitals with the diagnosis of CAD (International Classification of Diseases, Ninth Revision code 414.00). The search was restricted between 1997 and 2014 to maintain the consistency of coding for CAD as per International Classification of Diseases, Ninth Revision standards. This study does not include data from 2015 onwards because the revised coding for CAD as per International Classification of Diseases, Tenth Revision standards (introduced in 2015) does not match the International Classification of Diseases, Ninth Revision standard.


The operational definitions of constructs of interest for this study are as follows: (a) length of stay (LOS) is the number of nights spent in the hospital to receive care after being admitted to the hospital unit for CAD; (b) the charge is the amount of US dollars charged for using hospital services, excluding physician services; (c) discharge is the unit of analysis for HCUPnet, and discharges are number of cases with CAD who were admitted and discharged from the hospital; (d) discharge status is the discharge disposition post hospital stay, which can be either home, short-term hospital, nursing home, home healthcare, or leave against medical advice; and (e) inpatient mortality represents the number of patients who died in the hospital after admission from the emergency department per 10 000 admitted patients.

Data Analysis

An online query system available on the HCUPnet website was used to evaluate the trends of inpatient service utilization among patients given a diagnosis of CAD between 1997 and 2014.16,17 The unit of analysis was the discharge.16,18 Trends data were extracted, aggregated, cleaned, and examined for trends in the Excel spreadsheet. Data on number of discharges, LOS, hospital charges, inpatient hospital mortality, and discharge destination were stratified by each year. A descriptive summary and trends of number of discharges, LOS, hospital charges, inpatient hospital mortality, and discharge destination between 1997 and 2014 are described in the Results section.16


Table 1 shows the utilization of inpatient hospital services for CAD, stratified by year from 1997 to 2014. During this period, an estimated total of 1 333 996 discharges were reported for the patients given a diagnosis of CAD. The total discharge for CAD was 107 625 in 1997, followed by a dip in 1999 (102 625). The annual discharges increased gradually and peaked in the year 2001 (n = 115 855); then, there was a gradual decline in the total discharge in 2014 (27 020). As shown in Figure 1, the trends of inpatient service use for CAD by age groups, remained consistently higher for 65–84 years, followed by 45–64 years, 85 years and above, and 18–44 years. The highest cases admitted and discharged were between 65 and 84 years old (n = 707 492), followed by 45 to 64 years old (n = 445 713), 85 years and older (n = 113 722), and 18 to 44 years old (n = 48 687). During this period, the total number of cases admitted and discharged were men (n = 758 171) relative to women (n = 541 871). The trends of inpatient hospital service use for CAD stratified by insurance type show that the total number of cases admitted and discharged for CAD remained consistently higher for Medicare beneficiaries and lower among those with unspecified payer status, as shown in Figure 2. The total number of cases admitted and discharged for CAD was greatest among Medicare beneficiaries (n = 862 574) and lowest among those with unspecified payer status (n = 29 531).

Acute care use for coronary artery disease stratified by age groups between 1997 and 2014.
TABLE 1 - Inpatient Service Use for Coronary Artery Disease Stratified by Year, 1997–2014
Variable Year
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Total no. discharges 107 247 107 245 102 626 111 285 115 855 109 841 94 745 91 516 76 549 70 787 61 814 57 132 51 931 41 260 40 489 36 320 30 335 27 020
Mean LOS, d 3.2 3.06 2.9 2.9 2.8 2.9 2.7 2.7 2.8 2.7 2.7 2.8 2.8 2.7 2.7 2.8 2.9 3.3
Mean charges in US $ 9100 9731 10 425 10 500 11 881 14 151 15 069 16 496 18 063 20 120 22 220 26 920 27 492 29 908 33 509 36 860 44 606 49 643
In-hospital deaths (death rate per 10 000) 5962 6392 5487 5785 5427 4809 4411 4709 3951 5107 4821 7235 4885 5801 7219 7296 9725 7217
Routine discharge 73 587 73 206 69 175 75 218 79 534 76 323 65 755 62 558 51 357 47 264 43 395 40 412 36 952 28 962 28 944 27 010 22 150 19 640
Another short-term hospital 20 118 21 713 22 166 24 034 23 693 21 712 17 974 17 533 14 212 13 245 9819 8074 7835 5704 5061 3515 2840 2295
Another institution (nursing home, rehabilitation) 6456 6104 5473 5704 6304 5699 5221 4970 4795 4437 3997 3672 2897 2588 2503 2125 1890 1755
Home healthcare 4921 4223 4050 4406 4181 3918 3865 4559 4563 4108 3415 3575 3018 2938 2912 2795 2670 2530
Against medical advice 1468 1282 1165 1263 1410 1551 1414 1368 1284 1336 849 946 916 757 723 605 485 550
Source: HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD: Agency for Healthcare Research and Quality. For more information about HCUP data, see
Abbreviation: LOS, length of stay.

As shown in Table 1, the mean length of hospital stay remained consistent around 3 days between 1997 and 2014. In 2014, the mean LOS was the longest for those aged 65 to 84 years (3.5 days), whereas the mean LOS was shortest for those 18 to 44 years old and older than 85 years (approximately 3 days for both age groups). In 2014, the Medicaid beneficiaries (4.2 days) experienced the longest stay in the hospital, whereas the LOS was shorter (2.7 days) for those with unspecified payer status. The length of hospital stays among patients with CAD in rural and urban locations remained relatively similar (3–3.5 days) during this time.

The mean hospital charges increased remarkably during this period. The mean hospital charge increased more than 5 times from $9100 in 1997 to $49 643 in 2014 (see Table 1). The mean hospital charges were comparably higher among those with private insurance relative to those with unspecified payer status, as shown in Table 2. Similarly, the mean hospital charges remained relatively higher for the private (for-profit) hospital in comparison with government and not-for-profit hospitals, as shown in Table 2. Finally, the hospitals in the urban location observed higher mean charges compared with those in the rural location. Both urban and rural hospitals experienced a sharp rise in mean hospital charges in the year 2001 ($76 044 and $39 811, respectively), followed by a decline in 2002 ($17 132 and $7339, respectively); the mean charges gradually increased until the year 2014 ($51 666 and $25 548, respectively, in the rural and urban locations).

Acute care use for coronary artery disease stratified by insurance type between 1997 and 2014.
TABLE 2 - Trends in Mean Charges for Patients With Coronary Artery Disease Stratified by Year, 1997–2014
Variable Year
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Insurance type
 Medicare 8684 9217 9755 10 083 10 083 13 745 14 405 16 009 17 567 21 622 26 274 26 274 26 636 29 805 32 022 36 557 44 288 48 706
 Medicaid 10 156 10 242 10 695 12 511 12 511 15 095 16 490 16 630 17 608 22 096 25 260 25 260 25 890 28 422 32 925 36 348 43 345 50 520
 Private insurance 9920 10 994 12 080 11 337 11 337 15 590 16 856 17 926 20 230 24 774 29 902 29 901 32 063 32 006 39 959 38 972 47 122 54 511
 Uninsured 8634 9170 9644 8523 8523 11 585 13 973 18 659 16 912 19 391 24 101 24 101 22 844 27 612 32 798 30 593 42 594 45 876
 Other 9511 10 067 10 427 11 466 11 467 12 871 15 522 14 298 16 370 21 371 26 851 26 851 28 285 27 506 35 075 42 280 42 994 43 509
Hospital ownership
 Government 7284 7350 8154 9780 18 004 10 185 11 263 11 676 14 299 13 356 17 929 23 124 18 602 24 427 24 060 28 223 36 448 42 366
 Private, not-for-profit 9048 10 285 10 249 10 254 81 763 14 834 15 556 16 914 18 498 20 467 21 778 26 942 27 237 28 803 32 769 34 781 41 640 45 494
 Private, for-profit 10 739 9615 12 965 12 103 16 087 15 072 16 841 19 379 19 109 25 802 28 529 30 241 33 564 38 483 42 597 49 648 59 927 68 973
Geographical location
 Rural 4912 5124 5795 6132 39 811 7339 7769 9853 9254 10 367 12 888 13 598 14 463 15 585 17 234 29 339 24 891 25 550
 Urban 11 036 11 808 12 392 12 740 76 044 17 132 18 045 19 640 21 650 23 530 25 180 30 635 30 823 33 418 376 912 34 600 48 000 51 666
Source: HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD: Agency for Healthcare Research and Quality. For more information about HCUP data, see

The total number of routine discharges from the hospital for CAD cases decreased from 1997 (n = 107 247) to 2014 (n = 27 020). The post-discharge destinations show the total number of cases referred to short-term hospitals fell from 20 118 in 1997 to 2295 in 2014. Similarly, the total number of cases going to rehabilitation and nursing homes declined from 6456 in 1997 to 1755 in 2014. The number of cases receiving home health care decreased from 4921 in 1997 to 2530 in 2014. The overall number of inpatient hospital deaths rose from 5962 in 1997 to 7217 per 10 000 in 2014, with fluctuation in between. In 2014, the mortality rate was higher for males (7717 per 10 000 persons) in comparison to females (6968 per 10 000 persons). The percentages have been replaced with numbers to correspond with the information in the Table 1. In terms of mortality, the mortality rate fluctuated between 1997 and 2014. The in-hospital deaths gradually decreased from 5961 in 1997 to 3951 per 10 000 persons in 2005. This was followed by a substantial increase in the death rate to 9725 per 10 000 in 2013, and the inpatient death rate fell to 7217 per 10 000 in 2014. In 2014, the mortality rate was higher for men (7717 per 10 000 persons) in comparison with women (6968 per 10 000 persons).


There was a wide variation in the inpatient hospital utilization for CAD across the United States by gender, age, insurance, hospital ownership, and geographical location. The change in the utilization of inpatient care may be due to the implementation of public health reforms for the promotion of cardiovascular health at the population level and the implementation of payment reforms.

During this period from the year 1997 to 2014, the total number of discharges declined for CAD cases. This finding is consistent with past studies, which showed decreasing trends of inpatient hospitalization11,19 and discharge in patients with CAD.19 A greater number of patients admitted and discharged for CAD were older and middle aged, and men. Most patients with CAD who were admitted and discharged during this time had Medicare and private insurance. The overall inpatient deaths due to CAD increased during this time. This fall in annual discharge could be due to the overall decreasing trends in the prevalence of CAD in the United States.20 The decrease in the overall prevalence of cardiovascular disease might be due to the implementation of nationwide public health programs and policies targeted at preventing cardiovascular diseases at the community level.21 Healthy People 2000 was first initiated in 1990 by the US Department of Health and Human Services with the objectives of reducing cardiovascular risk factors at the population level, expanding the health services for early detection and management of cardiovascular disease, and reducing health disparities.21 In 2000, this program was revised and followed by another nationwide program, the Healthy People 2010.10 In addition to this, in 2002, the Centers for Disease Control and Prevention sponsored the Heart Disease and Stroke Prevention Program to prevent cardiovascular risk factors and the onset of cardiovascular disease and mitigate the adverse outcomes in 29 US states.22 These findings indicate that health programs implemented for the primary prevention of cardiovascular diseases may successfully prevent and reduce CAD-related hospital use and influence inpatient deaths.

The mean hospital charges increased drastically during this period. Our findings suggest that soaring health care costs may discourage the use of inpatient hospital services for CAD in the early stage when the disease is manageable. As a result, CAD patients may be admitted to hospitals in chronic, severe stages requiring more advanced treatment. The aggressive treatment provided at the critical phase may be more expensive, but may not improve health outcomes in CAD patients. Thus, the rise in inpatient deaths, parallel with the escalation of hospital expenditure, suggests that surging health care costs may not guarantee an improvement in health care quality and outcomes. These findings corroborate with several past studies that show hospital care costs are substantially rising for cardiovascular diseases.23,24 The rise in the inpatient hospital charges might be due to inflation and other patient factors, such as the presence of coexisting comorbid conditions and emotional distress, and hospital readmission.23–25 The increase in inpatient hospital charges may be responsible for an early discharge to posthospital facilities. The mean inpatient hospital charges were substantially higher among those with private insurance relative to those with Medicare and Medicaid payer status. The inpatient hospital charges under Medicare and Medicaid payment systems are regulated by the Centers for Medicare & Medicaid Services, which has enacted payment reforms and fees for various in-service procedures and care.26 In contrast, private health plans negotiate with the hospitals to set prices for in-service procedures and care through the process of contract negotiation, which might have attributed to greater hospital charges for those with private insurance plans.26 In addition, there was a huge difference in inpatient hospital charges for CAD cases in hospitals located at rural and urban locations. This finding may suggest the differences in the availability of treatment and care options for CAD in rural and urban hospitals. A systematic study showed that patients with stroke who receive inpatient hospital care in urban locations have more access to advanced treatment options, including thrombolysis therapy, evidence-based care, diagnostic interventions, and skilled care providers.27 Similarly, the mean hospital charges remained relatively higher for private/for-profit hospitals compared with government and not-for-profit hospitals, which is consistent with the existing studies.28 This variation in hospital charges can be due to differences in charge rates for diagnostic procedures and treatment provided in government versus proprietary hospitals.29

These findings indicate several policy and clinical implications. The findings suggest that public health programs targeted against cardiovascular disease might be effective in reducing CAD cases, which in turn, reduce inpatient hospital utilization. Future policies should emphasize secondary and tertiary prevention of cardiovascular disease, including prevention of cardiovascular adverse health outcomes. The payment reforms should also focus on regulating diagnostic procedure charges that can also contribute to inpatient hospital charges. The existing payment reforms seem to encourage CAD cases to be discharged early from the hospital to postacute facilities to curtail inpatient expenditure and LOS. This means that patients with CAD discharged to posthospital settings might require more care and support; thus, healthcare providers at posthospital settings should be well equipped in providing cardiac rehabilitation and other care support. At the same time, it is essential that the quality of care is not compromised during the hospital stay. Therefore, proper measures should be in place to evaluate whether the hospitals have adhered to care guidelines set by the regulating bodies while delivering care to patients with CAD.

Future research should use data sets, such as Medicare claims/Medical Expenditure Panel Study, that can provide richer insights into patient-level factors influencing the use of inpatient hospital services for patients with CAD. If possible, future studies should follow the panel of patients with CAD using a longitudinal study design to examine individual characteristics associated with inpatient hospital utilization. Future research should also possibly account for the covariates such as sociodemographics, health beliefs, and comorbidities that might affect inpatient hospital utilization among patients with CAD.

Although this study used large representative data to examine the difference in the utilization of inpatient hospital services for CAD, the findings should be considered carefully in light of limitations. First, findings are based on crude estimates of variables and may not indicate exact figures. This is a descriptive study, and no statistical analyses were performed to infer relationships among variables or control for confounders; thus, the causal inference could not be established. As the unit of analysis is discharge, specific patients with CAD were not examined. Therefore, despite being a longitudinal study, outcomes were examined among different patients, and a cohort of patients with CAD was not followed longitudinally. Because of a large number of missing values, the analyses of LOSs, mean hospital charges, and discharge outcomes could not be stratified by each age group, gender, insurance type, and hospital locations. Finally, the HCUPnet data only includes data from community hospitals; thus, the findings from this study may not represent all hospitals in the US.


The total charges for CAD rose substantially despite the consistent length of hospital stay and a decreasing number of discharges between 1997 and 2014. During this time, the percentage of routine discharge to homes without care, home healthcare, and rehabilitation facilities increased, whereas the discharge to other short-term hospitals reduced. Given the shortened LOS in hospital and raised hospital charges, it is important to promote cardiac rehabilitation care in posthospital settings.

What’s New and Important

  • Acute care utilization in CAD was highest among men, middle-aged and older adults, and Medicare and Medicaid beneficiaries.
  • A total number of discharges decreased, meanwhile hospital charges increased substantially by 445.5% during this period. This figure raises a critical issue regarding the affordability and accessibility of inpatient hospital care use among patients with CAD.
  • The total LOS remained consistent; however, more patients were being discharged to postacute care settings, indicating a pressing need to train healthcare providers working in community settings about advanced cardiac rehabilitation skills.
  • More studies are needed to understand how inpatient hospital service utilization varies by individual characteristic and comorbidities.


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charge; coronary artery disease; discharge; inpatient

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