Outcomes of the Shift in Care from Inpatient to Outpatient Procedures in Hysterectomy

Stephanie Makepeace

Background

Hysterectomy•Removal of the uterus•641,000 procedures a

year•Most common major

surgery in women ages 18 to 44, after cesarean section

32%

17%12%

12%

8%

7%

4% 4%4%

Hysterectomy Indications

Fibroids BleedingUterine Prolapse EndometriosisCancer PainPrecancerous growths InflammationOther

Merrill RM et al. Med Sci Monit. 2008; National Center for Health Statistics. 2006

Hysterectomy Type

Photo Source: http://en.wikipedia.org/wiki/Hysterectomy

Surgical Approach

Photo Source: http://www.cincyobgyn.com/services-hysterectomy-obgyn-fairfield-ohio.html

Traditional Open Vaginal

Laparoscopic

Laparoscopic- Assisted Vaginal

Healthcare Costs•US spends 2.8 trillion dollars a year•17.9% of the gross domestic product

Centers for Medicare and Medicaid Services. National Health Expenditures. 2013World Bank. Health Expenditure. 2011

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

0.0%

5.0%

10.0%

15.0%

20.0%United States Health Expenditure Over Time

Year

% o

f GD

P

Cost Reduction•Disease Prevention• Increase healthcare delivery efficiency•Value-based decision-making▫Minimally Invasive Procedures

Smaller incisions may reduce the chance of infection and shorten hospital stay

▫Healthcare Setting

Inpatient Setting Outpatient Setting

Overall Project Objectives• Identify trends in hysterectomy surgical

approach and surgical setting•Estimate difference in hysterectomy cost

between inpatient and outpatient setting using real world data

•Present hysterectomy data in interactive tool

Project Summary

Methods•Retrospective Review of Premier Hospital Database

from 2009 to 2012▫Database houses billing/coding for 45 million inpatient

and 210 million outpatient visits▫Accounts for ~20% of all US hospital discharges

• Identified applicable hysterectomy, infection, and cancer codes▫ International Classification of Diseases, 9th edition (ICD-

9) and current procedural terminology (CPT) codes•Study was approved by the University of Florida IRB

Data Analysis•Tableau Desktop

version 1.8 ▫Prepare visualizations

and descriptive statistics

•SPSS version 22 ▫Multivariate analyses by

ordinary least squares regression

Data Parameters CollectedPatient Characteristics

Randomly Generated Identification NumberAgeRaceInsurance TypeDisease severity rank (0-4)Cancer (yes/no)

Procedure YearProcedure Code and DescriptionProcedure Setting Procedure ApproachHospital Information

RegionType (rural, urban, teaching)Number of beds

Length of hospital stayIncidence of infection Payor Code/DescriptionPatient charges/cost

Results

Number of Hysterectomies (2009-2012)

Surgical Approach

Hysterectomy Type

Number of ProceduresInpatient Outpatient

Laparoscopic Subtotal/ Partial 10,571 20,701Total 54,876 133,209Radical 2,500 1,854

Open Subtotal/ Partial 14,306 610Total 93,794 2,943Radical 2,618 158

Vaginal Subtotal/ Partial 380 21,676Total 37,176 37,307Radical 85 661

Total Procedures 216,306 219,119

Hysterectomy Type Over Time

Stacked bar chart; Hysterectomies 2009 to 2012

Payer Type

Inpatient Outpatient

Unadjusted Patient Cost All Hysterectomies

Overall median unadjusted patient cost: $6,610 Min: $1Max:$2,691,805

Graph excludes patient costs >$40,000

Unadjusted Median Cost by Surgical Approach

Overall Inpatient Outpatient

Unadjusted Median Cost by Hysterectomy Type and Cancer Incidence

No CancerInpatient Outpatient Inpatient Outpatient

Cancer of Uterus/Cervix

Unadjusted Median Cost by Payer Group--Impact of Patient Age--

• Age was also higher in patients with cancer (61 years) compared to those without (45 years)

Median Patient Age (years) 45 64 39

% Patients with Cancer of Uterus/Cervix

55% 72% 50%

Unadjusted Cost Over Time

Unadjusted Median Cost by US Region

$8,070$6,268

$6,376

$6,271

$6,368

$5,049 $6,437

$7,543

$7,665

Highest Costs

Lowest Costs

*Pacific Region includes Alaska and Hawaii, not shown

Multivariable Regression• Difference in Patient Cost Accounting for:▫ Procedure Setting

Inpatient/Outpatient▫Hysterectomy Type

Total, Subtotal, Radical▫ Surgical Approach

Open, Vaginal, Laparoscopic▫Cancer Incidence

Yes/No▫ Age▫Race

White, Black, Asian, American Indian▫ Payer

Commercial, Medicaid, Medicare

Adjusted Patient Cost

Traditional LaparoscopicVaginal+11%-19%

Outpatient Inpatient-23%

(95% CI= 23% to 24%)

(95% CI= 10% to 11%)(95% CI= 19% to 20%)

Length of Stay

Setting Approach Median Minimum Maximum

Inpatient Laparoscopic 1 1 86

Open 2 1 112

Vaginal 1 1 34

Outpatient Laparoscopic 0 0 0

Open 0 0 0

Vaginal 0 0 0

Infection

Tableau Dashboard

Summary/Discussion

Summary•Outpatient Setting▫More hysterectomy procedures are being conducted

in the outpatient setting▫Lower patient cost▫Benefits to infection incidence and length of stay

•Minimally Invasive Techniques▫ In hysterectomies, the use of minimally invasive

techniques is on the rise within the outpatient setting▫Laparoscopic hysterectomies report a higher patient

cost compared to open or vaginal procedures

Limitations• Factors not taken into account▫Operating room time▫Physician Experience/ Learning Curve▫Patient recovery

Return to Activity Return to Work Cosmetics/ Appearance

•Selection bias▫Greater percent (67%) cancer patients treated inpatient▫ Inpatient had comorbidity index, outpatient did not

• Infection incidence is difficult to track, as patients may return to primary care physician for care

• ICD-9 and CPT codes not reviewed by expert

Implications•Real world data confirms increasing use of

outpatient hysterectomies and its potential cost benefit

•Future Use of Tableau▫Provided to patients to facilitate cost procedure

cost transparency▫Help identify epidemiological trends or disease

outbreaks▫Education tools

Public Health Practice Concentration Competencies

• Identify & understand the historical context of epidemiology, epidemiologic terminology, study designs & methodology

• Demonstrate ability to analyze & interpret epidemiologic data • Explain & communicate current epidemiologic & public health

problems for informing scientific, ethical, economic & political discussions of health problems

• Demonstrate communication skills key to public health workforce participation and advocacy

• Identify, retrieve, summarize, manage and communicate public health information

Questions?