Ambulatory Surgery in U.S. Hospitals, 2003: HCUP Fact Book No. 9 (continued)

HCUP Fact Book No. 9: Ambulatory Surgery in U.S. Hospitals, 2003 (continued)

Part I: Overview

How Did Ambulatory and Inpatient Surgeries Compare?

The American Hospital Association (AHA) defines "community hospitals" as non-Federal, short-term (or acute care) general and specialty hospitals whose facilities and services are available to the public, including children's, orthopedic, and rehabilitation hospitals, as well as non-Federal academic medical centers. Approximately 85 percent of all hospitals registered in the United States are community hospitals.⁵

Table 1, Characteristics of Community Hospitals, compares the characteristics of community hospitals in which both ambulatory and inpatient surgeries were performed.

In 2003, nearly 52 percent of all surgical visits and stays occurred in outpatient settings; figures ranged from 42 to 66 percent in the 17 selected States.
Adjusted for State population levels,³ approximately 4,100 ambulatory surgical visits per 100,000 individuals occurred. This rate ranged from 2,800 per 100,000 individuals in New Jersey to 5,600 per 100,000 individuals in Vermont.
For all States in 2003, the mean number of inpatient surgical stays per 100,000 individuals was nearly 3,800, ranging from 2,900 in Vermont to 4,500 in Missouri and Tennessee.

Select for Figure 1 (13 KB), Distribution of Surgical Visits and Stays by State.

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Who Obtained Ambulatory Surgeries?

Although the population of males and females was nearly equal in the 17 selected States,⁶ approximately 59 percent of ambulatory surgical visits occurred among females.
While more females than males obtained surgeries in both settings, females were disproportionally more likely to have an ambulatory surgical visit than males.

Select for Figure 2 (6 KB), Percent of Surgical Visits and Stays by Gender.

The mean age for both ambulatory surgical visits and inpatient surgical stays was about 46 years (data not shown).
Patients ages 18 to 44 comprised about 33 percent of ambulatory surgical visits—more visits than for any other age group. This group was followed closely by individuals ages 45 to 64 (30.1 percent). In comparison, inpatient surgical stays occurred most often among patients 65 and older.
Patients ages 65 and above comprised about 12 percent of the total population of the 17 selected States,⁷ but they accounted for 24 percent of all ambulatory surgical visits. Conversely, only 13 percent of ambulatory surgical visits occurred among patients ages 0 to 17, even though they constituted 25 percent of the total 17-State population.

Select for Figure 3 (7 KB), Percentage of Surgical Visits and Stays by Age Group.

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What Were the Most Common Ambulatory Surgeries?

Lens and cataract procedures accounted for nearly 9 percent of ambulatory surgeries and were performed primarily on patients 65 and older.
Three of the 10 most common ambulatory surgeries were related to the musculoskeletal system: other therapeutic procedures on the muscles and tendons (5.0 percent), other operating room (O.R.) therapeutic procedures on the joints (3.4 percent), and excision of the semilunar cartilage of the knee (3.2 percent).
Two of the 10 most common ambulatory surgeries were primarily performed on children: tonsillectomy and/or adenoidectomy (3.8 percent) and myringotomy, or ear tube surgery (3.0 percent).
Hernia repair and cholecystectomy each accounted for 3 percent of ambulatory surgeries.

Select for Table 2, Top 10 All-Listed Procedures.

Lumpectomies and diagnostic D&C—two surgeries primarily or exclusively performed on women—were two of the most common surgical procedures performed in the ambulatory setting (3.1 percent and 2.9 percent, respectively).
In 2003, about 90 percent of ambulatory surgeries were performed for therapeutic reasons; nearly 10 percent of ambulatory surgeries were performed for diagnostic reasons (data not shown).
By body system, more ambulatory surgeries involved the treatment and/or diagnosis of disorders of the musculoskeletal system (25.5 percent) than any other system. In comparison, more inpatient surgeries were performed to treat and/or diagnose disorders of the musculoskeletal system or the digestive system (18.3 percent each) (data not shown).
Surgeries performed on the musculoskeletal system, eye, integumentary system, ear, and nose, mouth, and pharynx were disproportionately performed in an outpatient setting; surgeries related to the eye, ear, and nose, mouth, and pharynx were 90 to 98 percent outpatient.
Surgeries performed to treat and/or diagnose disorders of the digestive, nervous, cardiovascular, male genital, heme and lymphatic, respiratory, and endocrine systems, as well as obstetrical surgeries, were primarily inpatient.
Surgeries involving the treatment and/or diagnosis of the female genital and urinary systems were equally performed as ambulatory and inpatient procedures.

Select for Figure 4 (15 KB), Ambulatory vs. Inpatient Surgeries by Body System.

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How Did Ambulatory Surgeries Vary by Gender and Age?

Gender

Lens and cataract procedures were the most common ambulatory procedure performed on both males (7.9 percent) and females (9.3 percent).
Three of the top 10 surgeries among females related to female-specific procedures—lumpectomy (5.1 percent), diagnostic D&C (4.9 percent), and other excision of the cervix and uterus (4.4 percent).
Transurethral excision, drainage, or removal of a urinary obstruction—a male-specific procedure—was among the top 10 ambulatory surgeries performed on males and accounted for nearly 3 percent of ambulatory surgeries performed on this population.
Hernia repair (6.7 percent), excision of the semilunar cartilage of the knee (4.3 percent), myringotomy (4.3 percent), other O.R. therapeutic procedures on nose, mouth, and pharynx (3.3 percent), and arthroscopy (2.6 percent) were among the top 10 surgeries for males but not for females.
Cholecystectomy (4.1 percent), decompression of the peripheral nerve (2.8 percent), and other O.R. therapeutic procedures on the skin and breast (2.5 percent) were top 10 surgeries performed on females but not for males.

Select for Table 3, Top 10 All-Listed Procedures, by Gender.

Age

Three procedures were common to all age groups: inguinal and femoral hernia repair, other therapeutic procedures on the muscles and tendons, and other operating room therapeutic procedures on joints.
Removal of the tonsils and/or adenoids and myringotomy were the most common ambulatory surgeries performed on children ages 0 to 17. These procedures accounted for 24 percent and 23 percent, respectively, of ambulatory surgeries performed on children.
Surgeries performed exclusively or primarily on women—other excision of cervix and uterus, diagnostic D&C, and lumpectomy—accounted for 3 of the 10 most common ambulatory surgeries performed on patients ages 18 to 44.
Among patients 45 to 64 years of age, 4 of the 10 most commonly performed ambulatory surgeries related to the musculoskeletal system: other therapeutic procedures on the muscles and tendons (7.0 percent), excision of the semilunar cartilage of the knee (5.0 percent), other O.R. procedures on the joints (4.7 percent), and partial bone excision (2.8 percent).
Approximately 1 out of 3 ambulatory surgeries performed on patients 65 and older involved cataract and lens procedures.

Select for Table 4, Top 10 All-Listed Procedures, by Age Group.

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Which Ambulatory Surgeries Were Associated With the Highest Charges?

Hospital charges are the amount the hospital bills for the entire visit or stay and do not include most professional (physician) fees. Charges represent what the hospital billed for the case, rather than the amount actually reimbursed. Note that charges reflect the total hospital charge for an encounter (i.e., visit or stay), not the charge for a particular surgery. In addition, the most expensive ambulatory surgeries are not very common. Collectively, the 10 surgeries associated with the most expensive ambulatory surgical visits represented less than 4 percent of all outpatient surgeries.

In 2003, the average hospital charge for an ambulatory surgical visit was $5,600, compared with $28,300 for an inpatient surgical stay.ⁱⁱ
Five of the top 10 surgeries associated with the most expensive ambulatory surgical visits involved the treatment and diagnosis of the cardiovascular system: percutaneous coronary angioplasty (PTCA), insertion of a cardiac pacemaker or defibrillator, other O.R. heart procedures, endovascular repair of aneurysm, and other O.R. procedures on vessels other than head and neck.
Two of the 10 most expensive ambulatory surgeries were related to the treatment of musculoskeletal system disorders: spinal fusion and laminectomy.
Open prostatectomy—a surgery performed only on men—was the fifth most expensive ambulatory surgery.

ⁱⁱ Inpatient surgical stays are typically more expensive than ambulatory surgery visits because of longer lengths
of stay and the use of multiple procedures.

Select for Figure 5 (13 KB), Procedures Associated With the Most Expensive Ambulatory Surgical Visits.

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Who Was Billed For Ambulatory Surgical Visits?

Select for Figure 6 (7 KB), Percentage of Surgical Visits and Stays Billed to Each Payer.

Payer data reflect the expected payer for an ambulatory surgical visit. It is important to note that in the outpatient hospital setting, payers are not billed for specific procedures; rather, they are billed for a patient's full surgical visit. Payer information is presented in the following general payer categories:

Medicare—fee-for-service and managed care Medicare patients.

Medicaid—fee-for-service and managed care Medicaid patients.

Private insurance—Blue Cross, commercial carriers, private health maintenance organizations (HMOs), and preferred provider organizations (PPOs).

Uninsured—insurance status of "self-pay" and "no charge."

Government insurance programs, primarily Medicare and Medicaid, were billed for about one-third of ambulatory surgical visits. In contrast, nearly half of inpatient surgical stays were billed to Medicare and Medicaid.
About 12 percent of ambulatory surgical visits and 17 percent of inpatient surgical stays were billed to Medicaid.
Private insurance was billed for approximately 55 percent of ambulatory surgical visits and nearly 46 percent of inpatient
surgical stays.
Uninsured patients accounted for 3 to 4 percent of ambulatory and inpatient surgical visits and stays.

Medicare

In 2003, about 14.6 million individuals in the 17 selected States—representing 13 percent of the population in these States—were covered by Medicare.⁴
Medicare was billed for nearly 24 percent of all ambulatory surgical visits.
Approximately 3 out of 4 outpatient surgeries related to lens and cataract procedures were billed to Medicare; these procedures constituted the most common ambulatory surgeries performed on patients with Medicare (28.7 percent).
Among ambulatory surgeries billed to Medicare, 4 of the top 10 procedures were for the treatment and/or diagnosis of the musculoskeletal system: other therapeutic procedures on muscles and tendons (4.1 percent), excision of the semilunar cartilage of the knee (2.1 percent), other O.R. therapeutic procedures on joints (1.9 percent), and partial bone excisions (1.4 percent).
Transurethral excision, drainage, or removal of urinary obstruction was a top 10 ambulatory surgery billed to Medicare but was not in the top 10 for other payer groups.Medicare was billed for 40 percent of all ambulatory surgeries related to this procedure.

Select for Table 5, Top 10 All-Listed Procedures, Medicare.

Medicaid

About 12.7 million individuals in the 17 selected States, representing 12 percent of the population in these states, were covered by Medicaid in 2003.⁴
Approximately 12 percent of ambulatory surgical visits were billed to Medicaid.
Two of the most common ambulatory surgery procedures billed to Medicaid were primarily performed on children: removal of the tonsils and adenoids and myringotomy.Medicaid was billed for approximately 23 percent of outpatient tonsillectomies and/or adenoidectomies and for 27 percent of outpatient myringotomies.
Other excision of the cervix and uterus (3.0 percent), diagnostic D&C (2.5 percent), and lumpectomy (2.2 percent) were 3 of the most common ambulatory surgeries billed to Medicaid.

Select for Table 6, Top 10 All-Listed Procedures, Medicaid.

Private Insurance

In 2003, about 78.3 million individuals in the 17 selected States, representing 71 percent of the population in these States, were covered by private insurers.⁴
Private insurers were billed for approximately 55 percent of all ambulatory surgical visits.
Three of the top 10 ambulatory surgery procedures billed to private insurers were for the treatment and diagnosis of musculoskeletal disorders: other therapeutic procedures on muscles and tendons (5.1 percent), other O.R. therapeutic procedures on the joints (3.8 percent), and excision of the semilunar cartilage of the knee (3.8 percent). Private insurers were billed for more than half of all ambulatory surgeries related to these procedures.
Private insurers were billed for 71 percent of ambulatory surgeries involving the removal of the tonsils and adenoids and 66 percent of myringotomies.
Approximately 3 out of 4 ambulatory surgeries involving diagnostic dilatation and curettage (D&C) and other excision of the cervix and uterus were billed to private insurers.
Nearly 2 out of 3 lumpectomies were billed to private insurers. In addition, private insurers were billed for two-thirds of all cholecystectomies (surgical removal of the gallbladder.)

Select for Table 7, Top 10 All-Listed Procedures, Private Insurance.

Uninsured

About 14.9 million individuals in the 17 selected States, representing 14 percent of the population in these States, were uninsured in 2003.⁴
Just over 3 percent of ambulatory surgical visits occurred among uninsured patients.
Other O.R. therapeutic procedures on the skin and breast were the most common ambulatory surgeries performed on the uninsured (11.3 percent). Approximately 1 in 6 of these procedures was performed on an uninsured patient.
Except for lens and cataract procedures, 9 of the top 10 most common ambulatory surgeries performed on uninsured patients were also the most common procedures performed on patients ages 18 to 44 years.

Select for Table 8, Top 10 All-Listed Procedures, Uninsured.

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