Health Care Institutions - Reasons For Hospitalization

The National Hospital Discharge Survey (NHDS) has been performed annually since 1965 by the National Center

TABLE 3.2

Emergency department visits within the past year among adults, by selected characteristics, selected years 1997–2001
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]
	1 or more emergency department visits				2 or more emergency department visits
Characteristic	1997	1999	2000	2001	1997	1999	2000	2001
Percent of adults with emergency department visit
All adults 18 years of age and over1,2	19.6	17.2	20.2	19.7	6.7	5.2	6.9	6.4
Age
18–44 years	20.7	17.7	20.6	19.8	6.8	5.6	7.0	6.5
18–24 years	26.3	21.7	25.9	24.0	9.1	7.3	8.9	8.7
25–44 years	19.0	16.5	18.9	18.4	6.2	5.0	6.4	5.8
45–64 years	16.2	14.6	17.6	18.0	5.6	4.3	5.6	5.6
45–54 years	15.7	14.3	17.9	17.7	5.5	4.3	5.8	5.5
55–64 years	16.9	15.1	17.0	18.5	5.7	4.3	5.3	5.9
65 years and over	22.0	19.9	23.7	22.3	8.1	5.6	8.6	7.5
65–74 years	20.3	17.3	21.6	19.7	7.1	4.7	7.4	7.1
75 years and over	24.3	23.1	26.2	25.4	9.3	6.7	10.1	8.0
Sex2
Male	19.1	16.1	18.8	18.9	5.9	4.3	5.8	5.7
Female	20.2	18.2	21.6	20.5	7.5	6.0	8.0	7.2
Race2,3
White only	19.0	16.6	19.4	19.1	6.2	4.7	6.4	6.1
Black or African American only	25.9	22.2	26.5	25.2	11.1	8.8	10.7	9.4
American Indian and Alaska Native only	24.8	29.2	30.5	33.9	13.1	11.7	12.8	15.5
Asian only	11.6	9.7	13.6	12.7	2.9		3.8	2.6
Native Hawaiian and Other Pacific Islander only	—				—
2 or more races	—	24.4	32.9	25.5	—	11.4	11.4	8.8
American Indian and Alaska Native; White	—	26.0	33.9	25.4	—	13.9	9.2	6.1
Hispanic origin and race2,3
Hispanic or Latino	19.2	15.3	18.4	18.4	7.4	4.5	7.1	7.0
Mexican American	17.8	14.4	17.4	15.6	6.4	4.1	7.1	5.6
Not Hispanic or Latino	19.7	17.5	20.6	20.0	6.7	5.3	6.9	6.4
White only	19.1	16.9	19.8	19.4	6.2	4.8	6.4	6.1
Black or African American only	25.9	22.2	26.5	25.3	11.0	8.8	10.7	9.4
Poverty status2,4
Poor	29.2	27.6	30.2	27.5	13.7	11.7	14.3	13.1
Near poor	24.9	21.7	25.1	26.2	10.0	8.0	10.6	10.4
Nonpoor	17.5	15.4	18.6	18.2	5.0	4.1	5.3	5.1
Hispanic origin and race and poverty status2,3,4
Hispanic or Latino:
Poor	22.9	17.1	24.4	19.9	10.2	6.6	11.3	10.1
Near poor	19.2	15.9	19.4	20.1	8.4	5.0	7.6	7.7
Nonpoor	17.9	14.5	17.1	17.6	5.5	3.8	6.1	5.3
Not Hispanic or Latino:
White only:
Poor	30.8	29.4	30.6	29.6	14.1	11.7	14.3	13.7
Near poor	25.5	22.2	26.8	27.9	9.8	7.6	11.5	11.0
Nonpoor	17.2	15.5	18.2	18.0	4.8	4.1	5.0	5.1
Black or African American only:
Poor	35.5	33.5	38.0	32.1	17.9	16.8	19.0	15.7
Near poor	30.8	27.8	29.9	28.8	12.9	13.0	13.1	12.8
Non poor	20.7	18.4	24.1	22.3	7.8	5.7	8.4	7.0
Health insurance status5,6
18–64 years of age:
Insured	18.8	16.1	19.5	19.2	6.1	4.7	6.4	6.2
Private	16.9	14.5	17.6	17.2	4.7	3.7	5.1	4.7
Medicaid	37.6	35.4	42.3	39.7	19.7	17.4	21.0	21.7
Uninsured	20.0	18.3	19.6	18.9	7.5	7.0	7.0	6.6
65 years of age and over:
Medicare HMO	20.2	20.1	24.4	23.6	6.7	5.7	8.5	8.8
Private	21.3	19.3	23.3	21.0	6.9	5.3	7.9	6.4
Medicaid	35.2	30.0	35.9	36.0	20.2	12.8	18.3	18.7
Medicare fee-for-service only	22.0	19.2	20.1	21.5	9.4	4.4	7.3	6.9

for Health Statistics. The NHDS is the longest continuously running nationally representative survey of hospital utilization and is considered the preeminent source for national data describing the characteristics of patients discharged from nonfederal short-stay hospitals. The 2002 NHDS found an estimated 33.7 million inpatients discharged, excluding newborns, from nonfederal short-stay hospitals in the United States.

— Data not available.
1Includes all other races not shown separately, unknown poverty status, and unknown health insurance status.
2Estimates are for persons 18 years of age and over and are age adjusted to the year 2000 standard using five age groups: 18–44 years, 45–54 years, 55–64 years, 65–74 years, and 75 years and over.
3The race groups, white, black, American Indian and Alaska Native (AI/AN), Asian, Native Hawaiian and Other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with data year 1999 race-specific estimates are tabulated according to 1997 Standards for Federal data on Race and Ethnicity and are not striclty comparable with estimates for earlier years. The five single race categories pluse multiple race categories shown in the table conform to 1997 Standards. The 1999 race-specific estimates are for persons who reported only one racial group; the category "2 or more races" includes persons who reported more than one racial group. Prior to data years 1999, data were tabulated according to 1977 Standards with four racial groups and the category "Asian only" included Native Hawaiian and Other Pacific Islander. Estimates for single race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. The effect of the 1997 Standard on the 1999 estimates can be seen by comparing 1999 data tabulated according to the two Standards: Age-adjusted estimates based on the 1977 Standard of the percent of adults with 1 or more emergency department visits are: 0.1 percentage points higher for white and black adults; 2.0 percentage points lower for AI/AN adults; and 0.3 percentage points higher for Asian and Pacific Islander adults than estimates based on the 1997 Standards.
4Poor persons are defined as below the poverty threshold. Near poor persons have incomes of 100 percent to less than 200 percent of the poverty threshold. Nonpoor persons have incomes of 200 percent or greater than the poverty threshold. Poverty status was unknown for 22 percent of adults in the sample in 1997, 27 percent in 1998, 29 percent in 1999 and 2000, and 30 percent in 2001.
5Estimates for persons 18–64 years of age are age adjusted to the year 2000 Standard using three age groups: 18–44 years, 45–54 years, and 55–64 years of age. Estimates for persons 65 years of age and over are age adjusted to the year 2000 Standard using two age groups: 65–74 years and 75 years and over.
6Health insurance categories are mutually exclusive. Persons who reported both Medicaid and private coverage are classified as having private coverage. Persons 65 years of age and over who reported Medicare HMO (health maintenance organization) and some other type of health insurance coverage are classified as having Medicare HMO. Starting in 1997 Medicaid includes states-sponsored health plans and State Child Health Insurance Program (SCHIP). The Category "insure" also includes military, other State, and Medicare coverage.
7MSA is metropolitan statistical area.
SOURCE: "Table 77. Emergency Department Visits within the Past 12 Months among Adults 18 Years of Age and Over, according to Selected Characteristics: United States, Selected Years 1997–2001," in Health, United States, 2003, National Center for Health Statistics, 2003, http://www.cdc.gov/nchs/data/hus/tables/2003/03hus077.pdf (accessed June 22, 2004)
Poverty status and health insurance status4,5	Percent of adults with emergency department visit
18–64 years of age:
Poor:
Insured	32.1	29.8	33.6	30.8	15.9	13.3	17.4	15.5
Uninsured	24.4	22.7	26.0	20.0	10.0	10.3	10.6	8.5
Near poor:
Insured	26.6	23.1	27.3	28.0	10.3	8.7	11.6	11.7
Uninsured	21.3	18.6	20.1	23.6	9.1	7.5	7.7	9.0
Nonpoor:
Insured	16.6	14.7	17.6	17.2	4.5	3.7	4.9	4.6
Uninsured	19.0	16.3	19.2	17.8	5.4	6.5	6.4	5.0
Geographic region2
Northeast	19.5	16.9	20.0	19.8	6.9	5.1	6.2	6.1
Midwest	19.3	17.2	20.1	19.6	6.2	5.1	6.9	6.0
South	20.9	17.7	21.3	20.9	7.3	5.7	7.6	7.3
West	17.7	16.4	18.7	17.6	6.0	4.5	6.3	5.6
Location of residence2
Within MSA7	19.1	16.6	19.6	19.4	6.4	1.9	6.6	6.3
Outside MSA7	21.5	19.5	22.5	21.3	7.8	6.4	7.8	7.0

In 2002 persons less than fifteen years old accounted for just 8% of hospital discharges and persons between fifteen and forty-four comprised 32% of discharges. Adults aged forty-five to sixty-four accounted for 23% of discharges and those age sixty-five and older made the largest contribution—38% of hospital discharges. (See Figure 3.1.) Figure 3.2 shows how the average age of persons discharged from the hospital has increased from 40.7 in 1970 to 52.1 in 2002.

The discharge rate was 1,174.6 per ten thousand population. The rate for females only was 1,388 per ten thousand; for males the rate was 952.3 per ten thousand. The numbers were higher for females primarily because women are hospitalized for childbirth and pregnancy-related conditions. (See Table 3.3.) The 2002 NHDS also reveals that male patients had longer average lengths of stay (ALOS) than female patients—5.3 days compared with 4.6 days. Lengths of stay and discharge rates varied by geography—ALOS ranged from 4.4 days in the Midwest to 5.6 days in the Northeast. The discharge rate per ten thousand population ranged from 955.4 in the West to 1,290.3 in the Northeast.

By Diagnosis

Heart disease is the number-one killer of Americans. In 2002 diseases of the circulatory system, which include heart disease, ranked first among diagnoses for patients discharged from nonfederal short-stay hospitals, and it accounted for 4.4 million discharges. Nearly two-thirds (2.8 million) of these patients discharged with a diagnosis of heart disease were age sixty-five or older, and among older adults there were 798.7 discharges per ten thousand population with a first-listed diagnosis of heart disease. (See Table 3.4.)

FIGURE 3.1

Table 3.5 shows that the second-leading discharge diagnosis was obstetric delivery, which accounted for nearly one-fifth (four million) of female patient discharges. Three other diagnostic categories also produced more than a million hospital discharges—1.7 million discharges attributable to psychoses (mental illness), 1.3 million discharges for pneumonia, and 1.2 million discharges for malignant neoplasms, or tumors. (See Table 3.4.) Figure 3.3 shows that ALOS varied by diagnosis from highs of eight days for psychoses and 7.1 days for malignant neoplasms to 2.6 days for delivery and 4.6 days for heart disease.

By Procedures

The NHDS revealed that in 2002 42.5 million surgical and nonsurgical procedures were performed on patients

FIGURE 3.2

discharged from short-stay hospitals. Nearly 75% of all procedures fell into just four broad categories: obstetrical procedures, operations of the digestive system, operations of the cardiovascular system, and miscellaneous diagnostic and therapeutic procedures that included computerized tomography (usually referred to as CT scan), arteriography and angiocardiography, diagnostic ultrasounds, and respiratory therapy.

Figure 3.4 reveals that about one-quarter of all procedures performed on females were obstetrical while the same proportion of procedures performed on men were cardiovascular. It also shows that males had more cardiovascular procedures than females (4 million versus 2.8 million) and females underwent more procedures of the digestive system than males (3.2 million versus 2.4 million).

The most commonly performed procedures for males were cardiovascular—removal of coronary artery obstruction and insertion of stents, cardiac catheterization, and coronary artery bypass graft—along with arteriography, angiocardiography, and endoscopy of the small intestine and diagnostic ultrasound. Female patients most frequently had obstetrical procedures—repair of obstetrical laceration, cesarean section, artificial rupture of membranes, episiotomy, and hysterectomy—as well as arteriography and angiography and endoscopy of the small intestine. (See Table 3.6.)

Organ Transplants

Organ transplants are a viable means of saving lives, and in 2003, 25,448 transplants were performed in 255

TABLE 3.3

Rate of discharges from short-stay hospitals by sex and first-listed diagnosis, 2002
[Discharges of inpatients from non-federal hospitals. Excludes newborn infants. Diagnostic groupings are based on the International Classification of Diseases, 9th Revision, Clinical Modification]
Category of first-listed diagnosis	Both sexes	Male	Female
— Category not applicable.
1Rates were calculated using U.S. Census Bureau estimates of the civilian population based on the 2000 census.
SOURCE: Carol J. DeFrances and Margaret J. Hall, "Table 6. Rate of Discharges from Short-Stay Hospitals by Sex and First-Listed Diagnosis: United States, 2002," in "2002 National Health Discharge Survey," Advance Data from Vital and Health Statistics, no. 342, Centers for Disease Control and Prevention, National Center for Health Statistics, May 21, 2004, http://www.cdc.gov/nchs/data/ad/ad342.pdf (accessed September 8, 2004)
	Rate per 100,000 population
All conditions	1,174.6	952.3	1,388.0
Infectious and parasitic diseases	30.5	29.7	31.4
Septicemia	11.9	11.1	12.7
Neoplasms	58.6	46.2	70.5
Malignant neoplasms	42.1	41.2	42.9
Malignant neoplasm of large intenstine and rectum	5.5	5.4	5.6
Malignant neoplasm of trachea, bronchus, and lung	5.6	6.1	5.1
Malignant neoplasm of breast	3.0		5.8
Benign neoplasms	14.9	3.5	25.8
Endocrine, nutritional and metabolic diseases, and immunity disorders	56.4	47.0	65.4
Diabetes mellitus	20.1	20.1	20.1
Volume depletion	17.7	14.5	20.7
Diseases of the blood and blood-forming organs	15.5	13.7	17.3
Mental disorders	85.8	87.9	83.8
Psychoses	59.4	58.1	60.5
Alcohol dependence syndrome	5.1	7.2	3.0
Diseases of the nervous system and sense organs	18.0	15.4	20.6
Diseases of the circulatory system	222.0	228.2	216.0
Heart disease	154.8	164.9	145.2
Acute myocardial infarction	28.5	34.1	23.1
Coronary atherosclerosis	38.2	47.4	29.3
Other ischemic heart disease	7.3	7.4	7.3
Cardiac dysrhythmias	27.5	26.8	28.0
Congestive heart failure	33.8	31.4	36.1
Cerebrovascular disease	32.8	30.7	34.8
Diseases of the respiratory system	123.4	119.3	127.2
Acute bronchitis and bronchiolitis	9.7	10.8	8.7
Pneumonia	45.7	44.0	47.3
Chronic bronchitis	18.1	16.3	19.8
Asthma	16.8	13.9	19.7
Diseases of the digestive system	115.6	104.3	126.5
Appendicitis	10.3	11.9	8.8
Noninfectious enteritis and colitis	10.8	9.1	12.4
Diverticula of intestine	9.1	7.5	10.7
Cholelithiasis	12.5	8.0	16.8
Diseases of the genitourinary system	63.3	39.8	85.8
Calculus of kidney and ureter	6.1	7.0	5.3
Complactions of pregnancy, childbirth, and the puerperium	18.4	…	36.0
Diseases of the skin and subcutaneous tissue	20.9	21.2	20.6
Cellulitis and abscess	14.7	15.0	14.4
Diseases of the musculoskeletal system and connective tissue	60.5	53.1	67.5
Osteoarthrosis and allied disorders	19.8	15.7	23.7
Intervertebral disc disorders	12.3	12.8	11.8
Congenital anomalies	6.2	6.9	5.5
Certain conditions originating in the perinatal period	5.8	6.6	5.0
Symptoms, signs, and ill-defined conditions	9.9	9.4	10.3
Injury and poisoning	93.9	94.7	93.2
Fractures, all sites1	34.7	30.8	38.4
Fracture of neck of femur	11.0	6.0	15.7
Poisonings	7.4	6.8	8.0
Supplementary classifications	170.0	28.7	305.5
Females with deliveries	137.6	—	269.7

hospital transplant centers across the country. The United Network for Organ Sharing (UNOS) compiles data on organ transplants, distributes organ donor cards, and maintains a registry of patients awaiting organ transplants. UNOS reported that as of July 2004, 85,867 Americans were waiting for transplants. According to UNOS about five thousand people die each year while waiting for an organ transplant because demand for organs continues to outpace supply.

Governors of many states began a variety of programs aimed at increasing public awareness of the lack of donor organs and honoring those who have chosen to become

TABLE 3.4

Number of discharges from short-stay hospitals by first-listed diagnosis and age, 2002
[Discharges of inpatients from non-federal hospitals. Excludes newborn infants. Diagnostic groupings are based on the International Classification of Diseases, 9th Revision, Clinical Modification]
Category of first-listed diagnosis	All ages	Under 15 years	15–44 years	45–64 years	65 years and over
— Category not applicable.
SOURCE: Carol J. DeFrances and Margaret J. Hall, "Table 2. Number of Discharges from Short-Stay Hospitals by First-Listed Diagnosis and Age: United States, 2002," in "2002 National Health Discharge Survey," Advance Data from Vital and Health Statistics, no. 342, Centers for Disease Control and Prevention, National Center for Health Statistics, May 21, 2004, http://www.cdc.gov/nchs/data/ad/ad342.pdf (accessed September 8, 2004)
	Number in thousands
All conditions	33,727	2,540	10,736	7,723	12,727
Infectious and parasitic diseases	877	156	204	185	332
Septicemia	341	12	34	76	219
Neoplasms	1,682	33	313	611	725
Malignant neoplasms	1,208	25	121	419	643
Malignant neoplasm of large intestine and rectum	159		5	46	107
Malignant neoplasm of trachea, bronchus, and lung	160		5	55	100
Malignant neoplasm of breast	85		11	36	38
Benign neoplasms	427		183	178	61
Endocrine, nutritional and metabolic diseases, and immunity disorders	1,619	187	328	454	649
Diabetes mellitus	577	33	147	205	193
Volume depletion	508	129	53	77	249
Diseases of the blood and blood-forming organs	446	71	106	81	188
Mental disorders	2,464	149	1,422	620	273
Psychoses	1,704		957	431	224
Alcohol dependence syndrome	145		87	53
Diseases of the nervous system and sense organs	518	81	134	114	189
Diseases of the circulatory system	6,373	31	434	1,871	4,037
Heart disease	4,446	17	273	1,313	2,843
Acute myocardial infarction	818		57	259	501
Coronary atherosclerosis	1,096		48	432	615
Other ischemic heart disease	211		18	86	107
Cardiac dysrhythmias	788		45	174	562
Congestive heart failure	970		32	219	717
Cerebrovascular disease	942		40	229	669
Diseases of the respiratory system	3,542	730	382	697	1,732
Acute bronchitis and bronchiolitis	279	209	8	22	40
Pneumonia	1,312	204	116	216	776
Chronic bronchitis	520		16	161	343
Asthma	484	187	109	109	80
Diseases of the digestive system	3,320	216	839	955	1,310
Appendicitis	295	70	155	50	21
Noninfectious enteritis and colitis	310	54	89	66	100
Diverticula of intestine	262		36	77	149
Cholelithiasis	359		116	109	133
Diseases of the genitourinary system	1,817	88	580	458	690
Calculus of kidney and ureter	176		81	62	29
Complications of pregnancy, childbirth, and the puerperium	528		524		—
Diseases of the skin and subcutaneous tissue	601		158	151	199
Cellulitis and abscess	422	41	109	126	147
Diseases of the musculoskeletal system and connective tissue	1,736	41	326	598	770
Osteoarthrosis and allied disorders	568		20	193	356
Intervertebral disc disorders	353		133	153	67
Congenital anomalies	178	124	31	15	7
Certain conditions originating in the perinatal period	166	165
Symptoms, signs, and ill-defined conditions	283	63	99	68	54
Injury and poisoning	2,697	233	780	621	1,063
Fractures, all sites	995	68	239	165	524
Fracture of neck of femur	315		6	24	282
Poisonings	214	18	120	48	28
Supplementary classifications	4,880	75	4,073	224	508
Females with deliveries	3,951	12	3,934	5	—

donors. For example, Alabama Governor Don Siegelman created an Alabama Donor Registry, Georgia Governor Roy Barnes designated March as Eye Donor Month, and Utah Governor Michael O. Leavitt and the state legislature adopted a resolution to improve public awareness about organ and tissue donation. Governors of at least nine states forged partnerships with local advocacy, medical, religious, and business groups to strengthen support for transplant programs.

State programs were also reinforced by a national organ donation initiative announced by Health and Human Services (HHS) Secretary Tommy G. Thompson in April 2001. Secretary Thompson vowed to create a national medal to honor families of organ donors, and

TABLE 3.5

Number of discharges from short-stay hospitals by sex and first-listed diagnosis, 2002
[Discharges of inpatients from non-federal hospitals. Excludes newborn infants. Diagnostic groupings are based on the International Classification of Diseases, 9th Revision, linical Modification]
Category of first-listed diagnosis	Both sexes	Male	Female
— Category not applicable.
SOURCE: Carol J. DeFrances and Margaret J. Hall, "Number of Discharges from Short-Stay Hospitals by Sex and First-Listed Diagnosis: United States, 2002," in "2002 National Health Discharge Survey," Advance Data from Vital and Health Statistics, no. 342, Centers for Disease Control and Prevention, National Center for Health Statistics, May 21, 2004, http://www.cdc.gov/nchs/data/ad/ad342.pdf (accessed September 8, 2004)
	Number in thousands
All conditions	33,727	13,389	20,338
Infectious and parasitic diseases	877	417	460
Septicemia	341	156	186
Neoplasms	1,682	650	1,033
Maligant neoplasms	1,208	579	629
Malignant neoplasm of large intestine and rectum	159	76	83
Malignant neoplasm of trachea, bronchus, and lung	160	86	74
Malignant neoplasm of breast	85		85
Benign neoplasms	427	49	378
Endocrine, nutritional and metabolic diseases, and immunity disorders	1,619	661	958
Diabetes mellitus	577	283	294
Volume depletion	508	204	304
Diseases of the blood and blood-forming organs	446	192	254
Mental disorders	2,464	1,236	1,227
Psychoses	1,704	817	887
Alcohol dependence syndrome	145	101	44
Diseases of the nervous system and sense organs	518	217	301
Diseases of the circulatory system	6,373	3,209	3,164
Heart disease	4,446	2,319	2,127
Acute myocardial infarction	818	480	338
Coronary atherosclerosis	1,096	666	429
Other ischemic heart disease	211	103	108
Cardiac dysrhythmias	788	377	411
Congestive heart failure	970	441	529
Cerebrovascular disease	942	432	509
Diseases of the respiratory system	3,542	1,678	1,864
Acute bronchitis and bronchiolitis	279	152	127
Pneumonia	1,312	618	694
Chronic bronchitis	520	230	291
Asthma	484	196	288
Diseases of the digestive system	3,320	1,466	1,854
Appendicitis	295	167	129
Noninfectious enteritis and colitis	310	128	182
Diverticula of intestine	262	106	157
Cholelithiasis	359	113	246
Diseases of the genitourinary system	1,817	560	1,257
Calculus of kidney and ureter	176	99	77
Complications of pregnancy, childbirth, and the puerperium	528	—	528
Diseases of the skin and subcutaneous tissue	601	299	303
Cellulitis and abscess	422	211	212
Diseases of the musculoskeletal system and connective tissue	1,736	747	989
Osteoarthrosis and allied disorders	568	221	347
Interverterbral disc disorders	353	180	174
Congenital anomalies	178	97	80
Certain conditions originating in the perinatal period	166	93	73
Symptoms, signs, and ill-defined conditions	283	132	151
Injury and poisoning	2,697	1,331	1,366
Fractures, all sites	995	433	562
Fracture of neck of femur	315	85	230
Poisonings	214	96	118
Supplementary classifications	4,880	403	4,477
Females with deliveries	3,951	—	3,951

called upon the traditional alliances between employers and labor unions to promote donation-awareness efforts. Called the "Workplace Partnership for Life," this coalition included some of the largest U.S. employers and organizations, such as Aetna, American Airlines, Bank of America, Daimler-Chrysler Corporation, United Auto Workers, Ford Motor Company, General Motors, 3M, MetLife, Verizon, and the United States Postal Service.

In March 1998 UNOS was ordered to change its organ allocation policy to more equitably distribute organs to various regions of the country. Under the previous system, when an organ became available in a local area, that organ was offered to the sickest patient in that area. If no local patient needed the organ, then it was offered regionally, then nationally. The government wanted organs distributed to the sickest patients first, regardless

FIGURE 3.3

of where they lived. The HHS Secretary at that time, Donna Shalala, stated, "People are dying unnecessarily, not because they don't have health insurance, not because they don't have access to care, but simply because of where they happen to live in the country. We need a level playing field for all patients."

The new regulations changed the allocation of organs from a regional system to a national system in which medical necessity, rather than geography, was the primary factor determining who received organs. The new rules met with great resistance in Congress. Some members felt that the government should have no role in deciding life and death issues, and others insisted that a national program would result in the closure of smaller transplant centers, forcing some transplant recipients to travel great distances for life-saving care. UNOS opposed the regulations, arguing that the new system would obstruct their ability to supply donated organs.

The new system, based on need rather than location, took effect in March 2000, although the issue of precisely who would decide the allocation of organs remained unresolved until April 2000, when the U.S. House of Representatives passed a proposal to restore decision-making to UNOS, where it has remained. In September 2000 UNOS signed a new three-year contract with the government that compelled the network to put the new rules into effect. By 2002 UNOS policies reflected the shift to a more equitable national organ distribution system.

In February 2004 the Organ Procurement and Transplantation Network/United Network for Organ Sharing

FIGURE 3.4

(OPTN/UNOS) revised and strengthened its policies to guard against potential medical errors in transplant candidate and donor matching. The policy revisions were developed in response to a systematic review begun after a medical error in February 2003, when a teenager named Jesica Santillan received a heart-lung transplant from a blood-type incompatible donor at Duke University Medical Center. News of this tragic error immediately prompted transplant centers throughout the United States to perform internal audits of their protocols and procedures to ensure appropriate donor/recipient matching.

The key policy revisions included stipulations that:

• The blood type of each transplant candidate and donor must be independently verified by two staff members at the institution involved at the time blood type is entered into the national database.
• Each transplant program and organ procurement organization (OPO) must establish a protocol to ensure blood type data for transplant candidates and donors are accurately entered into the national database and communicated to transplant teams. UNOS will verify the existence and effective use of these protocols during routine audits of OPOs and transplant programs.
• Organs must only be offered to candidates specifically identified on the computer-generated list of medically suitable transplant candidates for a given organ offer. If the organ offer is not accepted for any candidate on a given match run, an OPO may give transplant programs the opportunity to update transplant candidate data and re-run a match to see if any additional candidates are identified.

TABLE 3.6

Number of procedures for discharges from short-stay hospitals, by procedure category and sex, 2002
[Discharges of inpatients from non-federal hospitals. Excludes newborn infants. Procedure groupings are based on the International Classification of Diseases, 9th Revision, Clinical Modification]
Procedure category	Both sexes	Male	Female
— Category not applicable.
1The number of discharges with a coronary artery bypass graft was 306,000.
SOURCE: Carol J. DeFrances and Margaret J. Hall, "Table 10. Number of All-Listed Procedures for Discharges from Short-Stay Hospitals by Procedure Category and Sex: United States, 2002," in "2002 National Health Discharge Survey," Advance Data from Vital and Health Statistics, no. 342, Centers for Disease Control and Prevention, National Center for Health Statistics, May 21, 2004, http://www.cdc.gov/nchs/data/ad/ad342.pdf (accessed September 8, 2004)
	Number in thousands
All procedures	42,533	16,834	25,700
Operations on the nervous system	1,101	514	587
Spinal tap	316	161	156
Operations on the endocrine system	102	30	72
Operations on the eye	86	47	39
Operations on the ear	46	24	22
Operations on the nose, mouth, and pharynx	269	159	110
Operations on the respiratory system	1,022	283	439
Bronchoscopy with or without biopsy	251	147	104
Operations on the cardiovascular system	6,813	3,967	2,845
Removal of coronary artery obstruction and insertion of stents(s)	1,204	802	402
Coronary artery bypass graft1	515	373	142
Cardiac catheterization	1,328	799	529
Insertion, replacement, removal, and revision of pacemaker leads or device	420	213	207
Hemodialysis	552	288	264
Operations on the hemic and lymphatic system	354	178	175
Operations on the digestive system	5,597	2,350	3,247
Endoscopy of small intestine with or without biopsy	1,032	450	582
Endoscopy of large intestine with or without biopsy	278	235	343
Partial excision of large intestine	263	113	150
Appendectomy, excluding incidental	329	173	156
Cholecystectomy	436	143	293
Lysis of peritoneal adhesions	342	62	280
Operations on the urinary system	955	454	501
Cystoscopy with or without biopsy	173	86	87
Operations on the male genital organs	262	262	—
Prostatectomy	195	195	—
Operations on the female genital organs	2,161	—	2,161
Oophorectomy and salpingo-oophorectomy	533	—	533
Bilateral destruction or occlusion of fallopian tubes	329	—	329
Hysterectomy	669	—	669
Obstetrical procedures	6,646	—	6,646
Episiotomy with or without forceps or vacuum extraction	780	—	780
Artificial rupture of membranes	901	—	901
Cesarean section	1,059	—	1,059
Repair of current obstetric laceration	1,234	—	1,234
Operations on the musculoskeletal system	3,442	1,652	1,790
Partial excision of bone	218	112	106
Reduction of fracture	606	288	318
Open reduction of fracture with internal fixation	414	186	229
Excision or destruction of intervertebral disc	323	171	152
Total hip replacement	193	81	112
Total knee replacement	381	146	235
Operations on the integumentary system	1,348	616	732
Debridement of wound, infection, or burn	361	199	161
Miscellaneous diagnostic and therapeutic procedures	12,332	5,996	6,336
Computerized axial tomography	703	324	378
Arteriography and angiocardiography using contrast material	2,058	1,142	915
Diagnostic ultrasound	773	347	427
Respiratory therapy	1,070	546	524
Insertion of endotracheal tube	477	247	229
Injection or infusion of cancer chemotherapeutic substance	217	124	94

UNOS resolved to continuously review national policies and procedures for organ placement and to recommend policy and procedure enhancements to maximize the efficiency of organ placement and the safety of transplant candidates and recipients, as well as to ensure public confidence in the transplant system. As of July 2004, there had been no further reported occurrences of unintentional blood-type incompatible transplants.