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Health Care Institutions - Reasons For Hospitalization

system diseases discharges age

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.

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