Procedures in U.S. Hospitals, 1997

Foreword

The unprecedented volume and pace of change in the U.S. health care delivery system requires new information on health care and its delivery. The mission of the Agency for Healthcare Research and Quality (AHRQ) is to provide information on the health care system—on quality, outcomes, access, cost, and utilization—that decisionmakers can use to improve health care. To help fulfill this mission, the Agency develops and sponsors a number of databases, including the powerful Healthcare Cost and Utilization Project (HCUP). HCUP is a Federal-State-industry partnership to build a standardized health data system.

Through HCUP, AHRQ has taken a lead in developing databases, software tools, and statistical reports to inform policymakers, health system leaders, and researchers at the Federal, regional, and State levels. (Select for more information on HCUP.)

But for data to be useful, they must be disseminated in a timely, accessible way. In 1999, AHRQ launched HCUPnet, an interactive, Internet-based tool for identifying, tracking, analyzing, and comparing statistics on hospital utilization, outcomes, and charges. Menu-driven HCUPnet guides users in tailoring specific queries about hospital care online; with a click of a button, users receive answers within seconds.

A second new way we have developed to make these data more accessible and useful is the HCUP Fact Book series—reports that provide data about hospital care in the United States in an easy-to-use, readily accessible format. Each Fact Book will provide information about specific aspects of hospital care—the single largest component of our health care dollar. The first Fact Book provided an overview of hospital stays in the United States and types of conditions that were treated.

This second Fact Book provides information on procedures performed in U.S. hospitals:

• What are the most common procedures?
• What are the characteristics of patients who receive procedures?
• Which procedures are associated with the longest hospital stays, the most expensive hospitalizations, and the highest in-hospital mortality?
• Who is billed for procedures and what types of procedures are billed to these payers?
• What percentage of procedures is performed in high-volume hospitals?

Subsequent Fact Books will examine other topics such as hospital care for children, hospital care for women, and hospitals that serve the Medicaid and uninsured populations.

We invite you to tell us how you are using this Fact Book and other HCUP data and tools and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please E-mail us at hcup@ahrq.gov or send a letter to the address below.

Irene Fraser, Ph.D.
Director
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality, Suite 5000
540 Gaither Road
Rockville MD 20850

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Contributors

Without the following State partner organizations, the Healthcare Cost and Utilization Project would not be possible:

• Arizona Department of Health Services.
• California Office of Statewide Health Planning and Development.
• Colorado Health and Hospital Association.
• Connecticut Hospital Association (CHIME).
• Florida Agency for Health Care Administration.
• Georgia Hospital Association.
• Hawaii Health Information Corporation.
• Illinois Health Care Cost Containment Council.
• Association of Iowa Hospitals and Health Systems.
• Kansas Hospital Association.
• Maryland Health Services Cost Review Commission.
• Massachusetts Division of Health Care Finance and Policy.
• Missouri Hospital Industry Data Institute.
• New Jersey Department of Health and Senior Services.
• New York State Department of Health.
• Oregon Association of Hospitals and Health Systems and Office for Oregon Health Plan Policy and Research.
• Pennsylvania Health Care Cost Containment Council.
• South Carolina State Budget and Control Board.
• Tennessee Hospital Association.
• Utah Department of Health.
• Washington State Department of Health.
• Wisconsin Department of Health and Family Services.

In May 2000, these 22 HCUP State partners and AHRQ received the Secretary of Health and Human Services' Award for Distinguished Service for "leadership, teamwork, and creative thinking in increasing availability, utility, and value of data for policy-makers and researchers concerned with hospital quality, utilization and cost."

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Introduction

Americans had 35 million hospital stays in 1997, and during most of these stays patients underwent some type of procedure. Procedures are any type of invasive or noninvasive diagnostic or therapeutic interventions that appear on the discharge records of patients who stay in the hospital. Procedures can range from major operations such as coronary artery bypass graft (CABG) surgery, to diagnostic imaging such as computerized axial tomography (CT) scans, to noninvasive treatments such as alcohol and drug detoxification. There is considerable variation in the thoroughness of coding for minor procedures, such as infusing intravenous antibiotics; so not all of these types of procedures are recorded and presented here.

Procedures on discharge records are coded using a classification system called "ICD-9-CM", which places procedures into about 3,500 different categories. For ease in reporting these statistics, this report uses Clinical Classification Software (CCS). CCS is a clinical grouper developed at AHRQ that assigns ICD-9-CM codes into about 230 unique categories.

This Fact Book summarizes information from the Nationwide Inpatient Sample (NIS), a database maintained by AHRQ that is uniquely suited to providing a comprehensive picture of hospital care in the United States. Because of its tremendous size (7.1 million records), the NIS can provide information on relatively uncommon diagnoses and procedures, as well as on subpopulations such as various age groups.

The NIS covers all patients discharged from hospitals, including:

• The uninsured.
• Those covered by public payers such as Medicare and Medicaid.
• Those with private insurance.

Unlike any other publicly available data source in the United States, the NIS also provides information on total hospital charges for all patients. The NIS includes short-term, non-Federal, community hospitals. General and specialty hospitals such as pediatric, obstetrics-gynecology, short-term rehabilitation, and oncology hospitals are included. Long-term and psychiatric hospitals are excluded.

This report provides information on:

• Most common procedures, overall and by body system.
• Number of procedures done per hospital stay.
• Most common procedures, by age group and gender.
• Procedures associated with longest hospital stays.
• Procedures associated with highest overall charges.
• Procedures with highest in-hospital mortality.
• Charges billed to public or private payers, or uninsured.
• Procedures done in "high-volume" hospitals.

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Executive Summary

There are over 35 million hospital stays in the United States every year accounting for about 40 percent of personal health expenditures. Most of these hospital stays—over 60 percent—involve some type of procedure; during many stays, multiple procedures are performed.

Understanding the types of procedures performed in U.S. hospitals is a foundation for assessing costs and quality of care. For example, recent studies have suggested a link between volume of procedures performed and the outcomes for certain procedures. This Fact Book provides an overview of procedures performed in U.S. hospitals and examines the most frequent procedures, those with the highest resource use, who is billed for which procedures, and the volume of procedures performed.

Most Common Procedures

• Procedures of the cardiovascular system are performed for 1 in 4 hospital stays. Nearly 4 million cardiac catheterizations are performed annually in U.S. hospitals—with 1 in 10 discharges receiving a cardiac catheterization.
• One in 5 discharges has procedures related to childbirth and pregnancy.
• One in 6 discharges has procedures that involve the digestive system.

Age and Gender

• Appendectomy is the most common procedure for children ages 1-17 years (performed for nearly 5 percent of discharges in this age group). Other top procedures for children and adolescents include treatments for fractures (2.8 percent), cancer chemotherapy (2.8 percent), and psychiatric therapy (1.7 percent).
• Laminectomy (back surgery, 3.3 percent), hysterectomy (5.4 percent), and oophorectomy (removal of ovaries, 3.5 percent) are among the most common procedures for patients ages 18-44. These procedures are also among the top 10 most common procedures for patients 45-64 years of age.
• Alcohol and drug detoxification is one of the top procedures performed for adults ages 18-44 (performed for 4.6 percent of discharges in this age group).
• More than 20 percent of patients 45-79 years of age admitted to the hospital receive diagnostic cardiac catheterization.
• Several heart procedures are in the top 10 for adults:
  • Diagnostic cardiac catheterization.
  • CABG.
  • Percutaneous transluminal coronary angioplasty (PTCA).
  • Extracorporeal circulation auxiliary to open heart procedures.
  • Diagnostic ultrasound of the heart.
  • Cardiac pacemaker procedures.
• Cholecystectomy and colonoscopy are among the top 10 procedures for females but not for males. Laminectomy/excision of intervertebral disk (surgery for back pain) is among the top 10 procedures for males but not for females.
• In the 18-44 age group, about three-fourths of all hospital stays are for women. Sixty percent of these stays are for pregnancy and childbirth.
• When procedures related to pregnancy and childbirth are included, they account for 8 of the top 10 procedures performed on patients ages 18-44.

Long-Stay and Expensive Procedures

• Organ transplantations are associated with some of the longest and most expensive hospital stays.
• Four of the top 10 most costly hospital stays are related to procedures on the cardiovascular system: heart transplantation, heart valve procedures, other operating room (OR) heart procedures, and other vascular bypass and shunt.

In-Hospital Deaths

• Three of the top 10 procedures associated with the highest rates of in-hospital mortality are related to the respiratory system:
  • Respiratory intubation and mechanical ventilation.
  • Incision of pleura.
  • Diagnostic bronchoscopy.
• Other procedures associated with large numbers of in-hospital deaths indicate the presence of organ failure and critical illness:
  • Swan-Ganz catheterization.
  • Enteral and parenteral nutrition.
  • Hemodialysis.

Charges

• Medicare is billed for about three-fourths of all hospital stays that involve a cardiac pacemaker or defibrillator procedure and about half of all hospital stays involving cardiac catheterization, CABG, diagnostic ultrasound of heart, and PTCA.
• Medicare is billed for over 65 percent of all hospital stays during which patients receive hemodialysis (treatment for renal failure) because treatment for end-stage renal disease is covered by Medicare, regardless of the age of the patient.
• Seven of the top 10 procedures billed to Medicaid are for pregnancy, childbirth, and newborn infant care. Medicaid is billed for about one-third of all hospital stays involving these childbirth procedures.
• Among uninsured patients, 4 of the top 10 procedures are related to pregnancy, childbirth, and newborn infant care.
• One in 6 hospital stays for alcohol and drug detoxification is uninsured.

Procedures in High-Volume Hospitals

• Recent research suggests that for some procedures, postoperative mortality is lower at hospitals that perform a high volume of these procedures.
• Nearly 60 percent of hospitals that do heart transplantations are "high-volume" hospitals (based on thresholds defined in previous studies). About 55 percent of hospitals doing lower extremity arterial bypass and 50 percent of hospitals doing coronary angioplasty reach the high-volume threshold for that procedure.
• For 6 out of 10 procedures studied here, less than 20 percent of hospitals would be considered high-volume providers.
• Over 90 percent of patients receiving lower extremity arterial bypass and around 85 percent of patients receiving coronary angioplasty and heart transplantation receive these procedures in high-volume hospitals.
• About 30 percent of heart surgery for children, 38 percent of all CABG surgery, and nearly half of all patients receiving elective abdominal aortic aneurysm repair, carotid endarterectomy, and pancreatic cancer surgery receive these procedures in low-volume hospitals.
• For esophageal cancer surgery and cerebral aneurysm repair, most patients receive their procedures at low-volume hospitals.

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Findings

Most Common Procedures

What Are the Most Common Procedures Performed in U.S. Hospitals?

• Nearly 4 million cardiac catheterizations are performed in U.S. hospitals. About 1 in 10 hospitalized patients receives a cardiac catheterization.
• Four of the top procedures are related to the heart: diagnostic cardiac catheterization, CABG, diagnostic ultrasound of the heart, and PTCA. This reflects the high burden of cardiovascular disease in the Nation.
• Four of the most frequent procedures are related to pregnancy and childbirth: procedures to assist delivery, circumcision, repair of obstetric laceration, and fetal monitoring.
• About 1 in 25 patients receives respiratory intubation and mechanical ventilation—procedures generally provided to critically ill patients in the intensive care unit. These patients include newborns in respiratory distress and adults with respiratory failure, pneumonia, myocardial infarction, and stroke.
• Five of the top procedures are diagnostic: diagnostic cardiac catheterization, upper gastrointestinal endoscopy and biopsy, diagnostic ultrasound of heart, CT scan of head, and colonoscopy and biopsy.
• Laminectomy/excision of intervertebral disk (surgery for back pain) accounts for over a half million hospital discharges per year.

Table 1. Most Common Procedures

All-Listed Procedures*	Total Number of Discharges with this Procedure Category (in Thousands)	Percent of Discharges with this Procedure Category
1. Diagnostic cardiac catheterization, coronary arteriography	3,868	10.9
2. Manually assisted delivery, medical induction and other procedures to assist delivery	2,055	5.8
3. Respiratory intubation and mechanical ventilation	1,361	3.8
4. Blood transfusion	1,259	3.6
5. Circumcision of infant	1,186	3.4
6. Repair of current obstetric laceration following delivery	1,184	3.3
7. Fetal monitoring	1,180	3.3
8. Upper gastrointestinal endoscopy, biopsy	1,168	3.3
9. Coronary artery bypass graft (CABG)	739	2.1
10. Diagnostic ultrasound of heart (echocardiogram)	641	1.8
11. Percutaneous transluminal coronary angioplasty (PTCA)	608	1.7
12. Hysterectomy	594	1.7
13. Computerized axial tomography (CT) scan, head	578	1.6
14. Colonoscopy and biopsy	564	1.6
15. Laminectomy/excision of intervertebral disk	529	1.5

* The term "All-listed procedures" refers to all procedures performed during a hospital stay; patients often receive more than one procedure.

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Body System

What Type of Procedures Do Patients Receive by Body System?

• Over 1 in 4 hospital stays has procedures that involve the cardiovascular system.
• One in 5 discharges has procedures related to pregnancy and childbirth.
• About 1 in 6 discharges has procedures that involve the digestive system.

Select Figure 1 (9 KB), Discharges by Body System.

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Procedures per Stay

How Many Procedures Do Patients Receive per Hospital Stay?

• Three of 5 patients in U.S. hospitals receive at least one procedure during their hospital stay. One in 5 receives three or more.
• Patients who receive at least one procedure average 2.3 procedures during their hospital stay (data not shown).
• Patients who receive no procedure are most commonly newborn infants or medical patients—patients with conditions such as pneumonia, congestive heart failure, depression, and chronic obstructive pulmonary disease—who are in the hospital for medical reasons such as stabilization, medication, and observation.

Select Figure 2 (6 KB), Procedures per Stay.

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Age and Gender

What Are the Most Common Procedures by Age?

• Appendectomy is the most common procedure for children ages 1-17, performed for nearly 5 percent of all hospitalized children. Other top procedures include treatments for fractures, cancer chemotherapy, and psychiatric therapy.
• Laminectomy (back surgery), hysterectomy and oophorectomy (removal of ovaries) are among the most common procedures for patients ages 18-64. About 3 percent of all hospital stays in this age group involve laminectomy. Over 5 percent of all hospital stays for patients ages 18-44 are for hysterectomy.
• Alcohol and drug detoxification is one of the top procedures performed for adults 18-44 years of age. Nearly 5 percent of all hospital stays in this age group involve alcohol and drug detoxification.
• More than 20 percent of patients 45-79 years of age admitted to the hospital receive diagnostic cardiac catheterization.
• Several heart procedures are in the top 10 for adults:
  • Diagnostic cardiac catheterization.
  • CABG.
  • PTCA.
  • Extracorporeal circulation auxiliary to open heart procedures.
  • Diagnostic ultrasound of the heart.
  • Cardiac pacemaker procedures.
• About 6 percent of stays for infants and for adults ages 65-79 involve mechanical ventilation.
• Three percent of hospital stays for patients 80 and older are for the treatment of hip fractures. Colonoscopy is performed during about 3 percent of all hospital stays among patients 65 and older.
• When obstetrical procedures are included, 8 of the top 10 procedures performed on all patients 18-44 (male and female) are related to pregnancy and childbirth (data not shown). About 74 percent of all hospital stays in this age group are for women, and 60 percent of these stays are for pregnancy and childbirth.

Table 2. Most Common Procedures by Age Group

All Listed Procedures* by Age Group	< 1 yr	1-17 yr	18-44 yr	45-64 yr	65-79 yr	80+ yr
	Number of discharges with this procedure category in thousands (Percent of discharges)
Respiratory intubation and mechanical ventilation	258 (5.7)	46 (2.9)	180 (3.3)	321 (4.9)	500 (6.2)	253 (5.3)
Blood transfusion	30 (0.6)	32 1.9)	154(2.9)	296 (4.5)	463 (5.8)	300 (6.3)
Diagnostic ultrasound of heart (echocardiogram)	20 (0.5)				246 (3.1)	139 (2.9)
Circumcision	1,181 (26.2)
Prophylactic vaccinations and inoculations (e.g., hepatitis B)	557 (12.4)
Enteral and parenteral nutrition	41 (0.9)
Ophthalmologic and otologic diagnosis and treatment	25 (0.6)
Diagnostic ultrasound of head and neck	22 (0.5)
Tracheoscopy and laryngoscopy with biopsy	20 (0.5)
Diagnostic spinal tap	152 (3.4)	45 (2.8)
Respiratory therapy		50 (3.1)
Cancer chemotherapy		45 (2.8)
Psychological and psychiatric evaluation and therapy		28 (1.7)
Treatment, fracture or dislocation of lower extremity		23 (1.4)
Treatment, fracture or dislocation of hip and femur		22 (1.4)				145 (3.0)
Computerized axial tomography (CT) scan, head		31 (1.9)				146 (3.1)
Appendectomy		75 (4.6)	156 (2.9)
Cholecystectomy and common duct exploration			143 (2.7)
Alcohol and drug rehabilitation/detoxification			247 (4.6)
Laminectomy/excision of intervertebral disk			179 (3.3)	193 (2.9)
Hysterectomy			291 (5.4)	226 (3.4)
Oophorectomy (removal of ovaries)			188 (3.5)	213 (3.2)
Diagnostic cardiac catheterization, coronary arteriography			269 (5.0)	1,541 (23.3)	1,688 (21.1)	353 (7.4)
Upper gastrointestinal endoscopy, biopsy			161 (3.0)	292 (4.4)	428 (5.3)	264 (5.5)
Coronary artery bypass graft (CABG)				282 (4.3)	383 (4.8)
Percutaneous transluminal coronary angioplasty (PTCA)				258 (3.9)	261 (3.3)
Extracorporeal circulation auxiliary to open heart procedures				183 (2.8)	256 (3.2)
Cardiac pacemaker or cardioverter/defibrillator procedure					221 (2.8)	162 (3.4)
Colonoscopy and biopsy					217 (2.7)	154 (3.2)
Physical therapy exercises, manipulation, and other procedures						131 (2.8)

* The term "All-listed procedures" refers to all procedures performed during a hospital stay; patients often receive more than one procedure.
Note: Excludes procedures related to pregnancy and childbirth.

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How Do Procedures Received Compare by Gender?

• Two of the top 10 procedures for females are procedures of the reproductive system: hysterectomy and oophorectomy (removal of ovaries).
• Four of the top 10 procedures for males pertain to the cardiovascular system—three are therapeutic and one is diagnostic. In contrast, two of the top 10 procedures for females pertain to the cardiovascular system—both are diagnostic.
• Cholecystectomy and colonoscopy are among the top 10 procedures for females but not for males.
• Laminectomy/excision of intervertebral disk—surgery for back pain— is a top 10 procedure for males but not for females.

Table 3. Top 10 Procedures by Gender

All-Listed Procedures*	Total number of male discharges with this procedure category, in thousands (Percent of male discharges)	Total number of female discharge with this procedure category, in thousands (Percent of female discharges)
No procedure	5,012 (40.0)	6,266 (43.1)
Diagnostic cardiac catheterization, coronary arteriography	2,337 (18.6)	1,531 (10.5)
Respiratory intubation and mechanical ventilation	723 (5.8)	638 (4.4)
Blood transfusion	569 (4.5)	690 (4.8)
Upper gastrointestinal endoscopy, biopsy	557 (4.4)	611 (4.2)
Coronary artery bypass graft (CABG)	524 (4.2)
Percutaneous transluminal coronary angioplasty (PTCA)	398 (3.2)
Extracorporeal circulation auxiliary to open heart procedures	348 (2.8)
Laminectomy/excision of intervertebral disk	287 (2.3)
Diagnostic ultrasound of heart (echocardiogram)	315 (2.5)	326 (2.3)
Cholecystectomy and common duct exploration		324 (2.2)
Oophorectomy (removal of ovaries)		477 (3.3)
Colonoscopy and biopsy		330 (2.3)
Hysterectomy		594 (4.1)

* The term "All-listed procedures" refers to all procedures performed during hospital stay; patients often receive more than one procedure.
Note: Excludes procedures related to pregnancy and childbirth.

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