Outcomes of the shift in care from inpatient to outpatient procedures in hysterectomy
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Outcomes of the Shift in Care from Inpatient to Outpatient Procedures in Hysterectomy - PowerPoint PPT Presentation

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Outcomes of the Shift in Care from Inpatient to Outpatient Procedures in Hysterectomy. Stephanie Makepeace. Background. Hysterectomy. Removal of the uterus 641,000 procedures a year Most common major surgery in women ages 18 to 44, after cesarean section.

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

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

Stephanie Makepeace



  • 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 SciMonit. 2008; National Center for Health Statistics. 2006

Hysterectomy Type

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

Surgical Approach


Traditional Open


Laparoscopic- Assisted Vaginal

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

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. 2013

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 Setting

Outpatient Setting

Overall Project Objectives

  • Identify trends in hysterectomy surgical approach and surgical setting

  • Estimate difference in hysterectomy cost between inpatient and outpatient setting using real world data

  • Present hysterectomy data in interactive tool

Project Summary


  • Retrospective Review of Premier Hospital Database from 2009 to 2012

    • Database houses billing/coding for 45 million inpatient and 210 million outpatient visits

    • Accounts for ~20% of all US hospital discharges

  • Identified applicable hysterectomy, infection, and cancer codes

    • International Classification of Diseases, 9th edition (ICD-9) and current procedural terminology (CPT) codes

  • Study was approved by the University of Florida IRB

Data Analysis

  • Tableau Desktop version 1.8

    • Prepare visualizations and descriptive statistics

  • SPSS version 22

    • Multivariate analyses by ordinary least squares regression


Number of Hysterectomies (2009-2012)

Hysterectomy Type Over Time

Stacked bar chart; Hysterectomies 2009 to 2012

Payer Type



Unadjusted Patient Cost All Hysterectomies

Overall median unadjusted patient cost: $6,610

Min: $1


Graph excludes patient costs >$40,000

Unadjusted Median Cost by Surgical Approach




Unadjusted Median Cost by Hysterectomy Type and Cancer Incidence

No Cancer

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)

Unadjusted Cost Over Time

Unadjusted Median Cost by US Region

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




(95% CI= 23% to 24%)






(95% CI= 19% to 20%)

(95% CI= 10% to 11%)

Length of Stay


Tableau Dashboard



  • 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


  • 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


  • 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


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