Data Source



Diagnoses, ICD-9-CM, and Clinical Classifications Software (CCS)

The principal diagnosis is that condition established after study to be chiefly responsible for the patient's admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or that develop during the stay.



ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses. There are about 13,600 ICD-9-CM diagnosis codes. CCS categorizes ICD-9-CM diagnoses into a manageable number of clinically meaningful categories. This "clinical grouper" makes it easier to quickly understand patterns of diagnoses and procedures.



Procedures and Clinical Classifications Software (CCS)

The principal procedure is the procedure that was performed for definitive treatment rather than performed for diagnostic or exploratory purposes (i.e., the procedure that was necessary to take care of a complication).



CCS categorizes procedure codes into clinically meaningful categories.13 This "clinical grouper" makes it easier to quickly understand patterns of procedure use.



Case definition

For this report, all-listed circumcisions were defined as ICD-9-CM procedure: 64.0 - circumcision For this report, newborns were defined as ICD-9-CM principal diagnosis codes: 765.20 - unspecified weeks of gestation

765.29 - 37 or more weeks of gestation

V30.0 - single liveborn in hospital

V30.00 - single liveborn in hospital without complications

V30.01 - single liveborn in hospital with complications

V30.1 - single liveborn before admission

V30.2 - single liveborn non-hospital

V31.0 - twin-mate liveborn in hospital

V31.00 - twin-mate liveborn in hospital without complications

V31.01 - twin-mate liveborn in hospital with complications

V31.1 - twin-mate liveborn before admission

V31.2 - twin-mate liveborn non-hospital

V32.0 - twin-mate liveborn stillborn in hospital

V32.00 - twin-mate stillborn in hospital without complications

V32.01 - twin-mate stillborn in hospital with complications

V32.1 - twin-mate stillborn before admission

V32.2 - twin-mate stillborn non-hospital

V33.0 - twin not otherwise specified in hospital

V33.00 - twin not otherwise specified without complications

V33.01 - twin not otherwise specified with complications

V33.1 - twin not otherwise specified before admission

V33.2 - twin not otherwise specified non-hospital

V34.0 - other multiple newborn in hospital

V34.00 - other multiple newborn in hospital without complications

V34.01 - other multiple newborn in hospital with complications

V34.1 - other multiple newborn before admission

V34.2 - other multiple newborn non-hospital

V35.0 - other multiple stillborn in hospital

V35.00 - other multiple stillborn in hospital with complications

V35.01 - other multiple stillborn in hospital without complications

V35.1 - other multiple stillborn before admission

V35.2 - other multiple stillborn non-hospital

V36.0 - multiple newborn/stillborn in hospital

V36.00 - multiple newborn/stillborn in hospital without complications

V36.01 - multiple newborn/stillborn in hospital with complications

V36.1 - multiple newborn/stillborn before admission

V36.2 - multiple newborn/stillborn non-hospital

V37.0 - multiple birth not otherwise specified in hospital

V37.00 - multiple birth not otherwise specified in hospital without complications

V37.01 - multiple birth not otherwise specified in hospital with complications

V37.1 - multiple birth not otherwise specified before admission

V37.2 - multiple birth not otherwise specified non-hospital

V39.0 - liveborn not otherwise specified in hospital

V39.00 - liveborn not otherwise specified in hospital without complications

V39.01 - liveborn not otherwise specified in hospital with complications

V39.1 - liveborn not otherwise specified before admission

V39.2 - liveborn not otherwise specified non-hospital The estimates of circumcision rates are based just on newborns in the hospital, thus it excludes circumcisions performed outside the hospital as well as births occurring outside the hospital.



Types of hospitals included in HCUP

HCUP is based on data from community hospitals, defined as short-term, non-Federal, general and other hospitals, excluding hospital units of other institutions (e.g., prisons). HCUP data include OB-GYN, ENT, orthopedic, cancer, pediatric, public, and academic medical hospitals. Excluded are long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. However, if a patient received long-term care, rehabilitation, or treatment for psychiatric or chemical dependency conditions in a community hospital, the discharge record for that stay will be included in the NIS.



Unit of analysis

The unit of analysis is the hospital discharge (i.e., the hospital stay), not a person or patient. This means that a person who is admitted to the hospital multiple times in one year will be counted each time as a separate "discharge" from the hospital.



Costs and charges

Total hospital charges were converted to costs using HCUP Cost-to-Charge Ratios based on hospital accounting reports from the Centers for Medicare and Medicaid Services (CMS).14 Costs will reflect the actual expenses incurred in the production of hospital services, such as wages, supplies, and utility costs, while charges represent the amount a hospital billed for the case. For each hospital, a hospital-wide cost-to-charge ratio is used. Hospital charges reflect the amount the hospital billed for the entire hospital stay and do not include professional (physician) fees. For the purposes of this Statistical Brief, costs are reported to the nearest hundred.



Urban-rural location

Urban-rural location is one of six categories as defined by the National Center for Health Statistics:



Large Central Metropolitan: Central counties of metropolitan areas with a population of 1 million or greater

Large Fringe Metropolitan: Fringe counties of counties of metropolitan areas with a population of 1 million or greater

Medium Metropolitan: Counties in metro area of 250,000-999,999 population

Small Metropolitan: Counties in metro areas of 50,000-249,999 population

Micropolitan: Micropolitan counties, i.e. a non-metropolitan county with an area of 10,000 or more population

Non-core: Non-metropolitan and non-micropolitan counties Median community-level income

Median community-level income is the median household income of the patient's ZIP Code of residence. The cut-offs for the quartile designation are determined using ZIP Code demographic data obtained from Claritas. The income quartile is missing for homeless and foreign patients.



Payer

Payer is the expected primary payer for the hospital stay. To make coding uniform across all HCUP data sources, payer combines detailed categories into more general groups:



Medicaid includes fee-for-service and managed care Medicaid patients. Patients covered by the State Children's Health Insurance Program (SCHIP) may be included here. Because most state data do not identify SCHIP patients specifically, it is not possible to present this information separately.

Private insurance includes Blue Cross, commercial carriers, and private HMOs and PPOs.

Other includes TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs.

Uninsured includes an insurance status of "self-pay" and "no charge". When more than one payer is listed for a hospital discharge, the first-listed payer is used.



Region

Region is one of the four regions defined by the U.S. Census Bureau:



Northeast: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania

Midwest: Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas

South: Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, and Texas

West: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, and Hawaii About HCUP



HCUP is a family of powerful healthcare databases, software tools, and products for advancing research. Sponsored by the Agency for Healthcare Research and Quality (AHRQ), HCUP includes the largest all-payer encounter-level collection of longitudinal healthcare data (inpatient, ambulatory surgery, and emergency department) in the United States, beginning in 1988. HCUP is a Federal-State-Industry Partnership that brings together the data collection efforts of many organizations—such as State data organizations, hospital associations, private data organizations, and the Federal government—to create a national information resource.



HCUP would not be possible without the contributions of the following data collection Partners from across the United States:



Alaska State Hospital & Nursing Home Association

Arizona Department of Health Services

Arkansas Department of Health

California Office of Statewide Health Planning and Development

Colorado Hospital Association

Connecticut Hospital Association

Florida Agency for Health Care Administration

Georgia Hospital Association

Hawaii Health Information Corporation

Illinois Department of Public Health

Indiana Hospital Association

Iowa Hospital Association

Kansas Hospital Association

Kentucky Cabinet for Health and Family Services

Louisiana Department of Health and Hospitals

Maine Health Data Organization

Maryland Health Services Cost Review Commission

Massachusetts Division of Health Care Finance and Policy

Michigan Health & Hospital Association

Minnesota Hospital Association

Missouri Hospital Industry Data Institute

Mississippi Department of Health

Montana MHA — An Association of Montana Health Care Providers

Nebraska Hospital Association

Nevada Department of Health and Human Services

New Hampshire Department of Health & Human Services

New Jersey Department of Health and Senior Services

New Mexico Health Policy Commission

New York State Department of Health

North Carolina Department of Health and Human Services

Ohio Hospital Association

Oklahoma State Department of Health

Oregon Association of Hospitals and Health Systems

Pennsylvania Health Care Cost Containment Council

Rhode Island Department of Health

South Carolina State Budget & Control Board

South Dakota Association of Healthcare Organizations

Tennessee Hospital Association

Texas Department of State Health Services

Utah Department of Health

Vermont Association of Hospitals and Health Systems

Virginia Health Information

Washington State Department of Health

West Virginia Health Care Authority

Wisconsin Department of Health Services

Wyoming Hospital Association



About the NIS



The HCUP Nationwide Inpatient Sample (NIS) is a nationwide database of hospital inpatient stays. The NIS is nationally representative of all community hospitals (i.e., short-term, non-Federal, non-rehabilitation hospitals). The NIS is a sample of hospitals and includes all patients from each hospital, regardless of payer. It is drawn from a sampling frame that contains hospitals comprising about 95 percent of all discharges in the United States. The vast size of the NIS allows the study of topics at both the national and regional levels for specific subgroups of patients. In addition, NIS data are standardized across years to facilitate ease of use.



For More Information



For more information about HCUP, visit



For additional HCUP statistics, visit HCUPnet, our interactive query system, at



For information on other hospitalizations in the U.S., download HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States in 2008, located at



For a detailed description of HCUP, more information on the design of the NIS, and methods to calculate estimates, please refer to the following publications:



Introduction to the HCUP Nationwide Inpatient Sample, 2008. Online. May 2010. U.S. Agency for Healthcare Research and Quality.



Houchens, R., Elixhauser, A. Final Report on Calculating Nationwide Inpatient Sample (NIS) Variances, 2001. HCUP Methods Series Report #2003-2. Online. June 2005 (revised June 6, 2005). U.S. Agency for Healthcare Research and Quality.



Houchens, R., Elixhauser, A. Using the HCUP Nationwide Inpatient Sample to Estimate Trends. (Updated for 1988-2004). HCUP Methods Series Report #2006-05 Online. August 18, 2006. U.S. Agency for Healthcare Research and Quality.



Suggested Citation



Maeda, J. (Thomson Reuters), Chari, R. (RAND), and Elixhauser, A. (AHRQ). Circumcisions in U.S. Community Hospitals, 2009. HCUP Statistical Brief #126. February 2012. Agency for Healthcare Research and Quality, Rockville, MD.



Acknowledgements



The authors would like to acknowledge Eva Witt for programming assistance.



For this report, newborns were defined as ICD-9-CM principal diagnosis codes:The estimates of circumcision rates are based just on newborns in the hospital, thus it excludes circumcisions performed outside the hospital as well as births occurring outside the hospital.Types of hospitals included in HCUPHCUP is based on data from community hospitals, defined as short-term, non-Federal, general and other hospitals, excluding hospital units of other institutions (e.g., prisons). HCUP data include OB-GYN, ENT, orthopedic, cancer, pediatric, public, and academic medical hospitals. Excluded are long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. However, if a patient received long-term care, rehabilitation, or treatment for psychiatric or chemical dependency conditions in a community hospital, the discharge record for that stay will be included in the NIS.Unit of analysisThe unit of analysis is the hospital discharge (i.e., the hospital stay), not a person or patient. This means that a person who is admitted to the hospital multiple times in one year will be counted each time as a separate "discharge" from the hospital.Costs and chargesTotal hospital charges were converted to costs using HCUP Cost-to-Charge Ratios based on hospital accounting reports from the Centers for Medicare and Medicaid Services (CMS).Costs will reflect the actual expenses incurred in the production of hospital services, such as wages, supplies, and utility costs, while charges represent the amount a hospital billed for the case. For each hospital, a hospital-wide cost-to-charge ratio is used. Hospital charges reflect the amount the hospital billed for the entire hospital stay and do not include professional (physician) fees. For the purposes of this Statistical Brief, costs are reported to the nearest hundred.Urban-rural locationUrban-rural location is one of six categories as defined by the National Center for Health Statistics:Median community-level incomeMedian community-level income is the median household income of the patient's ZIP Code of residence. The cut-offs for the quartile designation are determined using ZIP Code demographic data obtained from Claritas. The income quartile is missing for homeless and foreign patients.PayerPayer is the expected primary payer for the hospital stay. To make coding uniform across all HCUP data sources, payer combines detailed categories into more general groups:When more than one payer is listed for a hospital discharge, the first-listed payer is used.RegionRegion is one of the four regions defined by the U.S. Census Bureau:HCUP is a family of powerful healthcare databases, software tools, and products for advancing research. Sponsored by the Agency for Healthcare Research and Quality (AHRQ), HCUP includes the largest all-payer encounter-level collection of longitudinal healthcare data (inpatient, ambulatory surgery, and emergency department) in the United States, beginning in 1988. HCUP is a Federal-State-Industry Partnership that brings together the data collection efforts of many organizations—such as State data organizations, hospital associations, private data organizations, and the Federal government—to create a national information resource.HCUP would not be possible without the contributions of the following data collection Partners from across the United States:State Hospital & Nursing Home AssociationDepartment of Health ServicesDepartment of HealthOffice of Statewide Health Planning and DevelopmentHospital AssociationHospital AssociationAgency for Health Care AdministrationHospital AssociationHealth Information CorporationDepartment of Public HealthHospital AssociationHospital AssociationHospital AssociationCabinet for Health and Family ServicesDepartment of Health and HospitalsHealth Data OrganizationHealth Services Cost Review CommissionDivision of Health Care Finance and PolicyHealth & Hospital AssociationHospital AssociationHospital Industry Data InstituteDepartment of HealthMHA — An Association of Montana Health Care ProvidersHospital AssociationDepartment of Health and Human ServicesDepartment of Health & Human ServicesDepartment of Health and Senior ServicesHealth Policy CommissionState Department of HealthDepartment of Health and Human ServicesHospital AssociationState Department of HealthAssociation of Hospitals and Health SystemsHealth Care Cost Containment CouncilDepartment of HealthState Budget & Control BoardAssociation of Healthcare OrganizationsHospital AssociationDepartment of State Health ServicesDepartment of HealthAssociation of Hospitals and Health SystemsHealth InformationState Department of HealthHealth Care AuthorityDepartment of Health ServicesHospital AssociationThe HCUP Nationwide Inpatient Sample (NIS) is a nationwide database of hospital inpatient stays. The NIS is nationally representative of all community hospitals (i.e., short-term, non-Federal, non-rehabilitation hospitals). The NIS is a sample of hospitals and includes all patients from each hospital, regardless of payer. It is drawn from a sampling frame that contains hospitals comprising about 95 percent of all discharges in the United States. The vast size of the NIS allows the study of topics at both the national and regional levels for specific subgroups of patients. In addition, NIS data are standardized across years to facilitate ease of use.For more information about HCUP, visit http://www.hcup-us.ahrq.gov For additional HCUP statistics, visit HCUPnet, our interactive query system, at www.hcup.ahrq.gov For information on other hospitalizations in the U.S., download HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States in 2008, located at http://www.hcup-us.ahrq.gov/reports.jsp For a detailed description of HCUP, more information on the design of the NIS, and methods to calculate estimates, please refer to the following publications:Introduction to the HCUP Nationwide Inpatient Sample, 2008. Online. May 2010. U.S. Agency for Healthcare Research and Quality. http://hcup-us.ahrq.gov/db/nation/nis/NIS_2008_INTRODUCTION.pdf Houchens, R., Elixhauser, A. Final Report on Calculating Nationwide Inpatient Sample (NIS) Variances, 2001. HCUP Methods Series Report #2003-2. Online. June 2005 (revised June 6, 2005). U.S. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports/methods/2003_02.pdf Houchens, R., Elixhauser, A. Using the HCUP Nationwide Inpatient Sample to Estimate Trends. (Updated for 1988-2004). HCUP Methods Series Report #2006-05 Online. August 18, 2006. U.S. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports/methods/2006_05_NISTrendsReport_1988-2004.pdf Maeda, J. (Thomson Reuters), Chari, R. (RAND), and Elixhauser, A. (AHRQ). Circumcisions in U.S. Community Hospitals, 2009. HCUP Statistical Brief #126. February 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb126.pdf The authors would like to acknowledge Eva Witt for programming assistance. *** AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of healthcare in the United States. We also invite you to tell us how you are using this Statistical Brief and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at



Irene Fraser, Ph.D., Director

Center for Delivery, Organization, and Markets

Agency for Healthcare Research and Quality

540 Gaither Road

Rockville, MD 20850







1 Pieretti, R. V. et al. 2010. Late complications of newborn circumcision. Pediatric Surgery International. 26(5): 515-518.

2 Xu, F., et al. 2007. Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: The National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sexually Transmitted Diseases. 34(7):479-484.

3 Zhang et al. (2011). Trends in in-hospital male circumcision—United States—1999-2010. Morbidity and Mortality Weekly Report. 60(34): 1167-1168.

4 American Academy of Pediatrics. 1999. Circumcision policy statement. Task Force on Circumcision. 103(3):686-693.

5 Tobian, A.A.R., et al. 2010. Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Archives of Pediatrics & Adolescent Medicine. 164(1):78-84.

6 Gray, R.H., et al. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 369(9562):657-666.

7 Bailey, R.C., et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet. 369(9562):643-656.

8 Auvert, B., et al. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Medicine. 2(11):e298.

9 Based on select HCUP State Inpatient Databases (SID) and State Ambulatory Surgery Databases (SASD), an additional 6 percent of circumcisions are performed in ambulatory surgery facilities in 2005 (excluding physician offices).

10 Merrill, C.T. (Thomson Healthcare), Nagamine, M. (Thomson Healthcare), and Steiner, C. (AHRQ). Circumcisions Performed in U.S. Community Hospitals, 2005. HCUP Statistical Brief #45. January 2008. Agency for Healthcare Research and Quality, Rockville, MD.

11 Zhang et al. (2011). Trends in in-hospital male circumcision—United States—1999-2010. Morbidity and Mortality Weekly Report. 60(34): 1167-1168.

12 Leibowitz, A. et al. 2009. Determinants and policy implications of male circumcision in the United States. American Journal of Public Health. 99(1): 138-145.

13 HCUP CCS. Healthcare Cost and Utilization Project (HCUP). December 2009. U.S. Agency for Healthcare Research and Quality, Rockville, MD.

14 HCUP Cost-to-Charge Ratio Files (CCR). Healthcare Cost and Utilization Project (HCUP). 2001-2008. U.S. Agency for Healthcare Research and Quality, Rockville, MD. AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of healthcare in the United States. We also invite you to tell us how you are using this Statistical Brief and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at hcup@ahrq.gov or send a letter to the address below:Irene Fraser, Ph.D., DirectorCenter for Delivery, Organization, and MarketsAgency for Healthcare Research and Quality540 Gaither RoadRockville, MD 20850Pieretti, R. V. et al. 2010. Late complications of newborn circumcision. Pediatric Surgery International. 26(5): 515-518.Xu, F., et al. 2007. Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: The National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sexually Transmitted Diseases. 34(7):479-484.Zhang et al. (2011). Trends in in-hospital male circumcision—United States—1999-2010. Morbidity and Mortality Weekly Report. 60(34): 1167-1168.American Academy of Pediatrics. 1999. Circumcision policy statement. Task Force on Circumcision. 103(3):686-693.Tobian, A.A.R., et al. 2010. Male circumcision for the prevention of acquisition and transmission of sexually transmitted infections: the case for neonatal circumcision. Archives of Pediatrics & Adolescent Medicine. 164(1):78-84.Gray, R.H., et al. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 369(9562):657-666.Bailey, R.C., et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet. 369(9562):643-656.Auvert, B., et al. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Medicine. 2(11):e298.Based on select HCUP State Inpatient Databases (SID) and State Ambulatory Surgery Databases (SASD), an additional 6 percent of circumcisions are performed in ambulatory surgery facilities in 2005 (excluding physician offices).Merrill, C.T. (Thomson Healthcare), Nagamine, M. (Thomson Healthcare), and Steiner, C. (AHRQ). Circumcisions Performed in U.S. Community Hospitals, 2005. HCUP Statistical Brief #45. January 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb45.pdf Zhang et al. (2011). Trends in in-hospital male circumcision—United States—1999-2010. Morbidity and Mortality Weekly Report. 60(34): 1167-1168.Leibowitz, A. et al. 2009. Determinants and policy implications of male circumcision in the United States. American Journal of Public Health. 99(1): 138-145.HCUP CCS. Healthcare Cost and Utilization Project (HCUP). December 2009. U.S. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp HCUP Cost-to-Charge Ratio Files (CCR). Healthcare Cost and Utilization Project (HCUP). 2001-2008. U.S. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/db/state/costtocharge.jsp