HCUP Fact Book No. 9: Ambulatory Surgery in U.S. Hospitals, 2003 (continued)
Part II:
Detailed Statistics
for Selected Procedures
and Populations
Procedures Influenced
by Technological
Advances
The development of various technologies, such as new surgical
techniques, devices, and pharmaceuticals (especially anesthesia), have
changed the pattern of care for surgeries in two important ways: (1)
new and emerging technologies have prompted a shift from inpatient
care to ambulatory care, and (2) technological advances have created
new markets and patterns of care.2 For example, the laparoscope (a long
metal tube with a camera lens at the end) is responsible for the shift to
outpatient settings for surgeries such as hernia repair or removal of
the gallbladder and appendix. Consequently, as surgical tools and
technologies advance, the surgeries that previously required extensive
incisions are now less invasive and less costly and also require less time.
Examples of surgeries that reflect evolving patterns of care because of
advances in technology include:
- Appendectomy—surgical removal of the appendix
- Cholecystectomy—surgical removal of the gallbladder
- Hernia repair—surgical repair of the abdominal wall
- Bariatric surgery—surgical reduction of the stomach
Select for Table 9, All-Listed Procedures.
Return to Contents
Appendectomy
Appendectomy—the surgical removal of the appendix—is almost
always performed as an emergency surgery. However, the use of the
laparoscope allows a surgeon to perform the procedure without
making a large incision in the abdomen. In most cases, a laparoscopic
appendectomy can be completed in an outpatient setting within 45
minutes. The patient is released the same day and can resume normal
activity more quickly than a patient with an open abdominal surgery.
Open and laparoscopic techniques are thought to be comparable in
terms of low rates of complications.8 However, length of stay, length
of overall recovery, and infection rates are reportedly lower with
laparoscopic appendectomy.8
- Approximately 16 percent of appendectomies were performed
on an outpatient basis in 2003.
- The mean age for an outpatient appendectomy was 30 years—about 6 years younger than the mean age for inpatient
appendectomies (data not shown).
- Over 98 percent of appendectomies were performed on patients
younger than 65 (data not shown); more than 6 in 10 outpatient
appendectomies were performed on patients ages 18 to 44.
- Although about 10 percent of all appendectomies occurred in
patients 65 and older, the proportion of inpatient appendectomies
performed on this age group was 5 times higher than the proportion
of outpatient appendectomies performed on older adults
(9.5 percent versus 1.9 percent).
- Although the number of inpatient appendectomies performed on
males and females was virtually equal, outpatient appendectomies
were performed at a somewhat higher rate on females compared
with males (52.6 percent versus 47.4 percent).
- Approximately two-thirds of all appendectomies were billed to
private insurers. Compared with inpatient appendectomies, a greater
proportion of outpatient appendectomies were billed to private
insurers (73.5 percent versus 62.5 percent).
Select for Figure 7 (5 KB), Percentage of Visits and Stays for Appendectomies
by Age Group.
Select for Figure 8 (5 KB), Percentage of Visits and Stays for Appendectomies
by Gender.
Select for Figure 9 (5 KB), Percentage of Visits and Stays for Appendectomies
Billed
to Payer.
Return to Contents
Cholecystectomy
A cholecystectomy is the surgical removal of the gallbladder. During a
laparoscopic cholecystectomy, three long instruments are inserted into
the body through small incisions, and, using the laparoscope to view the
inside of the body, the surgeon is able to remove the gallbladder.When
a laparoscope is used, the patient is released from the hospital within
24 hours, or sometimes sooner, depending on their ability to ambulate.
Recovery requires approximately 2 weeks. The conventional surgery
requires a long incision of the abdomen, and the recovery time is
between 4 and 8 weeks. Researchers believe that at least half of all
laparoscopic cholecystectomies can be performed on an outpatient
basis.9 However, use of this procedure in an ambulatory setting may
be limited by physician training and patient reluctance.9
- In 2003, half of all surgeries involving a cholecystectomy procedure
were performed on an outpatient basis.
- The mean age for an outpatient cholecystectomy was 8 years less
than the mean age for an inpatient cholecystectomy—46 years versus
54 years (data not shown).
- Almost half of outpatient cholecystectomies were performed on
patients ages 18 to 44, followed closely by patients between 45 and
64 years of age, who underwent 37 percent of these procedures.
An additional 14 percent of outpatient cholecystectomies were
performed on patients 65 and above.
- The proportion of inpatient cholecystectomies performed on
patients 65 and older (33.8 percent) was nearly 2.5 times the
proportion of outpatient cholecystectomies performed for this
age group (14.0 percent).
- Nearly 3 out of 4 cholecystectomy procedures were performed
on females; this group accounted for nearly 78 percent of all
cholecystectomies performed on an outpatient basis.
- Two out of 3 outpatient cholecystectomies were billed to private
insurers, while Medicare was billed for only 15 percent of these
ambulatory surgeries.
- Compared with inpatient cholecystectomy procedures, the
proportion of outpatient cholecystectomies billed to private
insurers was considerably higher (65.6 percent versus 43.4 percent).
Consequently, the proportion of outpatient procedures billed to
Medicare was lower than the proportion of inpatient procedures
billed to Medicare (15.0 percent versus 33.7 percent, respectively).
Select for Figure 10 (5 KB), Percentage of Visits and Stays for Cholecystectomies
by Age Group.
Select for Figure 11 (4 KB), Percentage of Visits and Stays for Cholecystectomies
by Gender.
Select for Figure 12 (5 KB), Percentage of Visits and Stays for Cholecystectomies
Billed
to Payer.
Hernia Repair
A hernia occurs when tissue protrudes from a torn or damaged
abdominal wall. An open hernia repair is typically performed in an
inpatient setting and requires a long incision in the abdominal area
so that the torn abdominal wall can be sewn together. Alternatively,
laparoscopic hernia repair is less invasive and requires three small
incisions—each no more than 1 centimeter long. Instead of sewing
the abdominal wall, a piece of mesh is inserted over the torn area,
reducing patient discomfort and recovery time. Unlike open hernia
repair, which uses local, spinal, or general anesthesia, laparoscopic
hernia repair requires general anesthesia and is typically done in an
ambulatory surgery setting.
- Nearly 89 percent of hernia surgeries were performed on an
outpatient basis in 2003.
- The mean age for an outpatient hernia repair was 46 years—12 years less than the mean age for an inpatient hernia repair
(data not shown).
- One-third of outpatient hernia repairs occurred in patients ages
45 to 64—slightly more than for patients ages 18 to 44 (26.9 percent)
and for patients 65 and older (24.5 percent).
- The proportion of inpatient hernia repairs performed on
patients 65 and older (53.8 percent) was more than twice the
proportion of outpatient hernia repairs performed on this age
group (24.5 percent).
- Nearly 9 out of 10 outpatient hernia repairs occurred in males.
- The proportion of inpatient hernia repairs performed on females
was more than twice the proportion of outpatient hernia repairs
performed on females (24.1 percent versus 11.1 percent).
- Private insurers were billed for more than 58 percent of
outpatient hernia repairs.Medicare was billed for nearly 1 in 4
of these ambulatory surgeries. Uninsured patients accounted for
less than 4 percent of outpatient hernia repair surgeries.
- Private insurers were billed for the highest proportion of outpatient
hernia repairs (58.3 percent). In contrast,Medicare was billed for the
highest proportion of hernia repairs performed on an inpatient basis
(50.5 percent).
Select for Figure 13 (5 KB), Percentage of Visits and Stays for Hernia Repair Surgeries
by Age Group.
Select for Figure 14 (4 KB), Percentage of Visits and Stays for Hernia Repair Surgeries
by Gender.
Select for Figure 15 (4 KB), Percentage of Visits and Stays for Hernia Repair Surgeries
Billed
to Payer.
Bariatric Surgery
Bariatric surgical procedures are major gastrointestinal operations used
to treat morbid obesity. Several different types of bariatric weight-loss
surgical procedures exist, which are known collectively as bariatric
surgery. As more people become aware of complications from obesity,
increasing numbers of affected individuals are opting for this surgery
to lose weight and thereby reduce their risk of diabetes, high blood
pressure, heart disease, and weight-related musculoskeletal issues. Due
to a marked increase in the number of bariatric surgeries performed in
the United States, health plans and Medicare have begun classifying
obesity as a disease and providing coverage for these procedures.10
Recently, laparoscopic techniques have enabled more bariatric surgeries
to be performed in an outpatient setting. Although the gastric bypass
is still called the "gold standard" in weight-loss surgery, many hospitals
are now promoting an alternative procedure known as a "lap band."
During this minimally invasive outpatient procedure, surgeons use
a laparoscope to wrap a band around the stomach in order to make
it smaller. Lap bands are more appealing to some patients because
traditional gastric bypass procedures require inpatient admission
and longer recovery times. In some cases, hospitals are also using
laparoscopic techniques to perform gastric bypass procedures in the
outpatient setting.
- In 2003, only 3 percent of bariatric surgeries were performed on
an outpatient basis (data not shown).
- The mean age for bariatric surgery was approximately 42 years,
regardless of inpatient or outpatient status (data not shown).
- Almost all bariatric surgeries performed in an outpatient setting
occurred in patients ages 18 to 64 (55.7 percent in patients ages
18 to 44 and 42.9 percent in patients ages 45 to 64).
- Nearly 83 percent of outpatient bariatric surgeries were performed
on females.
- Private insurers were billed for 8 out of 10 outpatient bariatric
surgeries. Only about 5 percent of these ambulatory surgeries
were billed to government insurance programs (i.e.,Medicare
and Medicaid).
- The rate of outpatient bariatric surgeries billed to uninsured patients
was almost 5 times the rate of inpatient bariatric surgeries billed to
this group (11.6 percent versus 2.4 percent). This finding may reflect
surgeries among patients who are otherwise insured, but opt to self-pay
for outpatient bariatric surgery, which is often less expensive,
when bariatric surgery is not a covered benefit.
Select for Figure 16 (5 KB), Percentage of Visits and Stays for Bariatric Surgeries
by Age Group.
Select for Figure 17 (4 KB), Percentage of Visits and Stays for Bariatric Surgeries
by Gender.
Select for Figure 18 (4 KB), Percentage of Visits and Stays for Bariatric Surgeries
Billed
to Payer.
Return to Contents
Ambulatory Surgeries
Specific to Certain
Populations
This section highlights ambulatory surgeries specific to select populations—children, women, or men—and may also reflect changing patterns of
care as surgeries shift from the inpatient setting to an ambulatory setting.
Some procedures, such as mastectomy and transurethral prostatectomy
(TURP), are just beginning to emerge as feasible in the ambulatory setting.
Examples of surgical procedures specific to selected populations include:
- Tonsillectomy and/or adenoidectomy—surgical removal of the
tonsils and/or adenoids
- Mastectomy—surgical removal of the breast
- Hysterectomy—surgical removal of the uterus
- Transurethral prostatectomy—surgical treatment of an
enlarged prostate
Select for Table 10, All-Listed Procedures.
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Tonsillectomy and/or Adenoidectomy in Children
Tonsillectomy and/or adenoidectomy is the surgical removal of the tonsils
and/or adenoids. This procedure is typically performed in children when
tonsils and adenoids become chronically infected and obstruct breathing.
The patient is given general anesthesia and the tissue is removed through
the mouth. Post-surgery bleeding is usually negligible, and patients are
released within 8 to10 hours after surgery. As recently as 5 years ago, the
performance of tonsillectomy and adenoidectomy in an ambulatory setting
was considered controversial. However, many recent studies have shown
that with adequate criteria for patient selection and careful observation after
surgery, these procedures can be safely performed as an outpatient surgery.11,12
- In 2003, 96 percent of all tonsillectomies and/or adenoidectomies
performed in children ages 0 to 17 occurred in an outpatient setting
(data not shown).
- The mean age for a tonsillectomy and/or adenoidectomy was approximately
7 years, regardless of inpatient or outpatient status (data not shown).
- The percentage of outpatient tonsillectomies and/or adenoidectomies
performed in boys and girls ages 0 to 17 was virtually equal.
However, in an inpatient setting, these procedures were performed
more often in boys, as compared with girls (56.8 versus 43.2 percent).
- Two out of 3 of these surgeries performed in an outpatient setting
were billed to private insurers.Medicaid was billed for approximately
28 percent, while uninsured patients accounted for only 1 percent of
outpatient tonsillectomy and/or adenoidectomy surgeries.
- Compared with inpatient tonsillectomies and/or adenoidectomies,
the proportion of these surgeries billed to private insurers was
considerably higher (66.6 percent versus 54.3 percent). Consequently,
the proportion of outpatient procedures billed to Medicaid was
lower than the proportion of inpatient procedures billed to Medicaid
(27.9 percent versus 40.7 percent, respectively).
Select for Figure 19 (5 KB), Percentage of Visits and Stays for Tonsillectomies and/or
Adenoidectomies by Gender.
Select for Figure 20 (4 KB), Percentage of Visits and Stays for Tonsillectomies and/or
Adenoidectomies Billed
to Payer.
Return to Contents
Mastectomy in Women
Many women with breast cancer undergo surgery as part of a standard
course of treatment. Advances in breast cancer treatment and trends
toward more breast-conserving procedures have resulted in fewer
procedures—including many surgeries—that require hospitalization.
While mastectomy, or complete removal of a breast, is typically
performed in a hospital setting, specialized outpatient facilities are
sometimes used. Receiving a mastectomy in an outpatient setting has
been a controversial and emotional issue, sparking public debate and
legislative action in many States. Currently, 20 States have mandated
minimum inpatient stay laws for mastectomy.13 However, some studies
have shown that women who choose to have outpatient mastectomies
experience better recovery and less adverse side effects.14 In general, an
outpatient mastectomy is recommended for younger women in good
health and with early-stage breast cancer.
- Approximately 1 in 5 mastectomies received by women in 2003
was performed in an outpatient setting (data not shown).
- The mean age for a woman receiving either an outpatient or
inpatient mastectomy was about 59 years (data not shown).
- Outpatient mastectomies were performed most often on women
45 to 64 years of age (50.8 percent). Approximately 35 percent of
outpatient mastectomies were performed on women 65 and older.
- Compared with inpatient mastectomies, the proportion of these
surgeries performed on patients 45 to 64 years of age was higher
(50.8 percent versus 43.8 percent). As a result, the proportion of
outpatient mastectomies performed on women ages 65 and older
was lower than the proportion of inpatient procedures performed
on this age group (35.2 percent versus 41.0 percent), respectively.
- Private insurers were billed for more than half of all outpatient
mastectomies.Medicare was billed for almost one-third of
outpatient mastectomies.
- The percentage of outpatient mastectomies billed to private
insurers was higher than the percentage of inpatient mastectomies
billed to these payers (53.1 percent versus 48.0 percent, respectively).
Conversely, inpatient mastectomies were billed at a higher
percent to government payers (i.e., Medicare and Medicaid),
as compared with outpatient mastectomies (48.5 percent
versus 40.8 percent, respectively).
Select for Figure 21 (5 KB), Percentage of Visits and Stays for Mastectomies
by Age Group.
Select for Figure 22 (4 KB), Percentage of Visits and Stays for Mastectomies
Billed
to Payer.
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Hysterectomy in Women
Hysterectomy, or the surgical removal of the uterus, can be performed
with the use of the laparoscope. Instead of creating a large incision on
the abdomen through which the uterus is removed, a laparoscope is
inserted through small incisions into the abdomen to either assist in
the vaginal removal of the uterus, or more recently, completely remove
the uterus using the laparoscopic approach. The laparoscopic-assisted
vaginal hysterectomy and the more recently developed complete
laparoscopic hysterectomy can be performed in an outpatient setting
since they allow faster recovery times for women.
- In 2003, 9 percent of hysterectomies were performed on an
outpatient basis (data not shown).
- The mean age for an outpatient hysterectomy was 41 years, or 5 years
less than the mean age for an inpatient hysterectomy (data not shown).
- Over half of all hysterectomies were performed on women 18 to 44
years of age, followed by nearly 40 percent for women ages 45 to 64.
However, this distribution varied depending on inpatient or outpatient
setting: women ages 18 to 44 accounted for 67 percent of outpatient
hysterectomies. Less than one-third of these procedures performed
in an outpatient venue occurred in women 45 to 64 years of age.
- Private insurers were billed for approximately 8 out of 10 outpatient
hysterectomies. Government insurance programs (i.e.,Medicare
and Medicaid) were billed for almost 11 percent of these surgeries
performed in an outpatient setting. However, nearly 22 percent of
inpatient hysterectomies were billed to Medicare or Medicaid.
Select for Figure 23 (5 KB), Percentage of Visits and Stays for Hysterectomies
by Age Group.
Select for Figure 24 (4 KB), Percentage of Visits and Stays for Hysterectomies
Billed
to Payer.
Return to Contents
Transurethral Prostatectomy in Men
Transurethral prostatectomy (TURP) is the most common type of
prostate surgery in men and is most often used to treat benign
enlargement of the prostate gland. During this procedure, the prostate
tissue is removed piece by piece using a special tool inserted through
the urethra. Because there are no incisions, the recovery time is between
1 and 3 days.
- Approximately 20 percent of TURPs were performed on an
outpatient basis in 2003 (data not shown).
- Patients receiving TURPs on an outpatient basis had a mean age
of 69 years, slightly lower than the mean age for patients receiving
inpatient TURPs, 73 years (data not shown).
- Men ages 45 and older accounted for nearly all outpatient TURP
procedures.More than 2 out of 3 of these procedures performed in
an outpatient setting occurred among men 65 and older.
- The proportion of outpatient TURPs performed on men ages 45
to 64 (30.9 percent) was higher than the proportion of inpatient
TURPs performed in this age group (18.7 percent). Conversely, the
proportion of inpatient TURPs performed on men 65 and older
(81.0 percent) was higher than the proportion of outpatient TURPs
performed in this age group (67.6 percent).
- Medicare was billed for more TURP procedures than any other
payer, regardless of inpatient or outpatient status. Approximately 1
in 5 TURPs was billed to private insurers. However, the proportion
of these procedures performed on an outpatient basis and billed to
private insurers was about 32 percent, compared with 18 percent of
inpatient TURPs billed to private insurers.
Select for Figure 25 (5 KB), Percentage of Visits and Stays for TURPs
by Age Group.
Select for Figure 26 (4 KB), Percentage of Visits and Stays for TURPs
Billed
to Payer.
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