Procedures in U.S. Hospitals, 2003: HCUP Fact Book No. 7 (continued)

HCUP Fact Book No. 7: Procedures in U.S. Hospitals, 2003 (continued)

Overview of Hospitals

Overview of Hospitals and Hospital Procedures in the United States

The following tables and charts provide an overview of the types of U.S. hospitals in 2003 as defined by the American Hospital Association (AHA). The AHA defines community hospitals as all non-Federal, short-term (or acute care), general and specialty hospitals whose facilities and services are available to the public.³ Community hospitals include obstetric-gynecologic, short-term rehabilitation, orthopedic, cancer, pediatric, and non-Federal public hospitals and academic medical centers. This Fact Book presents information pertaining to procedures recorded in hospital discharge records in U.S. community hospitals. Because this report offers comparisons of 1997 with 2003 hospital procedures, information about hospitals in 1997 is also presented.

Additionally, national estimates of general characteristics for community hospitals and hospital procedures for 1997 and 2003 follow.

Select for Table 1, AHA Hospital Categories, 1997, 2003.

Select for Figure 1 (5 KB), Types of U.S. Hospitals, 2003.

Select for Table 2, Characteristics of U.S. Community Hospitals, 1997, 2003.

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How Many Procedures Did Patients Receive Per Hospital Stay?

In 2003, U.S. hospitals reported more than 38 million hospital stays; over 60 percent of these stays involved at least 1 hospital procedure. More than 47 million hospital procedures were performed, with patients receiving an average of 2 procedures during their inpatient stay.
Nearly 40 percent of patients did not receive a procedure during their hospitalization. This situation occurred most commonly among newborn infants or medical patients. The category "medical patients" includes individuals with conditions such as pneumonia, congestive heart failure, depression, and chronic obstructive pulmonary disease, who are hospitalized for medical (versus surgical) reasons, such as stabilization, medication, and observation.
Approximately 20 percent of hospitalizations involved 3 or more procedures.
Procedures can be classified into 1 of 4 broad categories: minor diagnostic, minor therapeutic, major diagnostic, and major therapeutic. About 30 percent of hospital stays involved at least 1 major therapeutic procedure, while another 24 percent included minor therapeutic and diagnostic procedures.
Eight percent of stays included only diagnostic procedures.

Select for Figure 2 (5 KB), How Many Procedures Did Patients Receive per Hospital Stay?

Select for Figure 3 (6 KB), Types of Procedures Performed During Hospital Stays: Therapeutic Versus Diagnostic.

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What Were the Most Common Procedures?

Overall, little change occurred in the top 10 procedures performed in U.S. hospitals since 1997—9 of the top 10 procedures remained the same. In 2003, vaccinations were added to this list, replacing episiotomies as a top 10 procedure.
Many pregnancy- and childbirth-related procedures were among the most common procedures. These included procedures to assist delivery, repair of current obstetric laceration, circumcision, cesarean section (C-section), and fetal monitoring.
A 33-percent increase in C-sections was observed since 1997. Simultaneously, hospitals experienced a 41-percent decrease in episiotomies from 1997 to 2003.
As reported in Hospitalizations in the United States, 2002, cardiovascular diseases continued to be a common reason for hospitalization. Five of the top 10 conditions for hospitalization related to the heart: coronary atherosclerosis (hardening of the heart arteries and other heart disease), congestive heart failure, chest pain, heart attack, and irregular heart beat.
Once pregnancy- and childbirth-related procedures were excluded, 3 of the 10 most common procedures in 2003 were related to the cardiovascular system: diagnostic cardiac catheterization, PTCA, and echocardiogram.
Overall, cardiovascular procedures increased in frequency; however, CABG and extracorporeal circulation auxiliary to open heart procedures each decreased by 19 percent since 1997.
In 2003, blood transfusions were performed in 5 percent of discharges, representing nearly 2 million hospitalizations. This reflects a 64-percent increase in the percentage of blood transfusions performed from 1997, when these procedures occurred in over 1 million hospitalizations and represented only 3 percent of discharges.
One of the most common non-pregnancy-related procedures in 2003 is performed only on women: hysterectomy. Most hysterectomies were performed for non-cancerous conditions, such as fibroid tumors, endometriosis, and menstrual disorders.

Select for Table 3, Top 10 Procedures Performed in U.S. Hospitals, 2003.

Select for Table 4, Top 10 Procedures Performed in U.S. Hospitals (Excluding Pregnancy- and Childbirth-Related Procedures), 2003.

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What Types of Procedures Did Patients Receive, by Body System?

Procedures classified by body systemⁱ remained relatively stable since 1997: cardiovascular, obstetrical, and digestive procedures continued to be performed most frequently.
Cardiovascular procedures were performed during 13 percent of hospital stays. This reflects a slight increase from 1997, when these procedures were performed in about 11 percent of hospitalizations.
Obstetric and digestive procedures each continued to be performed in about 1 in 11 hospital stays. Three body systems accounted for the largest number of hospital procedures: cardiovascular, obstetric, and digestive procedures. Within each of these systems, patterns of specific procedure use changed over time.

ⁱInformation regarding procedures by body systems is based on groupings of Clinical Classifications Software (CCS) categories.

Select for Figure 4 (14 KB), What Types of Procedures Did Patients Receive, by Body System?

Cardiovascular Procedures

Since 1997, high-volume cardiac procedures, such as PTCA, were performed more frequently during U.S. hospital stays. However, 2 cardiac procedures were performed much less often in 2003: CABG and extracorporeal circulation auxiliary to open heart procedures.

Select for Figure 5 (16 KB), Cardiovascular Procedures, 1997-2003.

Obstetric Procedures

Between 1997 and 2003, the volume of C-sections increased by 46 percent while the volume of episiotomies decreased by 35 percent.
The frequency of forceps procedures decreased by more than 27 percent during this same period.

Select for Figure 6 (13 KB), Obstetric Procedures, 1997-2003.

Digestive Procedures

The digestive procedures reflecting the greatest increase since 1997 were colonoscopies and upper GI endoscopies; these increased by 20 percent and 12 percent, respectively.
Obesity-related operating room (OR) procedures, such as gastric bypass surgeries, increased by 645 percent since 1997 (based on Diagnosis Related Group [DRG] code 288).

Select for Figure 7 (12 KB), Digestive Procedures, 1997-2003.

Select for Figure 8 (8 KB), Obesity Operating Room Procedures, 1997-2003.

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What Were the Most Common Medical and Surgical Procedures for Various Age Groups?

In 2003, blood transfusions were among the top 10 procedures performed in all age groups, occurring in 77 percent more hospitalizations than in 1997. During this 7-year period, the number of transfusions for patients 45 to 64 years of age nearly doubled. The largest increase in the percentage of hospital stays involving a blood transfusion—nearly 70 percent—occurred for individuals age 65 and older. This increase in transfusions was accompanied by a 78-percent increase in the number of hospitalizations for anemia in 2003.
Similar to the pattern in 1997, respiratory intubation was also among the top 10 procedures for all age groups. But unlike blood transfusions, the number of intubations decreased over the 7-year period for each age group.
The 2 most common procedures for children under 1 year of age remained the same in 2003: circumcisions and vaccinations. Circumcisions continued to be performed on 1.2 million infant boys. Vaccinations continued to be the second most common procedure with a 40-percent increase in the percentage of inpatient vaccinations performed in young children across the 7-year period. The vast majority of these consisted of hepatitis B vaccines given to infants at birth.
Similar to 1997, appendectomy was the most common procedure for children ages 1-17; it was performed in 5 percent of all hospitalizations in this age group. Other top procedures included diagnostic spinal taps, blood transfusions, cancer chemotherapy, and respiratory intubation.
When obstetrical procedures were included, 44 percent of procedures performed on all patients 18 to 44 years of age were related to pregnancy and childbirth (data not shown).
After pregnancy- and childbirth-related procedures were excluded, hysterectomy emerged as the most common procedure and accounted for 5 percent of hospitalizations for patients ages 18-44, while oophorectomy accounted for another 3 percent. The percentage of cholecystectomies performed as inpatient procedures for this age group remained about the same, despite the move toward laparoscopic cholecystectomies that are often performed in outpatient settings.
Three of the top 10 procedures for individuals ages 45-64 involved the cardiovascular system: diagnostic cardiac catheterization, PTCA, and echocardiogram.
In 2003, several heart-related procedures continued to be among the most frequent procedures performed on patients ages 65-79: diagnostic cardiac catheterization, PTCA, echocardiogram, and CABG.
For individuals 80 years of age and older, 3 diagnostic procedures were among the top 10 most frequent procedures, comprising 12 percent of procedures in this age group: upper GI endoscopy, diagnostic cardiac catheterization, and echocardiogram. Cardiovascular procedures were performed in another 9 percent of hospitalizations.

Select for Table 5, Top 10 Procedures Performed in U.S. Hospitals for Various Age Groups (Excluding pregnancy and childbirth-related procedures),2003.

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Gender and Age Characteristics

How Did Procedures Received by Males and Females Compare?

On average, women and men received an equal number of procedures: 2 per hospital stay.
Excluding procedures related to pregnancy and childbirth, 7 of the top 10 procedures were the same for males and females. Of the 3 remaining, the most common procedures for women included cholecystectomy (removal of gall bladder) and 2 operations of the female reproductive system (hysterectomies and oophorectomies).
Three of the most common procedures received by males that were received less frequently by females included laminectomy (back surgery) and 2 cardiovascular procedures (PTCA and CABG).
Although the prevalence of colon cancer is equal in women and men, nearly 60 percent of the 636,000 in-hospital colonoscopies performed in 2003 were for women.

Select for Table 6, Top 10 Procedures Performed in U.S. Hospitals for Males and Females (Excluding Pregnancy- and Childbirth-Related Procedures), 2003.

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High-Volume Providers

What Share of the Nation's Hospitals Were High-Volume Providers for Specific Procedures?

Research suggests that the outcomes of certain procedures are related to the number performed in a given hospital.¹ These procedures often require high-technology support, but the exact nature of this "volume-to-outcome" relationship is not well understood.

Procedures in U.S. Hospitals, 1997 (HCUP Fact Book No. 2) provided data on the Nation's share of hospitals that are high-volume providers for the 10 procedures for which this volume-outcome relationship has been shown.ⁱⁱ This Fact Book updates those statistics with 2003 data.

For 7 of the 10 procedures, the percentage of hospitals that were considered high-volume providers did not change significantly from 1997. The percentage of hospitals considered high-volume providers decreased for CABG and abdominal aortic aneurysm and increased for pancreatic cancer.
The largest decrease since 1997 in the percentage of hospitals serving as high-volume providers was for CABG—from 31 percent to 15 percent.
Pancreatic surgery was the only procedure for which there was an increase in the percentage of hospitals that were considered high-volume providers.
More than half of the hospitals that performed the following procedures continued to be high-volume providers: heart transplantation (64 percent), lower extremity arterial bypass (58 percent), and coronary angioplasty (53 percent).
For 7 procedures, fewer than 20 percent of hospitals were high-volume providers in 2003.

ⁱⁱ Go to the Methods section for high-volume thresholds for each procedure.

Select for Figure 9 (16 KB), Percentage of Hospitals That Were High-Volume Providers for Specific Procedures, 1997-2003.

What Share of Patients Received Procedures in High-Volume Hospitals?

For 7 of the 10 procedures, the percentage of patients receiving procedures in high-volume hospitals did not change significantly from 1997.
The percentage of patients receiving procedures for cerebral aneurysms in high-volume hospitals increased by 51 percent—from 35 to 53 percent.
Conversely, the percentage of patients receiving procedures in high-volume hospitals decreased the most for those undergoing a CABG—from 63 to 41 percent. In 2003, about 45,000 more patients nationwide had a CABG in a low-volume hospital, as compared to 1997.
The percentage of patients undergoing an abdominal aortic aneurysm repair procedure also decreased by 29 percent during this time period.
In 2003, more than 92 percent of patients continued to receive lower extremity arterial bypasses and 87 percent of patients underwent PTCAs in high-volume hospitals.
The percentage of patients receiving heart transplants in high-volume hospitals in 2003 was just over 84 percent, as was the case in 1997.
Over half of all carotid endarterectomies continued to be performed in high-volume hospitals.

Select for Figure 10 (20 KB), Percent of Specific Procedures Performed at High-Volume Hospitals, 1997-2003.

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Hospital Charges

What Procedures Were Associated With the Highest Hospital Charges?

Hospital charges are the amount the hospital bills for the entire inpatient stay and do not include most professional (physician) fees. Charges represent what the hospital billed for the case, rather than the amount actually reimbursed.

It is important to note that charges reflect the total hospital charge for a hospitalization, not the charge for a particular procedure. Thus, a relatively inexpensive procedure can be associated with an expensive hospital stay if the stay itself is long and complicated. For example, procedures such as tracheostomy and Swan-Ganz catheterization are not inherently costly to perform, but they are generally performed on individuals with a critical illness who have extended stays in intensive care units.

After adjusting for inflation,6 the average charge for a hospital stay increased by 39 percent between 1997 and 2003, from $14,200 to $19,700.
Three of the top 10 procedures associated with the most expensive hospital stays were related to transplantation: bone marrow, kidney, and other organ transplants. This final category included transplants of the lung, heart, spleen, intestine, liver, and pancreas.
Three of the 10 most expensive stays involved procedures of the cardiovascular system: heart valve procedures, Swan-Ganz catheterization, and extracorporeal circulation auxiliary to open heart procedures.
In both 1997 and 2003, hospital charges were highest for stays involving organ transplantations of the pancreas, liver, intestine, heart, and lung. The mean charge associated with a hospital stay that included these five transplants was $275,600 (a 17-percent increase from 1997, after adjusting for inflation). Hospital stays in which a tracheostomy was performed were nearly as expensive, with a mean charge of $240,000 (a 23-percent increase from 1997, after adjusting for inflation).
Two new procedures, extracorporeal circulation auxiliary to open heart procedures and gastrostomy, were associated with the top 10 most expensive stays in 2003. The mean charges for these procedures were $99,100 and $98,800, respectively.
The costliest hospitalizations were not very common. Collectively, the 10 most expensive hospital stays represented less than 3 percent of all discharges.

Select for Figure 11 (15 KB), Procedures Associated With Most Costly Hospital Stays.

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Length of Stay

Which Procedures Were Associated With the Longest Hospital Stays?

Hospital lengths of stay indicate the number of nights a patient remained in the hospital for a particular stay.

The average length of stay for a hospitalization was 5 days.
Hospitalizations during which destruction of lesion of retina was performed had the longest lengths of stay—53 days—representing a 115-percent increase from 1997. This relatively inexpensive procedure is generally performed during long and complicated stays for premature infants and is used to treat retinopathy of prematurity.
In 1997, the longest length of stay was for hospitalizations during which a tracheostomy was performed, at 37 days. Tracheostomies continued to have a mean length of stay of 37 days.
Hospital stays that involved bone marrow and other organ transplantationsⁱⁱⁱ continued to be associated with some of the longest hospital stays.
Other procedures associated with long hospital stays are indicative of patients with serious chronic illnesses. Ileostomy, gastrostomy, and enteral and parenteral nutrition are performed for very ill patients requiring extensive care.
Six of the procedures performed during the most costly hospital stays were also among those associated with the longest hospitalizations: destruction of lesion of retina, tracheostomy, other organ transplant, bone marrow transplant, ileostomy, and gastrostomy.
Collectively, the 10 conditions with the longest lengths of stay represented fewer than 6 percent of all discharges.

ⁱⁱⁱ "Other organ transplantation" includes transplants of the lung, heart, spleen, intestine, liver, and pancreas. This category excludes kidney, bone, corneal, and bone marrow transplants.

Select for Figure 12 (13 KB), Procedures Associated With the Longest Hospital Stays.

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Payers of Care

Who Was Billed for Hospital Care?

Payer data reflect the expected payer for a hospital stay. It is important to note that in the inpatient hospital setting, payers are not billed for specific procedures; rather, they are billed for a patient's full hospital stay, often based on the diagnosis related group (DRG). The DRG assignment reflects the expected consumption of hospital resources based on characteristics of each stay, such as diagnoses, procedures, age of patient, and presence of complications or comorbidities.

Payer information is presented in the following general payer categories:

Medicare—Fee-for-service and managed care Medicare patients.
Medicaid—Fee-for-service and managed care Medicaid patients.
Private insurance—Blue Cross, commercial carriers, private health maintenance organizations (HMOs), and preferred provider organizations (PPOs).
Uninsured—Insurance status of "self-pay" and "no charge."
Other—Workers' Compensation, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), Title V, and other government programs.

Together, Medicare and Medicaid are billed for more than half (58 percent) of all hospitalizations. Private insurers are billed for 35 percent while uninsured hospitalizations account for about 5 percent of hospital stays. The remaining 3 percent of hospitalizations are billed to other insurers or the expected payer cannot be determined.

Medicare

Medicare continues to be billed for 34 percent of all hospitalizations, with a mean charge of $24,900.
About 40 million individuals, or 14 percent of the U.S. population, were covered by Medicare in 2003.²
Eight of the 10 procedures most commonly billed to Medicare remained the same from 1997 to 2003. Two new additions included procedures related to cardiac pacemaker and arthroplasty of the knee. These replaced CT scan of the head and physical therapy as top 10 procedures.
Of hospitalizations billed to Medicare, 4 of the top 10 procedures involved the cardiovascular system. Medicare was billed for one-half to three-fourths of all hospital stays involving these cardiovascular procedures: diagnostic cardiac catheterizations, PTCA, echocardiogram, and procedures related to cardiac pacemaker or cardioverter/defibrillator.
The percentage of hospital stays involving dialysis billed to Medicare remained about the same (65 percent in 1997 and 63 percent in 2003). These high figures are indicative of the fact that patients with end-stage renal disease are covered by Medicare, regardless of the patient's age.
In 2003, blood transfusions surpassed diagnostic cardiac catheterizations as the most common procedures performed during stays billed to Medicare.

Select for Table 7, Top 10 Procedures Billed to Medicare, 2003.

Medicaid

Medicaid was billed for 23 percent of all hospitalizations in 2003—slightly more than in 1997, when Medicaid was billed for 20 percent. The mean charge for Medicaid hospital stays was $16,700.
About 36 million individuals were covered by Medicaid in 2003; this figure represents 12 percent of the U.S. population.²
Nine of the top 10 procedures billed to Medicaid did not change since 1997. The only exception was hearing examinations, which replaced episiotomies as a top 10 procedure in 2003.
Six pregnancy- and childbirth-related procedures appeared among the top 10 procedures billed to Medicaid in 2003: medical procedures to assist delivery, C-section, repair of current obstetric laceration, circumcision, fetal monitoring, and artificial rupture of membranes to assist delivery. This list is similar to 1997, with the exception of episiotomy dropping out of the top 10. A seventh procedure—vaccinations—was also predominantly performed on newborns. After these pregnancy- and childbirth-related procedures (including vaccinations) were excluded, blood transfusion was the most common procedure billed to Medicaid.
When pregnancy- and childbirth-related procedures were excluded, 3 additional diagnostic procedures entered the top 10 procedures billed to Medicaid: upper GI endoscopy, diagnostic cardiac catheterization, and diagnostic spinal tap (data not shown).

Select for Table 8, Top 10 Procedures Billed to Medicaid, 2003.

Private Insurance

Private insurance was billed for 35 percent of all hospitalizations, which is comparable to the 1997 figure of 37 percent. The mean charge for privately insured hospital stays was $16,900.
Nearly 200 million individuals, or 69 percent of the U.S. population, were covered by private insurers in 2003.²
Eight of the 10 procedures most commonly billed to private insurers remained the same from 1997 to 2003. In 2003, blood transfusions and vaccinations replaced episiotomies and oophorectomies as top 10 procedures billed to commercial insurers.
Of hospitalizations billed to private insurers, 6 of the top 10 procedures were for pregnancy- and childbirth-related procedures: procedures to assist delivery, circumcision, repair of current obstetric laceration, C-section, fetal monitoring, and artificial rupture of membranes to assist delivery. A seventh procedure—vaccinations—was also performed mainly on newborns. These are the same pregnancy- and childbirth-related procedures that were commonly billed to Medicaid.
Similar to 1997, nearly three-fourths of hysterectomies were billed to private insurers.
Private insurers continued to be billed for just over one-third of hospital stays in which diagnostic catheterizations were performed.
After pregnancy- and childbirth-related procedures were excluded, oophorectomy became a top 10 procedure in 2003, with about 330,000 procedures billed to private insurers (data not shown).

Select for Table 9, Top 10 Procedures Billed to Private Insurers, 2003.

Uninsured

Uninsured hospitalizations continued to account for approximately 5 percent of all hospitalizations, with a mean charge of $16,800.
About 45 million individuals, or 16 percent of the U.S. population, were uninsured in 2003.²
Eight of the most commonly performed procedures in uninsured hospitalizations remained the same from 1997 to 2003. In 2003, blood transfusions and appendectomies replaced fetal monitoring and CT scans of the head in the top 10.
Three of the top 10 procedures being performed in uninsured hospitalizations were related to pregnancy and childbirth: procedures to assist delivery, circumcision, and repair of current obstetric laceration.
As in 1997, more than 20 percent of hospital stays that involved procedures for alcohol and drug rehabilitation/detoxification were not covered by insurance. It is not possible to determine if this is because insurance does not cover these conditions or because these conditions occur more frequently among uninsured patients.

Select for Table 10, Top 10 Procedures That Were Uninsured, 2003.

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In-Hospital Mortality

Which Procedures Were Associated With the Highest In-Hospital Mortality?

In-hospital mortality refers to death during the hospital stay. This section examines procedures that were performed most often in those hospital stays that resulted in death.

It is important to note that in-hospital deaths are not necessarily caused by these procedures but may simply indicate severe underlying disease. In fact, many of these procedures are not inherently risky procedures, but may be associated with hospital stays that result in high mortality linked to other causes. For example, patients may be admitted to the hospital for end-of-life care, and mortality is expected to be high.

The procedures involved in hospital stays that resulted in death remained largely unchanged since 1997. As in 1997, hospital stays involving conversion of cardiac rhythm, which indicates an unsuccessful attempt at resuscitation, most commonly ended in death. In 2003, 39 percent of hospital stays in which conversion of cardiac rhythm was performed resulted in death.
The second most common procedure associated with high inhospital mortality continued to be respiratory intubation and mechanical ventilation, with an in-hospital mortality rate of 29 percent. This procedure is performed in hospitalizations involving respiratory failure, myocardial infarction, stroke, pneumonia, and septicemia.
Hospital stays that included procedures indicating the presence of organ failure and critical illness continued to have high in-hospital mortality rates. These included Swan-Ganz catheterization, tracheostomy, ileostomy and other enterostomy, and enteral and parenteral nutrition.

Select for Table 11, Top 10 Procedures Associated With Highest In-Hospital Mortality, 2003.

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Patient Safety Indicators

How Did Selected Procedure-Based Patient Safety Quality Indicators Change from 1997 to 2003?

AHRQ has developed an array of health care decisionmaking and research tools that can be used by program managers, researchers, and others at the Federal, State and local levels. One of these tools is the AHRQ Quality Indicators (QIs) which use hospital administrative data to highlight potential quality concerns, identify areas that need further study and investigation, and track changes over time.

The AHRQ QIs are comprised of the Inpatient Quality Indicators, Prevention Quality Indicators, and Patient Safety Indicators. This section presents selected findings from the Patient Safety Indicators that relate to procedures performed in U.S. hospitals.

Patient Safety Indictors identify hospital stays during which a potentially avoidable patient safety event occurred. Below are comparisons of how U.S. hospitals performed in 2003 relative to 1997 on four procedure-based Patient Safety Indicators.

Complications of anesthesia remained stable at 8 complications per 10,000 surgical discharges.
Postoperative respiratory failure increased dramatically from 2.3 to 4.6 cases per 1,000 elective-surgery discharges, a 100-percent increase.
Postoperative sepsis increased from 8.5 to 12.5 cases per 1,000 elective-surgery discharges of longer than 3 days, a 46-percent increase.
Birth trauma decreased from 16.1 to 6.5 injuries to neonates per 1,000 live births, a 60-percent decrease.

More information about the AHRQ QIs is available at http://www.qualityindicators.ahrq.gov. Detailed data on quality of care in the U.S. is available on HCUPnet (http://hcupnet.ahrq.gov/).

Select for Figure 13 (5 KB), Complications of Anesthesia.

Select for Figure 14 (5 KB), Postoperative Respiratory Failure.

Select for Figure 15 (5 KB), Postoperative Sepsis.

Select for Figure 16 (5 KB), Birth Trauma—Injury to Neonate.

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