Allison Russo, M.P.H., Anne Elixhauser, Ph.D., Claudia Steiner, M.P.H., M.D., and Lauren Wier, M.P.HIntroductionAmbulatory surgery (AS), or outpatient surgery, is a planned surgical episode where the patient requires hospital care for less than 24 hours. Outpatient procedures account for a growing proportion of surgeries performed in U.S. Hospitals because AS increasingly substitutes for inpatient surgery for many procedures.
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1 Nationally, 63 percent of all surgeries in 2005 did not require an overnight hospital stay and were considered outpatient, compared with 51 percent in 1990 and only 16 percent in 1980. 2,3Two major factors explain this overall growth in ambulatory surgeries. First, advances in surgical technology and anesthesia have made surgery easier on patients and increased the demand for outpatient procedures. Second, in an effort to reduce rising healthcare costs, healthcare payment policies have encouraged AS. For example, the Medicare program adopted an outpatient prospective payment system authorizing payment for surgical services in a variety of settings, such as a physician’s office, a hospital outpatient department, or an ambulatory surgical center. A comparison of AS data to inpatient surgery data is essential for understanding utilization patterns and costs for specific surgical procedures.This Statistical Brief presents data from the Healthcare Cost and Utilization Project (HCUP) State Ambulatory Surgery Databases (SASD) and State Inpatient Databases (SID). These databases provide information on hospital-based ambulatory and inpatient surgeries performed in short-term, acute-care hospitals in the 28 states that provided AS data to HCUP in 2007.
These 28 states encompass about two-thirds of the U.S. These statistics exclude procedures performed in freestanding AS centers because these centers are not included in many State AS data sources.This report compares the utilization of ambulatory surgery procedures in hospitals to inpatient procedures in 28 states that provide data sources for both hospital-based ambulatory and inpatient surgery. The analysis is limited to major invasive procedures requiring anesthesia services or sedation, but excludes procedures that are performed infrequently in ambulatory surgery settings, procedures that are adjunct to the principal procedure, dental procedures, obstetrical procedures, and procedures that are done predominantly in outpatient settings outside of hospitals. 4 This report provides information about the distribution of inpatient versus outpatient surgical procedures by body system, as well as the most common surgical procedures performed in an outpatient setting.
In addition, ambulatory and inpatient volume, procedure rates, and hospital charge information are compared for each procedure. Unless otherwise noted, estimates are based on all-listed procedures. All differences between estimates provided in the text are statistically significant at the 0.05 level or better. In the 28 states evaluated, nearly 58 percent of surgical encounters in hospitals were performed on outpatients. There were nearly 5,600 ambulatory surgery (AS) visits per 100,000 population compared with almost 4,100 inpatient surgical visits per 100,000. The mean charge for AS was lower than for inpatient surgery—$6,100 versus $39,900.
The aggregate charge across the 28 states for AS was about one-fifth of total inpatient charges—$55.6 billion versus $259 billion. Procedures related to the digestive system accounted for 40 percent of all AS. Procedures done on the eye, ear, and nose/mouth/pharynx were predominantly outpatient. Roughly two-thirds of surgical procedures on the skin, digestive system, and urinary system were outpatient.
Colonoscopy and biopsy was the most commonly performed AS procedure in 2007, followed by upper GI endoscopy, lens and cataract procedures, diagnostic cardiac catheterization, and debridement of wound. Major procedures that were performed less frequently on an outpatient basis, but with significant numbers include PTCA, appendectomy, open prostatectomy, oophorectomy, hysterectomy, hip fracture/ dislocation repair, lower extremity amputation, and spinal fusion. FindingsCharacteristics of ambulatory surgery procedures performed in community hospitalsBased on data from the 28 states examined for this report, nearly 10.8 million ambulatory surgery (AS) visits took place in 2007, totaling $55.6 billion in aggregate charges (table 1). These visits resulted in over 12.4 million procedures (1.2 procedures per AS visit). This compares to 7.9 million inpatient stays that involved 11.0 million surgical procedures (1.4 procedures per hospital stay).
Overall, 57.7 percent of procedures performed in hospitals were ambulatory in nature. In 2007, this translated to approximately 5,600 hospital-based AS visits per 100,000 population, compared with 4,100 inpatient procedure stays per 100,000 population.The mean charge for hospital-based AS procedures was considerably lower than the charge for inpatient hospital stays that included procedures—$6,100 versus $39,900. Aggregate charges across the 28 states were about one-fifth of the national bill for inpatient—$55.6 billion versus $259 billion. Most hospital-based AS procedures were performed in large, metropolitan, private not-for-profit hospitals.
However, compared with inpatient procedures, AS was more likely to be performed in smaller hospitals, outside metropolitan areas, and in non-teaching settings.Ambulatory versus inpatient surgeries, by body systemFigure 1 shows that nearly all hospital-based procedures related to the eye (99.3 percent), ear (96.3 percent), and nose/mouth/pharynx (93.8 percent) were outpatient. About two-thirds of all hospital-based procedures on the skin (70.4 percent), digestive system (66.8 percent), and urinary system (61.7 percent) were also outpatient. Roughly half of all hospital-based procedures involving the musculoskeletal (54.0 percent), nervous (47.9 percent), female genital (47.5 percent), and endocrine systems (46.0 percent), were outpatient.In contrast, respiratory, cardiovascular, male genital, and hemic/lymphatic procedures were primarily inpatient. About one in three surgical procedures on the respiratory (31.2 percent) and cardiovascular (29.4 percent) systems were performed in an outpatient setting, while less than 10 percent of all procedures on male genital organs and the hemic/lymphatic system were outpatient.The most common ambulatory surgeries performed in community hospitalsTable 2 lists the 25 most common AS procedures performed in community hospitals. Colonoscopy and biopsy was the most common AS procedure and comprised nearly 18.1 percent of all procedures performed in an outpatient setting. Upper GI endoscopy and biopsy accounted for 10.8 percent of all outpatient procedures.
Other digestive system procedures commonly performed in the outpatient setting included: cholecystectomy, or gall bladder surgery (2.5 percent of all AS); hernia repair (inguinal and femoral–2.1 percent; other hernias–1.4 percent); and esophageal dilatation (1.3 percent). In fact, more ambulatory surgeries involved the digestive system (40.0 percent) than any other body system (data not shown).Though procedures on the cardiovascular system accounted for a small number of AS overall, diagnostic cardiac catheterization alone comprised 3.8 percent of all outpatient procedures in the hospitals in these 28 states.
Four of the 25 most common ambulatory procedures were related to the musculoskeletal system: excision of semilunar cartilage of knee (2.5 percent of all AS), partial bone excision (1.5 percent), arthroplasty other than hip or knee (1.4 percent), and other fracture and dislocation procedure (1.2 percent). Two commonly performed outpatient procedures on the skin were wound debridement (2.6 percent) and incision and drainage of the skin and subcutaneous tissue (1.4 percent).Lens and cataract procedures, most often performed on elderly patients, accounted for 5.5 percent of all AS in the hospitals in these 28 states.
5 Four of the 25 most common outpatient procedures were primarily or exclusively performed on women: other excision of cervix and uterus (2.1 percent of all AS), breast biopsy (1.9 percent), lumpectomy/quadrantectomy of the breast (1.9 percent), and diagnostic dilatation and curettage (D&C) (1.5 percent). Tonsillectomy and/or adenoidectomy and myringotomy (ear tube surgery)—two procedures primarily performed on children—were two of the most common surgical procedures performed in the ambulatory setting (2.5 percent and 1.9 percent of all procedures, respectively).Three procedures involving the urinary tract were also among the top 25 AS procedures performed in hospitals—endoscopy/biopsy (1.6 percent of all AS), transurethral procedures for urinary obstruction (1.5 percent), and ureteral catheterization (1.3 percent). Finally, decompression of peripheral nerves (e.g., carpal tunnel release) comprised 1.5 percent of all AS, while bronchoscopy made up 1.1 percent of all AS.Table 2 also provides information on the total number of procedures, rates, and the percentage of each procedure performed on an outpatient basis.
For many procedures, it is clear that very few are done in an inpatient setting. For example, lens and cataract procedures, excision of semilunar cartilage of the knee, tonsillectomy, breast biopsy, lumpectomy, myringotomy, D&C, and decompression of peripheral nerve have rates lower than 10 inpatient procedures per 100,000 population, while rates for their outpatient counterparts are 12–50 times higher (over 300 times higher for lens procedures).An inventory of ambulatory surgical procedures performed in community hospitalsThe appendix provides a comprehensive listing of all major procedures, by body system, performed in an outpatient setting in community hospitals. 6 Overall, the highest numbers of ambulatory surgical procedures were performed on the digestive and musculoskeletal systems.
The endocrine system accounted for the fewest outpatient procedures.The appendix also provides details on procedures less commonly performed in AS settings that were not covered in table 2. For example, although laminectomy (Clinical Classifications Software (CCS) 3) is not a predominantly outpatient procedure, 22.1 percent were performed in an ambulatory setting (42.7 AS procedures per 100,000 population versus 150.8 inpatient (IP) procedures per 100,000 population). Other major procedures that are not predominantly AS but with significant numbers of ambulatory cases include:. PTCA (CCS 45): 17.7 AS procedures vs. 242.4 IP procedures per 100,000 population. Appendectomy (CCS 80): 26.8 AS procedures vs. 118.9 IP procedures per 100,000 population.
Open prostatectomy (CCS 114): 3.0 AS procedures vs. 28.1 IP procedures per 100,000 population. Oophorectomy (CCS 119): 31.9 AS procedures vs. 121.4 IP procedures per 100,000 population.
Hysterectomy (CCS 124): 26.7 AS procedures vs. 166.6 IP procedures per 100,000 population. Hip fracture/dislocation repair (CCS 146): 8.1 AS procedures vs. 98.0 IP procedures per 100,000 population.
Lower extremity amputation (CCS 157): 8.1 AS procedures vs. 38.2 IP procedures per 100,000 population. Spinal fusion (CCS 158): 14.8 AS procedures vs. 124.0 IP procedures per 100,000 populationMean charges for outpatient procedures were always lower than for inpatient. However, the difference in inpatient and outpatient charges for operations on the male genital organs was minimal when compared to other surgeries. The highest mean charges per visit were found among outpatient procedures performed on the cardiovascular system.Data SourceThe estimates in this Statistical Brief are based upon data from the HCUP 2007 State Inpatient Database (SID) and 2007 State Ambulatory Surgery Database (SASD). This report evaluates inpatient and outpatient surgery data from 28 selected states that contributed data to both the 2007 SASD and SID: California, Colorado, Connecticut, Florida, Georgia, Hawaii, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah, Vermont, and Wisconsin.
Supplemental source included data on state population estimates from Table 1: Annual Estimates of the Population for the United States, Regions, States, and Puerto Rico: April 1, 2000 to July 1, 2007 (NST-EST2007-01), Population Division, U.S. Census Bureau, Release date: December 27, 2007.DefinitionsSurgical procedures and Clinical Classifications Software (CCS)Multiple surgical procedures can be listed on a record in the SID and SASD. Frequencies and rankings of procedures are based on all-listed—that is, all procedures listed on the record. Procedures are de-duplicated: if a particular procedure occurs multiple times during the same surgical visit or hospital stay, it is counted only once.CCS groupings of procedures were used throughout the report. CCS categorizes procedure codes into clinically meaningful categories. 7 This 'clinical grouper' makes it easier to quickly understand patterns of procedure use.Procedures on ambulatory surgery records can be coded using ICD-9-CM or the Common Procedural Terminology (CPT). When CPT was used, the CCS for Services and Procedures 8 was used to classify procedures into groupings comparable to the CCS.Case definitionRecords from the SASD meeting the following criteria were included:.
At least one 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. At least one major therapeutic or diagnostic operating room procedure as defined by the HCUP Procedure Classes. 9 Diagnostic procedures are included only if invasive, requiring anesthesia services or sedation.
Length of stay of 0 or 1 day. Originate from a hospital-based ambulatory surgery center having at least 200 ambulatory surgical visits per year. The ambulatory surgery facility is designated as a short-term, community, non-rehabilitation hospital.
Ambulatory versus inpatient surgeries by body system, 2007.
Number of Ministers:Some of the Cabinet Ministers of India and their Portfolios have been changed recently. Also, some of the new ministers have been appointed recently.
Here we have given the complete list of newly appointed cabinet ministers, Minister of State (Independent Charge) and Minister of state. Also, we have mentioned their portfolio and constituency in which they won the election.
Currently, there are 24 Cabinet Ministers, 9 Ministers of State (Independent Charge) and 24 Ministers of State in the list. Some of the old ministers’ portfolio has been changed. We have updated all the details about cabinet ministers of India 2019 clearly in the tabular form.This Indian cabinet ministers 2019 list prepared by us will be useful for the candidates preparing for the bank PO/clerk, railways, group exams, SSC and many other competitive exams.
Study the list and revise it regularly, so that you may not forget any details. The number of questions expected from this topic in the current affairs section is very little. Just one or two questions are expected. But in a competitive exam, even one or two marks can decide your fate. So don’t neglect these topics and try to hunt these questions in the exams. This is the current list of cabinet ministers.
If any changes are made in their cadres or any ministers are newly appointed to the cabinet, we will surely update the list immediately for your convenience. So candidates prepare for the exam with our cabinet ministers of India 2019 complete list. Watch New Cabinet Ministers of India 2019.
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