Comorbidities/Insurance/Discharges--Hospitalization in the United States, 1997

How Do Comorbidities Differ for Various Age Groups?

Three conditions rank among the top 10 comorbidities in each age group: fluid and electrolyte disorders, chronic obstructive lung disease, and anemias.
Hypertension and diabetes are among the top 10 comorbidities in all adult age groups (18 years and older).
Drug abuse, psychoses and depression are present as top 10 comorbidities for adolescents and adults up to age 44.
Alcohol abuse is a top 10 comorbidity for adults ages 18-64.

Table 6. Top 10 Comorbidities by Age Group

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	Years
Comorbidity	<1	1-17	18-44	45-64	65-79	80+
Comorbidity	Number of discharges (in thousands)
Fluid and electrolyte disorders	104	228	665	947	1,525	1,330
Chronic and obstructive lung disease (emphysema or chronic bronchitis)	14	106	382	843	1,629	869
Anemias	23	49	411	421	681	580
Other neurological disorders	8	45	182
Blood clotting disorder (coagulopathy)	6	16
Irregular heartbeat (cardiac dysrhythmia)	18			295	993	970
Hypothyroidism	2				552	413
Congestive heart failure	2				753	823
Heart valve disease	4					339
Pulmonary circulation disease	3
Drug abuse		33	517
Depression (affective disorders)		27	230
Psychoses		17	185
Solid tumor without metastasis		15		425	934	548
Paralysis		42
Hypertension			472	1,942	3,073	1,735
Diabetes mellitus without complications			239	961	1,505	665
Alcohol abuse			366	303
Kidney (renal) failure				297
Diabetes with chronic complications				365
Hardening of the arteries (peripheral vascular disease)					523

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Most Expensive and Longest Stays

Which Conditions Have the Highest Charges on Average?

The conditions with the highest charges are relatively uncommon. The 10 most expensive conditions combined represent less than 1 percent of all discharges.
Many of these expensive conditions involve invasive or high technology procedures. For example, infant respiratory distress syndrome can involve lengthy stays in intensive care.
Four of the top 10 most expensive conditions in the hospital are related to care of infants with complications (respiratory distress, prematurity, heart defects, lack of oxygen).
Two of the top 10 most expensive conditions are related to trauma (spinal cord injury and burns).
Three of the top 10 most expensive conditions are related to the circulatory system (heart valve disorders, heart defects, aneurysms).
Even though long lengths of stay can result in high expense, four of the most expensive reasons for hospital stays are NOT among the longest stays: heart valve disorders, cardiac congenital anomalies, aneurysms, and burns.
For all conditions, the average charge for a hospital stay is $11,000.

Table 7. Conditions with the Highest Charges

Principal diagnoses                        Mean charges           Mean length of stay
                                                                            (in days)
________________________________________________________________________________________

1.  Respiratory distress syndrome (infant)      $68,000                          24.6
 
2.  Spinal cord injury                           53,000                          15.9
3.  Prematurity (short gestation) and            50,000                          21.7
    birth weight
4.  Heart valve disorders                        48,000                           9.1
5.  Leukemias                                    44,000                          13.5
6.  Heart defects (cardiac and circulatory       42,000                           7.9
    congenital anamolies)
7.  Lack of oxygen in infants                    39,000                          12.7
    (intrauterine hypoxia and birth aphyxia)
8.  Central nervous system infections other      39,000                          13.6
    than meningitis
9.  Aortic, peripheral, and visceral             38,000                           8.9
    artery aneurysms
10. Burns                                        34,000                           8.9
________________________________________________________________________________________

¹Charges shown reflect those only for acute hospital care and do not include
professional fees, rehabilitation, followup care or home care costs.
NOTE: Diagnoses in bold are also among the longest lengths of stay in the hospital.

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What Conditions Lead to the Longest Hospital Stays?

The two conditions with the longest hospital stays are related to infants (respiratory distress and prematurity).
Conditions with lengthy hospital stays are relatively uncommon. Collectively, the 10 conditions with the longest stays represent less than 2 percent of all discharges.
Six of the most expensive conditions also have the longest lengths of stay in the hospital.
For all conditions, the average overall length of stay is 5 days.

Table 8. Conditions Leading to the Longest Hospital Stays

Principal diagnoses                   Mean length of stay                Mean charges¹
                                                (in days)
________________________________________________________________________________________

1.  Respiratory distress syndrome (infant)             25                     $68,000
2.  Prematurity (short gestation) and                  22                      50,000
    birth weight
3.  Spinal cord injury                                 16                      53,000
4.  Paralysis                                          15                      22,000
5.  Tuberculosis                                       14                      27,000
6.  Rehabilitation care                                14                      17,000
7.  Late effects of stroke (cerebrovascular disease)   14                      16,000
8.  Central nervous system infections other            14                      39,000
    than meningitis
9.  Leukemias                                          14                      44,000
10. Lack of oxygen in infants                          13                      40,000
    (intrauterine hypoxia and birth aphyxia)
________________________________________________________________________________________

¹Charges shown reflect those only for acute hospital care and do not include
professional fees, rehabilitation, followup care or home care costs.
Note: Diagnoses in bold are also among the highest charges in the hospital.

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Insurance and Hospital Stays

Who Is Billed for the Largest Share of Hospital Stays?

Private insurance is billed for 37 percent of all hospitalizations.
Government (Medicare and Medicaid) is billed for over half (54 percent) of all hospitalizations.
Elderly people (65 and over) in the United States comprise about 13 percent (3) of the population. However, about 35 percent of all hospitalizations are covered by Medicare, the most common insurance for the elderly.
Although nearly 17 percent (4) of people in the United States are uninsured, only 5 percent of hospitalized patients are uninsured at discharge from the hospital.

Select Figure 8 (14 KB), Primary Pay Sources.

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What Sorts of Hospital Care Are Billed to Private Insurers?

Private insurers are billed for 57 percent of all stays for infants born in the hospital, 59 percent of all stays for trauma to perineum due to childbirth, and 51 percent of all normal pregnancy stays.
Five of the top 10 conditions billed to private insurers are related to infancy and childbirth. These conditions make up about one-quarter of all private pay discharges.
Three of the top 10 conditions billed to private insurers are related to the heart.

Table 9. Privately Insured

Prinicipal diagnoses                       Number of           Private insurers' share
                                          discharges             of all hospital stays
                                      (in thousands)                for this condition
                                                                          (in percent)			
________________________________________________________________________________________

1.  Infants born in the hospital               2,195                              57.1
2.  Hardening of the arteries of the heart       473                              33.0
    (coronary atherosclerosis)
3.  Trauma to perineum due to childbirth         428                              58.9
4.  Normal pregnancy                             284                              51.2
5.  Pneumonia                                    271                              21.5
6.  Degenerative joint disease of spine          265                              48.4
    (spondylosis)
7.  Fetal distress and abnormal forces           247                              57.8
    of labor
8.  Other complications of birth                 242                              59.9
9.  Nonspecific chest pain                       240                              43.9
10. Heart attack (acute myocardial infarction)   235                              31.5

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What Sorts of Hospital Care Are Billed to Medicaid?

Six of the top 10 reasons for hospitalization billed to Medicaid are related to infancy and childbirth. These six conditions make up one-third of all Medicaid hospitalizations.
Almost 12 percent (5) of the U.S. population is covered by Medicaid. However, Medicaid is billed for over a third of all hospital stays for infants born in the hospital, normal pregnancy and delivery, fetal distress, and other complications of pregnancy.
Medicaid is billed for over half of all hospital stays for schizophrenia and over a fourth of all stays for depression.
Medicaid is billed for about one-third of all hospital stays for asthma.

Table 10. Medicaid

Prinicipal diagnoses                       Number of           Medicaid's share of all
                                          discharges           hospital stays for this
                                      (in thousands)            condition (in percent)
________________________________________________________________________________________

1.  Infants born in the hospital               1,303                              33.9
2.  Pneumonia                                    242                              19.2
3.  Trauma to perineum due to childbirth         241                              33.2
4.  Normal pregnancy and/or delivery             224                              40.4
5.  Depression (affective disorder)              166                              27.9
6.  Other complications of pregnancy             155                              41.6
7.  Fetal distress and abnormal forces of labor  147                              34.3
8.  Asthma                                       144                              33.2
9.  Schizophrenia and related disorders          135                              50.7
10. Other complications of birth                 131                              32.4

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What Sorts of Hospital Care Are Uninsured?

Five percent of stays for infants born in the hospital are uninsured.
Among uninsured patients, 3 of the top 10 conditions are related to mental health or substance abuse. It is not possible to determine if this is because insurance does not pay for these conditions or if these conditions occur more frequently among uninsured patients.
About 19 percent of hospital stays for alcohol-related mental disorders, 23 percent of stays for substance-related mental disorders, and 8 percent of stays for depression are uninsured.
Asthma and diabetes are both ambulatory care sensitive conditions—conditions for which appropriate outpatient care should be able to prevent the need for hospitalization.

Table 11. Uninsured



Prinicipal diagnoses                       Number of           Percent of all hospital
                                          discharges          stays for this condition
                                      (in thousands)                that are uninsured
________________________________________________________________________________________

1.  Infants born in the hospital                 191                               5.0
2.  Pneumonia                                     51                               4.0
3.  Alcohol-related mental disorders              47                              19.3
4.  Depression (affective disorders)              45                               7.6
5.  Substance-related mental disorders            43                              22.5
6.  Hardening of the arteries of the heart        41                               2.8
    (coronary atherosclerosis)
7.  Nonspecific chest pain                        40                               7.3
8.  Asthma                                        34                               7.9
9.  Diabetes mellitus with complications          31                               7.5
10. Trauma to the perineum due to childbirth      30                               4.1

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Discharges

What Happens to Patients When They Are Discharged From the Hospital?

Most discharges are routine; patients return home following completion of treatment in the hospital.
Overall, 2.5 percent of all hospitalizations end in death.
Another 2.5 percent of patients are sent to different hospitals.
About 11 percent of discharges go to long-term care and other facilities.
Less than 1 percent of hospital discharges leave against medical advice.

Select Figure 9 (16 KB), Hospital Discharges.

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How Do Discharges to Other Institutions Vary by Age?

Older patients are more often discharged to other institutions from the hospital than are younger patients.
About 41 percent of patients ages 85 and older are discharged to long-term care and other facilities, including skilled nursing facilities, intermediate care facilities, and nursing homes.

Select Figure 10 (18 KB), Discharges to Other Institutions.

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What Conditions Are Most Common in Patients Who Leave Against Medical Advice or Are Discharged to Another Institution?

Among the top 10 diagnoses for patients who leave the hospital against medical advice, 4 are mental health-related illnesses.
Over 20 percent of all patients who leave the hospital against medical advice have a substance- or alcohol-related diagnosis.
The other most common conditions among patients who leave against medical advice are medical problems, such as pneumonia or diabetes, rather than surgical problems.
Conditions where discharge is to other institutions tend to be those in which functional status has been compromised, such as stroke and hip fracture.

Table 12. Left Hospital Against Medical Advice

Prinicipal diagnoses                    Total number         Percent of all discharges
                                       of discharges                  who left against
                                      (in thousands)                    medical advice
________________________________________________________________________________________

1.  Substance-related mental disorder             32                              11.0
2.  Alcohol-related mental disorder               28                               9.9
3.  Affective disorders (principally depression)  15                               5.4
4.  Coronary atherosclerosis                      11                               3.9
5.  Nonspecific chest pain                        10                               3.5
6.  Pneumonia                                      9                               3.3
7.  Diabetes                                       7                               2.5
8.  Congestive heart failure                       7                               2.4
9.  Asthma                                         6                               2.2
10. Schizophrenia                                  6                               2.2

Table 13. Discharged to Other Institutions

Prinicipal diagnoses                    Total number         Percent of all discharges
                                       of discharges             to other institutions
                                      (in thousands)                
________________________________________________________________________________________

1.  Acute cerebrovascular disease (stroke)       291                               6.5
2.  Hip fracture                                 259                               5.8
3.  Pneumonia                                    248                               5.6
4.  Acute myocardial infarction (heart attack)   211                               4.8
5.  Coronary atherosclerosis                     202                               4.6
6.  Congestive heart failure                     183                               4.1
7.  Osteoarthritis                               179                               4.0
8.  Septicemia                                   120                               2.7
9.  Urinary tract infections                      96                               2.2
10. Fluid and electrolyte disorder                95                               2.1

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