Utilization and Cost of Gender-affirming Surgery in the United States From 2012 to 2019.

Abstract

To characterize the trends in and characteristics associated with the utilization and cost of gender-affirming surgery (GAS) in the United States from 2012 to 2019. GAS is one option among gender-diverse (GD) people to transition from their biological anatomy to the anatomy congruent with their gender. Little is known about its utilization and cost trends and whether patient and hospital characteristics are associated with differences in utilization and cost. This serial cross-sectional study collected retrospective data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), a representative pool of inpatient visits in the United States. Records from 2012 to 2019 that indicated ages 18 or older, GD diagnoses, and GAS procedures were identified using the International Classification of Diseases , Ninth and Tenth Revisions. Within this cohort, demographics, utilization, and cost were collected and analyzed using descriptive statistics and multivariable regression models. A total of 6325 records with GD diagnoses and GAS procedures were identified. From 2012 to 2019, utilization increased by more than 5-fold (0.9-5.0 per 100,000 records among all records), and the mean, inflation-adjusted cost increased by 36% ($19,451 to $26,517). This cost trend was similar by type of surgery, and genital surgery had consistently higher costs than chest surgery from 2012 to 2019 (genital: $21,487-$26,712, chest: $13,238-$21,309). Lower odds of utilization were found in records with Medicaid (OR = 0.27, 95% CI [0.22-0.35], P <0.001) and Medicare (OR = 0.15, 95% CI [0.11-0.23], P <0.001) compared with private insurance, as well as those in the lowest income quartile (OR = 0.68, 95% CI [0.54-0.85], P <0.001) compared with the highest quartile. Lower costs were found in records that indicated hospital location in the Midwest (27% lower, 95% CI [0.61-0.87], P <0.001), Northeast (34% lower, 95% CI [0.55-0.80], P <0.001) and South (39% lower, 95% CI [0.53-0.71], P <0.001) compared with the West. As demand for GAS increases with varying utilization and costs based on patient and hospital characteristics, there will likely be a need for more qualified surgeons, increased insurance coverage, and policies to ensure equitable access to GAS.