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. 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

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

Stephanie Makepeace

Background Procedures in Hysterectomy

Hysterectomy Procedures in 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 SciMonit. 2008; National Center for Health Statistics. 2006

Hysterectomy type
Hysterectomy Type Procedures in Hysterectomy

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

Surgical approach
Surgical Approach Procedures in Hysterectomy


Traditional Open


Laparoscopic- Assisted Vaginal

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

Healthcare costs
Healthcare Costs Procedures in Hysterectomy

  • 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
Cost Reduction Procedures in Hysterectomy

  • 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
Overall Project Objectives Procedures in Hysterectomy

  • 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
Project Summary Procedures in Hysterectomy

Methods Procedures in Hysterectomy

  • 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
Data Analysis Procedures in Hysterectomy

  • Tableau Desktop version 1.8

    • Prepare visualizations and descriptive statistics

  • SPSS version 22

    • Multivariate analyses by ordinary least squares regression

Results Procedures in Hysterectomy

Number of hysterectomies 2009 2012
Number of Hysterectomies (2009-2012) Procedures in Hysterectomy

Hysterectomy type over time
Hysterectomy Type Over Time Procedures in Hysterectomy

Stacked bar chart; Hysterectomies 2009 to 2012

Payer type
Payer Type Procedures in Hysterectomy



Unadjusted patient cost all hysterectomies
Unadjusted Patient Cost Procedures in HysterectomyAll 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 Surgical Approach Procedures in Hysterectomy




Unadjusted median cost by hysterectomy type and cancer incidence
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
Unadjusted Median Cost by Payer Group Incidence--Impact of Patient Age--

  • Age was also higher in patients with cancer (61 years) compared to those without (45 years)

Unadjusted median cost by us region
Unadjusted Median Cost by US Region Incidence

Highest Costs










Lowest Costs

*Pacific Region includes Alaska and Hawaii, not shown

Multivariable regression
Multivariable Regression Incidence

  • 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
Adjusted Patient Cost Incidence




(95% CI= 23% to 24%)






(95% CI= 19% to 20%)

(95% CI= 10% to 11%)

Length of stay
Length of Stay Incidence

Infection Incidence

Summary Incidence

  • 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 Incidence

  • 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 Incidence

  • 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
Public Health Practice Concentration Competencies Incidence

  • 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? Incidence