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February 2013

Anne Pfuntner, Lauren M. Wier, M.P.H., and Carol Stocks, R.N., M.H.S.A.



Introduction

Most hospitalizations involve one or more procedures, which can range from simple vaccinations to complex surgical procedures. The principal procedure is the procedure that is performed for definitive treatment (e.g., an appendectomy), but procedures can also be performed to make a diagnosis (e.g., tissue samples or exploratory surgery). Hospitalizations usually involve more than one procedure, which together constitute the all-listed procedures performed during a hospital stay.

This Statistical Brief presents data from the Healthcare Cost and Utilization Project (HCUP) on the most common all-listed procedures performed during hospital stays in the United States in 2010, overall and by patient age. Changes between 1997 and 2010 in the number of stays and the rate of hospitalization in the population are presented for hospital stays with the most common procedures performed in 2010. All differences between estimates noted in the text are statistically significant at the .001 level or better.

Findings

Most frequent all-listed procedures performed during hospital stays, 2010
Table 1 shows the most frequent all-listed procedures performed during hospital stays in 2010, as well as the change in the rate of hospitalizations with these procedures since 1997. Procedures were performed in 63 percent of the 39 million hospital stays in the United States in 2010. The rate of hospitalizations with procedures has remained relatively stable at about 800 per 10,000 population from 1997 to 2010.

Blood transfusion was the most common all-listed procedure performed during hospitalizations in 2010 (11 percent of stays with a procedure); the rate of hospitalization with blood transfusion has more than doubled since 1997.

Four cardiovascular procedures—diagnostic cardiac catheterization, diagnostic ultrasound of the heart (echocardiogram), hemodialysis, and percutaneous transluminal coronary angioplasty (PTCA)—were frequently performed in 2010. Although diagnostic cardiac catheterization was the fifth most common procedure in 2010, the rate of hospitalization with this procedure decreased 23 percent since 1997.

Musculoskeletal procedures also were frequently performed during hospital stays. Rates in 2010 for hospitalizations with knee arthroplasty (24 stays per 10,000 population) and spinal fusion (16 stays per 10,000 population) approximately doubled since 1997; the rate of hospitalization with hip replacement (15 stays per 10,000 population) increased 38 percent.

All-listed procedures performed during hospital stays with the most rapid growth, 1997-2010
Although the hospitalization rate for all stays and for stays during which any procedure was performed remained stable between 1997 and 2010, the hospitalization rate for stays during which some specific procedures were performed experienced rapid growth (table 2). Seven of the most rapidly growing all-listed procedures were also among those most frequently performed during hospital stays: prophylactic vaccinations and inoculations, blood transfusion, spinal fusion, knee arthroplasty, enteral and parenteral nutrition, hemodialysis, and respiratory intubation and mechanical ventilation.

Indwelling catheter was the most rapidly growing procedure between 1997 and 2010; the rate of hospitalization with this minor procedure more than tripled during this period (from 2 to 7 stays per 10,000 population). The rate of hospitalization with prophylactic vaccinations and inoculations, blood transfusion, and spinal fusion more than doubled between 1997 and 2010.

Most frequent all-listed procedures performed during hospital stays by patient age, 2010
Table 3 highlights the 5 most frequent procedures performed during hospitalizations in 2010 by patient age group, as well as the change in the rate of hospitalization with these procedures since 1997.

Although some procedures varied by age group, others were consistent across age groups. Blood transfusion was the most common procedure performed during hospital stays for adults ages 45-64, 65-84, and 85 and older in 2010, and the rate of hospitalization with transfusion approximately doubled from 1997 for each of these age groups. Blood transfusion also was 1 of the 5 most common procedures in 2010 among hospitalized children ages 1-17 and adults ages 18-44.

Respiratory intubation and mechanical ventilation also was a common procedure for all age groups except adults ages 18-44. The rate of hospitalization with respiratory intubation and mechanical ventilation grew rapidly between 1997 and 2010 for adults ages 45-64 (80 percent), ages 65-84 (37 percent), and age 85 and older (44 percent).

The most common procedures performed on hospitalized infants in 2010 were routine procedures, such as vaccinations and circumcision. The rate of infant hospitalization with vaccinations increased 155 percent since 1997. The rate of hospitalization with enteral and parenteral nutrition also grew rapidly for infants (235 percent). Appendectomy was the most frequent procedure performed in 2010 during hospital stays among children ages 1-17 (13 stays per 10,000 population).

Among adults ages 18-44, 4 of the top 5 procedures were related to pregnancy and childbirth: Cesarean section, repair of current obstetric laceration, artificial rupture of membranes to assist delivery, and fetal monitoring. The rate of hospitalization with Cesarean section increased 59 percent; however, the rates of hospitalization with repair of current obstetric laceration and artificial rupture of membranes to assist delivery remained stable between 1997 and 2010.

Among adults age 45 and older, cardiovascular and musculoskeletal procedures were common. Diagnostic cardiac catheterization was the second most common procedure among hospitalized adults ages 45-64 and the third most common procedure among adults ages 65-84 in 2010. The rate of hospitalization with this procedure decreased 33 percent for both age groups since 1997. Diagnostic ultrasound of the heart (echocardiogram) was the fourth most common procedure among adults age 85 and older. In terms of musculoskeletal procedures, knee arthroplasty was the fifth most common procedure among hospitalized adults ages 65-84; the rate of hospitalization with this procedure increased 66 percent since 1997. Treatment of a fractured or dislocated hip was the fifth most common procedure among hospitalized adults age 85 and older; the rate of hospitalization for this procedure decreased 29 percent since 1997.

Data Source

The estimates in this Statistical Brief are based upon data from the HCUP 2010 NIS. Historical data were drawn from the 1997 NIS. Supplemental sources included data on national population estimates from "Intercensal Estimates of the Resident Population by Single Year of Age, Sex, Race, and Hispanic Origin for the United States: April 1, 2000 to July 1, 2010," Population Division, U.S. Census Bureau, Release date: September 2011. (https://www.census.gov/data/datasets/time-series/demo/popest/intercensal-2000-2010-national.html).

Supplemental sources also included data on national population estimates from "Intercensal Estimates of the United States Resident Population by Age and Sex, 1990-2000: Selected Months," Population Division, U.S. Census Bureau, Release date: August 2004. Available at (https://www.census.gov/data/datasets/time-series/demo/popest/intercensal-1990-2000-national.html).

Many hypothesis tests were conducted for this Statistical Brief. Thus, to decrease the number of false-positive results, we reduced the significance level to .001 for individual tests.

Definitions

Procedures, ICD-9-CM, and Clinical Classifications Software (CCS)
The principal procedure is the procedure that is performed for definitive treatment rather than performed for diagnostic or exploratory purposes (i.e., the procedure that was necessary to take care of a complication). If two procedures appear to meet this definition, the procedure most related to the principal diagnosis is selected as the principal procedure. All-listed procedures include all procedures performed during the hospital stay whether for definitive treatment or for diagnostic or exploratory purposes.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to procedures. There are about 4,000 ICD-9-CM procedure codes.

CCS categorizes procedure codes into clinically meaningful categories.¹ This "clinical grouper" makes it easier to quickly understand patterns of procedure use. CCS categories identified as "Other" are typically not reported; these categories include miscellaneous, otherwise unclassifiable procedures that may be difficult to interpret as a group.

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 obstetrics and gynecology, otolaryngology, 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.

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 and 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 Center for Health Information and Analysis
Michigan Health & Hospital Association
Minnesota Hospital Association
Mississippi Department of Health
Missouri Hospital Industry Data Institute
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
New Mexico Department of Health
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
Oregon Health Policy and Research
Pennsylvania Health Care Cost Containment Council
Rhode Island Department of Health
South Carolina 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, nonrehabilitation 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 more than 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.

About HCUPnet

HCUPnet is an online query system that offers instant access to the largest set of all-payer healthcare databases publicly available. HCUPnet has an easy step-by-step query system, allowing for tables and graphs to be generated on national and regional statistics, as well as trends for community hospitals in the United States. HCUPnet generates statistics using data from HCUP's Nationwide Inpatient Sample (NIS), the Kids' Inpatient Database (KID), the Nationwide Emergency Department Sample (NEDS), the State Inpatient Databases (SID), and the State Emergency Department Databases (SEDD).

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 https://datatools.ahrq.gov/hcupnet.

For information on other hospitalizations in the United States, download HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States in 2009, 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, 2010. Online. May 2012. U.S. Agency for Healthcare Research and Quality. Available at http://www.hcup-us.ahrq.gov/db/nation/nis/NISIntroduction2010.pdf. (Accessed September 18, 2012).

Houchens R, Elixhauser A. Final Report on Calculating Nationwide Inpatient Sample (NIS) Variances, 2001. HCUP Methods Series Report #2003-2. Online. June 2005 (revised June 6, 2005). U.S. Agency for Healthcare Research and Quality. Available at http://www.hcup-us.ahrq.gov/reports/2003_02.pdf. (Accessed September 18, 2012).

Houchens RL, 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. Available at https://www.hcup-us.ahrq.gov/reports/methods/2006_05_NISTrendsReport_1988-2004A.pdf. (Accessed September 18, 2012).

Suggested Citation

Pfuntner, A (Truven Health Analytics), Wier, LM (Truven Health Analytics), Stocks, C (AHRQ). Most Frequent Procedures Performed in U.S. Hospitals, 2010. HCUP Statistical Brief #149. February 2013. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb149.pdf.

Acknowledgments

The authors would like to acknowledge the contributions of Eva Witt of Truven Health Analytics.

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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 HCUP Clinical Classifications Software (CCS). Healthcare Cost and Utilization Project (HCUP). U.S. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp. Updated March 2012. (Accessed September 18, 2012).