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

Table 9. All-Listed Procedures

All-Listed Procedures	Total Number of Ambulatory Surgical Visits (in thousands)	Percent Ambulatory	Mean Charge per Visit
Appendectomy	22	15.8	$9,500
Cholecystectomy and common duct exploration	152	51.5	$8,100
Hernia repair	153	89.1	$5,800
Bariatric surgery	1	3.2	$15,100

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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.

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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.

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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

Table 10. All-Listed Procedures

All-Listed Procedures	Total Number of Ambulatory Surgical Visits (in thousands)	Percent Ambulatory	Ambulatory Surgical Visits per 100,000 Population	Mean Charge per Visit
Tonsillectomy and/or adenoidectomy in children	150	96.3	206	$3,700
Mastectomy in women	7	21.6	14	$9,100
Hysterectomy in women	18	8.6	38	$9,700
Transurethral prostatectomy (TURP) in men	8	20.4	18	$7,000

Note: The denominator population for tonsillectomy and/or adenoidectomy rates is limited to the population of children ages 0 to 17 in the 17 selected States.⁹ Similarly, the denominator population is limited to the total female population for mastectomy and hysterectomy rates, and is limited to the total male population for TURP rates.⁸

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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.

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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.

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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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