June 2, 2014

The Cost Burden of Disease: United States and Michigan

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CHRT Issue Brief June 2014

Hospitalizations pose substantial human and economic burdens for patients, families and the U.S. health care system as a whole. Hospital care is typically the largest category of health spending, and both acute and chronic conditions drive hospital utilization. This issue brief describes trends in hospitalization rates by diagnosis and by charges for admissions, from 2007 to 2011 in Michigan and the United States. It updates a 2010 issue brief with the most recent available data.

The most significant finding in this analysis is that hospitalizations for septicemia rose sharply in both Michigan and in the United States from 2007 to 2011. This suggests an important shift in the disease burden of severe sepsis (one of several diagnoses categorized as septicemia). Septicemia rose above all heart disease diagnoses, which are among the most common reasons for hospitalization. In contrast with septicemia, the discharge rate for many heart conditions declined during this time. In 2011, total charges for septicemia were higher than for any other inpatient diagnosis both in Michigan and the United States.

Additional findings are consistent with trends reported in the previous issue brief, including:

  • Top diagnoses for hospitalizations included several heart conditions in each category (total volume, charges per discharge, total charges per diagnosis and total charges per procedure) in both Michigan and the United States. However, the discharge rate for most heart conditions fell in both regions from 2007 to 2011; in Michigan, seven of these discharge rates fell by at least 10 percent, as did three in the United States.
  • Three of the top procedures by total charges were surgeries related to chronic pain relief and mobility in both Michigan and in the United States, and the discharge rate for each procedure increased by at least 8 percent from 2007 to 2011.
  • The birth rate fell in both Michigan and the United States from 2007 to 2011, which was reflected by a decline in hospital deliveries during this time. However, in both regions, two of the top 10 diagnoses with the highest charges per discharge in 2011 were related to complications from pregnancy and childbirth.
  • Average charges per discharge were consistently higher nationwide than in Michigan for both total charges and charges per discharge.

Diagnosis at Discharge

In 2011 there were 39 million discharges from hospitals in the United States and 1.3 million in Michigan (123.9 and 127.8 discharges per 1,000, respectively). The 10 most common inpatient diagnoses were the same in Michigan and nationally. Figure 1 Six of these diagnoses were chronic conditions, and the remaining diagnoses were related to infectious diseases, surgical complications and childbirth.

Figure 1
Top 10 Most Frequent Hospital Discharges by Diagnosis, Michigan and United States, 20111

  Michigan United States
Principal Diagnosis Rank by Discharge Rate Discharge Rate/ 100,000 % of Total Discharges % Change in Discharge Rate,
2007–2011
Rank by Discharge Rate Discharge Rate/ 100,000 % of Total Discharges % Change in Discharge Rate,
2007–2011
Childbirth 1 1,134 8.9% -6.6% 1 1,225 9.9% -18.6%
Septicemia (except in labor) 2 465 3.6% 62.1% 3 351 2.8% 56.8%
Osteoarthritis 3 381 3.0% 14.5% 5 309 2.5% 14.5%
Pneumonia (except that caused by tuberculosis and sexually transmitted diseases) 4 353 2.8% -4.9% 2 358 2.9% -8.0%
Congestive heart failure, non-hypertensive 5 330 2.6% -12.1% 4 311 2.5% -8.4%
Cardiac dysrhythmias 6 294 2.3% 8.8% 7 255 2.1% 5.2%
Mood disorders 7 283 2.2% 1.4% 6 288 2.3% 12.0%
Chronic obstructive pulmonary disease and bronchiectasis 8 277 2.2% 28.6% 8 234 1.9% 19.0%
Spondylosis, intervertebral disc disorders, other back problems 9 260 2.0% -3.1% 10 214 1.7% 1.9%
Complication of device, implant or graft 10 260 2.0% 4.7% 9 224 1.8% 8.4%

Source: CHRT analysis of HCUP data

Septicemia (except in labor) had the largest increase in discharge rates among the total population within the 10 most common diagnoses from 2007 to 2011, with a 62 percent increase in Michigan and a 57 percent increase in the United States. Septicemia discharge rates remained higher in Michigan than in the United States during this time. Figure 2 This dramatic rise seems to indicate that the incidence of complicated infections, such as severe sepsis, is increasing, although the extent of the change may also be due to improved documentation and changing practice patterns.2 The category of septicemia comprises a variety of diagnosis codes, including sepsis and severe sepsis. Severe sepsis is a blood infection that can lead to multiple organ failure, and is often a complication of cancer or other illnesses, including pneumonia, intra-abdominal infection and urinary tract infections.3 Severe sepsis may be increasing because patients are less likely to die from other causes. To our knowledge, there is no U.S. research that clearly identifies whether severe sepsis is becoming more common at a population level, driving this increase in septicemia hospitalization rates. However, in Australia and New Zealand a similar recent trend was driven by a rise in the incidence of severe sepsis.4,5

Chronic obstructive pulmonary disease and bronchiectasis had the second largest increase in discharge rates among the total population, rising by 29 percent in Michigan and 19 percent nationally. Other notable discharge rate increases included osteoarthritis in Michigan and the United States (15 percent in both regions), and for mood disorders (12 percent nationally compared to one percent in Michigan). The smaller increase in mood disorder discharge rates in Michigan may reflect the fact that Michigan has fewer non-federal inpatient psychiatric beds than most other states.6 Giving birth was the most common reason for hospitalization in Michigan and the United States, although the birth rate fell from 2007 to 2011 in both regions.7 During this period, the rate of hospital deliveries fell by seven percent in Michigan and 19 percent nationally, the largest rate of decrease among the 10 most common inpatient diagnoses in both regions. Discharges for congestive heart failure (CHF) had the second largest rate of decrease during this time in both Michigan and the United States (12 percent and eight percent, respectively), although CHF remained among the top five most common inpatient diagnoses in both regions.

Figure 2
Hospitalization Rates for Septicemia per 100,000,
Michigan and United States, 2007 and 20118

Figure 2

Source: CHRT analysis of HCUP data

1 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP). Quick National or State Statistics. 2012. http://hcupnet.ahrq.gov/.

2 C. Rhee, S. Gohil, and M. Klompas. 2014. Regulatory Mandates for Sepsis Care – Reasons for Caution. New England Journal of Medicine, 370(18): 1673–1675. http://www.nejm.org/doi/full/10.1056/NEJMp1400276?query=featured_home (accessed 4/18/14).

3 C. Rhee, S. Gohil, and M. Klompas. 2014. Regulatory Mandates for Sepsis Care – Reasons for Caution. New England Journal of Medicine, 370(18): 1673–1675. http://www.nejm.org/doi/full/10.1056/NEJMp1400276?query=featured_home (accessed 4/18/14).

4 K.M. Kaukonen, M. Bailey, S. Suzuki, D. Pilcher and R. Bellomo. 2014. Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000–2012. JAMA, 311(13): 1308–1316. https://jama.jamanetwork.com/article.aspx?articleid=1850096 (accessed 3/25/14).

5 T. J. Iwashyna, D. C. Angus. 2014. Declining Case Fatality Rates for Severe Sepsis: Good Data Bring Good News with Ambiguous Implications. JAMA, 311(13): 1295-1297. http://jama.jamanetwork.com/article.aspx?articleid=1850095 (accessed 3/25/14).

6 Substance Abuse and Mental Health Services Administration. 2012. Mental Health, United States, 2010. (Rockville, MD: Substance Abuse and Mental Health Services Administration), p. 79. http://store.samhsa.gov/product/Mental-Health-United-States-2010/SMA12-4681.

7 Michigan Department of Community Health. 2013. Live Births and Crude Birth Rates: Michigan and the United States Residents Selected Years, 1900–2012 (data table). http://www.mdch.state.mi.us/pha/osr/natality/tab1.1.asp (accessed 4/21/14).

8 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP). Quick National or State Statistics. 2012. http://hcupnet.ahrq.gov/.

Charges per Discharge

In 2011, nine of the top 10 inpatient diagnoses with the highest charges per discharge were the same in Michigan and the United States. Figure 3 Hospital charges are not equivalent to actual paid amounts because public and private insurers negotiate payment discounts with hospitals. (Unfortunately, only uninsured patients are billed full charges for hospitalizations, although some health systems will negotiate discounts for people without insurance.) Data comparing actual spending by private payers after contractual discounts are applied is not publicly available. Charges associated with a hospitalization do, however, generally reflect the intensity of services provided during a hospital stay, with more complex diagnoses associated with higher charges.

Average charges per discharge were consistently higher nationwide than in Michigan. Among the top 10 diagnoses with the highest charges, two were related to complications of pregnancy and delivery. The discharge rate for the first of these diagnoses, intrauterine hypoxia and birth asphyxia, increased substantially from 2007 to 2011 in Michigan and the United States among the total population (51 percent and 66 percent, respectively).9 In contrast, the discharge rate for the second diagnosis, short gestation, low birth weight (LBW) and fetal growth retardation, decreased during this time (11 percent in Michigan and 23 percent in the United States). Compared to deliveries of healthy infants, charges for delivering premature or LBW infants were 15 times greater in Michigan and 14 times greater nationwide.10

Heart valve disorders had the second largest increase in discharge rates in Michigan and the United States from 2007 to 2011 (25 and 21 percent, respectively). The discharge rate for other central nervous infections and poliomyelitis increased nationally by 11 percent among the total population during this time, but decreased in Michigan by 26 percent. Another notable discharge rate decrease was for respiratory distress syndrome, which dropped by 28 percent in both Michigan and the United States.

Figure 3
Top 10 Charges per Discharge by Diagnosis, Michigan and United States, 201111

  Michigan United States
Principal Diagnosis Rank by Average Charges Charges, $ (mean) Discharge Rate/ 100,000 % Change in Discharge Rate,
2007–2011
Rank by Average Charges Charges, $ (mean) Discharge Rate/ 100,000 % Change in Discharge Rate,
2007–2011
Short gestation, low birth weight, and fetal growth retardation 1 $143,554 4 -10.5% 3 $157,560 6 -22.8%
Intrauterine hypoxia and birth asphyxia 2 $116,243 0.4 51.2% 7 $123,866 1 65.8%
Cardiac and circulatory congenital anomalies 3 $114,429 13 -10.7% 5 $139,976 13 -4.2%
Spinal cord injury 4 $107,218 4 2.5% 2 $161,767 4 -5.1%
Leukemias 5 $103,056 13 -8.5% 6 $135,934 13 -8.6%
Heart valve disorders 6 $98,395 38 24.5% 4 $150,951 36 21.0%
Respiratory distress syndrome 7 $87,048 2 -27.9% 1 $192,948 3 -28.1%
Other central nervous system infection and poliomyelitis 8 $85,591 2 -25.5% 8 $118,493 3 10.9%
Aortic, peripheral, and visceral artery aneurysms 9 $79,819 30 -8.9% 9 $113,381 28 -1.6%
Hodgkin's disease 10 $75,553 1 -7.0% - - - -
Cancer, other respiratory and intrathoracic - - - - 10 $112,790 1 0.8%

Source: CHRT analysis of HCUP data

9 It is important to note that the volume of admissions was low for many diagnoses with the highest charges per discharge, particularly in Michigan, suggesting that rate changes may not be meaningful.

10 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP). Quick National or State Statistics. 2012. http://hcupnet.ahrq.gov/.

11 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP). Quick National or State Statistics. 2012. http://hcupnet.ahrq.gov/.

Total Charges by Diagnosis

In 2011, Michigan and the United States had the same three top diagnoses by total charges: septicemia; osteoarthritis; and complication of device, implant, or graft. Figure 4 Total charges for septicemia, which take into account the volume of admissions and the charges associated with each admission, were the highest of any diagnosis.

In Michigan and the United States, three of the top diagnoses by total charges in 2011 were related to heart conditions (acute myocardial infarction, coronary atherosclerosis and CHF). The discharge rate among the total population decreased for each of these diagnoses in both regions from 2007 to 2011. The rate for coronary atherosclerosis declined most rapidly, by 38 percent in Michigan and 39 percent in the United States. Nationwide, a fourth heart-related condition was among the top 10 in 2011 (acute cerebrovascular disease), but the discharge rate for this diagnosis increased by 10 percent from 2007 to 2011.

Figure 4
Top 10 Total Charges by Diagnosis, Michigan and United States, 201112

  Michigan United States
Principal Diagnosis Rank by Total Charges Discharge Rate/ 100,000 Charges, $ (mean) Total Charges $ (Millions) % Change in Discharge Rate,
2007–2011
Rank by Total Charges Discharge Rate/ 100,000 Charges, $ (mean) Total Charges $ (Billions) % Change in Discharge Rate,
2007–2011
Septicemia (except in labor) 1 465 $41,928 $1,949 62.1% 1 351 $68,118 $74.2 56.8%
Osteoarthritis 2 381 $34,982 $1,318 14.5% 2 309 $51,826 $50.0 14.5%
Complication of device, implant, or graft 3 260 $45,319 $1,149 4.7% 3 224 $67,837 $47.3 8.4%
Acute myocardial infarction 4 238 $45,588 $1,086 -2.6% 5 196 $70,547 $42.9 -5.2%
Coronary atherosclerosis 5 228 $45,925 $1,052 -38.4% 7 194 $64,562 $38.9 -39.2%
Childbirth 6 1,134 $9,429 $1,035 -6.6% 4 1,225 $11,464 $43.6 -18.6%
Spondylosis, intervertebral disc disorders, other back problems 7 260 $36,523 $942 -3.1% 6 214 $62,028 $41.4 1.9%
Congestive heart failure, nonhypertensive 8 330 $26,230 $853 -12.1% 8 311 $38,561 $37.3 -8.4%
Respiratory failure, insufficiency, arrest (adult) 9 150 $55,952 $837 2.4% - - - - -
Pneumonia (except that caused by tuberculosis and sexually transmitted diseases) 10 353 $21,228 $741 -4.9% 9 358 $31,755 $35.4 -8.0%
Acute cerebrovascular disease - - - - - 10 191 $51,320 $30.6 9.5%

Source: CHRT analysis of HCUP data

12 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP). Quick National or State Statistics. 2012. http://hcupnet.ahrq.gov/.

Total Charges by Procedure

In 2011, eight of the top 10 procedures ranked by total charges in both Michigan and in the United States were surgical operations. The exceptions were respiratory intubation and mechanical ventilation—the highest charge procedure in both regions—and blood transfusions. Figure 5

Three heart procedures were among the top 10 with the highest total charges (percutaneous coronary angioplasty; insertion, revision, replacement, removal of cardiac pacemaker or cardioverter/defibrillator; and, coronary artery bypass graft). However, the discharge rate for each of these procedures fell among the total population from 2007 to 2011 in Michigan and the United States (reductions ranged from 13 to 29 percent).

Another three of the top procedures by total charges were related to chronic pain relief and mobility (spinal fusion, knee arthroplasty, and hip replacement). In both Michigan and the United States, the discharge rate for each of these procedures increased by at least 8 percent from 2007 to 2011. The largest discharge rate increase in the United States was for spinal fusion, which rose by 28 percent during this time. The spinal fusion discharge rate increased by 12 percent in Michigan in the same period.

Nationwide, cesarean sections (C-sections) were among the procedures with the highest total charges. From 2007 to 2011, the discharge rate for C-sections declined by 17 percent in the United States, but this decline was due to the declining birth rate. Nationally, the C-section rate among all births increased from 32 percent in 2007 to 33 percent in 2011.13 In Michigan, this rate increased from 30 percent to 33 percent during this time.14,15

Figure 5
Top 10 Total Charges by Procedure, Michigan and United States, 201116

  Michigan United States
Principal Diagnosis Rank by Total Charges Discharge Rate/ 100,000 Charges, $ (mean) Total Charges $ (Millions) % Change in Discharge Rate,
2007–2011
Rank by Total Charges Discharge Rate/ 100,000 Charges, $ (mean) Total Charges $ (Billions) % Change in Discharge Rate,
2007–2011
Respiratory intubation and mechanical ventilation 1 305 $63,740 $1,889 23.9% 1 310 $84,764 $81.7 24.1%
Spinal fusion 2 179 $57,344 $1,035 11.7% 2 149 $100,785 $46.9 28.3%
Percutaneous coronary angioplasty (PTCA) 3 207 $47,470 $994 -29.0% 4 166 $70,183 $36.3 -25.1%
Arthroplasty knee 4 270 $36,132 $983 8.4% 3 228 $54,158 $38.5 13.8%
Other OR procedures on vessels other than head and neck 5 122 $70,174 $852 -6.8% 6 100 $104,825 $32.7 -1.0%
Other vascular catheterization, not heart 6 228 $35,766 $749 6.7% 5 211 $54,717 $35.8 14.0%
Insertion, revision, replacement, removal of cardiac pacemaker or cardioverter/ defibrillator 7 91 $72,900 $685 -13.0% 10 85 $93,757 $25.0 -22.0%
Blood transfusion 8 273 $25,179 $675 15.9% 7 261 $34,361 $27.9 13.4%
Hip replacement, total and partial 9 169 $38,363 $655 11.0% 8 149 $59,499 $27.6 11.8%
Coronary artery bypass graft (CABG) 10 55 $101,061 $569 -26.4% - - - - -
Cesarean section - - - - - 9 407 $20,083 $25.5 -17.0%

Source: CHRT analysis of HCUP data

13 J.A. Martin, B.E. Hamilton, S. J. Ventura, et al. 2013. Births: Final Data for 2011. National Vital Statistics Reports, 62(1). (Hyattsville, MD: National Center for Health Statistics.) http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf.

14 J.A. Martin, B.E. Hamilton, S. J. Ventura, et al. 2013. Births: Final Data for 2011, Supplemental Tables. National Vital Statistics Reports, 62(1). (Hyattsville, MD: National Center for Health Statistics.) http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01_tables.pdf.

15 F. Manacker and B.E. Hamilton. 2010. Recent Trends in Cesarean Deliveries in the United States. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db35.pdf.

16 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP). Quick National or State Statistics. 2012. http://hcupnet.ahrq.gov/.

Conclusion

From 2007 to 2011, hospital discharge rates for septicemia rose sharply among the total population in both Michigan and the United States, faster than for any other top 10 inpatient diagnosis. In 2011, septicemia also had the highest total charges both nationally and in Michigan. Additional findings are consistent with earlier reported trends, including the prominence of heart conditions in each category of top volume and charges.


Suggested citation: Dreyer, Theresa; Zhang, Jennifer; and Udow-Phillips, Marianne. The Cost Burden of Disease: United States and Michigan. June 2014. Center for Healthcare Research & Transformation, Ann Arbor, MI.

For more information please contact us at: chrt-info@umich.edu