European Commission - Public Health: healthindicators.org

Hospital in-patient discharges, limited diagnoses

Definition of indicator

Number of hospital in-patient discharges from all hospitals during the given calendar year, with the principal diagnosis falling into the ISHMT group of diseases, expressed per 100,000 population.

Divided into categories of the International Shortlist for Hospital Morbidity Tabulation (ISHMT).

Calculation (numerator, denominator)

Hospital in-patient discharges per 100.000 inhabitants = (Total number of hospital in-patient discharges from all hospitals during the given calendar year, with the principal diagnosis falling into the ISHMT group of diseases / total population as by 1 July) * 100,000

Where:

1. NUMERATOR

* A HOSPITAL DISCHARGE is the formal release of a patient from a hospital after a procedure or course of treatment. A discharge occurs whenever a patient leaves because of finalisation of treatment, signs out against medical advice, transfers to another health care institution or on death. A discharge can refer to in-patients or day cases. Healthy newborns should be excluded. Transfers to another department within the same institution are excluded.

Inclusion

- Sign out against medical advice (voluntary discharges, judicial discharges, fled patients).

Exclusion

- Transfer to another department of the same hospital is not considered as a discharge.

- Day cases/discharges on the same day: day treatment cases (patients admitted for a medical procedure or surgery in the morning and released before the evening) should not be included.

-Healthy newborns.

* A HOSPITAL IN-PATIENT is a patient who is formally admitted (or “hospitalised”) to a hospital for treatment and/or care and stays for a minimum of one night in the hospital. Inpatient care includes accommodation provided in combination with medical treatment when the latter is the predominant activity provided during the stay as an inpatient. (See indicator "Influenza vaccination rate in elderly").

Inclusions

- Patients admitted as in-patients but who do not remain overnight for some reason (e.g. death) are recorded as in-patients.

- Patients admitted with the intention of discharge on the same day, but who subsequently stay in hospital over night, are recorded as in-patients.

Exclusion

- Day cases/discharges on the same day: day treatment cases (patients admitted for a medical procedure or surgery in the morning and released before the evening) should not be included.

- Healthy newborns.

2. DENOMINATOR

TOTAL POPULATION as defined in indicator "Population by age/gender".

Additional underlying concepts

Calculation details

The International Shortlist for Hospital Morbidity Tabulation (ISHMT) was developed by the Hospital Data Project (HDP) of the European Union Health Monitoring Programme for statistical comparison of hospital activity analysis. It was adopted in 2005 by Eurostat, the OECD (Organisation for Economic Co-operation and Development) and the WHO-FIC (Family of International Classifications) Network. Rationale: For international comparisons, the simultaneous use of ICD-9 and ICD-10 has called for a comparable shortlist consisting of groups defined by both ICD-9 and ICD-10 codes for comparisons between countries using different ICD revisions and for developing time series statistics. The Hospital Data Project (HDP) of the European Union Health Monitoring Programme aimed at maximising the statistical comparability of hospital activity analysis. Within the HDP an Expert Group was asked to compile a shortlist of diagnoses that could be used for this purpose. Such a list was proposed in the Final Report of the HDP in June 2003. The proposed shortlist was later discussed with major providers of international hospital statistics such as Eurostat and OECD. After a few minor modifications it was adopted in 2005 by Eurostat, OECD and NOMESCO for data collection and presentation. At the WHO-FIC Network Meeting in October 2005 the list was also adopted by the WHO-FIC Network to be published on the WHO website as the International Shortlist for Hospital Morbidity Tabulation (ISHMT). Currently, Eurostat and OECD use this list for disseminating information in their respective health databases.

International Shortlist for Hospital Morbidity Tabulation (2005)

• 0100 Certain infectious and parasitic diseases
• 0200 Neoplasms
• 0300 Diseases of the blood and bloodforming organs and certain disorders involving the immune mechanism
• 0400 Endocrine, nutritional and metabolic diseases
• 0500 Mental and behavioural disorders
• 0600 Diseases of the nervous system
• 0700 Diseases of the eye and adnexa
• 0800 Diseases of the ear and mastoid process
• 0900 Diseases of the circulatory system
• 1000 Diseases of the respiratory system
• 1100 Diseases of the digestive system
• 1200 Diseases of the skin and subcutaneous tissue
• 1300 Diseases of the musculoskeletal system and connective tissue
• 1400 Diseases of the genitourinary system
• 1500 Pregnancy, childbirth and the puerperium
• 1600 Certain conditions originating in the perinatal period
• 1700 Congenital malformations, deformations and chromosomal abnormalities
• 1800 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
• 1900 Injury, poisoning and certain other consequences of external causes
• 2100 Factors influencing health status and contact with health services
• 0000 All causes

To see the breakdown for each category and the definition for the items of this classification, please refers to

-Eurostat: http://ec.europa.eu/eurostat/ramon/nomenclatures/index.cfm?TargetUrl=ACT_OTH_DFLT_LAYOUT&StrNom=ISHMT_2005&StrLanguageCode=EN

-WHO: http://www.who.int/classifications/apps/icd/implementation/hospitaldischarge.htm

Why the indicator is measured the chosen way?

The number of discharges is the most commonly used measure of the utilisation of hospital services. Discharges, rather than admissions, are used because hospital abstracts for in-patient care are based on information gathered at the time of discharge. Elaborated data as rates per inhabitant are preferred to absolute number of discharges for the sake of meaningful comparisons. This elaborated data has a higher amount of information than raw data.

Reasons for the preferred definition

This is the Eurostat, OECD and WHO currently in use definition for the indicator measuring the utilisation of hospital services and so the burden of given diseases on health services (rate per 100,000 inhabitants). Declared discharges are an available proxy to registered discharges that may be used to test trends and differences captured by registered discharges.

Relevant dimensions (subgroups)

Country (also region), calendar year, gender, age group,

sector: public, not-for-profit and private hospitals.

Preferred data sources

Eurostat. Eurostat and OECD, both institutions, are collecting the data from national sources with a common questionnaire (CARE, non-expenditure, which includes a common MDS on hospitals).

Rationale

Non-expenditure health care data provide information on institutions producing health care in countries, on resources used and on output produced in the framework of health care provision. Data on health care form a major element of public health information as they describe the capacities available for different types of health care provision. The quantity and quality of health care services provided and the work sharing established between the different institutions are a subject of ongoing debate in all countries. Sustainability – continuously providing the necessary monetary and personal resources needed – and meeting the challenges of ageing societies are the primary perspectives used when analysing and using these data.

Regarding hospital in-patient discharges, it is the most commonly used measure of the utilisation of hospital services. Indicators based on hospital discharges from particular diseases can be used as an estimate of the burden of these diseases on health services. Can be used also as “second best” measure for occurrence of certain diseases. Nevertheless, they do not estimate the disease incidence, i.e. a real burden on the population; although they can be closely correlated. Finally, this indicator is often used in assessments of costs and efficiency.

Data availability, quality and periodicity

Eurostat and OECD provide yearly data on hospital discharges, based on national statistics. Currently, Eurostat and OECD have agreed to use the same definitions, wording and specifications in their respective data collections on health care statistics (non-expenditure data). A list of items common to the Eurostat and OECD annual data request was established, and definitions were elaborated and agreed for those items that are routinely collected by the two organisations. The WHO might use slightly different wording, but often covering the same meaning. Eurostat, OECD and WHO are planning to continue the effort to improve and harmonise definitions for items under non-expenditure health care statistics.

References

- OECD Manual 'A system of Health Accounts' (2000)

- Eurostat definitions and country specific notes of hospital beds

- Eurostat definitions and country specific notes of hospital discharges by diagnosis (ISHMT)

- Eurostat/OECD/WHO international shortlist for hospital morbidity tabulation (ISHMT): http://www.who.int/classifications/apps/icd/implementation/hospitaldischarge.htm and http://ec.europa.eu/eurostat/ramon/nomenclatures/index.cfm?TargetUrl=ACT_OTH_DFLT_LAYOUT&StrNom=ISHMT_2005&StrLanguageCode=EN

- Eurostat/OECD/WHO definitions and data collection specifications on health care statistics (non-expenditure data)

- Definitions and data collection specifications from Hospital Data Project

- European hospital morbidity database HMDB

Work to do

Discuss on:

• Should we collect hospital-HP.1 discharges or should we collect also nursing and residential care facilities-HP.2 discharges?
• Should we collect discharges for in-patient care that is developed as a secondary activity?
• The inclusion as inpatients or not of those patients admitted as inpatients but who do not remain overnight for some reason (e.g. death), (definition recommended by the HDP). Rationale: in the calculation of ALOS the days of stay will be operated on the basis of “date of discharge minus date of admission” so the days of stay for these patients will not be accounted for.