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The United States spends approximately one-third of every health care dollar on hospital care, making hospitalizations the single most expensive component of the health care system. In 2003, U.S. hospitals
reported more than 38 million hospital discharges. Over 60 percent of these discharges involved some type of procedure, and many individuals experienced more than 1 procedure during their stay. Procedures are defined as any diagnostic or therapeutic interventions (invasive or noninvasive) that appear on the discharge record of a hospitalized patient. Understanding the characteristics of hospital procedures is integral to reducing costs and improving the overall quality of hospital care.
Procedures in U.S. Hospitals, 2003 summarizes information about hospital procedures from the Nationwide Inpatient Sample (NIS), an all-payer hospital database maintained by the Agency for Healthcare Research and Quality (AHRQ). This report updates an earlier Fact Book that described hospital procedures in 1997.
This fact book describes:
How Many Procedures Did Patients Receive Per Hospital Stay?
Close to 60 percent of all patients received a procedure during their hospital stay. The 40 percent of patients who did not undergo a procedure typically consisted of newborn infants or medical patients who are hospitalized for medical (versus surgical) reasons, such as stabilization medication, and observation.
Similar to the pattern observed in 1997, patients who received at least 1 procedure averaged 2 procedures during their hospital stay. Approximately 20 percent of hospitalizations in 2003 included 3 or more procedures. About 30 percent of hospital stays involved at least 1 major therapeutic procedure performed in the operating room.
What Were the Most Common Procedures?
Overall, the top 10 procedures performed in the United States remained consistent between 1997 and 2003, with 9 of 10 unchanged. The most common procedures performed in U.S. hospitals continued to be related to pregnancy and childbirth. In 2003, vaccinations were added to this list, replacing episiotomies as a top 10 procedure.
Similar to the pattern observed in 1997, cardiovascular procedures continued to be performed most often during U.S. hospitalizations. In fact, excluding pregnancy- and childbirth-related procedures, 3 of the 10 most frequently performed procedures in 2003 were related to the heart. While most cardiovascular procedures increased in frequency, coronary artery bypass graft (CABG) and extracorporeal circulation to open heart procedures decreased by 19 percent each. Another notable difference from 1997 was a 64-percent increase in blood transfusions.
The most common principal procedures in U.S. hospitals were those that assisted with delivery and C-sections, followed closely by circumcisions.
How Did Procedures Vary by Body System, Age, and Gender?
The most common procedures by body system remained consistent from 1997 to 2003. Cardiovascular,
obstetrical, and digestive procedures continued to be performed most frequently. Cardiovascular procedures were the most common of all procedures, occurring in 13 percent of all hospitalizations. Obstetrical and digestive procedures remained the next most common procedures by body system, with both occurring in 11 percent of all hospital stays in 1997 and 2003.
Blood transfusions were among the top 10 procedures performed in each age group, occurring in 77 percent more hospitalizations than in 1997. This increase in the prevalence of transfusions was accompanied by a similar increase (78 percent) in hospital admissions for anemia.
The top procedures in each age group were:
- <1 year: Circumcision and vaccinations.
- 1-17 years: Appendectomies and diagnostic spinal taps.
- 18-44 years: Obstetrical procedures and hysterectomies.
- 45-64 years: Diagnostic cardiac catheterization and blood transfusions.
- 65-79 years: Diagnostic cardiac catheterization and blood transfusions.
- 80+ years: Blood transfusions and upper gastrointestinal (GI) endoscopy.
The most common procedures for men and women remained stable from 1997 to 2003. Males and females, on average, received an equal number of procedures: 2 per hospitalization. In 2003, 7 of the top 10 procedures performed in U.S. hospitals were identical for males and females.
Three of the top 10 procedures most commonly performed during hospital stays for females were cholecystectomy (removal of the gall bladder) and 2 operations of the female reproductive system—hysterectomy and oophorectomy (removal of the ovaries). Most of these hysterectomies and oophorectomies were for non-cancerous conditions.
Three procedures that were experienced most frequently by males were less common among women: laminectomy (back surgery) and 2 heart-related procedures—percutaneous coronary angioplasty (PTCA) and CABG.
Cesarean sections increased by 33 percent between 1997 and 2003, while episiotomies decreased by 41 percent.
Blood transfusions were performed during nearly 2 million hospital stays, or 5 percent of all hospitalizations. This represented a 64-percent increase from 1997 to 2003.
Hysterectomies and oophorectomies (removal of ovaries) were among the top 10 procedures for women.
Laminectomy, PTCA, and CABG were among the top 10 procedures for men.
What Share of the Nation's Hospitals Were High-Volume Providers for Specific Procedures?
Research suggests that for some procedures, in-hospital mortality is lower at hospitals that perform
a high volume of these procedures.1 This Fact Book examines the percentage of the Nation's hospitals that were considered high-volume providers in 1997 as compared with 2003. Ten procedures are specifically examined in this report: abdominal aortic aneurysm, carotid endarterectomy, lower extremity arterial bypass, CABG, PTCA, heart transplantation, pediatric heart surgery,
pancreatic cancer surgery, esophageal cancer surgery, and cerebral aneurysm surgery.
For the majority of these procedures, the percentage of hospitals serving as high-volume providers did not change significantly in 2003. However, fewer hospitals were considered high-volume providers for CABG and abdominal aortic aneurysm. The number of high-volume hospitals increased for pancreatic cancer.
The percentage of patients receiving procedures in high-volume hospitals decreased the most for CABG—from 63 percent to 41 percent. In 2003, 45,000 more patients underwent CABG nationwide in a low-volume hospital, as compared with 1997.
What Procedures Were Associated With the Highest Hospital Charges and Longest Lengths of Stay?
Hospital charges are the amount the hospital bills for the entire inpatient stay and do not include most
professional (physician) fees. 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 incurs high charges.
In 2003, the mean charge for a hospital stay was $19,700, with an average length of stay of 5 days. Three of the 10 most expensive stays were related to organ transplantation (bone marrow, kidney, and "other" organ transplantations). The most expensive hospitalizations involved "other" organ transplantations of the lung, heart, spleen, intestine, liver, and pancreas—with a mean charge of more than $275,600. In terms of length of hospitalization, procedures involving bone marrow and other organ transplant continued to be associated with some of the longest hospital stays.
Who Was Billed for Hospital Care?
HCUP data capture information on patients regardless of who pays for their care. In 2003, public programs (Medicare and Medicaid) were billed for 58 percent of all hospital stays; private insurance was billed for 35 percent of stays; and 5 percent of stays were uninsured. Other payer sources were billed for
approximately 3 percent of all hospital stays in U.S. community hospitals.
Medicare, the federally sponsored health care program for the elderly and disabled, served approximately 40 million individuals, most of whom were 65 years of age and older.2 Eight of the 10 most common procedures billed to Medicare were the same from 1997 to 2003. Two new additions included procedures related to cardiac pacemakers and arthroplasty of the knee, replacing computerized tomography (CT) scan of the head and physical therapy services. Four of the top procedures billed to Medicare involved the cardiovascular system. In 2003, blood transfusions surpassed diagnostic cardiac catheterizations as the most common procedures performed during stays billed to Medicare.
Medicaid, the Federal- and State-government sponsored health care program for low-income Americans, served about 36 million individuals in 2003.2 Nine of the top 10 procedures billed to Medicaid remained unchanged from 1997. In 2003, hearing examinations replaced episiotomies as a top 10 procedure. Six of the top 10 procedures were related to pregnancy and childbirth. Nearly half of all hospital stays involving vaccinations were billed to Medicaid, as compared with 31 percent in 1997. (These vaccinations typically consisted of hepatitis vaccines given to infants at birth.) After excluding pregnancy- and childbirth-related procedures, vaccinations emerged as the most common procedure billed to Medicaid, and 3 additional diagnostic procedures entered the realm of the top 10 procedures billed to this program: upper GI endoscopy, diagnostic cardiac catheterization, and diagnostic spinal tap.
Nearly 200 million individuals were privately insured through commercial insurance plans, including employer-sponsored health plans and self-purchased plans.2 Eight of the 10 most commonly billed procedures to private insurers remained the same between 1997 and 2003. In 2003, blood transfusions and vaccinations replaced episiotomies and oophorectomies as the most frequent procedures billed to commercial insurers. Six out of 10 procedures billed to private insurers were related
to pregnancy and childbirth. After pregnancy and childbirth-related procedures were excluded, oophorectomy emerged as a top 10 procedure, with about 330,000 billed to private insurers in 2003.
About 45 million Americans had no health insurance in 2003; however, only 5 percent of hospitalized
patients were uninsured at the time of discharge from the hospital.2 Eight of the most common procedures in uninsured hospitalizations were unchanged since 1997. In 2003, blood transfusions and appendectomies replaced fetal monitoring and CT scans of the head as top 10 procedures. The percentage of hospital stays involving procedures for alcohol and drug rehabilitation/detoxification that were not covered by insurance remained high, at 20 percent in 2003.
Four out of 10 procedures billed to Medicare involved the cardiovascular system.
Six out of 10 stays billed to Medicaid and private insurers involved procedures related to pregnancy and childbirth.
Twenty percent of hospital stays involving procedures for alcohol and drug rehabilitation/detoxification were uninsured.
What Procedures Were Associated With the Highest In-hospital Mortality?
The procedures involved in hospital stays that resulted in death remained largely unchanged since 1997. As in 1997, hospital stays involving a conversion of cardiac rhythm most commonly ended in in-hospital death; these stays had a 39-percent mortality rate.
How Did Patient Safety Indicators Change From 1997 to 2003?
Patient safety indicators identify hospitalizations during which a potentially avoidable safety event
occurs. This Fact Book presents comparisons of how U.S. hospitals performed in 2003 versus 1997 on 4 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.
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The mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. To help fulfill this mission, AHRQ develops a number of databases, including those of the powerful Healthcare Cost and Utilization Project (HCUP). HCUP is a Federal-State-Industry partnership designed to build a standardized, multi-State health data system; HCUP features databases, software tools, and statistical reports to inform policymakers, health system leaders, and researchers.
For data to be useful, they must be disseminated in a timely, accessible way. To meet this objective, AHRQ launched HCUPnet, an interactive, Internet-based tool for identifying, tracking, analyzing, and comparing statistics on hospital utilization, outcomes, and charges (http://hcupnet.ahrq.gov/). Menu-driven HCUPnet guides users in tailoring specific queries about hospital care online; with a click of a button, users receive answers within seconds.
In addition, AHRQ produces the HCUP Fact Books to highlight statistics about hospital care in the U.S. in an easy-to-use, readily accessible format. Each Fact Book provides information about specific aspects of hospital care—the single largest component of our health care dollar. These national estimates are benchmarks against which States and others can compare their own data.
This Fact Book provides critical information about hospital procedures for policymakers and researchers interested in improving the quality and efficiency of the U.S. health care system. It is an update to the
second HCUP Fact Book, which presented characteristics of hospital procedures in 1997. This report offers insights into characteristics of hospital procedures during 2003 and is useful for researchers interested
in understanding how these recent patterns compare with 1997 data. Efforts have been made to retain the general content of the initial Procedures in U.S. Hospitals, 1997 Fact Book to allow for easy comparison of 1997 with 2003 data.
AHRQ welcomes questions and comments from readers of this report who are interested in obtaining more information about hospital procedures in the United States. We also 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 firstname.lastname@example.org or send a letter to the address below.
Irene Fraser, Ph.D.
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
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HCUP is based on data collected by individual State Partner organizations (including State departments of health, hospital associations, and private agencies). These organizations provide the data to AHRQ where the data are converted to uniform data products. Without the following Partner organizations, HCUP and the Nationwide Inpatient Sample (NIS) would not be possible:
- Arizona Department of Health Services.
- California Office of Statewide Health Planning & Development.
- Colorado Health & Hospital Association.
- Connecticut Integrated Health Information (Chime, Inc.).
- Florida Agency for Health Care Administration.
- Georgia An Association of Hospitals & Health Systems (GHA).
- Hawaii Health Information Corporation.
- Illinois Department of Public Health.
- 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.
- Michigan Health & Hospital Association.
- Minnesota Hospital Association.
- Missouri Hospital Industry Data Institute.
- Nebraska Hospital Association.
- Nevada Department of Human Resources.
- New Hampshire Department of Health & Human Services.
- New Jersey Department of Health and Senior Services.
- New York State Department of Health.
- North Carolina Department of Health and Human Services.
- Ohio Hospital Association.
- Oregon Association of Hospitals and Health Systems, and Office of Oregon Health
Policy and Research.
- Rhode Island Department of Health.
- Pennsylvania Health Care Cost Containment Council.
- South Carolina State Budget and Control Board.
- South Dakota Association of Healthcare Organizations.
- Tennessee Hospital Association.
- Texas Department of State Health Services.
- Utah Department of Health.
- Vermont Association of Hospitals and Health Systems.
- Virginia Health Information.
- Washington State Department of Health.
- West Virginia Health Care Authority.
- Wisconsin Department of Health and Family Services.
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In 1999, AHRQ launched an initiative to provide timely data regarding hospital care in the United States by producing a series of easily accessible Fact Books that summarize several aspects of hospitalizations. The first published Fact Book, Hospitalization in the United States, 1997, provided a general overview of hospitalizations. The second Fact Book, Procedures in U.S. Hospitals, 1997, provided an overview of the types of procedures being performed in U.S. community hospitals.
Procedures in U.S. Hospitals, 2003 updates the second Fact Book. Similar to the 1997 version, this report draws from the Nationwide Inpatient Sample (NIS), a database maintained by AHRQ, to provide comprehensive information about procedures in U.S. community hospitals. Findings are based on "all-listed" procedures on each HCUP discharge record—and are not limited to the principal procedure code. AHRQ has attempted to maintain the general content of the earlier report to allow easy comparison between 1997 and 2003 information. This report answers these central questions:
Findings from this report indicate that many aspects of hospitalizations have remained stable since 1997, but there are key exceptions.
This Fact Book provides a rich depiction of hospital procedures in 2003. Information on data sources and methods are available at the end of this document. An appendix provides descriptive information about specific hospital procedures according to six key characteristics:
- Number of discharges with the procedure.
- Percent of all procedures.
- Percent of discharges with the procedure.
- Mean length of stay for hospitalizations with the specific procedure.
- Mean charges for hospitalizations with the procedure.
- In-hospital mortality for hospitalizations with the procedure.
A complete medical dictionary containing terms used in this Fact Book is available at http://www.nlm.nih.gov/medlineplus/mplusdictionary.html.
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