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

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

2. Background

3. 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

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

5. Surgical Approach Laparoscopic Traditional Open Vaginal Laparoscopic- Assisted Vaginal Photo Source: http://www.cincyobgyn.com/services-hysterectomy-obgyn-fairfield-ohio.html

6. 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

7. 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

8. 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

9. Project Summary

10. 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, 9th edition (ICD-9) and current procedural terminology (CPT) codes • Study was approved by the University of Florida IRB

11. Data Analysis • Tableau Desktop version 1.8 • Prepare visualizations and descriptive statistics • SPSS version 22 • Multivariate analyses by ordinary least squares regression

12. Results

13. Number of Hysterectomies (2009-2012)

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

15. Payer Type Inpatient Outpatient

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

17. Unadjusted Median Cost by Surgical Approach Overall Inpatient Outpatient

18. Unadjusted Median Cost by Hysterectomy Type and Cancer Incidence No Cancer Cancer of Uterus/Cervix Inpatient Outpatient Inpatient Outpatient

19. 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)

20. Unadjusted Cost Over Time

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

22. 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

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

24. Length of Stay

25. Infection

26. Tableau Dashboard

28. Summary/Discussion

29. 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

30. 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

31. 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

32. 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

33. Questions?