Number 169 ● May 23,1989 —

Hospital Inpatient Surgery: United States, 1983-87

by Lola

Introduction

concerns with rising health care

costs, changes in reimbursement for

health care, and advances in surgical

technology have led to rapid growth in

ambulatory surgery in recent years

(American College of Surgeons, 198t$

Shannon, 1985a). Ambulatory surgery

is expected to reduce costs because

many surgical procedures have been

shown to be less expensivewhen the ~

patient is not hospitalized (Olson,

1984), However, if increases in ambulatory surgery are not accompanied by

decreases in inpatient surgery, the

growth in ambulatory surgery could

lead to more total surgery and higher

total health care costs (Ermann,

1988).

According to data from the National Hospital Discharge Survey

(NHDS), total inpatient surge~ has

not been decreasing. Several types of

procedures that can be done on an

ambulatory basis have declined for

inpatient%but other procedures have

increased in frequency.

This report explores the patterns

of inpatient surgery from 1983 to

1987, a period of rapid change in the

health care system. The implementation in 1983 of a prospective payment

system for Medicare patients based on

Jean Kozak, Division of Health Care Statistics

diagnosis-related groups (DRG’s) and

the rapid growth in health maintenance organizations, preferred- provider organizations, and prospective

utilization review in private health insurance systems have helped stimulate

increases in ambulatory surgery

(Guterman et al., 198& Schramm and

Gabel, 1988). The discharge rate for

all patients in short-stay hospitals decreased by 17 percent horn 1983 to

1987, but the”change in the rate of

inpatient surgical procedures was not

statistically significant.

This report presents data on inpatient surgical procedures in 1983 and

1987 by age and sexj source of payment, and hospital bed size, Numbers

and rates for categories of surgical

procedures and specific procedures

are examined, including the main surgical procedures for each of four age

groups. These data provide a detailed

picture of how inpatient surgery has

changed as ambulatory surgery has

increased.

The data were collected by means

of the NHDS, a continuous, voluntary

survey conducted by the National

Center for Health Statistics since

1965. It encompasses patients

discharged from non-Federal shortstay hospitals. In 1983, 418 sample

hospitals participated in the survey by

supplying approximately 206,04)0 abstracts of medical records. In 1987,

400 participating hospitals provided

approximately 181,000 abstracts. A

brief description of the sample design,

data collection procedures, estimation

process, and sampling errors (table I),

along with definitions of the terms

used in this report can be found in the

section entitled “Technical notes.” Detailed discussions of these topics, and

the survey form used to collect the

dat~ have been published (NCHS,

1977, 1988a).

Up to four procedures are coded

for each NHDS discharge. The coding

is done according to the International

Classification of Diseases, 9th Revision,

Clinical Modificdon (Public Health

Service and Health Care Financing

Administration, 1980). Codes for nonsurgical diagnostic and therapeutic

procedures, such as computerized

axial tomography (CAT scan), diagnostic ultrasound, and diagnostic endoscopy, are included in the

classification system. Because this

study is concerned with changes in

surgical patterns, however, nonsurgical

procedures are not included. Table II

in “Technical notes” shows the nonsurgical codes that are excluded. It

should be noted that all obstetrical

procedures are included in this study.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National center for Health Statistics

Public Health Service Manning Feinleib, M.D., Dr. P.H., Director

Centers for Disease Control
2 Advance Data

Other NHDS reports contain data on

both surgical and nonsurgical procedures (NCHS, 1986, 1988b).

Highlights

●

●

●

●

●

●

●

●

From 1983 to 1987 the number

and rate of inpatient surgical procedures fell by a third for children

under 15 years of age but did not

change significantly for patients in

other age groups.

From 1983 to 1987 the proportion

of inpatient surgeries with private

insurance as the expected principal source of payment decreased,

and the proportions in the self-pay

and other categories increased.

In 1987 more inpatient surgery

was performed in hospitals with

200-299 beds and less inpatient

surgery was performed in hospitals with 100-199 beds and 500

beds or more than in 1983.

From 1983 to 1987 the number of

operations on the eye decreased

by more than a million; operations

on the female genital organs

declined by 979,0~ operations on

the nose, mouth, and pharynx fell

by 566,000; and operations on the

ear decreased by almost 200,000.

From 1983 to 1987 the number of

obstetrical procedures increased

by 1.4 million, and operations on

the cardiovascular system rose by

1.1 million.

For children under 15 years of age

(excluding newborn infants),

decreasing inpatient procedures

included myringotomy, tonsiktomyy adenoidectom~

circumcision; cardiac catheterization; repair of inguinal hernia; and

operations on muscles, tendons,

fascia, and bursa.

Decreases were reported for

patients 15-44 years of age in

inpatient rhinoplasty and repair of

nose; dilation and curettage of

uterus (D&C); bilateral destruction or occlusion of fallopian

tubes; and excision of lesion of

skin or tissue, other than tissue

debridement.

Obstetrical procedures that

increased from 1983 to 1987

included cesarean section, repair

●

●

●

●

of current obstetric laceration,

fetal EKG and other fetal monitoring, artificial rupture of membranes, and manually assisted

delivery.

For patients 45-64 years of age,

decreasing inpatient procedures

included cataract surgery; repair

of inguinal hernia; D&C, biopsy of

breast, skin, and subcutaneous

tissue; and excision of lesion of

skin or tissue, other than tissue

debridement.

Inpatient procedures that

increased for patients 45-64 years

of age included coronary angioplasty, cardiac catheterization,

puncture of vessel, procedures

auxiliary to open heart surgeq,

and excision or destruction of

intervertebral disc and spinal

fusion.

The rate of inpatient cataract surgery for patients 65 years of age

and over dropped by almost 90

percent from 1983 to 1987.

Increasing inpatient procedures

for patients 65 years of age and

over included bypass anastomosis

for heart revascularization; cardiac

catheterization; puncture of vessel;

procedures auxiliary to open heart

surge% biopsy on the digestive

system; arthroplasty and replacement of knee; and debridement of

wound, infection, and burn.

Inpatient surgery

From 1983 to 1987 discharges in

non-Federal short-stay hospitals

decreased by 5.4 million, from 38.8

million to 33.4 million (table 1). The

discharge rate fell 17 percent, from

1,669.6 to 1,381.6 per 10,000 population. The number of inpatient

surgeries did not change significantly.

It was 26.2 million in 1983 and 25.7

million in 1987. Likewise, the rate of

inpatient surgery per 10,000 population was not significantly different in

1983 (1,128.8) than in 1987 (1,061.6).

The average length of stay for

patients with a surgical procedure also

did not change significantly. It was 7.0

days in 1983 and 6.6 days in 1987.

There was an increase in the proportion of hospitalized patients with one

surgical procedure or more, from 45,1

percent in 1983 to 47.4 percent in

1987.

Age and sex

The number and rate of inpatient

surgery did not change significantly for

males or females from 1983 to 1987

(table 2). For children under 15 years

of age, however, the number and rate

of inpatient surgery fell by a third, and

the decreases were similar for males

and females. Many of the surgical procedures commonly performed on

children are relatively uncomplicated

and thus are good candidates for

ambulatory surgery. Several studies

have found that children make more .

use of ambulato~ surgery programs

than other age groups (Ermann,

1988). Neither males nor females in

any other age group had a significant

change in the number or rate of inpatient surgical procedures.

In 1983 and 1987 the number and

rate of inpatient surgical procedures

were higher for females than for

males. Females had over 7.5 million

more surgeries and a 71-percent

higher rate of surgeries than males

each year. Females 15-44 years of age

accounted for most of the difference

by sex. They had 6.8 million more procedures than males 15-44 years of age

in 1983, 7.3 million more in 1987. For

Table 1. Number ●nd rate of discharges ●nd inpatient surgeries: United Ststes, 1983-87

[Data are for non-Federal short-stay hospitals and exclude newborn infants]

hrpatbrlt /npatlent

Year Dbcharyes surgedas DLwha~ su~erkw

Number in thousands Rate per 10,000 populrdbn

1983

1984

1985

1986

1987

. . . . . . . . . . . . . . . . 36,763 26,22o 1,669.6 1,128.8

. . . . . . . . . . . . . . . . 37,162 25,5SU 1,665.1 1,091.5

.,, . . . . . . . . . . . . . 35,056 24,769 1,478.9 1,048.2

. . . . . . . . . . . . . . . . 34,256 25,041 1,431.2 1,046.2

. . . . . . . . . . . . . . . . 33,367 25,655 1,361.6 1,061.6
Advance Data 3

Table 2. Number ●nd rate of inpatient ●urgerles by ●ge ●nd sex: United States, 1983 and

1987

[Data are for non-Faderal short-stay hospitals and exclude newborn Infants]

Age andsex 1983 1967 1983 1987

Alleges . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

Urtder15yeafe. ..,....,.

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

16-44yeara . . . . . . . . . . . .

Male . . . . . . . . . . . . . . .

Female .,, , ..,.,....

45-64ye6ra . . . . . . . . . . . .

Mate . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

E5yearsendover . . . . . . . .

Male .,, , . .,, . . . . . . .

Female . . . . . . . . . . . . .

Number in thousands

26,220 25,655

9,268 9,073

16,953 16,5S3

1,766 1,195

1,062 725

724 471

12,656 12,577

2,s66 2,640

9,691 9,237

5,666 5,456

2,642 2,612

3,144 2,647

6,192 6,425

2,796 3,097

3,3e4 3,326

Rate perlO,OQO population

1,126.8 1,061.6

826.2 775.7

1,411.4 1,329.8

346.1 228.1

402.4 270.1

287.2 164.0

1,154.1 1,101.6

534.2 466.3

1,757.0 1,719.3

1,277.2 1,206.0

1,201.8 1,206.9

1,345.4 1,205.2

2,261.3 2,1S3.4

2,54S.4 2,555.3

2,070.6 1,878.5

NOIENumbemmay notaddtototakdue torcwdhg.

bothyears the rate ofinpatientsurgery for females in this age group was

more than three times the rate for

males,

Thispattern was notrepeated for

the other age groups. Males under15

years ofage hada greater number and

ahigher rateof inpatient surgical procedures than did females under 15

years of age in 1983 and 1987. The

rate of inpatient surgery waa not significantly different for males and

females 45--@ years of age, but

females had a greater number of surgeries in 1983. Males 65 years of age

and over had a higher rate of inpatient

surgery than females in that age group

in 1983 and 1987, but females had a

greater number of surgeries in 1983.

Source of payment

Table 3 shows numbers and percent distributions of inpatient surgical

procedures by expected principal

source of payment and hospitaI bed

size. The frequency of inpatient surgeries was also examined for

geographic regions of the country and

by hospital ownership categories, but

no significant changes were found

from 1983 to 1987 for those characteristics.

The expected principal source of

payment for a surgical procedure is

usually entered on the patient’s medical record at the time of admission to

the hospital. It maybe somewhat different from the actual source of payment as determined after discharge

(NCHS, 1987).

Private insurance consists of

health insurance provided by nongovernmental sources, including Biue

Cross, other insurance companies, private industry, and philanthropic

organizations. The proportion of inpatient surgeries with private insurance

as the expected source of payment

decreaaed from 56.9 percent in 1983

to 51.8 percent in 1987. This decline

was primarily due to decreases of

more than 40 percent in the number

of operations on the eye; operations

on the eaq and operations on the

nose, mouth, and pharynx. In spite of

the overall decline, the number of

operations on the cardiovascular system covered by private insurance

increased from 797,000 in 1983 to

1,171,000 in 1987.

The self-pay category consists of

surgical procedures that are expected

to be paid for by patients or their families rather than by private insurance

or government programs. The proportion of surgeries in this category

increased by 21 percent, from 5.3 percent in 1983 to 6.4 percent in 1987.

The increase was most marked for

operations on the cardiovascular system. The number of cardiovascular

operations in the self-pay category

almost doubled, from 55,000 in 1983

to 106,000 in 1987.

Changes from 1983 to 1987 in the

proportions of inpatient surgical procedures with Medicare or Medicaid as

the expected principal source of payment were not statistically significant.

Other payment sources increased from

4.8 percent to 6.8 percent of inpatient

surgeries. Other sources include

Workers’ Compensation, other governmentprograms, no charge, and

sources that could not be assigned to

any other category.

Hospital bed size

A major change in the number of

inpatient surgeries by hospital bed size

categories from 1983 to 1987 was the

increase, by 2.3 million, in the number

of surgeries in hospitals with 200-299

beds. This bed size category accounted

for 15.5 percent of inpatient surgeries

in 1983 but increased to 24.8 percent

in 1987. Most types of inpatient surgery increased in hospitals with

Table 3. Number ●nd percent distribution of Inpatient surgeries by expeoted principal

source of payment ●nd bed size: United States, 1983 and 1987

[Data are for nonfederal short-stay hospitals and exclude newborn infants]

Source ofpayment

and bed size IW3 1987 1963 1.967

All expectedprincipal

sourcesof payment . . . . . .

Private insurance . . . . . . . .

Medicare . . . . . . . . . . . . .

Medicaid . . . . . . . . . . . . . .

.%If-pay . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . .

All bed sizes . . . . . . . . . . .

a-txlbeds . . . . . . . . . . . .

loo-le91BCts . . . . . . . . . .

2oo-2e6beds . . . . . . . . . .

3oo-4wbeds . . . . . . . . . .

500tx3dsor more . . . . . . . .

Number In thousands

26,220

14,931

6,636

2,014

1,389

1,250

26,220

2,928

4,653

4,073

7,233

7,133

25,655

13,294

6,793

2,162

1,663

1,733

25,655

2,617

3,125

6,374

6,976

6,361

Percent distrlbutbn

100.0 100.0

56.9 51.6

25.3 26.5

7.7 8.5

5.3 6.4

4.6 6.6

100.0 lCO.O

11.2 11.0

18.5 12.2

15.5 24.6

27.6 27.2

27.2 24.8
4 Advance Data

200-299 beds, and the numbers of

operations on the cardiovascular system and obstetrical procedures more

than doubled from 1983 to 1987.

The number of inpatient surgeries

in hospitals with 100-199 beds

decreased by 1.7 million from 1983 to

1987. This bed size category accounted

for 18.5 percent of inpatient surgeries

in 1983, but only 12.2 percent in 1987.

The proportion of inpatient surgeries

in hospitals with 500 beds or more

also decreased, from 27.2 percent in

1983 to 24.8 percent in 1987. Hospitals in both of these size categories

experienced especially large decreases

in the numbers of operations on the

eye, operations on the ear, and operations on the female genital organs.

Surgical procedures

Decreasing procedures

The number and rate of inpatient

surgeries are shown in table 4 for 15

procedure categories. Nonsurgical procedures, listed in table II of

“Technical notes:’ have been extluded

from the categories. From 1983 to

1987, there were statistically significant decreases in the numbers and

rates of procedures in four categories

operations on the eye+operations on

the ear; operations on the nose,

mouth, and pharymq and operations

on female genital organs.

The number of operations on the

eye decreased by more than a million,

and the rate decreased by 69 percent

from 1983 to 1987. The decrease was

mainly from a decline in cataract surgery, which is now commonly done on

an ambulatory basis (Shannon, 1985b).

Operations on the ear decreased

by almost 200,000 from 1983 to 1987,

and the rate decreased by 54 percent.

Myringotomy, which made up half of

ear operations in 1983, also has been

done with increasing frequency on an

ambulatory rather than an inpatient

basis (Ermann, 1988).

The number of operations on the

nose, mouth, and pharynx dropped by

566,000 from 1983 to 1987, and the

rate for the category decreased by 40

percent. Several procedures in this

category declined in the 5-year period,

such as rhinoplasty and repair of nose,

forceps extraction and surgical

removai of tooth, tonsillectomy, and

adenoidectomy. These are all relatively

uncomplicated procedures that could

be expected to be done on an ambulatory basis.

Operations on the female genital

organs decreased almost as much as

eye operations. In 1987 there were

979,CK)0fewer inpatient surgical procedures on the femaie genital organs

than in 1983, and the rate of these

procedures decreased by 28 percent in

the 5-year period. Among the procedures in the category that decreased in

number were bilateral destruction or

occlusion of fallopian tubes, ionization

of cervix, D&C, aspiration curettage of

uterus, and biopsy on the female genital organs. Again, these are procedures that could be expected to be

done on an ambulatory basis.

Increasing procedures

Tko surgical categories increased

significantly from 1983 to 1982 operations on the cardiovascular system and

obstetrical procedures. In 1987, 1,1

million more cardiovascular operations

were reported than in 1983, and the

rate of these operations increased by

56 percent.

Specific cardiovascular procedures

are shown in table 5. The first, open

heart surgery, includes operations on

the valves, septa, and vessels of the

heart. It does not include removal of

coronary artery obstruction (coronary

angioplasty) or bypass anastomosis for

heart revascularization. In NHDS reports for the years before 1986, these

two procedures were included in the

open heart surgery category. When

they were excluded, the number and

rate of open heart surgeries did not

change significantly from 1983 to

1987.

Use of coronary angiopksty grew

dramatically from 1983 to 1987. The

number of procedures increased by

158,000, and the 1987 rate was almost

seven times the 1983 rate.

Table 4. Number and rate of inpatient surgeries by surgical category: United States, 1983 and 1987

[Data are for non-Federal short-slay hosplfds and exclude newborn infants]

Surg/cel category end ICD-9-CM oode’ 1963 1967 mu 1867

Allsurgloal prooeduras . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Operatbnson thenetvous system .,... . ...,.....,,.....,,........0145

Operatbnson theendoorfne system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..O&07

Operrdbnson theeye . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . ...08-16

Oparalbnson theeer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..IIHO

Operafbnson thenoaa, mouth, andpharynx . . . . . . . . . . . . . . . . . . . . . . ...21-29

Operatbnson therespiratory system . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..30+4

Operatbnson thecardbvasculer system. . . . . . . . . . . . . . . . . . . . . . . . . ...3549

Operetbns onthehemio endlymphatlosystem . . . . . . . . . . . . . . . . . . . . . ...40-41

Operatbnson thedigestive system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42-54

Operatbnson theurinery system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..5S69

Operatbnson malegenttal organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..6LM4

Oparafbns on female genltalorgans . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...66-71

Obstetrical procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72-75

Operatbnson themusculoskeletat system . . . . . . . . . . . . . . . . . . . . . . . . . ..76+84

Oparatbns ontheirrtegumentary syatem. . . . . . . . . . . . . . . . . . . . . . . . . . ..8S66

Number in thousands

26,220 25,655

648 563

105

1,s58 :3

372 176

1,4e6 930

745

1,= 2,978

4,Z 4,288

1,073 1,083

845 747

3,649 2,870

3.914 5,3S3

3,s02 3,313

1,830 1,600

Rate per 10,000 population

1,128.8 1,081,6

27.9 23.3

4.5 4.5

87,1 20.5

16.0 7.3

64.4 38.5

26.9 30.8

79.0 123.2

15.7 16.5

180.9 177.4

46.2 44.8

36.4 30.9

165.7 118.8

la8.5 221,7

150.8 137.1

78.8 68.2

lp~m g- & ~ W*M m based on h //t81Mlt/ofJs/ ClassmcatlonOfasessss,Mh %fSk21/ cmcal Modmcsrhrr. 3- tableIIIn“TSct-mkalm-” for-ru~ -m

SXCbCkd from eachod.qjory.
Advance Data 5

Tablo 5. Number ●nd rata of CSrdIOVJSCUhr operation United Ststes, 1983 ●nd 1987

[Data are for non-Fedemlshort-slayhospitalsand exclude newborn Infants]

CWbvesculer omtatbn and ICD-9-CM code’ 1%9 1987 1993 1W7

Number In thousands Rate per 10,CQOpopulalkm

Allcardbvascular oparalbnsz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...35-39 1,636 2,978 79.0 123.2

Open heart surgery , ,35.1-35.51,35.53-35.99, 36.2,38.9,37.10-37.11, 37.32-37.33,37.5 6a 72 2.5 3.0

Removal ofcorwmryarteryol.mtmctbn. . . . . . . . . . . . . . . . . . . . . . . . . . . . ..36.0 26 1.1 7.6

B-anwtomosh forheatiwUulatitMg . . . . . . . . . . . . . . . . . . . . . . . ..~.l 191 :3 8.2 13.7

Whc@heletilW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37.21 +7.23 508 21.9 35.6

Pecemalmr Insertbn, replacement, removal, arxt repatr. . . . . . . . . . . . . . ...37.7-37.6 169 234 6.2 9.7

Puncfureof veseel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..-3s.9 147 331 6.3 13.7

WuwauxllkwtoopnWWsuwe~. . . . . . . . . . . . . . . . . . . . . . . . . ...39.6 56 23e 2.4 9.9

‘ Proomiumgroup and c=adarwrnb.mare W on the kmnatioMI aa.wmrkm c/ Diseaws, eth Revision Clhlcd Mod%7catlon.

%rWa opordlcm not shown In!sW. IXdudes hemodlalvsls,code 39SS.

%lro rwnbcr of dkdmrg.d paiienl$withbypassan.mtornoslsfor heat revascularizsllonww l~,COO In 19S3and 245,000 in 1867.

Bypass surgeries increased from

191,000 in 1983 to 332,000 in 1987. In

a growing number of cases, however,

more than one bypass has been reported for an individual patient. Bypass procedures using saphenous veins

and mammary artery grafts, which are

coded separately, are being done during the same operation. In 1983, the

191,000 bypass operations represented

188,000 discharged patients, and in

1987, the 332,000 bypass operations

were on 245,000 discharged patients.

Thus, the number of discharges with

bypass operations increased 30 percent

from 1983 to 1987.

The most common cardiovascular

procedure, cardiac catheterization,

increased by 358,000 from 1983 to

1987. The rate per 10,000 population

for this procedure was 63 percent

higher in 1987 (35.8) than in 1983

(21.9). In contrast, the frequency of

another common procedure category,

pacemaker insertion, replacement, removal, and repair, did not change significantly during the 5-year period.

The number and rate of puncture

of vessel, which includes arterial and

venous catheterization and venous cutdown, more than doubled horn 1983

to 1987. Procedures auxiliary to open

heart surge~, mainly extracmporeal

circulation (use of a heart-lung

machine), more than quadrupled.

These increases probably reflect increaaed reporting as well as actual

growth in the use of the procedures.

Obstetrical procedures increased

by 1.4 million from 1983 to 1987

(table 6). The rate of obstetrical procedures grew from 98.5 per 100 deliveries in 1983 to 137.0 per 100

deliveries in 1987. The majority of

these procedures were relatively routine procedures to assist delivery.

Episiotomy—with or without forceps

or vacuum extraction-accounted for

half of all obstetrical procedures in

1983 and a third in 1987. Neither the

number or the rate of episiotomies

changed significantly from 1983 to

1987. Artificial rupture of membranes,

however, more than doubled in frequency reported during the 5-year

period, and manually assisted delive~

was reported almost five times more

frequently in 1987 than in 1983.

Tablo 6. Number ●nd rate of obstetrical proeedurex United Ststee, 1983 ●nd 1987

[Data are for nonfederal shott-stay hoapitats]

The cesarean section rate

increased from 20.3 per 100 deliveries

in 1983 to 24.4 per 100 deliveries in

1987. This was part of a long-term

upward trend in the use of cesarean

seetions. The rate of cesarean sections

was 5.5 per 100 deliveries in 1970,

10.4 per lCKIdeliveries in 1975, and

16.5 per 100 deliveries in 1980. Detailed studies of the increase in cesarean section rates have been published

(Placek and Taffel, 1980; Placek,

Taffel, and Moien, 198& Taffel,

Place~ and Liss, 1987).

Repair of current obstetric laceration increased 40 percent, fxom 12.1

per 100 deliveries in 1983 to 16.9 per

100 deliveries in 1987. This procedure

has also been increasing in tkquency

for some time. In 1970 the rate of obstetric laceration repairs was 5.9 per

100 deliveries in 1975 it was 7.2 per

100 deliveries; and in 1980 it was 9.4

per 100 deliveries.

Use of fetal EKG and fetal monitoring not otherwise specified

increased dramatically from 1983 to

1987. The number grew by 533,000,

and the 1987 rate per 100 deliveries

DbsMltWpt’ocedure and ICD-9-CM code’ 1983 1987 1W3 le67

Number in thousands Rate per 100 deliveries

Allob81ehicatproc adures . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72-75 3,914 5,356 96.5 137.0

Prcaduresl oasslsld elivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...72-73 2,405 2,938 eo.5 75.1

Episbtomy . . . . . . . . . . . . . . . . . . . . . . . . . . . ...72.1.72.21.72.31.72.71.73.6 1,943 1,633 48.9 46.9

Artifkial rupture of membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...73.0 207 476 5.2

Manually assisted delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73.5

12.2

Cesarean aectbn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74.0-74.2.74.4. 74.99

10.3

:: :2 2:

Repair of Went obstetric Iaceratbn. . . . . . . . . . . . . . . . . . . . . . . . . . ...75.5-75.6

24.4

479 660 12.1 16.9

Fetal EKG and fetal monitoring not otherwise spectfied. . . . . . . . . . . . . ...75.32. 75.34 114 647 2.9

Oiher obstetric procedures. ., ,

16.5

., .74.3,74891,750-75.31, 75.33, 75.35,75.4,75.7-75.9 106 161 2.7 4.1

1p~um g~v @ de ~m~m IIM ~ on the HeMsr/cnR/ aassh%won of/2keeses, 6ih fWsIOn C//n/-/ ~~/fi~f/ofl.
6 Advance Data

was5.7times the rate in 1983. The

rate of other miscellaneous obstetric

procedures also increased by more

than 50 percent from 1983 to 1987.

Surgical procedures by age

The number and rate of selected

surgical categories and procedures are

shown by age group in tables 7-10.

The specific categories and procedures

were chosen because of large numbers

of occurrences or because of special

interest. Not every category or procedure shown changed in frequency

from 1983 to 1987, and not every significant change could be shown.

Under15 years

Seven surgical categories

accounted for 86 percent of the inpatient surgery of children under 15

years of age in 1983, 84 percent in

1987 (table 7). These data exclude

surgeries performed on newborn infants. There were statistically significant decreases in the numbers and

rates for three of these categories in

the 5-year period: operations on the

ear; operations on the nose, mouth,

and phv, and operations on male

genital organs.

The number of operations on the

ear decreased by 127,000, which was

primarily because of the decrease, by

107,000, in the number of myringotomies. The rate of myringotomies declined by 64 percent.

Children under 15 years of age

had 213,000 fewer inpatient operations

on the nose, mouth, and pharynx in

1987 than in 1983. Tonsillectomies

with or without adenoidectomies decreased by 120,000, and there were

37,000 fewer adenoidectomies without

tonsillectomies. The rate of adenoidectomies fell the most, 73 percent, while

the tonsillectomy rate decreased by

44 percent.

The number and rate of tonsillectomies have been declining for many

years (NCHS, 1984). In 1965,981,000

inpatient tonsillectomies were performed on children under 15 years of

age, which was a rate of 165.5 per

10,000 population. The rate decreased

25 percent from 1965 to 1970,31 percent from 1970 to 1975, and 34 percent from 1975 to 1980.

Operations on the male genital

organs declined by 56,000 from 1983

to 1987. The major decrease was in

circumcisions. Both the number and

rate of circumcisions in 1987 were half

what they had been in 1983. However,

newborn infants, who were excluded

from these dat% had a much larger

number of circumcisions,

approximately 1.2 million in 1983 and

1987. Neither the number nor the rate

of circumcisions per 100 male newborn infants changed significantly in

the 5-year period.

Certain procedures within other

surgkd categories also decreased

from 1983 to 1987. The number and

rate of cardiac catheterizations for

children under 15 years of age fell by

more than 40 percent, even though the

total number of cardiac catheterizations increased during this period. The

number and rate of inpatient repairs

of inguinal hernias for children were

almost cut in half from 1983 to 1987.

Operations on muscles, tendons, fascia, and bursa decreased by 39 percent

in the 5-year period. None of the leading inpatient surgical procedures done

on children increased in frequency

from 1983 to 1987.

15-44 years

Six categories made up approximately 90 percent of the inpatient surgical procedures performed on

patients 15-44 years of age (table 8).

From 1983 to 1987 there was a statistically significant increase in the

Table 7. Number and rate of inpatient surgeries for patients under 15 yeara of age: United States, 1983 ●nd 1987

[Data are for non-Faderalshort-slayhospiislsand exclude newbornkrfanls]

Surglml category and ICD-9-CM code’ 1983 1967 la.? 1987

Number in thousands Rate par 10,003 populatbn

Allsurgical procaduresz. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,786 1,195 346.1 228.1

Oparatiorrsontheear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-20 220 93 42.6 17.7

Myringolomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20.0 169 e2 32.7 11.7

Operationsonthenosa, mouth,endpharynx . . . . . . . . . . . . . . . . . . . . . . ...21-29 451 23a 87.3 45.4

Tonsillectomywlttror withoutadenoldectomy. . . . . . . . . . . . . . . . . . . . . .28.2-28.3 279 159 54.1 30.3

Adenoldectomywithouttonsillectomy.. . . . . . . . . . . . . . . . . . . . . . . . . . . . .28.6 60 9.7

Operationsonthecardbvaacular syatem . . . . . . . . . . . . . . . . . . . . . . . . . . . .35-39

2.8

115 : 22.2

CardiaccattIeterization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37.21-37.23

10.7

3.6

Punctureofve5sd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..3S.9 : 2 E

Oparalbnson thedlgestive system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42-54 255 211 49.5 E3

Appendectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..47.o 75 6a 14.5 f2,7

Repairoflngulnal hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...63.0-53.1 81 42 15.6 8,0

Operationsonmalegenltrd organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60-64 126 70 24.5 13.3

Orchlectomyandorchiopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S2.3-62.5 27 19 5.2 3.7

Circumclsbn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...64.0 53 10.2

Operationsonthemusouloskeletal system. . . . . . . . . . . . . . . . . . . . . . . . . ..7WM 242 m? 48.8 3%

Reductionof fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...76.7. 79.0-79.6 100 86 19.4 16.4

Operationson muscles,tendons,fascia,and bursa . . . . . . . . . . . .e2-S3.1, 83.3-63.9 41 25 7.9

Oparatbns ontheintegumentary system . . . . . . . . . . . . . . . . . . . . . . . . . ...85-66 121 95 23.5 la

Excisionor destructionof Iesbn or tissueof skinor subcutaneoustissue . . . .S6.2-86.4 51 38 9.9 7.2

‘ Procdum groups at-d ode numbers are based on the /riemationd Cks/ffcsf/on of Wea.ws, ah r%islon, Cllnkal Mcdlr7caflon.See ~abieit In ‘Whnlcui ties” for nonsurgicalprowdurss

excludsd from each ca!sgofy.

z,m~de~ op.emti~ d swn In ‘tile.
Advance Data 7

Tabh 8. Number and rate of inpatient surgeries for patients 15-44 years of ●ge United States, 1983 and 1987

[Data are for non-Feder61 shorl-slay hospitals]

Sumhxl catemwarrd tCD-9CM code’ 1863 15S7 15S3 1967

Numtx3r In thousands Rate per 10,000 population

Allsurgkxd prooeduresz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12,666 12,577 1,154.1 1,101.6

Operalbnson thenose, mouth, andphfuvnx . . . . . . . . . . . . . . . . . . . . . . ...21-29 689 431 63,3 37.7

Rhinoplasty andrepalrof nmse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..21.a 17.3

Oparatbnson thedlgesthre system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..42+54

7.8

1,L? 1,$ 131.7 122.7

Appendeofomy, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47.o 165 186 15.1 16.3

Ch01SCy6t8Cf0My . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..5I.2 167 122 15.4 17.4

Dtvlsbnofperltonealadhesbns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...64.5 le4 16.5 17.0

Oparalbrrsonthefemelegenttalorgans . . . . . . . . . . . . . . . . . . . . . . . . . ...65-71 2,:: 2,098 267.9 183.7

Oophorectomyand salplngo-oophoractomy . . . . . . . . . . . . . . . . . . . . ..65.M5.e 314 276 28.9 24.2

Bilateral destructbn orocclusbn offalloplsn tubes. . . . . . . . . . . . . . . ...66.2-86.3 664 413 51.9 36.2

Hyslereotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...63.3-68.7 440 40.4 35.6

Dilatbnandcurettageofuterus... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..69.o 731 314 67.2 27.5

Obstelrlcalprooedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..72–75 3,S02 5,337 358.6 467.5

Oparatbnsonthemusculoskelelalsystem . . . . . . . . . . . . . . . . . . . . . . . . ...76-84 1,543 1,376 141.8 120.5

Openreductbrrof fracture, exceptjaw. . . . . . . . . . . . . . .76.79, 79.2-79.3,79.6-79.6 162 14.9 17.5

Exclsbnordestructbnoflnterverlebral diso . . . . . . . . . . . . . . . . . . . . ..s0.5. 61.0 143 176 13.1 15.4

Oparatbnson musoles, tendons,fesok4and bursa r . . . . . . . . . ..62-83.1.63.3-83.9 Iw 155 17.4 13.6

Opera!bnsontheintegumentarysystem . . . . . . . . . . . . . . . . . . . . . . . . . ...= 740 542 68.0 56.2

Debrldementofwound, infeofbn,orbum. . . . . . . . . . . . . . . . . . . . . . . . . ..88.2 86 137 7.9 12.0

Olher excksbn or destruotbn of Iesbn or ttssue of skin or subouteneous

Ussue .,, ,,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86.21,86.2HW.4 192 98 17.7 6.6

lp~rsaM dcdsfwmbers srebaeedonthehfenWonsl CliWSikStbfr~~-, 9fh ReWon, C//rice/ &fodHcat/on. 2-SE table II In ‘Technical rmtes” fur mxwrgicd procedures

OXCkJdd tiil &h cdq~.

zlw~ ~mtm not shown In tsble.

number and rate for one category,

obstetrical procedures. The speeific

procedures in this category were

8hownin table 6. Patients 1544 years

of age accounted for virtually all of the

obstetrical procedures.

Two surgical categories deereased

significantly from 1983to 1987: operations on the nose, mouth, and pharynx

and operations onthe female genital

organs. The number of operations on

the nose, mouth, and pharynx

deereased by 258,000, and the rate

decreased by 40 percent. A major part

of the decrease was from the decline

in rhinoplasty and repair of nose. The

1987 number and rate for this surgery

were less than half of what they had

been in 1983.

The number of operations on the

female genital organs for patients

15-44 years of age fell by 817,000

from 1983 to 1987. The rate decreased

by 31 percent. D&C deelined 417,000,

and the rate of D&C’s decreased by

59 percent. Bilateral destruction or

occlusion of fallopian tubes also decreased significantly; 151,000 fewer

were performed in 1987 than in 1983,

and the 1987 rate was 30 percent

lower than the 1983 rate.

Within the category of operations

on the integumentary system, one type

of procedure, debridement of wound,

infection, or burn, increased sharply

for patients 15-44 years of age. The

rate of this procedure rose 52 per~nt,

and the number was 51,000 higher in

1987 than in 1983. At the same time,

other excision or destruction of lesion

or tissue of skin and subcutaneous

tissue decreased sharply for this age

group. The rate was down 51 percent,

and the number decreased 94,000

from 1983 to 1987. The decreasing

procedures could be expeeted to have

become outpatient procedures

(Shannon, 1985c). The increase in debridements may reflect a change in

reporting practices.

45-M years

For patients 45-64 years of age,

the seven surgical categories shown in

table 9 accounted for more than 80

pereent of all inpatient surgical procedures. The number and rate of procedures in one category, operations on

the eye, deereased significantly from

1983 to 1987. The number was reduced by 179,000, and the rate declined 62 percent. Deereases in

cataract surgery-extraction of lens

and insertion of prosthetic lens— accounted for almost all of the deeline in

eye surgery. The rates of these cataract surgeries, which are often done at

the same time, dropped 87 and 84

percent, respectively, from 1983 to

1987.

The number of operations on the

cardiovascular system increased by

469,000 from 1983 to 1987, and the

rate increased by 60 percent. Most

striking was the increase in removal of

coronary artery obstruction (coronary

angioplasty), which grew from 16,000

in 1983 to 104,000 in 1987. The 1987

rate for coronary angioplasty was 6.5

times the 1983 rate for patients 45-64

years of age.

The number and rate of bypass

anastomosis for heart revaseukrization

also increased, but much of the growth

was because more thin one procedure

was being reported per patient. The

number of discharged patients in this

age group who had bypass surgery was

111,000 in 1983 and 121,000 in 1987,

which was not a statistically significant

increase.

Cardiac catheterization increased

by 163,000, and the rate of this procedure was 56 percent higher in 1987

than in 1983. The number and rate of

puncture of vessel reported for patients 45–64 years of age more than

doubled, and the number and rate of

procedures auxiliary to open heart

surgery reported in 1987 were four

times the number and rate reported in

1983.

Besides cardiovascular procedures,

another speeific procedure that increased for the group 45-64 years of
8 Advam? Data

Table 9. Number ●nd rate of inpatient surgeries for patienta 45-64 years of age: United States, 1983 and 1987

[Dafa are for non-Faderal short-stay hospitats]

Su@al categotyand CD-9-CM code’ 1.963 1867 I(W3 1987

Allsurgkai prooaduresz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oparatbnson theeye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .03-16

Extraction of lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13.1-13.6

Insartionofprosthetlclens..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...13.7

Oparatbnsontheoardbvasoularsystem . . . . . . . . . . . . . . . . . . . . . . . . . ...35-38

Removalofcoronaryarieryobstruofbn. . . . . . . . . . . . . . . . . . . . . . . . . . ...36.0

Bypassanastomostsforheartravaecularizatbn3 . . . . . . . . . . . . . . . . . . . . ...36.1

Cardlaccatheterbafbn .,..... . . . . . . . . . . . . . . . . . . . . . . . . . . .37.21+37.23

Puncfureofvessal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...36.9

Procaduresauxlliarytoopenhaari surgery . . . . . . . . . . . . . . . . . . . . . . . . ...39.6

Oparatbnsonthedigestivesyatem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..42+4

RaseoWmofink3stine.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..45S-45.8

Cholacystecfomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...51.2

Repairofinguinalhemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53.0%3.1

Bbpsiesonthedigesttvesystem4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oparatbnsontheurinarysystem.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..5M9

Oparatbnsonthefemalegenitalorgans . . . . . . . . . . . . . . . . . . . . . . . . . ...65-71

Oophorectomyendsalpirrgo-oophoreefomy . . . . . . . . . . . . . . . . . . . ...65.3-65.6

Hysterectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68.3+8.7

Dllatbnandcurettegeofuterus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..&9.O

Operatbnsonthemusouloskeletal system . . . . . . . . . . . . . . . . . . . . . . . . . ..76+4

Partialexclsbnofbone . . . . . . . . . . . . . . . . . . . . . . . . . . . .76.2-76.3. 77.6-77.8

Open reduclbn offracfure, exaaptJaw. . . . . . . . . . . . . . ,76.79, 79.2-79.3,79.%79.6

Exclsbn ordestruction ofintervertebral disc andsplnalfusbn . . . . . . . . ...80.5.81.0

Oparatbnson muscles, tendons,fascl%and bursa. . . . . . . . . ...62-63.1.83.3-83.9

Operatbnslnfheintegumentarysystem. . . . . . . . . . . . . . . . . . . . . . . . . . ...65-66

Blopsiasofbreast, skin, andsuboutaneousttssue . . . . . . . . . . . . .66.11-86.12. 66.11

Delwktementofwound, infecfbn, ortmm . . . . . . . . . . . . . . . . . . . . . . . . ...66.22

Ofherexclsbnor destrucfbnoflesbn ortissueofskinor subcutaneous

tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86.21,86.2&86.4

Number In thousands

5,686 5,458

295 116

106 14

82 13

753 1,222

16 104

112 170

277 440

36 91

2e 116

1,170 1,136

57 76

162 163

155 es)

142 147

2e8 306

535

153 163

160 188

J% 8:

84 70

68 86

69 133

116 91

658 434

60 45

46 67

141 56

RafepWIO,~ populatbn

1,277.2 1,206.0

86.4 25.5

23.8 3.1

18.3 2.9

169.1 270.0

3.5 22.9

25.2 37.7

6$?.3 97.2

8.2 20.1

25.7

29 251.0

12.9 16.7

36.4 36.1

34.8 22.0

31.9 32.4

67.1 67.5

153.6 116.3

34.3 36.1

40.4 4T.6

37.4 10.7

203.6 179.3

18.8 15.4

15.3 19.1

19.9 29.3

26.1 ZO.o

125.6 85.8

17.9 9.9

10.3 14.8

31.7 12.9

lp-uBgWP ~~~~bm amontbltiamtfonal cl~~t~cfm-, Wr%vfskJn,C/Mca/ hbdlfkdon.sea tnbblliniTechnlcal rxiaa”formwurgksl prowdurss

excluded from each categoty.

‘Imhdes opwatlma not shc+vn Inteble.

%srumbsrofdbcharged petientswithbypsaaeraston&Js forhmrtrevescularkationswaslll,0001nlSS3erd 121,020inlSS7.

41CB~~ da 42.x, 441.4_4415, 45.14-.45.15, 4!j.2M5.27, 4S.24-4i3,33, 49.22-40.23, =.1 1-=1 2,51 .12_5t .1 3P=1 1*.l 2, ‘.=*.=.

agewasexeision or destruction ofintervertebral disc and spinal fusion. The

number increased from 89,000 in 1983

to 133,000 in 1987.

Certain other procedures

decreased significantly in the 5-year

period. The number of repair of inguinal hernia was reduced by 56,000, and

the rate for the procedure fell 37 percent. The rate of D&C was down 71

pereent, and the number deereased by

118,000. There were 35,000 fewer biopsies of breast, skin, and subcutaneous tissue done on an inpatient basis,

and therate for these biopsies

deereased by 45 percent. The number

of other excision or destruction of

lesion or tissue of skin and subcutaneoustissue dc.clinedby 83,000, and the

rate decreased 59 percent,

65 years and over

Seven surgical categories that

accounted for more than 80 percent of

the inpatient surgical procedures performed on patients 65 years of age

and over are presented in table 10. As

was the case for patients 45-64 years

of age, operations on the eye

decreased significantly from 1983 to

1987, and operations on the cardiovascular system increased significantly.

The number of operations on the

eye performed on inpatients 65 years

of age and over decreased by 831,000

in the 5-year period. The deeline in

eye surgery was almost all from decreases in cataract surgeries. The rate

of lens extraction fell 90 percent, and

the rate of insertion of prosthetic lens

dropped 88 percent from 1983 to

1987.

The number of operations on the

cardiovascular system increased by

602,000 in the 5-year period. The

number and rate of bypass anastomosis for heart revascularization more

than doubled. The number of

discharged patients 65 years of age

and over who had one or more bypass

procedures increased from 66,000 in

1983 to 117,000 in 1987, and the rate

rose 63 percent during this period,

The number of cardiac catheterizations increased by 190,000 from

1983 to 1987, and the rate for the procedure more than doubled. As was the

ease for patients 45-64 years of age,

the number and rate of puncture of

vessel reported for patients 65 years of

age and over more than doubled from

1983 to 1987. The number and rate of

procedures auxiliary to open heart

surgery reported in 1987 were five

times those reported for 1983.

Among other speeific surgical procedures that increased from 1983 to

1987 was biopsy of the digestive system, which grew by 76,000. In addition, the rate of arthroplasty and

replacement of knee almost doubled,

and the number of this procedure increased by 47,000.

Like patients 15-44 years of age,

patients 65 years of age and over were

reported to have a significant increase

in debridement of wound, infeetion, or

burn. The number of these procedures

increased by 45,000, and the rate for

the elderly was 58 percent higher in
Advance Data 9

Tablo 10. Numbar ●nd rate of Inpatfent surgeries for patienta 65 yeara of ●ge and ovetv United Statea, 1983 and 1987

[Data are for non-Faderal short-slay hospltab]

SUr@af cahsgoty and tCD-9-CM coda’ 1963 1967 1993 1967

Number In thousands Refe per IO,OW rmulatbn

A118urgical procedures2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Opera!bnson lheeye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...03-16

Extractbnoflens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...13.1-13.6

Insertbnofpmsthetlclens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...13.7

Operatbnsonihecardbvascularsyslem . . . . . . . . . . . . . . . . . . . . . ...=

Bypassanastomoslsforhaart$svasculWi@b~d ~ ~ . . . . . . . . . . . . . . . . . . . ..36.1

Cardiaccalheterizalbn . ...”.... . . . . . . . . . . . . . . . . . . . . . . . . ..37.21~7.23

Pacemakerinsertbn, replacement, remov~, repair . . . . . . . . . . . . . . . ...37.7-37.8

Punctureofvessel. . . . . .. o..... . . . . . . . . . . . . . . . . . . . . . . . . . . ..33.9

ProceduresauxllUarytoopenheartsur9erY . . . . . . . . . . . . . . . . . . . . . . . . ..39.6

Operatbnsonthedbeslivesystem.. . . . . . . . . . . . . . . . . . . . . . . . . . . . ...42-54

Resecfionoflntestlne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..45.H5.a

Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...51.2

Repalroflngulnalhernla . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......~.~.l

Bbpslesonthedigestivesyslem4... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Operatbnsonlheurlnarysystem.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..5~9

Transurethral exclsbnordestructbn Ofbkxldertlssue . . . . . . . . . . . . . . . . ...57.4

Operatbnsonthemalegenltalorgans. . . . . . . . . . . . . . . . . . . . . . . . . . . ...60-64

prostatactomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...60.2-60.6

Operatbnsonlhemusculoalrelelalsyetem . . . . . . . . . . . . . . . . . . . . . . . . ...75-64

Reductbnoffracfura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..76.7.79.~79.6

ArlhroplasSyand replacementofknea. . . . . . . . . . . . . . . . . . . . . . . . .61.41-61.47

Arthroplastyand replacementofhlp . . . . . . . . . . . . . . . . . . . . . . . . . ..81.~1.6

Opsrafbnsontheintegumentarysyetem . . . . . . . . . . . . . . . . . . . . . . . . . . . .-

Debrklemantofwound, lnfecfbn,orbum. . . . . . . . . . . . . . . . . . . . . . . . . ..66.22

Otherexclsbnordeslructbn oflesbnorflesueof sklnorsubcufaneous

IISSUS . . . . . . . . .. O. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66.21863.23+3.4

6,192

1,077

601

427

759

67

136

150

51

16

1,344

133

156

140

169

423

69

410

274

811

175

44

116

410

63

6,425

246

57

54

1,361

152

326

174

140

107

1,640

153

172

111

265

448

76

442

318

924

220

66

161

430

106

101 61

2,261.3

393.2

162.6

156.0

277.0

24.6

60.4

54.8

16.6

6.6

490.7

46.6

57.0

51.1

69.1

164.4

32.6

149.6

99.9

2W.3

63.6

14.9

42.9

149.9

22.9

37.0

2,153.4

62.4

19.0

18.0

466.2

51.1

109.6

56.4

46.9

35.7

516.0

51.3

57.7

37.3

69.0

150.0

25.4

148.2

106.7

309.6

73.8

29.7

53.9

144.0

36.2

20.6

i~mg- ~~m~m axOwOnltwltiemmtbm/a8ssHkakn70f Dbeasus,sfht%vkb, Cllticaihfedfrkdlon. 3eetable llln”Technloal tmtes’’fornonsurglcal procedures

●xchidsdfromeach utsgoIv.

‘Irwbdmepemtlcm notshwnlntable.

%hsrurnbsrddlschqpd pstieritwlthtypsuansstormals forhswfrevsscularkatlon wss66,0001n1263edl 17,0001n1967.

41~~~~ ~“ 42.N, 44.,M,15, 45.1+45.45, 45,M.27, 4S.2GUW%, 4W2-113.23,~.1 1-.12,51.1241.13, 52.11*.12. ‘.=-%.=.

1987 than in1983. Atthe sometime,

other excision or destruction of lesion

ortissue ofskin and subcutaneous

tissue decreased. Thenumberfellby

40,000, and the rate decreased by 44

percent.

Summary

The procedures that decreased in

frequency for inpatients from 1983 to

1987 were ones either that have been

reported to be performed in growing

numbers in ambulatory settings, or

that have thecharacteri;tics (such as

short duration, minimal bleeding, and

low complication rates) of procedures

that could be done on an ambulatory

basis (Ermann, 1988). Thus, the decreases in the number of these procedures performed on inpatients

probably does not indicate a decrease

in the total number performed.

The increases in inpatient procedures had several possible explanations. Increases in relatively minor

procedures such as manually assisted

delivery or debridement of wound,

infection, or burn probably were from

increased reporting rather than sudden

growth in the use of these procedures.

The implementation of the prospective

payment system based on DRG’s was

expected to result in more complete

reporting of secondary diagnoses and

procedures (Cohen, Pokras, Meads,

and Krushat, 1987). More detailed

reporting could result in more favorable reimbursement rates for Medicare patients, and if doctors and

hospitals changed their reporting practices for patients covered by Medicare,

they were likely to change it for other

patients as well (Schramm and Gabel,

1988).

In addition, NHDS data collection

procedures changed in 1985 when part

of thedata began to repurchased

from commercial abstracting services

(see “Technical notes”). A greater

number of procedures per patient

have been reported for hospitals using

the commercial abstracting services

than for the other hospitels in the

survey.

Some procedures (for example,

coronary angioplasty and use of fetal

monitoring) were probably increasing

rapidly from 1983 to 1987 because

they were in the process of changing

from relatively new procedures done

on a limited basis to commonly used

procedures. However, reasons for the

rapid increases in some procedures

(such as, coronary bypass and arthroplasty and replacement of knee for

patients 65 years of age and over) are

not readily apparent and may be cause

for concern for health policymakers.
Advance Data 11

References

American College of Surgeons. 1988.

Socio-Economic Factbook for Swgey, 1988.

Chicago. American College of Surgeons.

Cohen, B. B,, R, Pokras, M. S. Meads, and

W.M. Krushat. 1987. How will diagnosisrelated groups affect epidemiologic

reseamh? Am. J Epidemiol. 126(1): 1–9.

Ermann, D. 1988. Surgery and the changing system of health care delivery. In SurgZ”-

cal ca~ in the United States: a policy

perspective, edited by M, L. Finkel. Bakimore, Md.: The Johns Hopkins University

Press.

Guterman, S,, P. W. Eggem, G. Riley, et

al, 1988. The first 3 years of Medicaxe prospective payment: An ovexview. Health

Cm Finan. Rev. 9(3];67-77.

National Center for Health Statistics,

M, G. Sirken, 1967a, Utilization of shortstay hospitals, summary of nonmedical statistic United States, 1965. Vital and

Health Statistics. Series 13, No. 2. PHS

Pub. No. 1000, Public Health Service.

Washington: U.S. Government Printing

Office.

National Center for Health Statistics, M. J.

Witkin, 1967b. Utilization of short-stay

hospitals by characteristics of discharged

patients United States, 1965. Vital and

Health Statistics. Series 13, No. 3. PHS

Pub, No. 1000. Public Health Service.

Washington: U.S. Government Printing

Office.

National Center for Health Statistics,

W. R. Simmons and G. A, Schnack. 1977.

Development of the design of the NCHS

Hospital Discharge Suxvey, V?tal and

Health Statistics. Series 2, No. 39. PHS

Pub. No. 1000. Public Health Setice.

Washington: U.S. Government Printing

Office.

National Center for Health Statistics, L. J.

Kozak and E. McCarthy. 1984. Hospital

use by children in the United States and

Canada. P7tal and Health Statistics. Series

5, No. 1. DHHS Pub. No. (PHS) 84-1477.

Public Health Service. Washington: U.S.

Government Printing Office.

National Center for Health Statistics,

S. Starr and R. Pokras. 1986. Surgical and

nonsurgical procedures in short-stay hospitals, United States, 1983. Vital and Health

Statistics. Series 13, No. 88. DHHS Pub.

No. (PHS) 87-1749. Public Health Sexvice.

Washington: U.S. Government Printing

Office.

National Center for Health Statistics, E. J.

Graves. 1987. Expected principal source of

payment for hospital discharges: United

States, 1985. Advance Data From Vital and

Health Statistics. No. 144. DHHS Pub. No.

(PHS) 88-1250. Public Herdth Service.

Hyattsville, Md.

National Center for Health Statistics, E. J.

Graves. 1988a. Utilization of short-stay

hospitals, United States, 1986, annual summary. Vital and Health Statistics. Series 13,

No, 96. DHHS Pub. No. (PHS) 88-1757.

Public Herdth Service. Washington: U.S.

Government Printing Office.

National Center for Health Statistics, Hospital Care Statistics Branch. 1988b. 1987

summary National Hospital Discharge

Smvey. Advance Data From Vital and

Health Statistics. No. 159 (Rev.). DHHS

Pub. No. (PHS) 88-1250. Public Health

SeMce. Hyattsville, Md.

Olson, L. L. 1984. Providers preparing for

major battle over market for outpatient

surge~. Modem Healthccue 14(12):82–92.

Placek, P. J., and S. M. Taffel. 1980.

Trends in cesarean section rates for the

United States, 1970-78. Public Health Rep,

95(6): 540-8.

Placek, P. J., S. M. Taffel and M. Moien.

1988.1986 c-section ns~ VEAC inch upward. Am. J. Public HeaIth 78(5):562–3.

Public Health SeMce and Health Care

Financing Administration. 1980. International Ckassijication of Diseases, 9th Rew”-

sion, Clinical Modification. DHHS Pub.

No. (PHS) 80-1260. Public Heakh Savice.

Washington: U.S. Government Printing

Office.

Schramm, C. J., and J. Gabel. 1988. Prospective payment, some retrospective observations. N. Engl. J, Med.

31x(25):1681–2.

Shannon, K. 1985a. Outpatient surgery up

77 percen~ Data. Hospitals 59(10):54.

Shannon, K. 1985b, Outpatient surge~

owes all to technology. HospitaZs 59(10):56.

Shannon, K. 1985c. Maximizing outpatient

surge~ could cut 600 million patient days

yearly. Ho~itals 59(10):61.

Taffel, S. M., P. J. Place~ and T. L. Liss.

1987. Trends in the United States cesarean

section rate and reasons for the 1980-85

rise. Am. 1 Public Health 77(8):955–9.
Advance Data 13

Technical notes

Survey methodology

Source of data

The National Hospital Discharge

Survey (NHDS) encompasses patients

discharged from short-stay hospitals,

exclusive of military and Veterans Administration hospitals, located in the

50 States and the District of Columbia. Only hospitals with six beds or

more and an average length of stay of

less than 30 days for all patients are

included in the survey. Discharges and

surgical procedures of newborn infants

are excluded from this report.

The original universe for the survey consisted of 6,965 hospitals contained in the 1963 National Master

Facility Inventory. New hospitals were

sampled for inclusion in the survey in

1972,1975,1977, 1979,1981,1983,

and 1985. In all, 553 hospitals were

sampled in 1983; 558 were sampled in

1987. Of these, 78 hospitals refused to

participate in 1983, and 92 refused in

1987. Another 57 hospitals in 1983

and 66 hospitals in 1987 were out of

the scope of the survey either because

they had closed or because they did

not meet the definition of a short-stay

hospital, In 1983, the 418 participating

hospitals provided approximately

206,000 abstracts, which contained

data on 130,000 surgical procedures.

In 1987,400 participating hospitals

supplied 181,000 abstracts that

included data on 128,000 surgical procedures.

Sample design and data collection

All hospitals with 1,000 beds or

more in the universe of short-stay hospitals were selected with certainty in

the sample. All hospitals with fewer

than 1,000 beds were stratified, the

primary strata being 24 size-by-region

classes. Within each of these primary

strata, the allocation of the hospitals

was made through a controlled sekxtion technique so that hospitals in the

sample would be properly distributed

with regard to type of ownership and

geographic division. Sample hospitals

were drawn with probabilities ranging

horn certainty for the largest hospitals

to 1 in 40 for the smallest hospitals.

The within-hospital sampling ratio for

selecting sample discharges varied inversely with the probability of selection of the hospital.

In 1985, for the first time, two

data collection procedures were used

for the survey. The first was the traditional manual system of sample discharge selection and data abstraction.

The second involved the purchase of

data tapes from mmmercial abstracting services. In 1987 this automated

method was used in approximately 17

percent of the sample hospitals.

In the manual procedure hospitals, sample discharges were selected

using the daily listing sheet of

discharges as the sampling frame.

These discharges were selected by a

random technique, usually based on

the terminal digit or digits of the patient’s medical record number. The

sample selection and abstraction of

data from the face sheets and

discharge summaries of the medical

records were performed by the hospital staff or by representatives of the

National Center for Health Statistics

(NCHS). The completed forms were

forwarded to NCHS for coding, editing, and weighting procedures.

For the automated procedure hospitals, tapes containing machinereadable medical record data

were purchased from commerical abstracting services. These tapes were

subject to NCHS sampling, editing

and weighting procedures.

The medical abstract form and the

abstract service data tapes contain

items relating to the personal characteristics of the patient, including birth

data, sex, race, and marital status (but

not name and address); administrative

information including admission and

discharge dates, discharge status, and

medical record numbe~ and medical

information, including diagnoses and

surgical and nonsurgical procedures.

Since 1977, patient zip code, expected

source of payment, and dates of procedures have been collected. The medical record number and patient zip

code are considered confidential information and are not available to the

public.

Presentation of estimates

Statistics produced by NHDS are

derived by a complex estimating procedure, The basic unit of estimation is

the sample inpatient discharge. The

estimating procedure used to produce

unbiased national estimates in NHDS

has three principal components inflation by reciprocals of the probabilities

of sample selection, adjustment for

nonresponse, and ratio adjustment to

&ed totals. These components of estimation are described in appendix I of

two earlier publications (NCHS,

1967a, 1967b).

Based on consideration of the

complex sample design of NHDS, the

following guidelines are used for presenting NHDS estimates in this reporh

● If the sample size is less than 30,

the value of the estimate is not

reported. Only an asterisk ~) is

shown in the tables.

. If the sample size is 30-59, the

value of the estimate is reported

but should be used with caution.

The estimate is preceded by an

asterisk ~) in the tables.

Standard errors and rounding of

numbers

The standard error is a measure

of the sampling variability that occurs

by chance because only a sample,

rather than an entire universe, is surveyed. The relative standard error of

the estimate is obtained by dividing

the standard error by the estimate itself and is expressed as a percent of

the estimate. Relative standard errors

NOTE See M of referencesfollowingthe text.

Table 1.Approximate relativo standard

errors for the numbar of surgical

procedures: United States, 1983 ●nd 1987

Sizeofestbnate IW3 I(A97

5,000 . . . . . . . . . . . . . 17.1 48.3

10, BOO. . . . . . . . . . . . . 14.0 15.3

25,CQ0 . . . . . . . . . . . . . 10.9 12.4

50,000 . . . . . . . . . . . . . 9.2 10.8

100,000 . . . . . . . . . . . 7.8 9.4

250,000. . . . . . . . . . . . 6.5 6.0

500,0C0. . . . . . . . . . . . 5.7 7.2

1,000,000 . . . . . . . . . . . 5.1 6.5

2,S00,000 . . . . . . . . . . . 4.4 5.8

5,000,000 . . . . . . . . . . . 4.0 5.3

10,000,000 . . . . . . . . . . 3.6 4.9

25,00J3,0C0 . . . . . . . . . . 3.3 4.5
14 AdvanceData

for numbers of surgical procedures

are shown in table I for 1983 and

1987.

Estimates have been rounded to

the nearest thousand. For this reason,

figures within tables do not always add

to the totals. Rates were calculated

from original, unrounded figures and

will not necessarily agree precisely

with rates calculated from rounded

data.

Tests of significance

In this report, the determination

of statistical inference is based on the

two-tailed Bonferroni test for multiple

comparisons using a 0.05 level of significance. Terms relating to

differences, such as “higher” and

“less: indicate that the differences are

statistically significant. Terms such as

“similar” and “no difference” mean

that no statistically significant difference exists between the estimates being compared. A lack of comment on

the difference between any tsvo estimates does not mean that the diff@-

ence was tested and found to be not

significant.

Definitions of terms

Age—Age refers to the age of the

patient on the birthday prior to admission to the hospital inpatient service.

Bed size of hospital—Bed size is

measured by the number of beds,

cribs, and pediatric bassinets regularly

maintained (set up and staffed for

use) for patients. Bassinets for newborn infants are not included. Bed size

is reported by the hospitals based on

the number of beds at or near midyear.

Dischcnge-A discharge is the formal release of a patient by a hospital;

that is, the termination of a period of

hospitalization by death or disposition

to place of residence, a nursing home,

or another hospital. The terms “discharge” and “patients discharged” are

used synonymously.

Disch~e rate–The ratio of the

number of hospital discharges during

a year to the number of people in the

civilian population on July 1 of that

year is the discharge rate.

l@ectedptincipd soume of paynzent-The expected principal source

of payment is reported by the patient

or the patient’s representative at the

time of admission. In this report, payment sources are grouped as follows:

private insurance-Private insurance is provided by nongovernmental sources, including Blue

Cross and other insurance companies, private industxy, and philanthropic organizations.

Medicaw-Medicare is a nationwide program providing health

insurance protection to people 65

years of age and over, people eligible for Social Security disability

payments for more than 2 years,

and people with end-stage renal

disease.

Medicaid-Medicaid is a joint

Federal-State program that provides benefits for people, including

the elderly, who meet their State’s

definition of “low income.”

Se~-pay-The self-pay category

consists of patients who expect the

costs of hospitalization to be paid

for primarily by themselves,

spouses, parents, or next of kin,

Other-Other sources include

Workers’ Compensation and other

government programs, such as

CHAMPUS (for dependents of

military personnel); other nonprofit sources, such as church welfarq hospitalizations for which

there was no charge; and sources

that could not be assigned to any

other category.

HospitaZ-Hospital refers to shortstay general and special hospitals that

have six beds or more for inpatient

use and an average length of stay of

less than 30 days. Military and Veterans Administration hospitals are not

included.

Patient—A patient is a person who

is formally admitted to the inpatient

service of a short-stay hospital for observation, care, diagnosis, or treatment. The number of patients refers

to the number of discharges during

the year including multiple discharges

of the same individual from one or

more short-stay hospitals. All newborn

infants, defined as those admitted by

birth to the hospital, are excluded

from this report. The terms patient,

inpatient, and discharge are used synonymously.

Population —The population estimates used in computing rates are

from published and unpublished estimates of the U.S. civilian population

on July 1 of the data year. These estimates are provided by the U.S. Bureau of the Census and are consistent

with population estimates published in

CurrentPopulation Repti, Series

P-25.

Rate of su@calproceduws-The

ratio of the number of surgical procedures during the year to the number

of persons in the civilian population on

July 1 of that year determines the rate

of surgical procedures,

Su@calprocedure-A surgical

procedure is a surgical operation listed

by the physician on the medical record

of a patient discharged fi-om the inpatient service of a short-stay hospital. In

the NHDS, all terms listed on the face

sheet of the medical record under captions such as operation, operative procedures, operations and/or special

treatments are transcribed in the order

listed. A maximum of four 4-digit

codes are assigned per sample discharge according to the International

Ckmi@ation of Diseares, 9th Revision,

Clinical Modijkzh”on (ICD-9-CM)

(Public Health Service and Health

Care Financing Administration, 1980).

Although both surgical and nonsurgical procedures are coded, nonsurgical procedures are excluded tlom

this report. Table II shows the nonsurgical codes that are excluded.

NOTE See list of references following the text.
Advance Data 15

Table IL Code numbers for procedure categories ●nd nonsurgical procedures excluded from each category

[BasedontheInternatbrral Classhkatkm tiDtsa9sas, 9th Revi?sbrr,Clkrk=slh4imihkatW

Fwcalum Categoly category code N#surgka Co&s exck%d

Operalbnson thenervoussystem . . . . . . . . . . . . . . 01-0s 03.31

Operatbnson theendocrina system.. . . . . . . . . . . . W-07

Operations cmtheeye . . . . .. o...... . . . . . . . . . 06-16 11.21,12.21,14.11,16.22

Operatbnson theear . . . . . . . . . . . . . . . . . . . . . . 16-20 20.31

Operatbns on the nose, mouth, end pharynx . . . . . . . 21-29 29.11

Operalbns on the resplrabry system. . . . . . . . . . . . . 31.41 -31.42,33.21 ~.23,34.21*.22

Operalbns on the cardbvascular system . . . . . . . . . . 3E-3e 39.95

Opsratbns on the hemlc end Iymphatlc system . . . . . . 40-41

Operatbns on the dlgestlve system. . . . . . . . . . . . . . 42-54 42.2142.23,44.11 -44.13,45.1 1-45.13,45.21 -45.24,46.21+6.22,51 .11,54.21

Operatbns ontheutinary system . . . . . . . . . . . . . . . 65-69 55.21 -55.22,56.31,57.31-57.32, 56.21-56.22

Operatbns on the male genital organs. . . . . . . . . . . . 60.19

Oparatbns on the female genital organs. . . . . . . . . . . 65-71 66.11-66.12,70.22

Obstetrbel prcwcfures . . . . . . . . . . . . . . . . . . . . . . 72-75

Oparatbns on the musculoskeletel system . . . . . . . . . 76-64 60.20-60.29

Operatbns on the Ndegumentary system . . . . . . . . . . 65-66

Miscellaneous diagnostic end therapeutic procedures . . a7-39 87.01-99.99

*U, S, GOWRNMCNT PRINTING 0fFICE;19L19- 241-2131 :80025
16 AdvanceData

Recent Issues of Advance Data From Vital and Health Statk?tics

No. 168. Health Characteristics of No. 166. ATDS Knowledge and Atti- No. 164. AIDS Knowledge and AttiWorkers by Oeeupation and Sex tudes of Hispanic Americans (Issued tudes for September 1988 (Issued

United States, 1983-85 (Issued April April 11, 1989) hnuary 3, 1989)

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tudes for October and November 1988 March 30, 1989) Deeember 15, 1988)

(Issued April 19, 1989)

Suggested citation

NationalCenter for Health Statistics, L, J, Kozak,

1989. Hospital inpatient surgery:United States,

1983-87. Advance Data Fmm VIII and Hssttfr

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