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February 2012

Rebecca Anhang Price, PhD, Elizabeth Stranges, MS, Anne Elixhauser, PhD



Introduction

Cancer is the leading cause of death among men and women under age 85.¹ The most commonly diagnosed types of cancer for adult men are prostate, lung, and colorectal; for adult women, breast, lung and colorectal.² Cancer death rates decreased by 22.2 percent in men and 13.9 percent in women between 1990-1991 and 2007, largely due to decreases in death rates for lung and prostate cancers among men, breast cancers among women, and colorectal cancers among both men and women. Decreased death rates for breast, colorectal, and prostate cancers during this time are largely attributable to improvements in early detection and treatment.³

This Statistical Brief presents data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample on hospital stays for cancer care among adults age 18 and older in 2009. Characteristics of these stays are compared by type of cancer and compared with adult hospitalizations for all other conditions. The most common cancer hospitalizations are identified and trends in the number of stays from 2000 to 2009 are displayed. Stays with a secondary diagnosis of cancer are enumerated, and the most frequent principal diagnoses for these stays are noted. All differences between estimates noted in the text are statistically significant at the 0.05 level or better.

Findings

General findings
In 2009, there were 4.7 million cancer-related hospitalizations among adults in the U.S. In one-quarter of them, cancer was identified as the principal diagnosis (1.2 million stays). Adult stays principally for cancer cost $20.1 billion, accounting for about 6 percent of adult inpatient hospital costs. Between 2000 and 2009, the number of adult hospital stays principally for cancer decreased by 4 percent, while the number of hospital stays for all other reasons increased by 11 percent (data not shown).⁴ Some of the decrease in the number of inpatient stays for cancer may be due to the growing number of outpatient cancer treatment options.

General characteristics of hospital stays for cancer
Table 1 presents the general characteristics of adult hospitalizations principally for cancer compared to hospitalizations for all other conditions in 2009. On average, adults hospitalized for cancer were 2.5 years older than those admitted for other conditions (64.0 years of age versus 61.5 years). Similar to stays for all other conditions, hospital stays primarily for cancer were fairly equally divided among males and females.

The in-hospital death rate during stays principally for cancer was 5.8 percent—more than twice as high as for all other hospital stays.

About 56 percent of adult hospitalizations primarily for cancer were covered by government payers (47.8 percent by Medicare and 8.6 percent by Medicaid) and 37.2 percent were paid for by private insurance. On the other hand, for all other adult stays, a larger percentage were covered by government payers (62.4 percent) or were uninsured and fewer were privately insured.

On average, adult hospitalizations principally for cancer were 1.6 days longer and cost more than hospitalizations for other conditions (6.6 days versus 5.0 days; $16,400 versus $10,700 per stay; $3,300 versus $2,800 per day).

As shown in table 2, cancer hospitalization rates among those 65 and older were 16 times higher than among 18-44 year olds and 2.5 times higher than among 45-64 year olds. In contrast, the hospitalization rate for all other non-maternal care was only 7 times higher among those 65 and older than among 18-44 year olds but also about 2.5 times higher than among 45-64 year olds.

There were no significant differences in cancer hospitalization rates among patients residing in higher and lower income communities, rural and urban areas, and different regions of the United States. In contrast, rates of all other non-maternal hospital stays were 25 percent higher among patients from lower income communities than among those from all other communities. In addition, rates of all other non-maternal hospital stays were approximately 30 percent lower in the West than in any other region.

Trends in the most common cancer hospitalizations
Among adult men, the most common cancer hospitalizations in 2009 were for prostate cancer, secondary malignancies (i.e., metastatic cancers), and lung cancer (figure 1). From 2000 to 2009, kidney cancer hospitalizations increased 40 percent, while stays for colon cancer and bladder cancer decreased 14 percent and 12 percent, respectively.

Among adult women, the most common cancer hospitalizations in 2009 were for secondary malignancies, breast cancer, and lung cancer (figure 2). From 2000 to 2009, stays for lung cancer, cancer of the uterus and cancer of the ovary remained relatively stable. Stays for all other common cancers decreased. Most notably, hospitalizations decreased 28 percent for breast cancer and 26 percent for cervical cancer.

Cost and length of stay by cancer site
As shown in table 3, the most common hospitalizations principally for cancer in 2009 were secondary malignancies (216,500 stays), cancer of the bronchus and lung (149,700 stays), and cancer of the colon (99,800 stays). Similarly, aggregate costs for adult cancer hospitalizations were highest for these three conditions: $3.2 billion for secondary malignancies, $2.3 billion for lung cancer and $1.8 billion for colon cancer.

The most expensive cancer hospitalizations were for leukemia ($40,200 mean cost per stay), multiple myeloma ($28,700), and non-Hodgkin's lymphoma ($24,900). These three cancers also resulted in the longest average lengths of stay: 15.5 days for leukemia, 11.6 days for multiple myeloma, and 10.2 days for non-Hodgkin's lymphoma. However, the highest costs per hospital day were for cancer of the prostate ($4,600 per day), cancer of the breast ($4,100 per day), and cancer of the thyroid ($3,500 per day).

Most common secondary cancer diagnoses
In addition to the 1.2 million hospital stays with a principal diagnosis of cancer, 3.4 million stays had a secondary diagnosis of cancer, where patients were hospitalized with a principal diagnosis other than cancer. Stays with a secondary diagnosis of cancer cost $38.5 billion, bringing the total cost of cancer-related hospital stays to $58.6 billion.

Consistent with the most commonly occurring stays with a principal diagnosis of cancer, nearly one-fifth (18.1 percent) of all stays with a secondary diagnosis of cancer were for breast cancer, 14.9 percent were for prostate cancer, and 14.6 percent for secondary malignancies, respectively (table 4).

Most common principal reasons for hospitalizations with cancer as a secondary diagnosis
One in twenty hospital stays with a secondary diagnosis of cancer (5.2 percent) had a principal diagnosis of pneumonia. Another 4.4 percent of secondary cancer stays had a principal diagnosis of septicemia. Approximately 5.5 percent of all stays with a secondary diagnosis of cancer had a principal diagnosis of a treatment-related complication: complication of surgical procedures or medical care (2.8 percent) or complication of devices, implants or grafts (2.7 percent). Stays primarily for circulatory disorders, including congestive heart failure (3.5 percent of cancer-related stays) and cardiac dysrhythmias (3.0 percent), were also common principal diagnoses.

Data Source

The estimates in this Statistical Brief are based on data from the HCUP NIS 2009. Historical data were drawn from the 2000 NIS. Supplemental sources included data from the U.S. Census Bureau, Population Division, Annual Estimates of the Population for the United States, Regions, and Divisions.

Definitions

Diagnoses, ICD-9-CM, and Clinical Classifications Software (CCS
The principal diagnosis is that condition established after study to be chiefly responsible for the patient's admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or that develop during the stay.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses. There are about 13,600 ICD-9-CM diagnosis codes.

CCS categorizes ICD-9-CM diagnoses into a manageable number of clinically meaningful categories. This "clinical grouper" makes it easier to quickly understand patterns of diagnoses and procedures.

Case definition
For this report, hospitalizations for cancer were defined as those with a principal diagnosis of CCS 11-43.

Types of hospitals included in HCUP
HCUP is based on data from community hospitals, defined as short-term, non-Federal, general and other hospitals, excluding hospital units of other institutions (e.g., prisons). HCUP data include OB-GYN, ENT, orthopedic, cancer, pediatric, public, and academic medical hospitals. Excluded are long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. However, if a patient received long-term care, rehabilitation, or treatment for psychiatric or chemical dependency conditions in a community hospital, the discharge record for that stay will be included in the NIS.

Unit of analysis
The unit of analysis is the hospital discharge (i.e., the hospital stay), not a person or patient. This means that a person who is admitted to the hospital multiple times in one year will be counted each time as a separate "discharge" from the hospital.

Costs and charges
Total hospital charges were converted to costs using HCUP Cost-to-Charge Ratios based on hospital accounting reports from the Centers for Medicare and Medicaid Services (CMS).⁵ Costs will reflect the actual expenses incurred in the production of hospital services, such as wages, supplies, and utility costs, while charges represent the amount a hospital billed for the case. For each hospital, a hospital-wide cost-to-charge ratio is used. Hospital charges reflect the amount the hospital billed for the entire hospital stay and do not include professional (physician) fees. For the purposes of this Statistical Brief, costs are reported to the nearest hundred.

Urban-rural location
Urban-rural location is one of six categories as defined by the National Center for Health Statistics:

• Large Central Metropolitan: Central counties of metropolitan areas with a population of 1 million or greater
• Large Fringe Metropolitan: Fringe counties of counties of metropolitan areas with a population of 1 million or greater
• Medium Metropolitan: Counties in metro area of 250,000-999,999 population
• Small Metropolitan: Counties in metro areas of 50,000-249,999 population
• Micropolitan: Micropolitan counties, i.e. a non-metropolitan county with an area of 10,000 or more population
• Non-core: Non-metropolitan and non-micropolitan counties

Median community-level income
Median community-level income is the median household income of the patient's ZIP Code of residence. The cut-offs for the quartile designation are determined using ZIP Code demographic data obtained from Claritas. The income quartile is missing for homeless and foreign patients.

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

• Medicare includes fee-for-service and managed care Medicare patients.
• Medicaid includes fee-for-service and managed care Medicaid patients. Patients covered by the State Children's Health Insurance Program (SCHIP) may be included here. Because most state data do not identify SCHIP patients specifically, it is not possible to present this information separately.
• Private insurance includes Blue Cross, commercial carriers, and private HMOs and PPOs.
• Other includes Workers' Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs.
• Uninsured includes an insurance status of "self-pay" and "no charge".

When more than one payer is listed for a hospital discharge, the first-listed payer is used.

Region
Region is one of the four regions defined by the U.S. Census Bureau:

• Northeast: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania
• Midwest: Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas
• South: Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, and Texas
• West: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, and Hawaii

Discharge status
Discharge status indicates the disposition of the patient at discharge from the hospital, and includes the following six categories: routine (to home), transfer to another short-term hospital, other transfers (including skilled nursing facility, intermediate care, and another type of facility such as a nursing home), home healthcare, against medical advice (AMA), or died in the hospital.

About HCUP

HCUP is a family of powerful healthcare databases, software tools, and products for advancing research. Sponsored by the Agency for Healthcare Research and Quality (AHRQ), HCUP includes the largest all-payer encounter-level collection of longitudinal healthcare data (inpatient, ambulatory surgery, and emergency department) in the United States, beginning in 1988. HCUP is a Federal-State-Industry Partnership that brings together the data collection efforts of many organizations—such as State data organizations, hospital associations, private data organizations, and the Federal government—to create a national information resource.

HCUP would not be possible without the contributions of the following data collection Partners from across the United States:

Alaska State Hospital & Nursing Home Association
Arizona Department of Health Services
Arkansas Department of Health
California Office of Statewide Health Planning and Development
Colorado Hospital Association
Connecticut Hospital Association
Florida Agency for Health Care Administration
Georgia Hospital Association
Hawaii Health Information Corporation
Illinois Department of Public Health
Indiana Hospital Association
Iowa Hospital Association
Kansas Hospital Association
Kentucky Cabinet for Health and Family Services
Louisiana Department of Health and Hospitals
Maine Health Data Organization
Maryland Health Services Cost Review Commission
Massachusetts Division of Health Care Finance and Policy
Michigan Health & Hospital Association
Minnesota Hospital Association
Missouri Hospital Industry Data Institute
Mississippi Department of Health
Montana MHA — An Association of Montana Health Care Providers
Nebraska Hospital Association
Nevada Department of Health and Human Services
New Hampshire Department of Health & Human Services
New Jersey Department of Health and Senior Services
New Mexico Health Policy Commission
New York State Department of Health
North Carolina Department of Health and Human Services
Ohio Hospital Association
Oklahoma State Department of Health
Oregon Association of Hospitals and Health Systems
Pennsylvania Health Care Cost Containment Council
Rhode Island Department of Health
South Carolina State Budget & Control Board
South Dakota Association of Healthcare Organizations
Tennessee Hospital Association
Texas Department of State Health Services
Utah Department of Health
Vermont Association of Hospitals and Health Systems
Virginia Health Information
Washington State Department of Health
West Virginia Health Care Authority
Wisconsin Department of Health Services
Wyoming Hospital Association

About the NIS

The HCUP Nationwide Inpatient Sample (NIS) is a nationwide database of hospital inpatient stays. The NIS is nationally representative of all community hospitals (i.e., short-term, non-Federal, non-rehabilitation hospitals). The NIS is a sample of hospitals and includes all patients from each hospital, regardless of payer. It is drawn from a sampling frame that contains hospitals comprising about 95 percent of all discharges in the United States. The vast size of the NIS allows the study of topics at both the national and regional levels for specific subgroups of patients. In addition, NIS data are standardized across years to facilitate ease of use.

For More Information

For more information about HCUP, visit http://www.hcup-us.ahrq.gov.

For additional HCUP statistics, visit HCUPnet, our interactive query system, at www.hcup.ahrq.gov.

For information on other hospitalizations in the U.S., download HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States in 2008, located at http://www.hcup-us.ahrq.gov/reports.jsp.

For a detailed description of HCUP, more information on the design of the NIS, and methods to calculate estimates, please refer to the following publications:

Introduction to the HCUP Nationwide Inpatient Sample, 2008. Online. May 2010. U.S. Agency for Healthcare Research and Quality. http://hcup-us.ahrq.gov/db/nation/nis/NIS_2008_INTRODUCTION.pdf

Houchens, R., Elixhauser, A. Using the HCUP Nationwide Inpatient Sample to Estimate Trends. (Updated for 1988-2004). HCUP Methods Series Report #2006-05 Online. August 18, 2006. U.S. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports/methods/2006_05_NISTrendsReport_1988-2004.pdf

Suggested Citation

Anhang Price, R. (RAND), Stranges, E. (Thomson Reuters) and Elixhauser, A. (Agency for Healthcare Quality and Research). Cancer Hospitalizations for Adults, 2009. HCUP Statistical Brief #125. February 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb125.pdf

Acknowledgements

The authors would like to acknowledge Mika Nagamine and Lindsay Terrel for their assistance with this Brief.

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AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of healthcare in the United States. We also invite you to tell us how you are using this Statistical Brief and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at hcup@ahrq.gov or send a letter to the address below:

Irene Fraser, Ph.D., Director
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850



¹ Heron M. Deaths: Leading causes for 2007. National vital statistics reports; vol 59, no 8. Hyattsville, MD: National Center for Health Statistics. 2011.
² Altekruse S.F., Kosary C.L., Krapcho M., (editors) ea. Surveillance, Epidemiology, and End Results Cancer Statistics Review, 1975-2007. Bethesda, MD: National Cancer Institute; 2010.
³ Siegel R., Ward E., Brawley O., Jemal A. Cancer statistics, 2011: The impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin. Jul-Aug 2011;61(4):212-236.
⁴ The number and cost of maternal stays was excluded from the totals provided here. Maternal stays were also excluded from the non-cancer hospital stay data presented in tables 1 and 2.
⁵ HCUP Cost-to-Charge Ratio Files (CCR). Healthcare Cost and Utilization Project (HCUP). 2001-2008. U.S. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/db/state/costtocharge.jsp.