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

Hysterectomy Removal of the uterus 641,000 procedures a year Most common major surgery in women ages 18 to 44, after cesarean section Merrill RM et al. Med Sci Monit. 2008; National Center for Health Statistics. 2006

Hysterectomy Type Photo Source:

Surgical Approach Photo Source: Traditional OpenVaginal Laparoscopic Laparoscopic- Assisted Vaginal

Healthcare Costs US spends 2.8 trillion dollars a year 17.9% of the gross domestic product Centers for Medicare and Medicaid Services. National Health Expenditures World Bank. Health Expenditure. 2011

Cost Reduction Disease Prevention Increase healthcare delivery efficiency Value-based decision-making ▫ Minimally Invasive Procedures  Smaller incisions may reduce the chance of infection and shorten hospital stay ▫ Healthcare Setting Inpatient SettingOutpatient Setting

Overall Project Objectives Identify trends in hysterectomy surgical approach and surgical setting Estimate difference in hysterectomy cost between inpatient and outpatient setting using real world data Present hysterectomy data in interactive tool

Methods Retrospective Review of Premier Hospital Database from 2009 to 2012 ▫ Database houses billing/coding for 45 million inpatient and 210 million outpatient visits ▫ Accounts for ~20% of all US hospital discharges Identified applicable hysterectomy, infection, and cancer codes ▫ International Classification of Diseases, 9 th edition (ICD-9) and current procedural terminology (CPT) codes Study was approved by the University of Florida IRB

Data Analysis Tableau Desktop version 1.8 ▫ Prepare visualizations and descriptive statistics SPSS version 22 ▫ Multivariate analyses by ordinary least squares regression Data Parameters Collected Patient Characteristics Randomly Generated Identification Number Age Race Insurance Type Disease severity rank (0-4) Cancer (yes/no) Procedure Year Procedure Code and Description Procedure Setting Procedure Approach Hospital Information Region Type (rural, urban, teaching) Number of beds Length of hospital stay Incidence of infection Payor Code/Description Patient charges/cost

Number of Hysterectomies ( ) Surgical Approach Hysterectomy Type Number of Procedures InpatientOutpatient LaparoscopicSubtotal/ Partial 10,57120,701 Total 54,876133,209 Radical 2,5001,854 OpenSubtotal/ Partial 14, Total 93,7942,943 Radical 2, VaginalSubtotal/ Partial 38021,676 Total 37,17637,307 Radical Total Procedures 216,306219,119

Hysterectomy Type Over Time Stacked bar chart; Hysterectomies 2009 to 2012

Payer Type InpatientOutpatient

Unadjusted Patient Cost All Hysterectomies Overall median unadjusted patient cost: $6,610 Min: $1 Max:$2,691,805 Graph excludes patient costs >$40,000

Unadjusted Median Cost by Surgical Approach Overall InpatientOutpatient

Unadjusted Median Cost by Hysterectomy Type and Cancer Incidence No Cancer InpatientOutpatient InpatientOutpatient Cancer of Uterus/Cervix

Unadjusted Median Cost by Payer Group --Impact of Patient Age-- Age was also higher in patients with cancer (61 years) compared to those without (45 years) Median Patient Age (years) % Patients with Cancer of Uterus/Cervix 55%72%50%

Unadjusted Cost Over Time

Unadjusted Median Cost by US Region $8,070 $6,268 $6,376 $6,271 $6,368 $5,049 $6,437 $7,543 $7,665 Highest Costs Lowest Costs *Pacific Region includes Alaska and Hawaii, not shown

Multivariable Regression Difference in Patient Cost Accounting for: ▫ Procedure Setting  Inpatient/Outpatient ▫ Hysterectomy Type  Total, Subtotal, Radical ▫ Surgical Approach  Open, Vaginal, Laparoscopic ▫ Cancer Incidence  Yes/No ▫ Age ▫ Race  White, Black, Asian, American Indian ▫ Payer  Commercial, Medicaid, Medicare

Adjusted Patient Cost Traditional Laparoscopic Vaginal +11%-19% Outpatient Inpatient -23% (95% CI= 23% to 24%) (95% CI= 10% to 11%) (95% CI= 19% to 20%)

Length of Stay SettingApproachMedianMinimumMaximum InpatientLaparoscopic1186 Open21112 Vaginal1134 OutpatientLaparoscopic000 Open000 Vaginal000

Infection

Summary Outpatient Setting ▫ More hysterectomy procedures are being conducted in the outpatient setting ▫ Lower patient cost ▫ Benefits to infection incidence and length of stay Minimally Invasive Techniques ▫ In hysterectomies, the use of minimally invasive techniques is on the rise within the outpatient setting ▫ Laparoscopic hysterectomies report a higher patient cost compared to open or vaginal procedures

Limitations Factors not taken into account ▫ Operating room time ▫ Physician Experience/ Learning Curve ▫ Patient recovery  Return to Activity  Return to Work  Cosmetics/ Appearance Selection bias ▫ Greater percent (67%) cancer patients treated inpatient ▫ Inpatient had comorbidity index, outpatient did not Infection incidence is difficult to track, as patients may return to primary care physician for care ICD-9 and CPT codes not reviewed by expert

Implications Real world data confirms increasing use of outpatient hysterectomies and its potential cost benefit Future Use of Tableau ▫ Provided to patients to facilitate cost procedure cost transparency ▫ Help identify epidemiological trends or disease outbreaks ▫ Education tools

Public Health Practice Concentration Competencies Identify & understand the historical context of epidemiology, epidemiologic terminology, study designs & methodology Demonstrate ability to analyze & interpret epidemiologic data Explain & communicate current epidemiologic & public health problems for informing scientific, ethical, economic & political discussions of health problems Demonstrate communication skills key to public health workforce participation and advocacy Identify, retrieve, summarize, manage and communicate public health information

Questions?