{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T05:54:38Z","timestamp":1781848478227,"version":"3.54.5"},"reference-count":36,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T00:00:00Z","timestamp":1781827200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Intracerebral hemorrhage (ICH) imposes a substantial burden on inpatient resources, yet hospital costs and length of stay (LOS) are often evaluated as separate endpoints. This study aimed to identify interpretable clinical-administrative strata and recurrent high-utilization care patterns among spontaneous ICH hospitalizations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This single-center retrospective cohort study included 1,851 spontaneous ICH hospitalizations from 5 November 2022 to 31 October 2024. Clustering variables were restricted to age, admission source, diagnosis-derived hemorrhage-location category, primary ventricular hemorrhage\/intraventricular extension, hypertension-coded status, diabetes, and chronic kidney disease\/renal failure. Cost-composition ratios, total cost, LOS, procedures, discharge disposition, departments, and acute in-hospital complications were excluded from cluster formation and reserved for descriptive analyses, adjusted modeling, or association-rule mining. Gower dissimilarities with k-medoids clustering were evaluated across K = 2\u20138 using elbow analysis, average silhouette coefficient, permutation-based gap statistic, subsampling stability, cluster size, clinical interpretability, and parsimony.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The\n                      <jats:italic>K<\/jats:italic>\n                      = 3 solution was retained as the parsimonious working solution, with the highest average silhouette coefficient among\n                      <jats:italic>K<\/jats:italic>\n                      = 2-7 (0.440), a 14.7% reduction in within-cluster dissimilarity from\n                      <jats:italic>K<\/jats:italic>\n                      = 2, acceptable subsampling stability (mean adjusted Rand index, 0.702), and no small outlier cluster (minimum\n                      <jats:italic>n<\/jats:italic>\n                      = 308). The three strata were emergency-presentation (\n                      <jats:italic>n<\/jats:italic>\n                      = 450), hypertension-uncoded\/lobar-leaning (\n                      <jats:italic>n<\/jats:italic>\n                      = 308), and non-emergency hypertension-coded\/deep-ICH (\n                      <jats:italic>n<\/jats:italic>\n                      = 1,093). Unadjusted total cost and LOS differed across clusters, but these differences were attenuated after adjustment for sex, payment method, admission department, secondary-diagnosis burden, complications, and procedures. High-cost and prolonged-LOS association rules were dominated by tracheostomy-centered combinations involving DVT\/PE, CVC\/PICC, chronic kidney disease\/renal failure, pneumonia, respiratory failure, or major neurosurgery.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>This pathway-oriented framework organized ICH hospitalizations into interpretable baseline clinical-administrative strata and identified recurrent comorbidity\/procedure\/complication patterns associated with high utilization. These findings may support risk-aware benchmarking and resource management under diagnosis-related group\/diagnosis-intervention packet payment reform, although validation using granular clinical severity data is required.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1828871","type":"journal-article","created":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T05:46:49Z","timestamp":1781848009000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Combined clustering and association-rule analysis for hospital costs and length of stay in spontaneous intracerebral hemorrhage hospitalizations"],"prefix":"10.3389","volume":"14","author":[{"given":"Qiuping","family":"Li","sequence":"first","affiliation":[{"name":"Faculty of Nursing, Youjiang Medical University for Nationalities","place":["Baise, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ying","family":"Wang","sequence":"additional","affiliation":[{"name":"Faculty of Nursing, Youjiang Medical University for Nationalities","place":["Baise, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suren Rao","family":"Sooranna","sequence":"additional","affiliation":[{"name":"Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London","place":["London, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lihong","family":"Zhao","sequence":"additional","affiliation":[{"name":"Faculty of Nursing, Youjiang Medical University for Nationalities","place":["Baise, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liuying","family":"Tang","sequence":"additional","affiliation":[{"name":"Department of Infectious Diseases, Baise People's Hospital","place":["Baise, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,6,19]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1038\/s41572-023-00424-7","article-title":"Intracerebral haemorrhage","volume":"9","author":"Puy","year":"2023","journal-title":"Nat Rev Dis Primers"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"795","DOI":"10.1016\/S1474-4422(21)00252-0","article-title":"Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the global burden of disease study 2019","volume":"20","year":"2021","journal-title":"Lancet Neurol"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"1279","DOI":"10.1212\/01.wnl.0000238349.28146.46","article-title":"Predictors of hospital length of stay and cost in patients with intracerebral hemorrhage","volume":"67","author":"Russell","year":"2006","journal-title":"Neurology"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"158","DOI":"10.1186\/s12883-017-0930-2","article-title":"Hospital treatment costs and length of stay associated with hypertension and multimorbidity after hemorrhagic stroke","volume":"17","author":"Specogna","year":"2017","journal-title":"BMC Neurol"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"1081","DOI":"10.3171\/2020.8.JNS201839","article-title":"Inpatient mortality and healthcare resource utilization of nontraumatic intracerebral hemorrhage complications in the US","volume":"135","author":"Park","year":"2021","journal-title":"J Neurosurg"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"105050","DOI":"10.1016\/j.ijmedinf.2023.105050","article-title":"An interpretable machine learning approach for predicting 30-day readmission after stroke","volume":"174","author":"Lv","year":"2023","journal-title":"Int J Med Inform"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"1743","DOI":"10.1001\/jama.260.12.1743","article-title":"The quality of care. How can it be assessed?","volume":"260","author":"Donabedian","year":"1988","journal-title":"JAMA"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"857","DOI":"10.2307\/2528823","article-title":"A general coefficient of similarity and some of its properties","volume":"27","author":"Gower","year":"1971","journal-title":"Biometrics"},{"key":"ref9","doi-asserted-by":"crossref","DOI":"10.1002\/9780470316801","volume-title":"Finding Groups in Data: An Introduction to Cluster Analysis","author":"Kaufman","year":"1990"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"53","DOI":"10.1016\/0377-0427(87)90125-7","article-title":"Silhouettes: a graphical aid to the interpretation and validation of cluster analysis","volume":"20","author":"Rousseeuw","year":"1987","journal-title":"J Comput Appl Math"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"411","DOI":"10.1111\/1467-9868.00293","article-title":"Estimating the number of clusters in a data set via the gap statistic","volume":"63","author":"Tibshirani","year":"2001","journal-title":"J R Stat Soc Series B Stat Methodol"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"193","DOI":"10.1007\/BF01908075","article-title":"Comparing partitions","volume":"2","author":"Hubert","year":"1985","journal-title":"J Classif"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"461","DOI":"10.1016\/S0167-6296(01)00086-8","article-title":"Estimating log models: to transform or not to transform?","volume":"20","author":"Manning","year":"2001","journal-title":"J Health Econ"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"392","DOI":"10.1037\/0033-2909.118.3.392","article-title":"Regression analyses of counts and rates: Poisson, over dispersed Poisson, and negative binomial models","volume":"118","author":"Gardner","year":"1995","journal-title":"Psychol Bull"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"207","DOI":"10.1145\/170036.170072","article-title":"Mining association rules between sets of items in large databases","volume":"22","author":"Agrawal","year":"1993","journal-title":"SIGMOD Rec"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"369","DOI":"10.1016\/j.jbi.2015.06.020","article-title":"Mining and exploring care pathways from electronic medical records with visual analytics","volume":"56","author":"Perer","year":"2015","journal-title":"J Biomed Inform"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"156","DOI":"10.4187\/respcare.08206","article-title":"AARC clinical practice guideline: management of adult patients with tracheostomy in the acute care setting","volume":"66","author":"Mussa","year":"2021","journal-title":"Respir Care"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"450","DOI":"10.1001\/jamaoto.2021.0025","article-title":"Association of early vs late tracheostomy placement with pneumonia and ventilator days in critically ill patients: a 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