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Care of Women in U.S. Hospitals, 2000

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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, multi-State 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. 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; and, with a click of a button, users receive answers within seconds.

A second 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. The second Fact Book provided information on procedures performed in U.S. hospitals.

This third Fact Book answers many questions about hospital care for women such as:

  • In what ways do hospitalized women differ from hospitalized men?
  • What are the most common reasons for hospitalizations?
  • For what preventable conditions are women hospitalized?
  • Who is billed for various types of hospital stays?
  • What are the patterns of hospital care for pregnancy and delivery?

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. In addition, AHRQ continually seeks to learn how HCUP and other AHRQ products have influenced practice, patient outcomes, and health policy. 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
540 Gaither Road, Suite 5000
Rockville, MD 20850

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Contributors

Without the following 28 State partner organizations, the Healthcare Cost and Utilization Project would not be possible:

  • Arizona Department of Health Services.
  • California Office of Statewide Health Planning & Development.
  • Colorado Health & 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.
  • Iowa Hospital Association.
  • Kansas Hospital Association.
  • Kentucky Department for Public Health.
  • Maine Health Data Organization.
  • Maryland Health Services Cost Review Commission.
  • Massachusetts Division of Health Care Finance and Policy.
  • Missouri Hospital Industry Data Institute.
  • New Jersey Department of Health & Senior Services.
  • New York State Department of Health.
  • North Carolina Department of Health and Human Services.
  • Oregon Association of Hospitals & Health Systems.
  • Pennsylvania Health Care Cost Containment Council.
  • South Carolina State Budget & Control Board.
  • Tennessee Hospital Association.
  • Texas Health Care Information Council.
  • Utah Department of Health.
  • Virginia Health Information.
  • Washington State Department of Health.
  • West Virginia Health Care Authority.
  • Wisconsin Department of Health & Family Services.

In May 2000, 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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Acknowledgments

Thanks to James Maedke and Shiqiang Li at Social and Scientific Systems, Inc., for their invaluable assistance in statistical programming and to DonnaRae Castillo, AHRQ Office of Health Care Information, for editorial assistance.

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Introduction

Women accounted for about 60 percent of all adult hospital stays during 2000. This report provides an overview of hospital care for women and compares hospital stays for women and men. It also includes a special section on obstetric care in hospitals.

This report summarizes information from the Nationwide Inpatient Sample, or NIS, a database maintained by the Agency for Healthcare Research and Quality (AHRQ). The NIS is uniquely suited to providing a comprehensive picture of hospital care. Because of its tremendous size (about 7 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 (Medicare and Medicaid), and those with private insurance. It also provides information on total hospital charges for all patients, unlike any other data source in the United States.

This report provides information on:

Hospital stays for men and women:

Hospital stays for obstetric patients:

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Executive Summary

Part 1. Hospital Stays for Men and Women

  • Excluding obstetric patients, the biggest difference in age composition between men and women is in the 80+ age group. About 1 in 4 nonobstetric hospital stays for women and 1 in 7 for men are in this group.
  • Six out of the top 10 conditions for nonobstetric hospital stays are related to the circulatory system. These conditions make up 18 percent of all hospital stays for women and 23 percent of all stays for men.
  • Gallbladder disease is among the top 10 conditions for nonobstetric female patients but not for males.
  • Depression is the most common reason for nonobstetric hospital stays among women age 18 to 44.
  • Alcohol/drug detoxification is a top 10 procedure for women age 18-44, while treatment for hip fractures and hip replacement are among the top 10 procedures for women age 80 and older.
  • For two cardiac conditions—heart attack and hardening of the arteries of the heart—about 1 in 3 hospitalizations for women includes no procedure. But for men, only 1 in 4 receives no procedure for heart attack and only 1 in 5 receives no procedure for hardening of the arteries of the heart. Men are more likely than women to receive cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft (CABG).
  • Hypertension is the most common comorbidity among nonobstetric patients admitted to hospitals. About 35 percent of women in the hospital and 31 percent of men have hypertension as a coexisting condition.
  • Obesity is a top 10 comorbidity for both hospitalized men and women age 18 to 64.
  • Three ambulatory care sensitive (ACS) conditions—diabetes with complications, asthma, and urinary tract infection—are among the top 10 common reasons for hospitalization among nonobstetric female patients who are uninsured or covered by Medicaid. These are conditions for which good outpatient care might prevent hospitalization.
  • HIV disease is among the top 10 conditions with the highest in-hospital mortality for nonobstetric female patients age 18-44.
  • For men and women age 45-79, half of the top 10 conditions with the highest in-hospital mortality are related to cancers.
  • The average length of hospital stay increases by age regardless of sex. Nevertheless, for each age cohort, male patients have higher total hospital charges than nonobstetric female patients.

Part 2. Hospital Stays for Obstetric Patients

  • Pregnancy and childbirth account for almost 1 out of 4 hospital stays for women.
  • Delivery of a child accounts for 88 percent of obstetric hospital stays.
  • Women with Medicaid coverage or who are uninsured account for about 4 out of 10 obstetric hospital stays.
  • Women hospitalized for antepartum or postpartum care are more likely to be uninsured or covered by Medicaid than women admitted for delivery.
  • Women admitted to hospitals due to pregnancy loss are more than twice as likely to be uninsured than any other type of obstetric patients.
  • About 1 in 3 women with a primary cesarean section is age 18 to 24 and only 1 in 6 is age 35 or older.
  • Women with private insurance are more likely to have cesarean sections than women uninsured or covered by Medicaid.
  • About 1 in 12 women who have vaginal delivery without instrumentation experiences perineal or cervical laceration or other obstetric trauma. This compares with nearly 1 in 4 women who have vaginal delivery that includes use of instruments, such as forceps or vacuum extraction.
  • The cesarean section rate increased slightly from 21.3 percent in 1997 to 23.2 percent in 2000. In contrast, the rate for vaginal birth after cesarean section (VBAC) decreased from 35.3 percent to 28.6 percent over the same time period.

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Part 1. Hospital Stays for Men and Women

How Does Age Composition Differ for Men and Women?

  • Two out of 5 hospital stays for all female patients are for women in the 18-44 age group. Close to 60 percent of these stays are due to pregnancy and childbirth (data not shown).
  • Excluding obstetric patients, 53 percent of hospitalizations for women are for patients age 65 or older. This compares with 46 percent of men. The biggest difference is in the 80+ age group—23 percent of nonobstetric hospital stays for women are in this oldest age category compared with 15 percent for men.

Select Figure 1 (16 KB), Age Composition by Sex.

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How Do Men and Women Differ in Source of Admission to the Hospital?

  • Half of hospital stays for all female patients are admitted routinely while about 2 in 5 originate in the emergency department (ED).
  • Excluding obstetric patients, the proportion of hospital stays admitted through the emergency department (ED) is slightly lower among women (49 percent) than among men (51 percent).
  • Transfers from other health care institutions account for only around 6 percent of all nonobstetric hospital stays.

Select Figure 2 (29 KB), Source of Admission to Hospital.

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What Are the Most Common Reasons for Hospitalization, By Body System?

  • The most common reason for hospitalization among women is pregnancy and childbirth. About 4.4 million hospital stays are due to obstetric conditions.
  • Among nonobstetric patients, diseases of the circulatory system are the most common reason for hospitalization for both men and women, followed by diseases of the respiratory, digestive, and musculoskeletal systems.
  • The number of hospitalizations for endocrine, nutritional and metabolic diseases is almost 60 percent higher for females than for males (569,000 vs. 357,000).
  • The number of hospital stays associated with drug/alcohol abuse for males (303,000) is more than double that for females (138,000).
  • Mental disorders are among the most common reasons for hospitalization for both men and women.

Select Figure 3 (19 KB), Most Common Reasons for Hospitalization, By Body System.

How Do the Most Common Reasons for Hospitalization of Women Differ from Those for Men?

  • The most common diagnosis for hospitalization among all women is trauma to perineum due to childbirth. (Women with this diagnosis were hospitalized for childbirth and, as a result of delivery, were treated for perineal trauma.)
  • Pneumonia, congestive heart failure, and hardening of the arteries of the heart are the top three conditions among nonobstetric female and male patients.
  • Six out of the top 10 conditions for nonobstetric female and male patients are related to the circulatory system. These conditions make up 18 percent of all hospital stays for nonobstetric female patients and 23 percent of all stays for males.
  • The number of hospitalizations for two cardiac conditions—hardening of the arteries of the heart and heart attack—are over 40 percent higher for males than for nonobstetric female patients.
  • Depression ranks as the fifth and gall bladder disease as the tenth most frequent condition for nonobstetric female patients. Neither condition is in the top 10 for males.
  • Back pain is among the top 10 reasons for hospitalization of men but not of women.
  • Nonobstetric female patients have 27 percent more discharges for chronic obstructive lung disease than men (344,000 vs. 270,000).

Table 1. Top 10 Principal Diagnoses, by Sex


Principal diagnosis Female patients Nonobstetric female patients Male patients
Total number of discharges (thousands) Percent of all female discharges Total number of discharges (thousands) Percent of all nonobstetric female discharges Total number of discharges (thousands) Percent of all male discharges
Trauma to perineum due to childbirth 785 4.3        
Pneumonia 581 3.1 581 4.1 514 4.4
Congestive heart failure 564 3.1 564 4.0 460 4.0
Coronary atherosclerosis (hardening of the arteries of the heart) 546 3.0 546 3.9 814 7.0
Normal pregnancy and delivery 475 2.6        
Chest pain 435 2.4 435 3.1 358 3.1
Affective disorders (depression) 361 2.0 359 2.6    
Chronic obstructive lung disease 344 1.9 344 2.5 270 2.3
Cardiac dysrhythmia (irregular heartbeat) 336 1.8 336 2.4 311 2.7
Acute cerebrovascular disease (stroke) 324 1.8 324 2.3 255 2.2
Acute myocardial infarction (heart attack)     314 2.2 454 3.9
Biliary tract (gallbladder) disease     311 2.2    
Spondylosis, intervertebral disc disorders, other back problems         290 2.5
Complication of device, implant or graft         257 2.2

Note: Rows with bold type signify circulatory system-related diagnoses.

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What Are the Most Common Reasons for Hospitalization of Nonobstetric Female Patients, by Age Group?

  • Pneumonia is the only condition that ranks in the top 10 for all age groups of nonobstetric female patients. It is the second most common reason for hospital stays among women 80 years and older.
  • Depression is the most common reason for nonobstetric hospital stays among women age 18 to 44. Three of the top 10 conditions for this age group pertain to gynecologic diseases and disorders.
  • Hardening of the arteries of the heart and congestive heart failure are among the top 10 conditions for all age groups 45 and older.
  • Hip fracture is the third most common reason for hospitalization among women age 80 or older.
  • Five of the top 10 conditions for hospitalized women 65 years and older are related to the circulatory system—hardening of the arteries of the heart, congestive heart failure, irregular heartbeat, heart attack, and stroke.

Table 2. Top 10 Principal Diagnoses for Nonobstetric Female Patients, by Age Group

Principal diagnosis 18-44 years 45-64 years 65-79 years 80+ years
  Number of discharges in thousands
(percent of discharges in each age group)
Affective disorders (depression) 205 (7.0) 98 (2.6)    
Benign neoplasm of uterus 139 (4.8) 111 (3.0)    
Biliary tract disorders (gallbladder disease) 117 (4.0) 90 (2.4)    
Spondylosis, intervertebral disc disorders, other back problems 85 (2.9) 107 (2.9)    
Asthma 70 (2.4)      
Menstrual disorders 69 (2.4)      
Endometriosis 66 (2.3)      
Schizophrenia and other related disorders 65 (2.2)      
Chest pain 63 (2.2) 193 (5.2) 126 (3.0)  
Pneumonia 60 (2.1) 117 (3.1) 185 (4.5) 218 (6.8)
Coronary atherosclerosis (hardening of the arteries of the heart)   178 (4.8) 244 (5.9) 103 (3.2)
Chronic obstructive lung disease   100 (2.7) 156 (3.7)  
Congestive heart failure   94 (2.5) 213 (5.1) 242 (7.6)
Complication of device, implant or graft   79 (2.1)    
Osteoarthritis     145 (3.5)  
Cardiac dysrhythmia (irregular heartbeat)     143 (3.4) 115 (3.6)
Acute myocardial infarction (heart attack)     124 (3.0) 109 (3.4)
Acute cerebrovascular disease (stroke)     121 (2.9) 131 (4.1)
Rehabilitation     119 (2.9) 93 (2.9)
Hip fracture       149 (4.7)
Fluid and electrolyte disorders       107 (3.3)
Urinary tract infection       103 (3.2)

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What Are the Most Common In-Hospital Procedures Received by Nonobstetric Female Patients?

  • Among the top 10 procedures for women admitted to the hospital for nonobstetric reasons, two pertain to the reproductive system—hysterectomy and oophorectomy (removal of ovaries)—while three pertain to the digestive system—upper gastrointestinal endoscopy, colonoscopy, and cholecystectomy.
  • For procedures related to the cardiovascular system, two procedures—both are diagnostic—appear in the top 10 for nonobstetric female patients while five procedures—three are therapeutic and two are diagnostic—emerge in the top 10 for male patients.
  • Laminectomy/excision of intervertebral disk (surgery for back problems) is among the top 10 procedures for males but not for nonobstetric female patients.
  • Close to 6 percent of stays for both men and women patients include blood transfusions.

Table 3. Top 10 Procedures for Male and Nonobstetric Female Patients

All-listed proceduresa Nonobstetric female patients Male patients
 Total number of discharges with this procedure category, in thousands (percent of discharges)
No procedure 6,070 (43.3) 4,611 (39.8)
Diagnostic cardiac catheterization, coronary arteriography 1,687 (12.0) 2,534 (21.8)
Blood transfusionb 828 (5.9) 668 (5.8)
Upper gastrointestinal endoscopy and biopsy 657 (4.7) 592 (5.1)
Respiratory intubation and mechanical ventilation 630 (4.5) 680 (5.9)
Hysterectomy 613 (4.4)  
Oophorectomy (removal of ovaries) 485 (3.5)  
Colonoscopy and biopsy 352 (2.5)  
Cholecystectomy and common duct exploration 318 (2.3)  
Hemodialysis 299 (2.1) 293 (2.5)
Diagnostic ultrasound of heart (echocardiogram) 286 (2.0) 281 (2.4)
Coronary artery bypass graft (CABG)   499 (4.3)
Percutaneous transluminal coronary angioplasty (PTCA)   452 (3.9)
Laminectomy, excision of intervertebral disc   297 (2.6)
Extracorporeal circulation auxiliary to open heart procedures   274 (2.4)

a The term "All-listed procedures" refers to all procedures performed during a hospital stay.
b The data likely represent an underestimate of the actual number of transfusions.

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What Are the Most Common In-Hospital Procedures for Nonobstetric Female Patients, by Age Group?

  • Two gynecologic procedures—hysterectomy and oophorectomy—are among the top 10 for nonobstetric female patients under 65 years of age.
  • Alcohol/drug detoxification is a top 10 procedure for women 18 to 44 years of age.
  • Diagnostic cardiac catheterization, blood transfusion, upper gastrointestinal endoscopy, and respiratory intubation/mechanical ventilation are in the top 10 for all age groups.
  • Diagnostic cardiac catheterization is performed during 1 in 6 hospital stays for women 45-79 years old but is much less common in other age groups.
  • Two cardiac diagnostic procedures—cardiac catheterization and echocardiogram—are among the top 10 procedures for all women age 65 and older. CABG and PTCA only appear in the top 10 for women 65-79 while cardiac pacemaker procedures rank in the top 10 only for women age 80 or older.
  • Treatment for hip fractures, physical therapy, and hip replacement are among the top 10 procedures for women age 80 and older.

Table 4. Top 10 Procedures for Nonobstetric Female Patients, by Age Group

All-listed procedures* 18-44 years 45-64 years 65-79 years 80+ years
 Total number of discharges with this procedure category, in thousands (percent of discharges)
Hysterectomy 304 (10.4) 246 (6.6)    
Oophorectomy 195 (6.7) 227 (6.1)    
Cholecystectomy 119 (4.1) 94 (2.5)    
Excision, lysis peritoneal adhesions 104 (3.6)      
Diagnostic cardiac catheterization, coronary arteriography 93 (3.2) 603 (16.2) 763 (18.3) 229 (7.2)
Blood transfusion 90 (3.1) 183 (4.9) 296 (7.1) 259 (8.1)
Upper gastrointestinal endoscopy, biopsy 86 (3.0) 157 (4.2) 232 (5.6) 181 (5.7)
Appendectomy 85 (2.9)      
Alcohol and drug rehabilitation/detoxification 78 (2.7)      
Respiratory intubation and mechanical ventilation 74 (2.5) 165 (4.4) 239 (5.7) 153 (4.8)
Hemodialysis   103 (2.8) 118 (2.8)  
Laminectomy   100 (2.7)    
Percutaneous transluminal coronary angioplasty (PTCA)   80 (2.1) 112 (2.7)  
Colonoscopy and biopsy     126 (3.0) 106 (3.3)
Arthroplasty knee     112 (2.7)  
Diagnostic ultrasound of heart (echocardiogram)     109 (2.6) 77 (2.4)
Coronary artery bypass graft (CABG)     108 (2.6)  
Treatment, fracture or dislocation of hip and femur       110 (3.4)
Insertion, revision, replacement, removal of cardiac pacemaker or cardioverter/defibrillator       97 (3.0)
Physical therapy exercises, manipulation, other procedures       80 (2.5)
Hip replacement, total and partial       74 (2.3)

*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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How Does Procedure Use Differ for Men and Women Hospitalized for Two Common Cardiac Conditions?

  • Heart attack and hardening of the arteries of the heart are among the top 10 diagnoses for both male and nonobstetric female patients.
  • Among nonobstetric female patients, about 1 in 3 hospitalizations for these two conditions includes no procedure. But for male patients, only 1 in 4 receives no procedure for heart attack and only 1 in 5 receives no procedure for hardening of the arteries of the heart.
  • For these two cardiac conditions, men are more likely to receive cardiac catheterization, PTCA, and CABG than women. The proportion of hospital stays during which CABG is performed is over 50 percent higher for men than for women. (For heart attack, about 12 percent of stays for men vs. 8 percent for women involve CABG; for hardening of the arteries of the heart, nearly 24 percent of stays for men vs. 15 percent for women include this procedure.)

Select Figure 4 (12 KB), Procedure Use for Two Cardiac Conditions.

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How Do the Common Comorbidities for Nonobstetric Female Patients Compare with Those for Men?

  • Hypertension is the most common comorbidity among nonobstetric patients admitted to hospitals. About 35 percent of women in the hospital and 31 percent of men have a coexisting condition of hypertension.
  • Other common comorbidities are diabetes (18 percent for both men and women), fluid and electrolyte disorders (slightly higher for women, 15 vs. 13 percent), and chronic lung disease (15 percent for women and 16 percent for men).
  • Hypothyroidism and depression are among the top 10 comorbidities for nonobstetric female patients while alcohol abuse and peripheral vascular disease are among the top 10 comorbidities for male patients.

Table 5. Top 10 Comorbidities, by Sex

Comorbidity* Nonobstetric female patients Male patients
 Total number of discharges with this procedure category, in thousands (percent of discharges)
Hypertension 4,941 (35.3) 3,614 (31.2)
Diabetes 2,522 (18.0) 2,106 (18.2)
Fluid and electrolyte disorders 2,101 (15.0) 1,445 (12.5)
Chronic lung disease 2,051 (14.6) 1,826 (15.7)
Deficiency anemias 1,385 (9.9) 918 (7.9)
Hypothyroidism 1,350 (9.6)  
Cardiac arrhythmias (irregular heartbeat) 1,260 (9.0) 1,069 (9.2)
Congestive heart failure 1,151 (8.2) 820 (7.1)
Solid tumor without metastasis 845 (6.0) 779 (6.7)
Depression 839 (6.0)  
Alcohol abuse   630 (5.4)
Peripheral vascular disease (hardening of the arteries)   550 (4.7)

*Comorbidities can make a hospital stay more expensive and complicated. They are coexisting medical conditions that are not directly related to the principal diagnosis, or the main reason for admission, and are likely to have originated prior to the hospital stay.
Source: Elixhauser A, Steiner C, Harris DR, et al. Comorbidity measures for use with administrative data. Medical Care 1998; 36(1):8-27.

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How Do Comorbidities Differ Across Age Groups?

  • Hypertension, fluid and electrolyte disorders, chronic lung disease, diabetes, and deficiency anemias are among the top 10 comorbidities in every age group.
  • Obesity is a top 10 comorbidity for both male and nonobstetric female patients age 18 to 64.
  • Alcohol and drug abuse and psychoses are present in the top 10 only for the group of 18 to 44 years of age.
  • For those age 65 and older, peripheral vascular disease and renal failure are among the top 10 comorbidities for males; hypothyroidism is among the top 10 for females.

Table 6. Top 10 Comorbidities, by Age Group and Sex

Comorbidity 18-44 years 45-64 years 65-79 years 80+ years
Non-obstetric female patients Male patients Non-obstetric female patients Male patients Non-obstetric female patients Male patients Non-obstetric female patients Male patients
Total number of discharges (in thousands) 2,913 2,577 3,733 3,648 4,167 3,624 3,195 1,749
  Percent of discharges in each age/sex group
Hypertension 9.3 11.2 32.8 33.5 46.7 40.7 46.9 35.9
Fluid and electrolyte disorders 8.7 8.5 11.5 10.6 16.3 13.6 23.1 19.9
Cardiac arrhythmias (irregular heartbeat)       4.4 11.1 13.1 19.3 22.3
Congestive heart failure         10.0 9.7 17.5 17.0
Chronic lung disease 7.7 5.3 13.8 12.9 19.2 22.5 16.0 23.0
Diabetes without complications 5.0 4.9 16.3 16.2 21.0 20.6 15.0 15.7
Deficiency anemias 6.2 4.1 7.9 6.5 10.8 9.2 14.3 13.6
Hypothyroidism     8.2   12.2   13.6  
Solid tumor without metastasis     5.2   8.2 10.5 8.2 13.4
Valvular disease             5.7  
Peripheral vascular disease
(hardening of the arteries)
          7.6   7.6
Renal failure     4.1 4.6   5.5   6.2
Affective disorders (depression) 6.0 3.9 6.8   5.5      
Obesity 5.4 3.4 7.6 4.8        
Drug abuse 5.2 8.7            
Alcohol abuse 3.8 9.6   7.4        
Psychoses 3.6 3.5            
Diabetes with chronic complications       4.0        

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