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Source of Data for This Report

The results presented in this report are drawn from the Healthcare Cost and Utilization Project (HCUP), a Federal-State-Industry partnership to build a multi-State health care data system. This partnership is sponsored by the Agency for Healthcare Research and Quality (AHRQ) and is managed by staff in AHRQ's Center for Delivery, Organization, and Markets (CDOM). HCUP is based on data collected by individual HCUP Partners (including State departments of health, hospital associations, and private agencies), which provide these data to AHRQ. HCUP would not be possible without statewide data collection projects and their partnership with AHRQ.

For the year 2003, 38 HCUP Partners contributed their data to AHRQ, where all files were validated and converted into a uniform format. The uniform HCUP databases enable comparative studies of health care services and the use and cost of hospital care, including:

  • Effects of market forces on hospitals and the care they provide.
  • Variations in medical practice.
  • Effectiveness of medical technology and treatments.
  • Use of services by special populations.

HCUP includes short-term, non-Federal, community hospitals, as defined by the American Hospital Association (AHA). This definition encompasses general hospitals and specialty facilities, such as pediatric, obstetrics-gynecology, short-term rehabilitation, and oncology hospitals. Long-term care and psychiatric hospitals are excluded, as are substance abuse treatment facilities.

HCUP includes several sets of inpatient and outpatient databases for health services research. This report is based on the 2003 State Inpatient Databases (SID) and the 2003 State Ambulatory Surgery Databases (SASD). The SID contain the universe of the inpatient discharge abstracts in 38 Partner States, translated into a uniform format to facilitate multi-State comparisons and analyses. The SASD capture surgeries performed on the same day in which patients are admitted and released. All of the SASD databases from 20 Partner States include abstracts from hospital-affiliated ambulatory surgery sites. Some contain the universe of ambulatory surgery encounter abstracts for that State, including records from both hospital-affiliated and freestanding surgery centers.

This report evaluates inpatient and outpatient surgery data from 17 selected States that contributed data to both the 2003 SASD and SID: Colorado, Connecticut, Georgia, Indiana, Kentucky, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New York, North Carolina, South Carolina, Tennessee, Utah, Vermont, and Wisconsin.iii


iiiAlthough 20 States contributed to both the 2003 SASD and SID, only 17 used the ICD-9-CM procedure codes (rather than CPT codes) necessary for this report.


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Methods

This Fact Book is based on data in the HCUP SID and the SASD. Selected methodological issues relevant to this report follow.

Unit of Analysis

For this report, any reference to "visit" or "hospital stay" indicates that the unit of analysis is the record rather than the surgical procedure.Any reference to "surgeries" indicates that the unit of analysis is a major operating room procedure. Multiple surgical procedures can be listed on a record in the SID and SASD. Frequencies and rankings of surgeries are based on all-listed—that is, all surgical procedures listed on the record—and de-duplicated procedures. If a particular procedure occurs multiple times during the same surgical visit or hospital stay, it is counted only once.

Inclusion Criteria

Records from the SASD meeting the following criteria were included:

  • Presence of at least 1 surgical procedure as defined by an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code in the range of 00.50-86.99 or 88.40-88.59.
  • Containing at least 1 major therapeutic or diagnostic operating room procedure as defined by the procedure classes described below.
  • Length of stay of 0 or 1 day.
  • Originating from a hospital-based ambulatory surgery center having at least 200 ambulatory surgical visits.
  • Obtained from a facility designated as a short-term, community, non-rehabilitation hospital.

Records from the SID meeting similar criteria were included:

  • Presence of at least 1 surgical procedure as defined by an ICD-9-CM procedure code in the range of 00.50-86.99 or 88.40-88.59.
  • Containing at least 1 major therapeutic or diagnostic operating room procedure as defined by the procedure classes described below.
  • Originating from a hospital with at least 200 inpatient surgical stays.
  • Obtained from a facility designated as a short-term, community, non-rehabilitation hospital.

Procedure Classes

The Procedure Classes tool provides an easy way to categorize ICD-9-CM procedure codes into 1 of 4 broad categories: major diagnostic, major therapeutic, minor diagnostic, and minor therapeutic. This tool was created to facilitate health services research on hospital procedures using administrative data. All ICD-9-CM procedure codes are assigned to 1 of the following categories:

  • Major Diagnostic—All procedures considered valid operating room procedures by the Diagnosis Related Group grouper and that are performed for diagnostic reasons.
  • Major Therapeutic—All procedures considered valid operating room procedures by the Diagnosis Related Group grouper and that are performed for therapeutic reasons.
  • Minor Diagnostic—Non-operating room procedures that are diagnostic.
  • Minor Therapeutic—Non-operating room procedures that are therapeutic.

This Fact Book examines only ambulatory and inpatient hospital discharge records where at least one ICD-9-CM procedure code was classified as either a major diagnostic or major therapeutic procedure.

More detailed information on the Procedure Classes tool can be obtained from the HCUP User Support Web site at: http://www.hcup-us.ahrq.gov/toolssoftware/procedure/procedure.jsp.

Procedures and Clinical Classifications Software (CCS)

Surgical procedures are recorded within the HCUP databases using ICD-9-CM codes. Although ICD-9-CM codes may be used to provide descriptive statistics, the granular nature of these codes is difficult to summarize. Thus, for this report, the AHRQ-developed Clinical Classifications Software (CCS) is used to aggregate ICD-9-CM procedure codes into a limited number of clinically meaningful categories for most tables. More detailed information on CCS can be downloaded from the HCUP User Support Web site at: http://www.hcup-us.ahrq.gov/home.jsp.

Payer

Payer is the expected payer for the surgical visit or hospital stay. To make coding uniform across all HCUP data sources, "Payer" combines detailed categories into more general groups:

  • Medicare includes fee-for-service and managed care Medicare patients.
  • Medicaid includes fee-for-service and managed care Medicaid patients.
  • Private insurance includes Blue Cross, commercial carriers, and private HMOs and PPOs.
  • Uninsured includes an insurance status of "self-pay" and "no charge."
  • Other includes Workers' Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs.

Up to two payers can be coded for a surgical visit or hospital stay in HCUP data.When this occurs, the following hierarchy is used:

  • If either payer is listed as Medicaid—payer is "Medicaid."
  • For non-Medicaid stays, if either payer is listed as Medicare— payer is "Medicare."
  • For stays that are neither Medicaid nor Medicare, if either payer is listed as private insurance—payer is "private insurance."
  • For stays that are not Medicaid,Medicare, or private insurance, if either payer is some other third-party payer—payer is "other."
  • For stays that have no third-party payer and the payer is listed as "self-pay" or "no charge"—payer is "uninsured."
  • If no insurance information is available—payer is missing.

Charges

Charges in HCUP data are the amount the hospital charged or billed for the entire surgical visit or hospital stay and do not reflect charges for individual surgical procedures. Charges do not necessarily reflect reimbursements or costs and do not include most professional (physician) fees. Cost-to-charge ratios are available to convert inpatient hospital charges to inpatient hospital costs, but an equivalent ratio for outpatient hospital data is currently not available.

Specific Surgical Procedures

Part II of this report provides detailed statistics for specific surgeries and populations. These surgeries have been identified using the following ranges of ICD-9-CM procedure codes or CCS categories:

Surgeries ICD-9-CM Codes CCS Procedure Category
Appendectomy Procedure codes: 47.01-47.19 80
Cholecystectomy and common duct exploration Procedure codes: 51.21-51.24 or 51.41-51.59 84
Hernia repair Procedure codes: 53.00-53.39 85
Bariatric surgery Procedure codes: 43.81-43.89, 44.31, 44.39, 44.50-44.59, 44.69,45.90, or 45.91
and
Diagnosis codes: 278.00-278.01
Excludes records with at least one cancer diagnosis in the following range: 150.0-159.9
Tonsillectomy and/or adenoidectomy Procedure codes: 28.2-28.3 or 28.6-28.7 30
Mastectomy Procedure codes: 85.41-85.48 167
Hysterectomy Procedure codes: 68.3-68.9 124
Transurethral prostatectomy (TURP) Procedure codes: 60.21-60.29 or 60.96-60.97 113

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References

1 National Center for Health Statistics. Health, United States, 2004 with chartbook on trends in the health of Americans. Hyattsville, MD: 2004.

2 Kozak LJ, McCarthy E, Pokras R. Changing patterns of surgical care in the United States, 1980-1995. Health Care Finance Rev. 1999 Fall;21(1):31-49.

3 U.S. Census Bureau, Population Division. Annual estimates of the population for the United States and States, and for Puerto Rico: April 1, 2000 to July 1, 2005. http://www.census.gov/popest/states/NST-ann-est2005.html. (Accessed March 27, 2009).

4 DeNavas-Walt C, Proctor BD, Mills RJ. Income, poverty, and health insurance coverage in the United States: 2003. Current Population Reports, P60-226. Washington, DC: U.S. Census Bureau, 2004. http://www.census.gov/prod/2004pubs/p60-226.pdf. (Accessed March 27, 2009).

5 American Hospital Association. Fast facts on US hospitals. Updated November 7, 2008. http://www.aha.org/aha/resource-center/Statistics-and-Studies/fast-facts.html. (Accessed March 27, 2009).

6 U.S. Census Bureau, Population Division. Annual estimates of the population by sex, race, and Hispanic or Latino origin for States: April 1, 2000 to July 1, 2004. http://www.census.gov/popest/states/asrh/SC-EST2004-03.html. (Accessed March 27, 2009).

7 U.S. Census Bureau, Population Division. Estimates of the resident population by selected age groups for the United States and States and for Puerto Rico: July 1, 2004. http://www.census.gov/popest/states/asrh/SC-est2004-01.html. (Accessed March 27, 2009).

8 American College of Surgeons. When you need an operation: about appendectomy. http://www.facs.org/public_info/operation/app.pdf#search=%22American%20College%20of%20Surgeons%20 About%20Appendectomy%22. (Accessed March 27, 2009).

9 Reddick RJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Am J Surg. 1990 Nov;160(5):485-7.

10 Encinosa WE, Bernard DM, Steiner CA, Chen CC. Use and costs of bariatric surgery and prescription weight-loss medications. Health Aff (Millwood). 2005 Jul-Aug;24(4):1039-46.

11 Brigger MT, Brietzke SE. Outpatient tonsillectomy in children: a systematic review. Otolaryngol Head Neck Surg. 2006 Jul;135(1):1-7.

12 Lalakea ML, Marquez-Biggs I, Messner AH. Safety of pediatric short-stay tonsillectomy. Arch Otolaryngol Head Neck Surg. 1999 Jul;125 (7):749-52.

13 Kaiser Family Foundation. State mandated benefits: coverage of inpatient mastectomy stay, 2004. (Updated 2008) http://www.statehealthfacts.org/comparemaptable.jsp?ind=489&cat=10. (Accessed March 27, 2009).

14 Dooley WC. Ambulatory breast cancer surgery. Ann Surg Oncol. 2000 Apr;7(3):174-5.

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For More Information

More information regarding HCUP data is available at http://www.ahrq.gov/data/hcup, as well as on the HCUP User Support Web site at http://www.hcup-us.ahrq.gov.

SASD data are available for purchase for the following data years and numbers of States:

  • 1997 data: 6 States (Colorado, Florida, Maryland, New Jersey, New York, and Utah)
  • 1998 data: 7 States (added Wisconsin)
  • 1999 data: 8 States (added Maine)
  • 2000 data: 10 States (added Kentucky and North Carolina)
  • 2001 data: 11 States (added Nebraska)
  • 2002 data: 11 States (no new additions)
  • 2003 data: 10 States (dropped New York)
  • 2004 data: 9 States (dropped Maine)

SID data are available for purchase for the following data years and numbers of States:

  • 1990 data: 10 States (Arizona, Colorado, Florida, Iowa, Maryland, Massachusetts, New Jersey, New York,Washington, and Wisconsin)
  • 1991 data: 10 States (no new additions)
  • 1992 data: 10 States (no new additions)
  • 1993 data: 11 States (added Oregon)
  • 1994 data: 11 States (no new additions)
  • 1995 data: 13 States (added California and South Carolina)
  • 1996 data: 13 States (no new additions)
  • 1997 data: 14 States (added Utah)
  • 1998 data: 14 States (no new additions)
  • 1999 data: 16 States (added Maine and Michigan)
  • 2000 data: 19 States (added Kentucky, North Carolina, and West Virginia)
  • 2001 data: 20 States (added Nebraska)
  • 2002 data: 21 States (added Nevada)
  • 2003 data: 21 States (no new additions)
  • 2004 data: 18 States (dropped Maine, New York, and Utah)

SASD and SID data can be purchased for research through the HCUP Central Distributor sponsored by AHRQ: telephone: (866) 556-4287 (toll-free), fax: 866-792-5313, or e-mail: HCUPDistributor@ahrq.gov. The HCUP Central Distributor can provide information on which States are included in both databases for any year.

Price of the data ranges from $20 to $3,170, depending on the data file, State, and requesting organization. Prices may be higher for customers outside the United States, Canada, and Mexico.

AHRQ is always looking for ways in which AHRQ-funded research, products, and tools have changed peoples' lives, influenced clinical practice, improved policies, and affected patient outcomes. Impact case studies describe AHRQ research findings in action. These case studies have been used in testimony, budget documents, and speeches. If you are aware of any impact your research has had on health care policy, clinical practice, or patient outcomes, please let us know by using the contact information below.

Healthcare Cost and Utilization Project (HCUP)
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
Phone: 866-290-HCUP (866-290-4287)
E-mail: hcup@ahrq.gov

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Acknowledgments

The authors acknowledge the following for their contributions to this Fact Book: Devi Katikineni, Andy Mosso, and Tess Monasterio (SSS) for statistical programming; Gail Eisen and Nancy Jordan (Thomson Medstat) and DonnaRae Castillo (AHRQ) for editorial services; Katheryn Ryan (Thomson Medstat) for administrative support; and The Madison Design Group for design and layout.

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