DATA EVALUATION AND METHODS RESEARCH

.1

The Status of HospitalD~chargeDatain Denmark,Scotland,West Germany,and the UnitedStates

Study of comparability of cross-national hospital discharge data.Descriptions of discharge reporting systems with emphasis oncoverage, types of data collected, procedures and definitions usedin data collection and analysis, and statistics routinely available.Discussion of health services system characteristics likely to affectrates of hospital use.

DHHS Publication No. (PHS) 81-1362

Series 2Number 88

US, DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health Service

Office of Health Research, Statistics, and TechnologyNational Center for Health StatisticsHyattsville, Md. June 1981

Library of Congress Cataloging in Publication Data

Kozak, Lola Jean.The status of hospital discharge data in Denmark, Scotland, West Germany, and the

United States.

(Vital and health statistics: Series 2, Data evaluation and methods research; no. 88)(DHHS publication; no. (PHS) 81-1362)

Includes bibliographical references.Supt. of Dots. no.: HE 206209: 2/881. Hospital utilization-Denmark-Statistical services. 2. Hospital utilization–Scotkmd-

Statistical services. 3. Hospital utilization-Germany, West–Statistical services. 4. Hospitalutilization—United States—Statistical services. I. Andersen, Ronald, joint author. II. Ander-son, Odin Waldemar, 1914- joint author. III. Title. IV. Series: United States. NationalCenter for Health Statistics. Vital and health statistics: Series 2, Data evaluation andmethods research; no. 88. V. Series: United States. Dept. of Health and Human Services.DHHS publication; no. (PHS) 81-1362. [DNLM: 1. Cross-Cultural comparison-Statistics.

2. Patient discharge–Statistics. W2 A N148vb no. 88]RA409.U45 no. 88 [RA971.6] 312’.07’23s 80-607865ISBN 0-8406-0211-1 [362.1’1’0684]

.

NATIONAL CENTER FOR HEALTH STATISTICS

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy DirectorJACOB J. FELDMAN, Ph.D., Associate Director for Analysis and Epidemiology

GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Statistics SystemGARRIE J. LOSEE,Associate Director for Data Processingand Services

ALVAN O. ZARATE, Ph.D., Assistant Director for International StatisticsE. EARL BRYANT, Assoctite Director for Interview and Examination Statistics

ROBERT C. HUBER, Associate Director for ManagementMONROE G. SIRKEN, Ph.D., Associate Director forl?esearch and Methodology

PETER L. HURLEY, Assoctite Director for Vital and Health (he StatisticsALICE HAYWOOD, Information Officer

OFFICE OF INTERNATIONAL STATISTICS

ALVAN O. ZARATE, Ph.D., Director

Vital and Health Statistics-Series 2-No. 88

DHHS Publication No. (PHS) 81-1362Librmy of CongressGztalog CardNumber 80-607865

ACKNOWLEDGMENTS

This report was financed in part by Purchase Order PLD-08633-78 from theNational Center for Health Statistics and by the Center for Health AdministrationStudies of the University of Chicago.

The report was made possible by a number of persons in several countries whoprovided the authors with the benefit of their considerable knowledge and experi-ence and supplied published and unpublished materials. These people are listed inappendix I. A particular debt is owed to coordinators in Denmark, Scotland, andWest Germany, who bore the brunt of continuing requests for information andcritiqued drafts of the report: Karen Dreyer in Denmark, M. A. Heasman andJ. M. G. Wilson in Scotland, and Elisabeth Schach and H. U. Senftleben in WestGermany. Manfred Pflanz of West Germany, recently deceased, also helped tocoordinate the study in its early stages. To the extent that this report faithfullyreflects the situations in the countries studied, the authors gratefully acknowledgethe informants and coordinators. of course, for “any errors of fact or interpreta-tion we must bear sole responsibility.

Special thanks also go to National Center for Health Statistics staff RobertHartford, Office of International Statistics, and Hugo Koch, Division of HealthCare Statistics, who took time from their regular duties to translate materials forthe study.

...Ill

CONTENTS

Acknowledgments ...................................................................................................................................

Comparison of Characteristics of the Countties ......................................................................................The Countries ..................................................................o....................................................o............The Hospital Systems ........................................................................................................................

Denmark .................................................................................................................................................General Hospital Discharge Reporting Systems ..................................................................................

Methods of Data CoUwtion ................ .........................................................................................CovemW ........o............o...o.......................................................................o....................... ..............Items Collected ............................................................................................................................Definitions and Procedures ..........................................................................................................Information Published or AvMable .................................................................................... ..........

Other Discharge Reporting Systems ..................................................................................................Data Collection ............................................................................................................................Items Atiable ......................................................................................... ....................................

Aggregate Hospital Repoms ...............................................................................................................Household Surveys ............................................................................................................................

Scotland ..................................................................................................................................................General Hospital Discharge Reporting System .................... ...............................................................

Methods of Data Co~ection .........................................................................................................

Items Collected ............................................................................................................................Definitions and Procedures ..........................................................................................................Information Published or Avdable ..............................................................................................

Other Discharge Reporting Systems ...................................................................................................Aggregate Hospital Repoms ........................................... ..................... ...............................................Household Sumey ..............................................................................................................................

Data Collection ............................................................................. ...............................................Items Avdable .............................................................................................................................

West Germany .........................................................................................................................................General Hospital Discharge Reporting Systems ..................................................................................

Sickness Insurance Funds .............................................................................................................Mesti&Hokttin ........................................................................................................................

Other Dkcharge Reporting Systems ......................................................... ................. .........................Psychiatric Reporting System .............................................................................................. .........Army Reporting System ...............................................................................................................

Aggregate Hospital Repofis ...............................................................................................................Household Suwey ............................................................................................................... ...............

U.S. National Hospital Discharge Suwey ....................... ..........................................................................Methods of Data CoUection ...............................................................................................................Coverage ............................................................................................................................................Items CoUected ......... .........................................................................................................................Definitions and Prmedures ................................................................................................................Information Published or Avdable ...................................................................................................Summary .o..o.........o.........................................................................................................o..................

...us

1

:5

8

:9

1011

:;12121314

141415161617171820212121

2222222326

z2829

30323234

;;40

v

Health Services Systems .. ... ... .. .. .... .. .. ... ... . ... .. ... ... . .. .. . .. . .. .... . .... . ... .. .. .... ... .. . .... .. ... . .... .. .. ... . .... .. ... .. ... .. ... .. ...Long-Term-Care Facilhies ... . .... .. ... .. ... .. ... .. . ... ... ... .. ... . .... .. ... .. .... . .. .. . ... .. .... .. .. .. . .... .. ... . .. .. .. .. ... ... .. . .... ... ..Ambulatory and Home Care Services ... ... . ... .. .. .. .. . .... . .... . .... .. . .. .. ... .. .... . .... . ... .. .. ... .. ... .. ... .. ... .. .... .. . ... .. ...Costs of Receiving Health Care .. ... . .... .. .. .. .. .... .. ... . .... .. ... . .. .. .. .... . ... .. .... .. .. .. ... ... . ... .. ... .. ... .. ... ... ... .. ... .. .. ..Summary ... ... .. ... .. ... .. .. ... .. ... . ... ... ... . .... .. .. .. .. ... ... .. .. .... . ... .. .... . ......o.. . ... ... . .. .. .. ... ... .. .. . .. . ... ... ..o.. ...............

Summary and Conclusions .. ... .. ... .. .. ... .. ... .. ... .. ... .. .. ... . .... .. ... .. .... . .... . .... .. ... .. ... .. ... .. ... .. .. .. ... .. .. ... ... ... . .. ... . ... .

References .. .... . ... .. ... ... .. .. ... .. ... .. .... . .. .... . ... . .... .. ... .. .. ... .. ... .. ... .. ... .. ... .. .... . ... .. .... . .. ... .. ... .. ... ... ........................

AppendixesI. Contributors to Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II. Sources of National Hospital Utilization Statistics in the United States in Addhion to theNational Hospital Disch-age Survey .. .. ... .. .. . .. .... .. ... .. ... .. ... .. ... .. ... .. ... .. ... .. .. ... .. ... .. ... . ..... .. ... . ..... .. ..

LIST OF TEXT TABLES

A.

B.

c.

D.

E.

F.

G.

H.

J.

K.

Spatial distribution of populations by country .. ... .. ... .. .... . ... .. ... .. ... .. .... .. .. ... ... . ... ... . .... .. .... .. .. ... ... .. ...

Percent distribution of populations by age and sex, according to country .. .. .. . ... .. .. .. .. . .. .. ... .. .. ... .. ...

Selected mortality indexes by counq ... . ... .. ... .. ... .. ... .. .. .. .. . .. . .... .. . .... . .. .. .. ... .. .... . .... . .... .. ... .. .... . ... ... ...

Number of hospitals, beds, and beds per 1,000 population by ownership, type of hospital, andcountry . ... .. ... .. ... ... .. .. .. .... .. ... . ... ... . .... . ... ... .. .. .. ... ... .. .. ... .. ... .. .... .. .. ... ... .. .. .. .... .. ... ... ... .. ... ... ...................

Percent dktribution of hospital beds by type and size of hospital, according to country..., .. .. .. . . ....

Selected short-term hospital utilization statistics by comtW ..... . .. .. .. ... .. ... .. .. .. .. ... .. ... ... ... .. ... . .. .... . ...

General hospital discharge reporting systems, by country and reporting system .. ... .. ... .... . .... .. ... .. .. .

Compzmbilh y of coverage of general hospital diicharge reporting systems, by country andreporting system .... ... .. . .... .. .... . ... ... ... . .... . . .. .. . .... . .... .. ... . .... .. .... . ... .. .. .. . .... .. .... . .... .. ... .. ... .. ... .. ... ... ... ......

Comparison of items collected in the United States with those collected in Denmark, Scotland,and West Germany, by reporting system ..... . ... .. ... ... .. ... ... .. ... .. ... .. .... .. .. ... .... .. ... . ..... . ... .. .... .. ... .. ... .. .. ..

Coding of diagnoses in general hospital dkcharge reporting systems, by country and reportingsystem ... .. ... .. .. .. ... .. ... .. ... .. ... .. .. ... .. ... .. .. ... .. ...o.... .. .. ... ....o.. ... . .. .. . .... .. ... ... ... .. .... . ..o. .. .. . .. ... . ... .................

4040424548

48

50

55

56

4

4

5

6

7

8

31

33

35

36

SYMBOLS

Data not available--------——----—----—--- ---

Category not applicable--------------—--------- . . .

Quantity zero-—————————-. ——--—--

Quantity more than O but less than 0.05-–- 0.0

Figure does not meet standards ofreliability or precision-—--------—-—- *

THE STATUS OF HOSPITAL DISCHARGE DATA

IN DENMARK, SCOTLAND, WEST GERMANY,

AND THE UNITED STATES

Lola Jean Kozak, Office of International Statistics, National Center for Health Statistics, andRonald Andersen and Odin W. Anderson, Center for Health Administration Studies,

Graduate School of Business, University of Chicago

INTRODUCTION

Interest in the health services systems offoreign countries has increased in recent years.These systems are valuable sources of informa-tion on alternative approaches to health caredelivery problems in the United States. Numer-ous studies of other health services systems havebeen undertaken, and much research that couldexplore and evaluate the differences in the sys-tems has been suggested. A major requirementfor further research is the availability of com-parable and accurate data. Government agenciesin most developed countries routinely collect awide array of statistics on health services thatmight supply the necessary data base, but manyquestions about the comparability of these sta-tistics remain unanswered.

This report examines the status of one typeof routinely collected health data: hospital utili-zation statistics. These data were chosen foranalysis for several reasons. Hospitals play a cen-tral role in most health services systems, theydeal with the most serious health disorders, andthey generally absorb the largest share of totalhealth expenditures. Also, countries usually col-Iect a considerable amount of hospital data, andcross-national comparisons of hospital statisticsare common.

In most developed countries there axe threetypes of data systems that collect hospital utili-zation statistics: discharge reporting systems,

aggregate hospital reports, and household sur-veys. Discharge reporting systems collect ab-stracts of information about the characteristicsof individual discharges, usually including age,sex, and diagnosis. The discharge reporting sys-tems that cover general hospitals are examinedin the most detail in this report, but some infor-mation is given on discharge reporting systemsthat cover special types of hospitals or patients.Aggregate hospital reports and household sur-veys are also briefly reviewed here. Aggregatehospital reports contain information about ahospital’s total number of discharges and beddays but not about individuzd patients. House-hold surveys usually focus on levels of health orambulatory care use, but they often collectsome information about hospital use.

This report is the second in a series of threeon the status of cross-national hospital dischargedata. The first report describes discharge report-ing systems in Australia, Canada, England andWales, Finland, France, and Sweden.1 The re-porting systems in the six countries were similarenough to be promising data sources for cross-national research, but important differenceswere also discovered. For instance, variations inthe systems’ coverage and in definitions and pro-cedures used for data analysis would have to betaken into account before data comparisonscould be made.

This report expands on the first report intwo ways. First, to learn more about the rangeand frequency of the similarities and differencesin discharge reporting systems, the reporting sys-tems in three additional countries–Denmark,Scotland, and West Germany–are examined.Second, to facilitate comparisons of the U.S.hospital statistics with those of other countries,characteristics of the U.S. National Hospital Dis-charge Survey are discussed. A detailed descrip-tion of the National Hospital Discharge Surveyhas been published and is not repeated here,but the comparability of the U.S. survey withreporting systems in other countries is explored.

In the third report of the serieshospital utili-zation data from all nine countries and theUnited States will be compared. Estimates willbe made of the effects of differences in dis-charge reporting systems on the data produced.Each country’s hospital utilization statistics willbe adjusted to take these effects into account.

The discharge reporting systems of Den-mark, Scotland, and West Germany were chosenprimarily because these countries display varioushealth services system characteristics that mayaffect the development and operation of dis-charge reporting systems. For instance, a coun-try with a centralized public health services sys-tem is likely to have less difficulty organizing anationwide discharge reporting system than is acountry with a more diverse health service. Eng-land and Wales, with its centralized NationalHealth Service, was one of the first countries tobegin operating a reporting system and has suc-ceeded in collecting comparable countrywidedata. Scotland takes part in the National HealthService with England and Wales, but the ScottishHealth Service is administered separately, andScotland has created its own discharge reportingsystem. Whether this discharge reporting systemdiffers from the one in England and Wales wasthought to merit investigation.

Denmark has a largely public but decen-tralized health services system. Most hospitalsare owned and operated by individual countiesrather than by a single national health service.This form of organization could make it moredifficult to create and maintain a nationwide dis-charge reporting system. In Sweden decentraliza-tion has led to problems; in Finland it has not.

As in Denmark, most Swedish and Finnish hos-pitals are owned by local government units. InSweden the counties own the hospitals and de-termine the form of the discharge reporting sys-tems. Some counties have established a compre-hensive reporting system for all their hospitals;others collect data only from some of their hos-pitals. As a result, uniform national dischargedata are not available from these reporting sys-tems. In contrast, Finland has created a nationaldischarge reporting system to which all hospitalsreport similar data. This difference has arousedinterest about Denmark and its ability to obtainuniform national discharge data.

West Germany’s health services system isalso decentralized; the States rather than theFederal Government are largely responsible forproviding health services. Moreover West Ger-many contains a substantial number of privatehospitals, which, in other countries, are oftenexcluded from or fail to participate in govern-ment discharge reporting systems. The result canbe seriously biased data, as is the case in France.However West Germany has a health insurancesystem. Discharge reporting systems have beenlinked to health insurance systems in Australiaand Canada, and in spite of health services de-centralization and the large number of privatehospitals in both countries, their reporting sys-tems collect comprehensive dkcharge data. Thisreport investigates whether West Germany usesits health insurance system in this way or adoptsother approaches to data collection.

All three countries were also selected forstudy because they contain research colleagueswith whom the authors had previously estab-lished working relationships. The modest fund-ing available for the study precluded travel tothe countries for data-gathering purposes andlimited the authors to published and unpub-lished materials that could be acquired fromvarious agencies and to correspondence withresearch colleagues in the three countries. Manyof them recommended others knowledgeable inhospital statistics, who provided further assist-ance with the study.

The major contributors to the study arelisted in appendix I. They supplied compre-hensive replies to the original questions, pa-tiently answered followup queries, and provided

valuable comments on drafts of the report. Theyalso helped to obtain copies of recent hospitaIstatistics publications from each country. Thestatistical publications and personal communica-tions were the main sources of information forthe report, but a review of other relevant litera-ture concerning the availability, comparability,and quality of the hospital data was also con-ducted. Information about the U.S. NationaIHospital Discharge Survey was obtained fromthe Division of Health Care Statistics of the U.S.National Center for Health Statistics as well asfrom published descriptions of the survey.

The report is divided into several sections.The first section provides demographic and hos-pital system data on the three countries and in-cludes a comparison of these data with similar

U.S. data. In subsequent sections the hospitalstatistical systems in Denmark, Scothnd, and”West Germany are described. These sections con-tain detailed descriptions of discharge reportingsystems that cover general hospitals and briefreviews of discharge reporting systems for spe-cial types of hospitals or patients, annual hospi-tal reports of aggregated hospital utilizationdata, and natiomd househoId surveys that in-clude data about hospital use. In later sectionsthe U.S. National Hospital Discharge Survey iscompared with the discharge reporting systemsof the three countries, and selected aspects ofhealth service systems that can be expected toaffect hospital utilization are discussed. Theclosing section provides a summary andconclusions.

COMPARISON OF

THE COUNTRIES

CHARACTERISTICS OF THE COUNTRIES a

Table A shows that Denmark’s populationand area are the smallest of the three countries.Its area is about the size of the New Hampshireand Massachusetts combined; Massachusettsalone contains a larger population. Scotland’sarea is similar to that of South Carolina; thecountry also contains fewer inhabitants thandoes Massachusetts. Although West Germany’sarea is about the size of Oregon, it has almostthree times the population of California. It is byfar the most densely populated of the countries,but Denmark and Scotland also average consid-erably more persons per square kilometer thandoes the United States. The percent of popula-tion in urban areas is apparently highest in theUnited States and lowest in West Germany, butthe countries define urban areas differently.

Table B shows the age and sex distributionsof the countries’ populations. While they aregenerally similar, some differences exist. Com-pared with the United States, each of the otherthree countries has a smaller percent of persons

aSlmikar informationabout Australia, Canada, Eng-land and Wales, Finland, France, and Sweden can be

found inreference1, pages4-8.

age 15-44 years and a higher percent ages 45-64years and 65 years and over. West Germany hasthe highest percent of persons age 65 years andover and the lowest percent under age 5 years.The proportion of females in highest in WestGermany and lowest in Denmark.. ..—

Table C shows selected mortality statisticsfor each country. The infant mortality statisticsvary markedly, with Denmark’s infant mortalityrate significantly lower than the other countries’rates. Denmark also reports the longest life ex-pectancy at birth for males. Danish males canexpect to live almost 2 years longer than malesin the United States. However U.S. females canexpect to live slightly longer than Danish fe-males, and over 2 years longer than females inScotland and West Germany.

The United States reports the lowest deathrates, but this would be expected because thepercent of the population under age 45 is high-est in the united States. Scotland has the highestdeath rates, even though it has a larger percentof population under age 45 than does WestGermany. Heart disease accounts for a greaterproportion of alI deaths in the United Statesthan it does in the other three countries, butmalignant neoplasms account for a greater pro-portion of all deaths in Denmark than in theother countries.

3

Table A. Spatial distribution of populations by country

Country

Population distribution and yaar

Population–1 977 ..............................................................................................Area in square kilometers ..................................................................................Personsper square kilometer–1977 ..................................................................Percent of population in urban areas–1 970 ......................................................

11969.

SOURCES: References 3 and 4.

Denmark

5,088,00043,096

11867

Scotland

5,166,00078,772

6671

Table B. Percant distribution of populations by age and sex, according to country

WestGermany

61,714,000246,577

247162

Age and sax

Female .............................................................................................................................

Under 5 years

Male .................................................................................................................................Fawle .............................................................................................................................

5-14 years

Male .................................................................................................................................

15-44 years

Male .................................................................................................................................

45-64 years

Male ................................................................................................................................ .Femle .............................................................................................................................

65 years and over

Famle .............................................................................................................................

SOURCE: Reference 3.

UnitedStatas

216,817,0009,363,123

2374

Country

Denmark ScotlandWast United

1976 1976 Germany Statas1976 1977

100.0

49.550.5

3.63.5

7.97.5

21.420.5

10.811.3

5.87.8

Percent distribution

100.0

46.151.9

3.53.3

::

20.020.0

10.611.9

5.18.3

100,0

47.652.4

2.62.5

8.17.7

21.820.6

9.612.3

5.59.3

100.0

48.651.4

3.63.4

22.422.7

9.710.5

4.46.4

Table C. Selacted mortality indexes by country

Mortality indax

Infant mortalityl ............. ................................................................................................

Average life expectancy: 2Mala ,,,, ,,, ...,.,..,,,, .........................................................................................................Female ........................................................................................................................

———So[acted causa of death:3

All causes.................................................................................................................. ..Malignant neoplasms...................................................................................................Heart tiwase ................ ...............................................................................................

Country

Denmark Scotland West UnitedGermany States

Rate par 1,000 live births

8.9 I 16.1 I 17.4 I 14.1

Years at birth

71.1 68.3 68.376.8 74.6 74.8

Rate @rr 1,000 population

10.6 12.5 12.12.5 2.6 2.53.8 4.0 3.5

11977 data for Denmark, Scotland, and the United States, 1976 data for west Germany.

21977 data for Wofland and the United states, 1975.76 data for Denmark, 197476 data for west @~~anyo

31977 data for the United states, 1976 data for Denmark and Scotland, 1975 for west Germany.

SOURCES: References 3, 5, end 6.

Table

THE HOSPITAL SYSTEMS

D presents information about the hos-pital systems- of each country. Public ownershiprefers to hospitals owned by the local, State, ornational government, and private ownershiprefers both to nonprofit and profitmaking hospi-tals. Private ownership of hospital facilities ismost marked in the United States. However themajority of these hospitals are community hos-pitals, owned and operated by nonprofit groups.Most U.S. public hospitals are owned by State orlocal authorities. West Germany has the sameproportions of public and private hospitals asdoes the United States, but West German publichospitals contain more beds than do the privatehospitals. As in the United States, most WestGerman public hospitals are owned by State orlocal authorities, and most private hospitals arenot profitmaking. Almost all hospitals in Scot-land and Denmark are public institutions. Nostatistics were available on the private hospitalsin Scotland, but it is known that they accountfor less than 5 percent of all Scottish hospitalbeds. In Denmark about 7 percent of all hospital

69.377.1

8.81.83.3

beds are in private hospitals. The public hospi-tals in Denmark are almost all owned and oper-ated by the counties, while in Scotland the pub-lic hospitals are part of the National HealthService.

The statistics in table D on short-term andlong-term hospitals are not strictly comparable.In the United States short-term hospitals are de-fined as hospitals that have an average length ofstay of less than 30 days, and long-term hospitalsare those with an average length of stay of 30days or more. In Denmark hospitals are not cate-gorized by length of stay, but since the length ofstay of each individual hospital is reported, it ispossible to regroup the hospitals into short-termand long-term categories based on the U.S. defi-nitions. In West Germany hospitals are referredto as either acute care or special care hospitalsdepending on the type of services provided inthem. In general the acute care hospitals haveaverage lengths of stay of less than 30 days, andthe special hospitals have average lengths of stayof over 30 days, but this is not always the case.Nevertheless acute care hospitals are reported asshort-term hospitals and special care hospitalsare reported as long-term hospitals in table D. In

5

Table D. Number of hospitals, beds, and beds per 1,000 population by ownership, type of hospital, and country

Ownership and type of hospitel

Ownarship

Public .............................................................................................~............................Private .........................................................................................................................

Type

Short-term ..................................................................................................................Long-term ...................................................................................................................

Total .......................... .................................................................................

Ownership

Public ..........................................................................................................................Private .........................................................................................................................

Typa

Short-term ..................................................................................................................Long.term ...................................................................................................................

Ownership

Public ..........................................................................................................................Private ................................................................... ......................................................

TyPS

Short-term .......................................... ........................................................................Long-term ........................................................................ ...........................................

Country

Denmark1977

135

11520

10530

43,436

40,3733,063

31,43112,005

SCotlandl1977-78

WestGermany

1977

Number of hospitals

349

349. . .

181168

3,416

1,2562,158

2,1851,231

Number of hospital beds

53,987

53,987-..

26,07327,914

722,953

380,083342,870

487,566235,387

UnitadStatas1978

7,159

2,6074,552

6,595564

1,350,087

540,253608,644

1,100,368249,728

Bads par 1,000 population

8.5 I 10.41 11.7 I 6.2

7.9 10.4 6.2 2.50.6 ..- 5.5 3.7

6.2 5.0 7.9 5.02.4 I 5.4 I 3.8 I 1.1

lData me for Nation~ Health Service hospitals,excludinghospita~for the mentally deficient. Private hospitals account for less than

5 percent of all hospital beds.

SOURCES: References 6-9.

Scotland hospitals are not grouped by length of age lengths of stay of 30 days or more are calledstay, and length of stay data are not available for long-term hospitals.hospitals; they are only available for specialties. Over three-fourths of all U.S. hospital bedsThe Scottish hospitals with half or more of their are in short-term hospitals. Denmark and Westbeds in specialties that have average lengths of Germany are not too different; at least two-stay of less than 30 days are called short-term thirds of their hospital beds are in short-termhospitals in table D, and the hospitals with more hospitals. In contrast, over one-half of the Scot-than half their beds in specialties that have aver- tish beds are in long-term hospitals. Although

the U.S. total bed-to-population ratio is lowerthan the other countries’, Scotland reports thesame number of short-term hospital beds-per-population as does the United States. West Ger-many has the highest total bed-to-populationratio and the highest number of short-term bedsper population.

Table E shows the distribution of hospitalbeds in hospitals of different sizes and types.The definitions of short-term and long-term hos-pitals are the same as for table D. The long-termhospitals, many of which are psychiatric hospi-tals, tend to be larger than the short-term hospi-tals. This is particularly true in the United States,wkere hospitals containing 1,000 beds or moreaccount for less than 5 percent of the short-termhospital beds but over 40 percent of the long-term hospital beds. More short-term hospitalbeds in the United States are in hospitals with200-499 beds than in any other size category.

This size category also accounts for a larger per-cent of short-term hospital beds than any othercategory in Scotland and West Germany. In Den-mark, though, over half of the short-term hospi-tal beds are in hospitals with 500 beds or more.Another contrast is that Scotland has a largerpercent of beds in hospitals with less than 100beds than do the other countries.

Table F presents utilization statistics forshort-term hospitals, which are deilned the sameas for table D with the exception of the Scottishhospitals. Since no utilization statistics wereavailable by hospital, the Scottish statistics wereobtained by subtracting the statistics on special-ties with average lengths of stay of 30 days ormore from the totals for all Scottish HealthService hospitals. This procedure probably ex-cludes some patients and beds that are includedin the other countries’ statistics since someshort-term hospitals include departments for

Table E. Percent distribution of hospital beds by type and size of hospital, according to country

Type of hospital and bed size

Short-term hospitals

All sizes.........................................................................................................

O-24 bads.......................................................................................................................26-49 beds.....................................................................................................................50.99 beds.............. ......................................................................................................100.199 beds ...... ...........................................................................................................200-499 beds.................................................................................................................600.999 beds.................................................................................................................1,000 beds or more ..... ...................................................................................... .............

Long-term hospitals

All sizes.........................................................................................................

O-24 beds.......................................................................................................................2549 beds.....................................................................................................................50-99 kds .....................................................................................................................100-199 hds .................................................................................................................20CM99 beds.................................................................................................................600-999 beds............................................................................................ .....................1,000 beds or more ........................................................................................................

Country

~

Percent distribution

100.0

0.20.73.3

16.924.928.026.0

100.0

2.85.57.2

12.936.730.4

4.5

100.0 i 100.01

0.20.03.5

13.913.132.936.4

1.15.5

11.911.922.433.613.7

100.0

0.61.94.5

15.943.918.814.4

100.0

0.62.99.1

20.825.415.427.5

100.0

0.64.2

10.419,241.020.1

4.4

100.0

0.10.63,06.6

15.032.742.0

It)ab are for National Health Service hospitals, excluding hoapitala for the mentally deficient.

SOURCES: References 7-1o.

7

Table F. Salected short-term hospital utilization statistics by country

Country

Short-term hospital utilization statistic Danmark Scotlandl West United

1977 1977-78 Germany States1977 1978

Dischargesper 1,000 population .................................................................................... 178 125 150 170Bed days per 1,000 population ...................................................................................... 1,749 1,205 2,382 1,351Mean length of stay in days ........................................................................................... 10 10 16 8Bed occupancy rate in wrcent ....................................................................................... 78 67 83 73Discharges per bed per year ........................................................................................... 29 25 19 34

lData me for ~U National Heelth Setice hospit~awiththe following specialties excluded: mentef ithse8s, mentrd deficiency,geriatrics, young chronic sick, tuberculosis, rehabilitation, convalescence, and general practice long-stay.

SOURCES: References 6, 8, 9, 11.

long-term care.b On the whole, though, the sta- length of stay twice that in the United States. Intistics refer to similar patients and hospital addition, the bed-day-per-population ratio andfacilities in each country. the bed occupancy rate are higher in West Ger-

The United States stands out on two meas- many than in the other countries. Denmark hasures: It has the lowest mean length of stay of the highest discharge-per-population ratio, andthe countries and the highest average number of Scotland has the lowest. Scotland also has thedischarges per bed. Wes; Germany-presents the lowest bed-day-per-populationgreatest contrast to the United States. It has the occupancy rate of the countries.lowest number of discharges per bed and a mean

ratio and bed

DENMARK

Many separate hospital discharge reportingsystems have begun operation in Denmarkduring the last 10 years. However all collectsimilar data and use uniform procedures anddefinitions. The reporting systems supply datato national inpatient registers. One register re-ceives information on somatic inpatients, that is,inpatients with physical illnesses and injuries.A second register obtains data on all psychiatricinpatients. Additional hospital utilization dataare available from questionnaires collected annu-ally from all Danish hospitals. Household sur-veys are not a source of hospital data. No na-tional health survey has been undertaken inDenmark for several decades.

bIn a subsequent report, the statistics from eachcountry will be adjusted to take such differences intoaccount.

GENERAL HOSPITAL DISCHARGEREPORTING SYSTEMS

In the 1960’s a small number of Danish hos-pitals started pilot projects to collect hospitaldischarge data. The next step was taken by theDanish National Health Service, an advisorybody composed primarily of physicians, nurses,and pharmacists that has a major influence onhealth policymaking in Denmark. In 1968 theNational Health Service set up a working groupto explore the possibility of creating a dischargereporting system for use in all the country’s hos-pitals.12 The working group developed an inpa-tient registration system called M 70, which fivehospitals adopted in 1970. In 1971 two otherinpatient registration systems were established:the &hus system in &hus Municipal Hospital,and the Funen system in Odense Hospital. Thethree systems grew rapidly. By 1973 registrationsystems covered all the hospitals in 10 of the

country’s 16 hospital area.+ and some of thehospitals in 2 other areas. Two-thirds of all gen-eral hospital admissions were reported at thattime.1s By 1979 all but five of the country’shospitals were involved in a registration system,and over 98 percent of all admissions were cov-ered by one.gj 14

The National Health Service and the Asso-ciation of County Councils established a coordi-nating group in 1972 to ensure that comparabledata were collected by all the registration sys-tems. The group included representatives fromthe three general hospital registration sy~tems,the psychiatric inpatient register, the Associa-tion of County Councils, and the Rigshospitalet,which is a university hospital run by the State.The group agreed on a uniform set of items tobe collected by each registration system and de-veloped official definitions and classificationsfor use in all systems. The registration systemscontinue to differ in some ways, but the differ-ences are now mostly technical in nature. 12Since 1976 the National Health Service has re-quired hospitals to send it magnetic tapes con-taining certain basic information about everyinpatient once a year. The tapes are used toform the National Patient Register of somatichospital discharges.

The national and local registers were begunto facilitate clinical and epidemiological researchby increasing access to the information in hospi-tal records, and to collect useful data for medi-cal and administrative decisionmaking withinhospitals and for hospital planning on local, re-gional, and national levels. It was also hopedthat cost data could be linked to registrationdata so that more meaningful analyses of hospi-tal costs could be made. The National PatientRegister is just beginning full operations, butdata from it are already being used for hospitalplanning and medical research.lq ,

Methods of Data Collection

Two systems of data collection are used inDanish hospitals: online and batch.14 Hospitalswith online systems add admission data to com-

cThe hospital areas are the 14 Danish counties andthe 2 municipalities of Copenhagen and Frederiksberg.

puterized patient records at the time of admis-sion; they add information concerning surgicalprocedures when the procedures are performed;and they add discharge data, including diag-noses, when the patient is discharged. Hospitalswith batch systems use a specially designed re-porting form as the front page of the patient’smedical record. They transfer information fromthe form to magnetic tape at the end of eachmonth for all patients discharged during thatmonth. In both systems information is ab-stracted from the medical record and items arecoded by medical secretaries in the hospitals,who approximately correspond to medicalrecord administrators in the United States. Am-biguous cases are referred to hospital doctors forclarification.

Additional data processing is done severalways in the 14 Danish counties. Rigshospitaletand the counties of Vejle and Funen each have acomputer. Frederiksborg and Roskilde countiesprocess data together, as do S@nderjylkmd andRibe counties. The counties of Northern Jut-Iand, &hus, and Viborg have joined a furtherdevelopment of the khus system, now run by apublic computer center, Kommunedata. Somecounties that use the batch system also havedata processed by Kommunedata. Datacentralen,a computer center established in 1959 by theDanish State, counties,” and cities, processesbatch system data from the municipality ofCopenhagen and from some other hospitals.14

Each hospital prepares computer tapes forthe National Patient Register and uses the sameset format. The tapes, which contain informa-tion on each hospital discharge in a calendaryear, are sent to the National Health Servicearound April 1 of the next year.

Coverage

At the beginning of 1979 the inpatientregisters for somatic patients covered the dis-charges in all publicly owned somatic hospitalsand in all but 5 of the 16 private somatic hospi-tals.14 Together the 5 hospitals contained only702 beds, or 2 percent of all somatic beds in thecountry. One with 320 beds, St. Joseph’s Hospi-tal in Copenhagen, closed September 1, 1979.Another with 105 beds, Fysiurgisk Hospital in

.

9

Hornbaek, plans to transfer its functions toRigshospitalet and take part in its registrationsystem. The three remaining hospitals treat long-staying patients; two of them specialize in thetreatment of rheumatism.

Psychiatric hospitals send patient data to aspecial register and are not covered by the otherregistration systems. However hospitals withlong-staying patients are covered by the systems.Six long-term hospitals and four specifllzed hos-pitals in which the average length of stay ex-ceeds 30 days are included in the systems. To-gether these hospitals contain 1,553 beds–4.8percent of all somatic beds–and they accountfor 0.5 percent of the discharges and 5.3 percentof the bed days in somatic hospitals.g

AU patients discharged from the hospitalsincluded in the systems are reported, exceptingthose treated in psychiatric departments, whoare reported to the Psychiatric Register. Mater-nity patients and newborns are reported in thesame way as other discharges, except that someobstetric departments collect additional infor-mation. While women with normal pregnanciesmay choose to deliver their babies at home, in1977 only 0.6 percent of births took place out-side hospitals and clinics.1E

Items Collected

The National Patient Register contains vari-ous items about each inpatient discharged froma somatic hospital.1 ~-lZ Identification items in-clude hospital and hospital department codestaken from the Danish N-ation~ Health ServiceHospital Classification list. The patient’s 10-digitCentral Persons Register (CPR) number is alsoreported. All residents of Denmark have a CPRnumber, which indicates the person’s birth date,sex, and serial number. The health insurancesystem uses CPR numbers to register consump-tion of all medical care services.16 The potentialtherefore exists for connecting the records ofseparate admissions and other uses of medicalcare. Some work has been done to link a pa-tient’s total contacts with a hospital service fora single disease, but these efforts are limited atpresent.l 7

National Patient Register information aboutthe use of hospital services includes the hour and

date of admission, and an optional item, thedate of referral. The place from which the pa-tient was admitted is recorded (home, other hos-pital department, other hospital, nursing home,old age home, emergency department, other,born in the hospital, or not known). The kind ofadmission is also reported (acute, through out-patient department for preliminary examination,other cases through outpatient department,other cases called from waiting list, called ac-cording to decision on previous discharge, orborn in the hospital). The type of patient isgiven, that is, inpatient (patient who receives 24-hour treatment), day patient (part-time -patientwho does not-normally spend.nights in the hospi-tal), or night patient (part-time patient who doesnot normally spend days in the hospital). Thedate of discharge is recorded, as is the place towhich the patient was discharged (home, otherdepartment, other hospital, nursing home, oldage home, convalescent home, other, death, ornot known). Whether the patient was dischargedaiive or dead, and if dead whether an autopsywas performed, are additional items. If the pa-tient was discharged to another hospital or de-partment, the number from the National HealthService Hospital Classification list is recorded.Kinds of aftercare (followed in the same hospitaloutpatient department, in another hospital’soutpatient department, by patient’s own doctor,other, none, death, and not known) are reported,and there is an optional item concerning anyposthospitalization treatment that has beenarranged in an institution (same department,other department, other hospital, nursing home,old age home, convalescent home, other institu-tion, no other institutional care, death, or notknown).

Inpatient characteristics reported to the Na-tional Patient Register, besides birth date andsex (which are part of the CPR numberJ includemarital status, municipality of residence, and aconsiderable amount of medical data. A numberof diagnoses can be reported for each patient,and several items of information are suppliedconcerning each diagnosis. First, any modifica-tion of the diagnosis is recorded (none, observa-tion case-diagnosis not proven, observation case-diagnosis disproven, late effects, earlier, recur-rent, treated or_under treatment, and operated).‘An almost unlimited number of operations can

10

be recorded for each diagnosis, protided theentries do not fill space allotted for other diag-noses, and it is possible to indicate whether twoor more operations were part of a complex surgi-cal procedure. If a patient underwent an opera-tion in a department other than the one towhich he or she was admitted, the number ofthe operating department may also be given.Finally, there is an item on whether the patientwas involved in an accident, and if so, the typeof accident (no, traffic accident, occupationalaccident, sports accident, home accident, otheraccident including attempted homicide, andoptional categories of suicide attempt, and un-certain whether accident or suicide attempt).

Diagnoses are coded using an adaptation ofthe eighth revision of the International Classifi-cation of Diseases, in which codes have beenexpanded to five digits. A sixth digit may beadded for greater detail, and this is sometimesdone by specialized departments. In each casethe doctor decides which diagnosis should belisted as the most important or primary one. Thedoctor also decides the order of importance ofoperations for each diagnosis. An adaptation ofa Swedish four-digit classification system is usedto code operations. Fifth and sixth digits can beadded for greater detail and to indicate opera-tion complications. Included in the classificationsystem are codes for certain extensive examina-tions and nonsurgical forms of treatment, suchas complicated X-ray examinations, biopsies,and cystoscopies.

Definitions and Procedures

Utilization statistics from the National Pa-tient Register include data for long-term andshort-term patients. In addition to long-termhospital patients, long-staying patients withingeneral hospitals, such as those in physiotherapy,convalescent, and long-term care departments,are reported to the register.

The bed-day statistics obtained from theregister concern the number of days of hospitali-zation of patients discharged during the year.The day of admission is counted as a bed day,but the day of discharge is not. If the hospitalstay lasts less than 24 hours, it is counted as 1bed day in length.

Deaths are counted as discharges in calcu-lating utilization statistics, but they can be sepa-rately identified. Transfers between emergencydepartments or intensive care units and otherhospital departments are counted as part of asingle admission, but all other transfers betweenhospital departments are considered dischargesand new admissions. However, transfers can belinked through the use of the CPR number.

The average length of stay is obtained bydividing the total number of days in the hospitalfor a given group of discharges by the number ofhospital stays in the group. The occupancy rateat a point in time is computed by dividing thenumber of occupied beds by the official numberof beds registered in the hospital and multiply-ing by 100. When the occupancy rate for a cer-tain period of time is desired, the number of beddays used during the period is divided by thenumber of registered beds multiplied by thenumber of days in the period, and the resultingfigure is multiplied by 100. In some cases all theregistered beds are not in use, so the number ofavailable beds is used instead of the number ofregistered beds. Patient turnover is calculated bydividing the number of patients admitted duringa certain period by the average number of bedsavailable in the hospital during that period.

Information Published or Available

Some data from the various local inpatientregistration systems have been available since1966. Until 1978 the National Health Servicepublished summary statistics from these systemsin its annual Medical Report II: Report on Hos-pital and Other Institutions for the Treatment ofthe Sick in Denmark.l 8 One example of thetables included in the report is the number ofdischarges by main diagnosis (100 diagnosticcategories), age (14 or under, 15-69, 70 andover), sex, and count y; another is the number ofoperations in each of 16 categories of operationsby hospital and hospital department.

The National Health Service began a newseries of publications in 1972, called MedicalStatistics Reports. By 1976 most of the hospitaldata published in Medical Report II were alsopublished in the Medical Statistics Reports series,so the decision was made to terminate MedicalReport H. National data from the registration

11

systems have not yet been published in MedicalStatistics Report. One 1978 publication didcontain statistics from the registration systemsin three local hospital areas: Copenhagen,Storstr$ms, and Ringk@bing.l 9

The National Health Service sends unpub-lished statistical tables from the National PatientRegister to hospital authorities around the coun-try, but national statistics have not yet becomeavailable. Individual registration systems alsoproduce unpublished statistical tables. Each sys-tem provides its users with diagnostic and surgi-cal files prepared cumulatively for each trimesterand for each year. 1z

OTHER DISCHARGEREPORTING SYSTEMS

Denmark’s Psychiatric Register began opera-tion before the general hospitals’ registrationsystems did. Nationwide registration of personswith mental retardation and certain neurologicaland psychiatric diseases %egan in the 1920’s.Additional psychiatric disorders began to bereported in 1938, and since 1953 all admissionsto and discharges from state mental hospitalshave been registered. In 1969 the registrationsystem was computerized, and by 1970 allpsychiatric institutions were reporting to it.20

The Institute of Psychiatric Demography inkhus is responsible for operating the Psychi-atric Register. It maintains a computer file on allpatients that have received psychiatric treat-ment, and when a patient is admitted to a psy-chiatric facility, the institute sends the facilitycopies of all information from the patient’s pre-vious psychiatric admissions. The institute regu-larly prepares diagnostic files for participatinghospitals and compiles annual reports for thehospitals and the National Health Service.12 Theinstitute also undertakes special research proj-ects concerning the distribution of psychiatricdisorders in certain areas and the use of psychi-atric services.z1-23

Data Collection

The Psychiatric Register receives informa-tion several times during the course of a patient’shospitalization. An initial report that includes

the patient’s name, address, marital status, andother personal data is sent to the institute whena patient is admitted. If the patient remains inthe hospital for 3 months, a second report, con-taining the diagnosis, is sent to the institute. Theinstitute also receives a copy of the hospital’sdischarge letter to the patient’s general practi-tioner that contains a summary of the casehistory. A discharge form is also completed, gen-erally by a hospital medical secretary, and it issent to the institute.20

The register covers all inpatients in public orpfivate psychiatric hospital facilities. In addi-tion, psychiatric units in general hospitals–including the psychiatric departments for chil-dren and adolescents–report their inpatients.The register also covers neurosis sanatoria andinstitutions for alcoholics.

Items Available

The discharge forms sent to the PsychiatricRegisterz” include an item that identifies thehospital in which the patient was treated. Thepatient is identified by his or her CPR number.The date and type of admission are recorded(civil commitment, voluntary commitment,judicial observation, or sentence for custody ortreatment), as is the place from which admitted(residence, general hospital psychiatric ward,psychiatric hospital, sanatorium, child psychi-atric ward, somatic ward, or none of the above).Whether the patient was referred from one ofthe hospital’s outpatient clinics is also noted.

The date and type of discharge are reported(alive, died in the hospital, or died during tem-porary absence), as well as the place to whichthe patient was discharged (residence, generalhospital psychiatric ward, psychiatric hospital,sanatorium, somatic ward, child psychiatricward, or none of the above). Referral to thehospital’s outpatient clinic is recorded sepa-rately. Whether the patient has ever receivedtreatment in a general hospital psychiatric ward,a psychiatric hospital, a sanatorium, a child psy-chiatric unit, or other psychiatric unit is noted,as is whether the patient is a twin.

A main and three auxiliary diagnoses can bereported; the patient’s doctor determines themain diagnosis. The same Danish adaption of theInternational Classification of Diseases that is

12

USt2d m SOmatlC lIOSpltalS 1s USed tO COde the

diagnoses.

Several tables, routinely produced from thePsychiatric Register,$!0 consist of informationabout a detailed list of diagnoses. These lists areavailable for each hospital and for groups of hos-pitals (mental hospitals, general hospital psychi-atric wards, and sanatoria). The tables give thenumber of first admissions and all admissions foreach diagnosis by sex. The number of admissionswith each diagnosis listed as the main diagnosisis reported by sex, as is the number of admis-sions with each diagnosis listed as either themain o.ra secondary diagnosis. Other tables show15 main diagnostic categories. The numbers ofadmissions by sex and age are given for eachdiagnostic category in one table; in another thenumbers of discharges by sex and length of stayare reported for each diagnostic category.

The tables are sent annually to the NationalHealth Service. They were published in MedicalReport H until it ceased publication in 1978.The last edition of the report contains data per-taining to psychiatric patients hospitalized infiscal year 1974-75. In 1979 similar tables con-taining data about psychiatric patients hospi-talized in 1975-76 were published separatelyin the Medical Statistics Reports series.24

A 1978 publication in the Medical StatisticsReports series also covers Psychiatric Registerdata.zs It reports numbers and rates of inpa-tients in psychiatric treatment facilities on April1, 1976 (the date when psychiatric state hospi-tals were transferred to the local county admin-istrations). The data were presented by residencein local hospital areas; by type of institution andresidence; by age (age 0-14 years, 15-24, 25-44,45-64, and age 65 years and over) and residence;and by diagnosis, length of stay, and residence.

Unpublished data from the PsychiatricRegister are sent to individual hospitals quar-terly and annually. The hospitals receive a list ofdiagnoses that includes the name, CPR number,and other information on each patient.zo

AGGREGATE HOSPITAL REPORTS

In addition to re~ortin~ data to the National

Service. The questionnaires request informationabout hospital facilities, costs, personnel, andutilization. General hospitals began using thequestionnaires in 1960, and now all Danish hos-pitals use them. Data for a calendar year arereported, and the completed questionnaires areforwarded to the National Health Service byMarch 1 of the following year.

The hospital utilization questionnaire re-quires the name of the hospital and department,the National Health Service hospital, depart-ment, and specialty code numbers, and the totalnumber of patients treated in the hospital. Sepa-rate data are reported for two groups of pa-tients: 24-hour patients and part-time patients(part-time patients are those who receive onlyday or night care). The numbers of patients ineach group who were in the hospital on the firstday of the year and on the last day of the yearare recorded. The numbers of admissions, dis-charges, and deaths in each group are also given.A separate count is made of the number of pa-tients in each group who had been in the hospi-tal for the entire calendar year or longer. Thetotal number of bed days used by each group ofpatients during the year is reported, along withthe number of registered beds. Outpatient visitsare also counted: The form requires the totalnumber, the number of acute visits, and thenumber of nonacute visits in the year.

The National Health Service uses the sameformulas and definitions to calculate utilizationstatistics from the completed questionnaires as itdoes for the analysis of National Patient Registerdata, except that bed days used during the yearrather than bed days of discharges are com-puted. The statistics were published in MedicalReport H until it was discontinued. Now theyare available in publications titled “Output Sta-tistics for the Hospital System,y’g which are aregular part of the Medical Statistics Reportsseries.

The publications list all Danish hospitals anddepartments within hospitals. The following arereported for each department: beds, admissions,discharges, deaths, patients present at the end ofthe year, bed days, average daily number of pa-tients, occupancy rate, and average length ofstay. The numbers of acute, nonacute, and total

Patientannual

Register, D~ish h&pital staffs completequestionnaires for the National Health

outpatient visits~ven. A second

to each departmentlist presents similar

are alsodata by

13

hospital region for 15 somatic specialties and forpsychiatry and child psychiatry. In addition, thenumbers of admissions, discharges, deaths, andpatients present at the end of the year are re-ported separately for part-time patients by hos-pital and department. Summary tables showutilization statistics for each hospital region andtype of hospital.

HOUSEHOLD SURVEYS

No major household health survey has beenundertaken in Denmark in recent years. Theneed for periodic surveys has been recognized,especially for those that would gather dataabout illness and patterns of contact with pri-mary health services.z6 However no plans to ini-tiate such surveys have been made. 14

The only nationwide health survey that hasbeen done in Denmark is the two-part MorbiditySurvey of the 1950’s. The first part, the 1951-54Sickness Survey, obtained information on asample of 87,000 adults living at home. Inter-viewers were asked detailed questions about thediseases they had experienced and about suchsocial characteristics as age, sex, marital status,

housing situation, income, and occupation. Theyalso reported any hospitalizations that hadoccurred during a monthlong period, as well asthe hospital’s name and address, the admissiondate, and the illness or injury for which theywere admitted. In 1960 the survey results werepublished in The Sickness Survey of Denmadi.z7

The second part of the Morbidity Survey,the 1952-53 Hospital Survey, gathered informa-tion on a sample of 33,000 adults who had beenadmitted to public medical and surgical hospi-tals. Patients in the State-run university hospitalor specialized departments of other hospitalswere excluded. Each admission in the samplewas reported in part by a doctor, nurse, or secre-tary, and in part by the research staff. Utiliza-tion data included the time spent in the hospital,waiting time before admission, previous admis-sions, and followup care. The reported socialcharacteristics of the patients included age, sex,marital status, occupation, income group, andpayment status. Medical data consisted of diag-noses, operations, nursing treatment during hos-pitalization, laboratory tests, X-ray examina-tions, and condition on discharge. In 1959 theresults of the survey were published in The Hos-pital Survey of Denmark.z8

Discharge reporting systems in Scotlandcover all inpatients treated by the ScottishHealth Service. Three reporting systems areused: one for maternity inpatients, one for psy-chiatric inpatients, and one for other hospital in-patients. Also, summary statistics on all types ofScottish Health Service inpatients are collectedtwice a year. In addition, Scotland is includedwith England and Wales inhold Survey, which obtainsinformation.

the General House-hospital utilization

GENERAL HOSPITAL DISCHARGEREPORTING SYSTEM

Hospital statistics were first collected inScotland in the 1940’s. A nationwide Cancer

Registration that received data on hospital pa-tients was established in 1945, and certain coun-ties conducted studies of hospital-treated illnessunder the sponsorship of the Nuffield ProvincialHospitals Trust.zg Not until the Scottish HealthService began, however, were plans made for acomprehensive reporting system.

The National Health Service (Scotland) Actof 1947 divided Scotland into five regions; ineach a Regional Hospital Board administeredhospital and specialist services. The Departmentof Health, which became the Scottish Home andHealth Department in 1962,provided central ad-ministration. In 1950 the regional boards andthe Department of Health established a plan tocollect national hospital discharge statistics. In1951 the Northern Region began to collect dis-charge data from its general and maternity hos-pitals, but various constraints prevented the

other regions from introducing the system. Overthe next few years, individual hospitals in theother regions adopted the reporting system, butnot until 1961 were the Scottish Hospital In-Patients Statistics (SHIPS) collected throughoutthe country. At that point maternity hospitalswere excluded from the reporting system, but aseparate reporting system for obstetrical inpa-.-

~ tients was introduced in 1969.~YIn 1974 the Scottish Health Service was

reorganized. Fifteen health areas were created,each administered by a health board. The newlyformed Common Services Agency took overmany of the staff functions of the Home andHealth Department, and the Information Serv-ices Division of the new agency became responsi-ble for the collection and analysis of SHIPS.

Initially the main purpose of SHIPS was toprovide hospital use information for the healthservice’s regional and central administrators. Ad-ministrators were especially concerned with hos-pital usc since hospitals were the most costlypart of the health service. It was expected thatthe collection of individual patient recordswould allow more flexibility in the analysis ofhospital use than was possible with aggregatehospital reports, and that information obtainedfrom the analysis would be very valuable to ad-ministrators who must decide how to best usehealth resources and plan for the future.2g~30

In addition, SHIPS data were expected toprovide important epidemiological information.Data on the conditions for which hospital pa-tients were treated and on patients’ demographiccharacteristics helped to outline some of themore serious morbidity patterns in the commu-nity. The data had to be interpreted with carebecause only a portion of total morbidity wasreported, and cases of treatment rather than in-dividual persons were reported. However thedata were still considered useful additions toother sources of epidemiological information.3 1

After a few years, the potential value ofSHIPS to individual hospital managers andclinicians became apparent. In 1968-69 the Scot-tish Consultant Review of l&Patient Statistics(SCRIPS) were introduced. SCRIPS are annualreturns that report each physician’s inpatientworkload and supply comparative data on otherworkloads in the country as a whole. The in-

tended purpose of SCRIPS was to provide physi-cians with a basis for self-assessment of theirpatient care practices. This was expected to re-sult in more effective and efficient treatmentpractices. In addition, receiving individual re-ports could stimulate clinicians’ interest in hos-pital data collection and lead them to improvethe data’s accuracy and timeliness.32

The quality of the data has been an ongoingconcern. Detailed studies have been done of theextent and type of errors in the data,33~34 andmuch attention has been given to possible waysof improving the data collection process, includ-ing upgrading recordkeeping within the hospi-tals.35 At present, validity checks in the com-puter system can remove reports of impossibleor highly unlikely events, such as hysterectomiesin males or senile dementia in children.

Much use is made of the data. The ScottishHome and Health Department and health boardadministrators utilize the data to plan and moni-tor the health service. Many physicians consultthe SCRIPS and request additional ad hoc anal-yses from the Information Services Division, anduniversity researchers have increasingly requestedspecial types of data.

Methods of Data Collection

When an inpatient is discharged from a Scot-tish Health Service hospital or hospital depart-ment, discharge form SMR 1 is completed. Whilethe physician in charge of the case is officiallyresponsible for seeing that the form is accuratelycompleted, medical records and clerical staff ab-stract the patient data, usually with little guid-ance from the physician .30 The records staffs areemployed by the health boards; the InformationServices Division has no direct managerial con-trol. Often, completing the discharge forms isonly one of the records staff’s many responsibili-ties, and delays and backlogs develop. The hos-pital staff codes all the information required onthe forms except for the inpatient’s occupation,which is coded centrally.w..

In most cases the hospitals send the dis-charge forms to the area health boards, and theboards forward them to the Information ServicesDivision for processing at the national computercenter. Two health hoards process their own

15

data. Two other computer centers, one in Edin-burgh and one in Glasgow, analyze data for thelarge hospitals in each of those areas. The localdata centers perform the same validity check asis used in national processing and must submitthe basic set of standardized data to the nationalcomputer center. However they are free to col-lect whatever additional data they wish.sq Thenational center transfers all discharge data ontocomputer tapes, performs the validity and feasi-bility checks, and produces the routine output.The tapes are retained in order to meet specialrequests for tabulations.

Coverage

SHIPS only cover patients treated by theScottish Health Service, but more than 95 per-cent of all hospital beds in the country are partof the service. Scottish Health Service maternityand psychiatric patients are not covered bySHIPS regardless of whether they are treated inspecialized hospitals or specialized wards of gen-eral hospitals. Data concerning these patients arecollected but are sent to separate reporting sys-tems and are processed and tabulated separately.

All other inpatients should be reportedwhether they are in general or specialized hospi-tals or units. The Information Services Division

(ISD) has no way to be certain that a form iscompleted for every discharge, but comparisonsbetween the number of discharge forms receivedby ISD and the total number of discharges re-ported on the annual aggregate hospital returnshave found an unexplained difference of lessthan 1 percent in number of dischargesreported.~ 1

Long-term-care hospitals and units are partof the health service and therefore are includedin the reporting system. Since no separate set ofinstitutions similar to U.S. nursing homes existsin Scotland, almost all long-term inpatient careis provided by the health service hospitals.8G Thefollowing long-term specialties are covered bythe reporting system: rehabilitation and physicalmedicine units whose patients average 30-dayhospital stays, respiratory tuberculosis unitswith 46-day average stays, geriatric assessmentunits with 62-day average stays, geriatric long-

term units with 345-day average stays, and wardsfor younger chronic patients with 478-day aver-age stays.37

Items Collected

The SMR 1 form37 used to collect hospitalstatistics contains several identification items,including the hospital code number and the pa-tient’s case reference number. Many hospitalsassign a single case number. to a patient for allhis or her admissions, but some assign numbersto admissions in sequence or use some other SyS-tem, so that patients admitted more than onceobtain different case numbers each time they arein the hospital.38 The patient’s last name, firstname initial, and last name at birth are akorecorded.

Hospital utilization items collected includethe date the patient was placed on the waitinglist for admission, and the date, source, and typeof admission. The date of the principal opera-tion is recorded, as is the date of discharge,whether the patient was discharged alive ordead, the type of bed the patient occupied priorto discharge, and the hospital division or unitfrom which the patient was discharged or trans-ferred. The physician in charge of the patient’scase is also identified.

Social and demographic items collected in-clude age, birth date, marital status, and resi-dence. Residence has been recorded by postalarea since 1974, but much difficult y has beenencountered in the use of these codes. The occu-pation of each patient is recorded as well. If thepatient is a married woman, the husband’s occu-pation is also recorded. If the patient is a child,the father’s occupation is recorded. Often thehusband’s or father’s occupation is not reported.In other cases the information given is impre-cise, but the information is mainly used toassign patients to a social class, and it has beenfound to be adequate for statistical purposes.so

The medical items include the principal diag-nosis, three other diagnoses, and the externalcause of injury (“E”) codes. The principal diag-nosis is defined as the main condition treated orinvestigated during the admission. If no diag-nosis is made, the main symptom or problem is

16

recorded.37 Since January 1, 1980, the ninthrevision of the International Classification ofDiseasessg has been used to code diagnoses. Aprincipal operation and one other operation canbe reported, and the operations are coded usingEngland’s Office of Population C&suses andSurveys codes. Both operations and diagnosescan be coded to four digits.

Definitions and Procedures

The statistics routinely produced from theSHIPS data include both long-term and short-term patients. Patients treated in the long-termspecialties account for only about 4 percent ofthe discharges reported to SHIPS, but since theyuse 37 percent of the total bed days, they have aconsiderable impact on the statistics. Specialanalyses are often done of general hospital useby patients age 65 years and over who are themajor users of the long-term specialties.40

The bed-day statistics refer to days used bythe patients discharged during the yearlongreporting period. Until 1979 admission and dis-charge days were each counted as bed days, butnow only the admission day is counted as abed day.41

The number of discharges includes the num-ber of deaths and transfers. Admissions endedby regular discharges, by deaths, and by trans-fers are often referred to as “spells” in the hospi-tal; data on each type of spell can be obtainedseparately if desired. Transfers between hospitalsand between different specialties within a singlehospital are counted as discharges and new ad-missions. In 1976 approximately 8 percent of allspells were interhospital transfers and 3 percentwere intrahospital transfers.3T Transfers and re-peat hospitalizations of the same patient can belinked through use of the following identifyingdata collected on the discharge forms: name,sex, birth date, and sometimes hospital casenumber.38 However the routine statistics are forspells, not patients.

Discharge and bed-day rates are calculatedper 1,000,000 population or per 100,000 popu-lation.3T~40 Until 1974 discharge rates referredto the population of the patient’s area of treat-ment, but since 1975 they have referred to the

)

patient’s area of residence. The average length ofstay is obtained by dividing the number of beddays by the number of spells of treatment.

Information Published or Available

The data collected by SHIPS have been pub-lished annually since 1961 in Scottish HospitalIn-Patient StatzMcs.37 Tables in the publicationpresent statistics on the total number of dis-charges and discharge rates, bed days, bed-userates, mean length of stay, mean waiting time,and number of surgical operations. These statis-tics are cross-tabulated by various items of infor-mation, including sex, diagnosis, age group (age0-4 years, 5-14, 15-24, 25-44,45-64,65-74, andage 75 years and over), health board area, sourceof admission (emergency, from the waiting list,booked case, or admission from other sources),condition at discharge (dead or alive), place towhich discharged (home, convalescent hospital,other hospital, Local Authority or other care,transfer within the hospital, died, or irregulardischarge), hospital division or unit at discharge,and number and type of operations. Five-yeartrend data are also given on number of dischargesand mean length of stay by sex and diagnosis.

The annual publication Scottish Health Sta-tistics40 also presents data from the reportingsystem. The tabulations are less extensive, butthe most recent publication contains tables onthe discharge rate by diagnosis over a 7-yearperiod; the discharge rate by diagnosis and healthboard area; the number of discharges and meanstay by sex, diagnosis, and age (O-4 years, 5-14,15-44, 45-64, and 65 years and over); and thenumber of discharges and beds used by area oftreatment and area of residence.

Unpublished tables are routinely sent to eachhospital and health board concerning the hospi-tal’s activity and the activity of the hospitals inthe board’s area, respectively. While the tablescontain information similar to that which is pub-lished, it is analyzed for each hospital and itsdivisions or units. The number of discharges istabulated by age, sex, condition at discharge,source of admission, area of residence, and diag-nosis. The mean length of stay is given by sex,age, and diagnosis; regional and national mean

17

stays are provided for comparison. The numberand percent of discharges who were admittedfrom the waiting list and the mean waiting timeare reported by sex and diagnosis, along withregional and national waiting times for each sub-category. The health district of residence of dis-charged patients is given for the hospital as awhole and for each hospital department.so~s1

In addition, each hospital receives a diag-nostic index consisting of information on all itsdischarges; the patients are listed by diagnosis.For each patient, the birth date, sex, other diag-noses, physician, month admitted, area of resi-dence, marital status, occupation, social class,source of admission, days on waiting list, days inthe hospital, unit from which discharged, condi-tion at discharge, and operations are reported.31An operation index is also provided.

The SCRIPS returns, which are sent to eachphysician and detail his or her activity, are alsocompiled from the SHIPS data. One SCRIPStable reports the distribution of cases the physi-cian treated during the year, categorized by diag-nosis. The number of cases, percent of all casesin the specialty, median stay, median waitingtime, percent of cases admitted as emergencies,percent of cases discharged to home, percentoperated upon, and number of fatalities aregiven by sex for each diagnostic category. Ex-cept for the number of fatalities, statistics aregiven in each category for all cases treated in thesame specialty in Scotland as a whole. A secondtable, sent to surgeons, reports the distributionof cases by type of surgical procedure and givesthe same statistics for cases in each procedurecategory (except the percent operated). The per-cent of cases with an admission-to-operationinterval of less than 3 days and the medianoperation-to-discharge hospital stay are also in-cluded. Again, all the statistics are given by sex,and statistics for all cases operated upon in thesame specialty in Scotland as a whole are re-ported in each category, except fatalities. Adiagnostic index is also provided to physiciansthat lists all the physician’s discharges by diag-nosis and reports the birth date, sex, up to fourdiagnoses, external cause of injuriels, month ofadmission, health board of residence, maritalstatus, source of admission, type of admission,days on the waiting list, days of stay, unit from

which discharged, disposition, up to two opera-tions, and the case number of each discharge.

OTHER DISCHARGEREPORTING SYSTEMS

Data about Scottish psychiatric and mater-nity patients are collected by virtually independ-ent discharge reporting systems.d The mentalhealth reporting system, begun in 1963, coverspatients in mental hospitals, general hospitalpsychiatric units, and mental deficiency hospi-tals in the Scottish Health Service. The mater-nity reporting system began to cover healthservice patients in maternity hospitals and ma-ternity wards of general hospitals in 1969. Themental health system has achieved 100-percentcoverage of hospitalized psychiatric patients,and the maternity system covered 99.6 percentof inpatient deliveries in 1977.41 Less than 1percent of all deliveries in Scotland take place athome. Data are collected on home deliveries intwo areas of the country, but the data are notincluded in the published maternity statistics.

The two specialized reporting systems oper-ate in much the same fashion as does the generalhospital reporting system. Information ab-stracted from the medical record is entered ontoa discharge form for each patient dischargedfrom a participating hospital or unit. The psychi-atric services also complete admission forms oneach patient. The medical records or clericalstaff codes the forms and forwards them eitherto the area health board or to the InformationServices Division (ISD) of the Common ServicesAgency. Most psychiatric hospitals send theirforms directly to ISD, but two health boards,Grampian and Tayside, computer process theirown psychiatric data. Maternity data are usuallysent first to the health boards and then to ISD.

Most items collected on the mental healthand maternity discharge reporting forms are the

dIt is not strictly correct to refer to the psychiatricreporting system as a discharge system, since it is basedon reporting both at the time of admission and dis-charge, and the main emphasis is on the admissionreports.

18

same as those collected on the general hospitalrcl~orting forms.34 The hospital and specialtyam identified on all the forms, and the patient’scase reference number, name, initials, and birthSLrname are requested by all. The admission anddischarge dates are reported, as is the type ofdischarge. Social and demographic items on allthe forms include birth date, area of residence,and occupation. Common medical items includediagnoses and condition at discharge.

The maternity forms require additional in-formation including the mother’s marital statusand marriage date, religion, number of previouspregnancies and their outcome, operations, andclinician. Detailed data on the pregnancy, labor,and delivery are requested, and the sex and birthweight of the child are reported.AZ Mental healthforms require additional information that con-cerns the patient’s diagnoses on admission andlegal status at admission and discharge.34

For the most part, the two specialized re-porting systems use the same definitions andformulas as does the general hospital system.Some additional statistics are calculated for psy-chiatric patients, such as the number of admis-sions, admissions per 100,000 population,number of residents, and residents per 100,000population. The term “resident” refers to pa-tients present in the psychiatric facility on De-cember 31 of a particular year. The psychiatricsystem also uses the term “transfer-in” for anadmission that results from an inpatient movingfrom one psychiatric hospital to another.AO

Since the early 1970’s data from the mentalhealth reporting system have been published an-nually in Scottish Mental Health In-Patient Sta-tistics.43 The publication containing 1974 dataand those that have appeared subsequently arecomposed of 16 types of tables; most are in setsof 4. The set consists of one table that presentsinformation on all patients in psychiatric hospi-tals and units, and three separate tables that pre-sent the same information for mental hospitalpatients, psychiatric unit patients, and mentaldeficiency hospital patients. The information inall the tables is reported separately for males andfemales.

In addition to sex, the publication reportsadmissions by age (0-14 years, 15-24, 25-34,35-44 ,. ... 75-84, and 85 years and over), diag-

nosis (detailed and short lists), legal category of

admission, health board of treatment, and sourceof referral (psychiatric outpatient cIinic; psychi-atric day unit; domiciliary visit; nonpsychiatricclinic or ward; general practitioner; seIf, rela-tives, or friends; prison or judicial; LocalAuthority agency; transfer from other psychi-atric inpatient care; or other sources such asministers, voluntary agencies, and the like). Thenumber and percent of all admissions that arereadmission are also reported. Statistics on resi-dents in the hospital at the end of the year arereported by age, diagnosis, health board of treat-ment, and duration of stay (less than 1 week,1 week to 1 month, 1-2 months, 2-3 months,3-6 months, 6-9 months, 9-12 months, 12-18months, 18 months to 2 years, 2-5 years, 5-10years, 10-15 years, 15-20 years, and 20 years ormore). Discharges are reported by age, diagnosis,duration of stay, and disposal on discharge(died, left on own accord, home, hostel, trans-ferred to mental hospital, transferred to mentaldeficiency hospital, transferred to psychiatricunit, transferred to geriatric care, transferred toother inpatient care, penal institution, other,‘and not known). Time-series data covering an8-year period are presented on admissions,residents, and discharges.

Scottish Health Statistics also presents datafrom the mental health reporting system.Though less extensive than data in ScottishMental Health In-Patient Statistics, the data in

Scottish Health Statistics are usually more up-to-date. Scottish Health Statistics, 1977,40 pub-lished in 1978, contains tables of provisionaldata from 1977. The data are separated into twosets of tables: one for mental hospitals and psy-chiatric units together, and the other for mentaldeficiency hospitak. Reported statistics includethe number and rate of admissions, percent read-mission, number and rate of residents, numberof discharges, and mean length of stay. Variablesused to cross-tabulate the statistics include sex,age, diagnosis, health board of residence, typeand category of admission, and type of disposalat discharge. Time-series data covering 1965 to1977 are also presented.

No separate publication is produced fromthe data coIlected by the maternity reportingsystem, but some statistics from the system are

19

included in Scottish Health Statistics. In Scot-tish Health Statistics, 1977,40 1976 statisticsare reported for mothers and newborns. Onetable presents the number and mean stay ofmaternity admissions by type of admission(antenatal; postnatal; delivery; and other, mainlyabortion) and age (less than 20 years, 20-24,25-29, . . . . 40-44, and 45 years and over).Another table gives the number of discharges,mean length of stay, and percent distributionof maternity discharges in length-of-stay cate-gories (less than 3 days, 3-7, 8-14, 15-28, and29 days and over) by type of admission (abor-tion; antenatal; delivery, in labor; delivery, notin labor; postnatal; transfers; and others, notpregnant) and type of unit (specialist or generalpractitioner). The number of maternity dis-charges, percent discharged from obstetric con-sultant units versus obstetric general practiceunits, and mean stay of discharges are reportedby area of residence. The number of deliveries ispresented, along with the percent of differentmodes of delivery (spontaneous, forceps,vacuum extraction, breech, cesarean, and other),the number and percent that were induced, andamong induced deliveries, the method used(arm, oxytocins, arm and oxytocins, and others),all according to health board of treatment. Theoutcome of pregnancy, whether a still or livebirth, and birth weight in grams (under 500,500-1,000, 1,000-1,500, . . . . 4,000-4,500, andover 4,5 00) are tabulated by area of residence.Finally, the number and rate per 1,000 livebirths of perinatal deaths are given by birthweight and area of residence.

Like the general hospital reporting systems,the specialized reporting systems produce un-published tabulations, which are sent to thehealth boards and hospitals in the systems. Inaddition, psychiatric clinicians receive returns onthe activity of their hospitals.

AGGREGATE HOSPITAL REPORTS

Besides individual discharge reports, all Scot-tish Health Service hospitals complete aggregatestatistical reports of their workloads. The hospi-tals complete the so-called ISD(S)l forms andsend them to their health boards. In some areas

the forms are submitted to the health boardsweekly; in others, monthly. Twice a year thehealth boards forward magnetic tapes that con-tain most of the data from the forms to the In-formation Services Division (ISD) of the Com-mon Services Agency. The ISD compiles twoannual summaries, one for the year endhgMarch 31 and one for the year ending Sep-tember 30.44

The forms contain information about thetotal number of available bed days, and fromthis information ISD calculates the average dailynumber of beds that were staffed and availablefor the reception ‘of patients. Since 1976, whenform ISD(S)l was introduced, the calculation ofthe average daily number of beds has includedborrowed, temporary, and lent beds. (Previouslysuch beds were not taken into account; there-fore, adjustments must be made when statisticsare compared over time.) AIso reported is thenumber of aIlocated staffed bed days, which isthe sum of the daily number of beds allocated toa specialty that were staffed and available forthe reception of the patients during the year.

The number of total occupied bed days isgiven, which is the sum of the number of beds ina specialty occupied at the time of the daily bedcount on each day during the year. The bedcount generally takes place between midnightand 8 a.m. Since 1976 total occupied bed dayshas also included borrowed, temporary, and lentbed days. The category also includes patients ontemporary leave from the hospital at the time ofthe bed count. It should be noted that totaloccupied bed days is not equivalent to total beddays of discharges, which is obtained from thedischarge reporting systems. Unlike total occu-pied bed days, total bed days of discharges in-cludes bed days used in a previous year or yearsif a discharge’s hospitalization extended throughmore than one reporting period, and it excludesthe bed days of patients still in the hospital atthe end of the reporting period.

The number of inpatients discharged is re-ported on ISD(S)l; this form includes deaths,transfers between hospitals, and transfers be-tween specialties within hospitals, as well asroutine discharges. Intrahospital transfers fromone specialty to another have been counted asdischarges only since 1976 and are also reportedseparately. Patients, such as day patients or

20

night patients, who are not hospitalized for full24-hour periods are not counted as discharges.

Statistics ca.Iculated from the colIected dataincIude the average duration of stay, percentoccupancy, turnover interval, and throughput.The average duration of stay is obtained bydividing the total occupied bed days by thenumber of discharged inpatients. The inclusionof intrahospita.1transfers in the number of dis-charges led to a slight reduction in the averagestays reported since 1976. Percent occupancy isthe total occupied bed days multiplied by 100and divided by the number of available staffedbeds. Turnover interval is the number of avail-able staffed bed days minus the total occupiedbed days divided by the number of inpatientsdischarged. Throughput is the number of dis-charged inpatients multiplied by365 and dividedby the number of available staffed bed days.

Data from the ISD(S)l forms are reported inthe following annual publications: HospitalUtilisation Statz’stics,l1 Scottish Health Statis-tz’cs,hoand Hospital Bed Resources.~ One set oftables in Hospital Utilisation Statistics gives sta-tistics for Scotland as a whole and for eachhealth board by specialty. Almost 50 differentspecialties are listed, including such medical andsurgical specialties as cardiology, urology, andthoracic surgery, and obstetric, psychiatric, andlong-term specialties. The tables present thenumber of approved beds; the number of per-sons on the waiting list; the number of allocated,borrowed, lent, temporary, all available, andtotal occupied bed days; the number of dis-charges and deaths; and the number of intrahos-pital transfers into and out of the specialty. Asecond set of tables shows the average numberof allocated staffed beds, the number on thewaiting list per allocated staffed bed, the num-ber of allocated staffed beds per 100,000 popu-lation, throughput, mean stay, turnover interval,and the number of discharges per 100,000 popu-lation for each specialty by health board. Sepa-rate sets of tables with similar formats report oninpatients in joint-user hospitals, wh;ch areLocal Authority institutions that make bedsavailable to health boards, and on inpatients incontractual hospitals, which are institutionsoperated by voluntary bodies in which the healthboards use beds. Data are also presented on out-patient visits to health service hospitals.

Many of the same statistics are included inScottish Health Statistics, again tabulated byspecialty and health board. Hospital Bed Re-sources contains information on available staffedbeds and bed complements of aUScottish hospi-tals and the totaI bed stock in each health dis-trict of the country.

HOUSEHOLD SURVEY

Scotland has been included in the GeneralHousehold Survey since the survey began in1971. The ongoing survey is conducted by theSocial Survey Division of the Office of Popula-tion Censuses and Surveys (OPCS), which islocated in England. It covers five main subjectareas: population, housing, employment, educa-tion, and health. The data from the survey areexpected to suppIy government agencies with in-formation that wilI assist resource aUocation de-cisions. The survey results have routinely beensent to about a dozen government departments,and researchers outside the government haveshown increasing interest in them.

Data Collection

The survey data are colIected from a largesample of households in Great Britain. In 1977,15,315 households were included.45 Interviewsare conducted with all adult household mem-bers, who also furnish information about theirchildren under age 16. Institutionalized indi-viduals are excluded from the study. The sampleis drawn in a two-stage process, first sampIingelectoral wards and then selecting addresseswithin each ward from the Electoral Register.The sampIes are stratified by type of area (met-ropolitan or nonmetropoIitan), by socioeco-nomic group of the head of the household, andby the proportion of householders who areowner-occupiers.

Items Available

A great deal of information is collectedabout the social and demographic characteristicsof the individuals in households covered by thesurvey. Age, sex, marital status, length of time at

21

present address, type of housing, skin color,country of birth, family size, type of employ-ment, income, education level, and region areinvestigated. Information about the utilizationof ambulatory and inpatient health services isalso collected, as are data on the incidence ofacute and chronic sickness. The information onhospitalization includes a question about inpa-tient care during the 3 months prior to the inter-view and the length of stay in the hospital. If aperson is currently on a waiting list for hospitaladmission, the length of the wait is reported.

The OPCS has published the survey resultsin a series titled General Household Survey .45 In

1979, data collected in 1977 were published asthe seventh number in this series. In recent yearsthe information in the publication on hospitali-zations has been limited to tables of the numberof medical and surgical inpatient visits per 1,000persons in a 3-month reference period, and theaverage number of inpatient nights per visit,both given by age group and sex. The publisheddata are for Great Britain as a whole, thoughsometimes statistics for England and Wales arereported separately. Unpublished statistics onScotland are available and can be obtained, sub-ject to certain restrictions, in the form of eithertables or magnetic data tapes.

WEST GERMANY

In West Germany hospital discharge data areavailable from a variety of sources. Sickness in-surance funds collect information about theirmembers’ hospitalizations. One small West Ger-man State, Schleswig-Holstein, operates a dis-charge reporting system in its acute care hospi-tals. In another State, Northrhine-Westphalia, apsychiatric hospital reporting system has beenorganized. In addition, army hospitals have aspecial reporting system. Official hospital statis-tics for the country as a whole are collected bymeans of aggregate hospit,al reports by the Fed-eral Statistical Office in cooperation with Statestatistical offices. The Federal Statistical Officealso operates the Microcensus, an ongoing na-tional household survey that collects some infor-mation about hospitalization.

GENERAL HOSPITAL DISCHARGEREPORTING SYSTEMS

The sickness insurance funds’ data systemsand the Schleswig-Holstein reporting system arethe main sources of national and regional diag-nostic data for patients treated in general hospi-tals. The sickness insurance funds and their hos-pital data systems are discussed first in thissection, followed by a description of theSchleswig-Holstein system.

Sickness Insurance Funds

Compulsory health insurance was establishedin Germany in 1883. At that time a number ofvoluntary sickness benefit societies already ex-isted in the country. While the insurance lawrequired certain workers to join a society orfund and established regulations concerning theoperation of the funds, it allowed the funds toremain independent entities. The insurance sys-tem has since expanded, but continues to beadministered by autonomous funds.

In 1976 there were 1,425 sickness insurancefunds in operation.4G The funds are governed byboards of directors, whose members equallyrepresent employers and workers. The State gov-ernments and the Federal Ministry of Labor andSocial Affairs supervise the funds, which coverapproximately 96 percent of the population.4 yMembership in a fund is compulsory for mostworkers, including all manual and salariedworkers whose income is below a certain level, alevel that changes periodically. Other workerscan join funds as voluntary members. The fami-lies of workers are not, in a strict sense, mem-bers of the funds, but insurance coverage doesextend to them.

There are eight types of sickness insurancefunds: Local Sickness Funds, Company SicknessFunds, Guild Sickness Funds, Agricultural Sick-ness Funds, Seaman’s Sickness Funds, Miner’s

22

Sickness Funds, Compensation Sickness Fundsfor Workers, and Compensation Sickness Fundsfor Employees. Over half of the insured workersin West Germany belong to the first of these, theLocal Sickness Funds.48 Workers usually jointhe Local Sickness Fund in their area, unlessthey are employed by a large business that hasits own fund, belong to a guild with a fund, orare involved in an occupation that operates afund. Many of the funds are organized into asso-ciations at the State and Federal levels by typeof fund; such as State and Federal associationsof the Local Sickness Funds.

The sickness insurance funds collect reportsof the hospital use of members and their fami-lies. Reports are made of all insured hospitaliza-tions, whether the patients are treated in theacute care hospitals or in the special care hospi-tals, which primarily treat long-staying patients.The data are not separated by type of hospital.Additional information, including the age, sex,and diagnoses of insured hospitzd patients, is col-lected by the funds on a sample basis. The diag-noses are coded according to the InternationalClassification of Diseases.4g

The individual sickness insurance funds sendthe collected data to the State sickness fundassociations, which forward the data to the Fed-eral associations. The various Federal associa-tions supply the data to the Ministry of Laborand Social Affairs, which adds it to its Sozial-datenbtmk (social data bank). Some ho’ipltal-usestatistics from the data bank are pubIished regu-larly, for instance in Survey of Social Secwz”ty ;50unpublished data are availabIe for special studies.

The different Federal associations of thesickness insurance funds also publish annual re-ports. These reports contain more detailed infor-mation about hospital use than does the Surueyof Social Security but are less comprehensive,since each association’s report only covers thehospitalizations of its members and their fami-lies. An example of an association report is thepublication of the Federation of Local Sick-ness Funds on types and causes of illness, anddeaths.s 1 The 1979 edition of this publicationcontains 1977 statistics from 267 Local Sick-ness Funds that represent 90 percent of alI thefund members. The participating funds reported

data from a 20-percent sample of the hospitalcases that they handled. The data are presentedseparately for various membership categories(compulsory members, voluntary members, pen-sioners, and members’ famiIies). The number ofhospital cases and bed days, average number ofdays per case, and number of cases and bed daysper 10,000 members are shown for each mem-bership category, by sex and diagnosis. The samestatistics are given for each membership categoryexcept families of members and are divided bysex, diagnosis, and age (14 years or under, 15-19,20-24 9 ...9 60-64, and 65 years and over). Thesame statistics are also reported for compulsorymembers and are divided by sex, age, and causeof illness (work accident excluding road acci-dent; road accident; occupational disease; trafficaccident excluding road accident; sports acci-dent; other accident; murder, assault, battery;suicide, suicide attempt, self-inflicted injury; andmilitary service injury).

A major advantage of the sickness insurancefund diagnostic statistics is that the size of popu-lation to which they refer is known. The numberof persons with compulsory membership in afund is established annually and is available byage. The number of persons in the members’families is determined every 4 years.A6 Thus adenominator exists for epidemiological statistics.

Schleswig-Holstein

In addition to sickness insurance fund hospi-taI statistics, discharge data have been colIectedby the State Statistica.I Office in Schleswig-Holstein since 1969. Schleswig-Holstein is one ofWest Germany’s 10 States. It is located in thenorthern part of the country, bordering Den-mark, and contains 2.5 million people, 4 percentof the country’s population.E z

The Schleswig-Holstein reporting system re-ceives data only from acute care hospitals. Inthe first year of operation, 34 hospitals partici-pated in the system, and they accounted for45.6 percent of all patients treated in the State’sacute care hospitals that year. Almost every yearsince, additional hospitals have joined the sys-tem. By 1977, 53 hospitak, accounting for70.1 percent of the State’s acute care hospital

23

patients, participated. While participation is vol-untary, all the acute care hospitals in the Stateare expected to take part in the system in thenear future.53

The reporting system wasestablished to pro-vide needed data for health planning and hospi-tal management, and as a possible basis for epi-demiological research. It was thought that thecollected information would greatly assist themanagement of public programs concerninghealth, especially those to design health caredelivery systems that fit needs of the popula-tion. Individual hospital’s procedures, coverage,and efficiency were also expected to be betterunderstood by means of the collected data. Thesystem has served as a model for other State andFederal Government officials who are interestedin establishing comprehensive hospital data sys-tems elsewhere in West Germany.

The data from the system have been foundto have certain disadvantages. A current epide-miological study of the relationship betweenleukemia and a complex of nuclear power plantsserves as one example. The study is hamperedbecause persons with leukemia often receivetreatment in hospitals, especially university hos-pitals, that have not been participating in thereporting system. Furthermore, since the statis-tics count cases rather than persons, advances inthe treatment of leukemia that have reduced thedeath rate and that have led to repeated briefperiods of hospitalization have resulted in hospi-tal statistics that appear to show increased mor-bidity where no real increase exists.54 The re-porting system’s inability to obtain accurateutilization rates of cases per population will be amajor problem until complete coverage of theacute care hospitals is reached. Even then theresidents of Schleswig-Holstein who are treatedin other States’ hospitals will be excluded fromthe system, and the residents of other Statestreated in Schleswig-Holstein will be included,which will complicate epidemiological studies.The fact that the statistics refer to cases ratherthan to persons is a problem common to mostdischarge reporting systems and will remain aproblem unless a system of record linkage isdeveloped.

Methods of data collection. –kformation iscollected continuously in the Schleswig-Holstein

reporting system. When a patient is admitted toa participating hospital, his or her data sheet isbegun. Further information is added when thepatient is discharged. A physician usually codesthe sheets; occasionally other hospital personnelprovide assistance.54

The data sheets can be sent directly to theState Statistical Office, but many hospitals havedata processing equipment and transfer the in-formation from the sheets to punch cards ormagnetic tapes. Thus the State office receivesdata in various forms. The office produces asingle data set from all the material sent to it,processes the data by computer, and performsconsistency checks (for instance, checking sex-specific diseases to ensure that they are reportedfor the proper sex). Sets of tables, some ofwhich are published annually, are then producedby computer. Unpublished tables are returnedfree of charge to the participating hospital.

Several proposals have been made to increasethe system’s scope. For example, about half ofthe hospitals that participate in the reportingsystem, including almost all the public hospitals,are also associated with a data processing systemthat emphasizes financial management and in-surance claims. This system is maintained at theSchleswig-Holstein Data Center, which is wherethe State Statistical Office maintains its databank. If the specialized data processing systemwere slightly broadened, its data could be addedto the State’s diagnostic statistics. Another planinvolves a new reporting form, suggested by theState Statistical Office, that would combinediagnostic data with hospital data from othersources and would allow the information to bereadily transformed into machine readableform.54

Coverage. –As mentioned earlier, theSchleswig-Holstein reporting system only coversthe State’s acute care hospitals. The special hos-pitals, which primarily treat long-staying pa-tients, do not participate. All types of acute carehospitals may join the system, and by 1976 allthe public hospitals owned by the State or itscities were participating, along with all denomi-national hospitals and some of the other privatehospitals.ss The participating hospitals may nottotally represent all acute care hospitals in theState, but patients’ average length of stay in the

24

participating hospitals is the same as in allSchleswig-Holstein acute care hospitals.8~56 Asmore hospitals join the reporting system, anyexisting biases will be corrected.

The participating hospitals report all theirdischarges. Therefore patients in psychiatricwards are covered as are other long-staying pa-tients, such as those in tuberctdosis units whoaveraged 93-day stays in 1976.56 Maternity pa-tients are reported in the same way as other in-patients, and separate data sheets are also com-pleted for infants born in the hospital.

The data collected by the reporting systemcannot be considered representative of hospitali-zation in West Germany as a whole. Schleswig-Holstein has one of the lowest bed-to-populationratios in the country, and Schleswig-Holsteinacute care hospitals have a lower average dis-charge rate, bed-day rate, mean length of stay,and occupancy rate than do all other WestGerman acute care hospitals.8

Items collected. –The data sheet used in thedischarge reporting system contains several iden-tification items. The hospital and the specialtydepartment in which the patient is treated areidentified by numbers. A patient admissionnumber is also given. The patient’s accommo-dation (one-bed room, two-bed room, roomwith more than two beds) is reported. If thereason for the hospital stay was not the treat-ment of an established diagnosis but rather anopinion about the patient’s condition (an admis-sion by order of a third party, usually the courtsor insurance authorities) this is noted. The typeof payment for the hospitali,zation is also re-ported (self-payment; payment by an insurancefund, and if so, what kind of fund; payment bywelfare: or other tv~e of ~avment L

Items concern&g ho~pi&d utilization includethe admission and discharge dates. The kind ofadmission is coded as newborn, transfer fromanother department, transfer from another hos-pital, or other. The kinds of discharges includedischarge to home, transfer to another depart-ment, transfer to another hospital, transfer to anursing home, died and autopsy performed, anddied and autopsy not performed.

Social and demographic items are the pa-tient’s age, sex, and residence. The day andmonth of birth are reported for children under

1 year of age; for others only the year of birthis required. The district of residence shouldalways be reported. The community of residenceis an optional item and usually is not reported.Special note is made of patients who are out-of-State residents.

Three diagnoses can be reported and arecoded to three or four digits using the eighthrevision of the International Classification ofDiseases. The primary diagnosis, defiied as themain illness for which the patient was treated, isrecorded first. The doctor in charge of the hos-pital ward decides which is the main diagnosiswhen there are more than one. Each diagnosis isdescribed as either a final diagnosis, a provisionaldiagnosis, or a “state after.” “State after” meansthat the treatment was not for the illness itself,which no longer existed, but for a condition thatoccurred after or was due to the illness.

Definitions and procedures. –The collecteddata do not differentiate short-staying and long-staying patients. Most long-staying patients inthe State are treated in the special hospitals,however, and data are not collected in thesehospitals. Since statistics are divided by type ofhospital department, the statistics for depart-ments that provide treatment to long-stayingpatients, such as the tuberculosis departments,can be isolated.

The term “completed cases” is used to referto regular discharges, deaths, and transfers.54Transfer patients are counted as completed caseswhether they are interhospital or intrahospitaltransfers. Death statistics are usually presentedseparately as well as together with other com-pleted cases. The number of healthy newborns isnot included in the number of completed cases,but the number of sick newborns is included.

A bed day is counted for each patientpresent in the hospital at midnight.4T The dayof admission would therefore be counted as abed day, but the day of discharge would not. Ahospital stay of less than 1 day would not becounted as 1 bed day unless the patient was inthe hospital at midnight.

The average length of stay is computed bydividing the number of bed days of completedcases by the number of completed cases. Thestandard deviation associated with the averagelength of stay is also calculated, and the

25

coefficient of variation, obtained by dividing thestandard deviation by the mean length of stay, iscomputed.56

Information published and available. –Statis-tics from the reporting system are published bythe State Statistical Office 2 years after the yearthey were collected. Unpublished statistics aregenerally available to participating hospitals withless delay. The 10 university-affiliated hospitalsin the system usually receive data about their pa-tients 1 year after collection. Some tabulationsare also sent to all participating hospitals in Mayfollowing the end of the year the data werecollected.sA

Published statistics from the reporting sys-tem are available in Diseases of Inpatients inSchleswig-Holstein .~6 Its two major tables pre-sent information on a list of selected diagnosesthat cover 90 percent of all diagnoses. Bothtables contain the number of completed casesand deaths, the average length of stay, and thestandard deviation and coefficient of variationassociated with the average length of stay for theselected diagnoses. Each table also reports thenumber of cases, bed days, and average length ofstay by diagnosis and age (less than 1 year, 1-14,15-44, 45-64, and 65 years and over). One tablepresents this information separately for the diag-noses in various hospital specialties (surgery;gynecology; obstetrics; internal medicine; infec-tious diseases; pediatrics; urology; orthopedics;ear, nose, and throat; psychiatry and neurology;dermatology and venereology; ophthalmology;teeth and gums; and radiation) and for diagnosesin hospitals without specialties.

Another set of tables presents informationon 18 diagnostic groups. The number and per-cent of completed cases and deaths, the numberof bed days, and the number of bed days percase are given by sex and diagnostic group. Thenumber of completed cases is also reported byage group, sex, and diagnostic group. The per-cent of the cases in each age and diagnosticgroup is given for all patients and then sepa-rately for males and females. Within each agegroup the percent distribution of cases in thediagnostic groups is also given, first for all pa-tients in each age group and then separately for

males and females.

Four tables give statistics that are not sepa-rated by diagnosis. One reports the number ofbeds covered in the system and the percent ofcovered beds among all beds by type of hospitaland hospital department. The second table pre-sents the number of cases and the number ofbed days per case, the latter separated by sex, bytype of hospital department. The third tablegives the number of discharges, the average stayby sex, the percent of patients, and the percentof the population, by age group. The fourth re-ports the number of deaths that occurred ineach type of hospital department.

Unpublished tables sent to each hospital in-clude lists of cases treated by the hospital andby separate hospital departments according tothe main diagnosis. For each case the admissionnumber, sex, age, and additional diagnoses arereported. Other unpublished tables present ag-~egated data for the hospital as a whole and forthe separate departments, by diagnosis, age, andaverage length of stay. Also reported are thenumber of admissions and discharges cross-tabulated by health insurance group responsiblefor payment and type of accommodation.ss

OTHER DISCHARGEREPORTING SYSTEMS

Psychiatric Reporting System

While West Germany does not have a nationalpsychiatric discharge reporting system, psychi-atric patient data are colIected in one State,Northrhine-Westphalia. The State, located onthe west side of West Germany, borders theNetherlands and Belgium. Its population, 17million persons, is the largest of the 10 States.szThe psychiatric reporting system covers the ad-ministrative regions of Dusseldorf and Cologne,which together contain about 9 million people.

Data collection. –The psychiatric reportingsystem is run by the Rhineland Provincial Union,a nongovernment association, and covers 10association-owned psychiatric hospitals. Thehospitals had a total of 10,627 beds in 1980,including beds for mentally handicapped pa-tients.5T The hospitals were collecting statistics,

26

including some diagnostic statistics, even beforeWorld W“arII. Co~puter data processing beganin 1960, and in 1976 the hospitals installed dataterminals for direct access to the association’scentral computer.

Information about each patient is collectedat the times of admission and discharge. Hospitalpersonnel add the information to the computerdaily. Some data are processed by individualhospitals, but most are processed centrally bythe association administrative staff.

Transfers to other hospitals and deaths areconsidered discharges. Intrahospital transfers arereported but do not count as discharges. Admis-sion and discharge days are counted as separatebed days, and hospital stays of less than 24hours are counted as 1 bed day. Total bed daysfor a year are computed by summing the num-ber of patients in the hospital each midnight.Patients who are on leave for short periods, suchas holidays, are regarded as present for the mid-night count. Mean length of stay is calculated bymultiplying the number of bed days by 2 anddividing the result by the total number of admis-sions and discharges. The statistics produced bythe reporting system generally include both long-staying and short-staying patients, but short-staying patients can be identified separately.57

Items available.–A large amount of informa-tion is collected for each patient admitted toone of the 10 psychiatric hospitals in the system.The hospital and department to which the pa-tient is admitted are identified, as are the pa-tient’s name and admission number. Alsoreported are the date and time of admission, thelegal basis of the admission, the place from whichadmitted, the source of admission (such as prac-ticing physician, psychiatric clinic, or police),the number of admissions, the time since last ad-mission, and whether the admission followed asuicide attempt. Patient characteristics recordedinclude birth date, sex, nationality, maritalstatus, religion, occupation, place of residence,and residential status (such as lives alone, liveswith siblings, or lives with spouse and child).Three admission diagnoses can be reported, andsince 1972 the International Classification ofDiseases has been used to code the diagnoses.Detailed information about the source and type

of payment for the hospital stay is also given.If a patient is transferred from one hospital

ward to another, the date of the transfer, theward to which moved, and up to three transferdiagnoses are noted. If the legal basis of the hos-pitalization has changed, the new legal basis isalso recorded. When a patient is discharged thecollected information includes the date and hourof the discharge, up to three discharge diagnoses,the place to which discharged, and to whom thepatient’s care was transferred (general practi-tioner, neurologist, other specialist, or other).

Each year the Rhinekmd Provincial Unionpublishes a statistical report called Data, Factsand Trends.58 The 1979 edition contains 1978summary statistics from each psychiatric hospi-tal and various statistical tables of the character-istics of the psychiatric patients for all the hos-pitals. The statistics for each hospital includenumber of beds, total admissions, first admis-sions, transfers-in, total patients treated, totaldischarges, transfers-out, deaths, patients in thehospital on December 31, bed days, averagenumber of patients in the hospital per day, meanlength of stay, and occupancy rate. Each hospitalreports the number and percent of admissionsand discharges in seven diagnostic categories,five age categories, and five legal categories. Thenumber of admissions, treated patients, and dis-charges from each postal region the hospitalserves are also reported. All information is givenfor the hospitals together as well as separately,and changes in several of the statistics from1971 to 1978 are shown.

Most of the tables on patient characteristicsgive the number and percent of admissions insets of categories by sex. For instance, the num-ber and percent of admissions in marital statuscategories (single, married, divorced, widowed,and unknown) are given for males, females, andall patients. Tables show the distributions of ad-missions by age, number of admissions, timesince last admission, residential status, source ofadmission, place from which admitted, whethersuicide attempt, and occupation. The numb erand percent of admissions are also given by legalstatus and diagnosis, by age and diagnosis, andby age and legal status. The number and percentof treated patients, discharges, and deaths are

27

reported for length-of-stay categories, and thenumb er and percent of discharges are given byplace to which discharged. One table shows thenumber of admissions and discharges, and theaverage number of admissions per day for eachmonth of the year. Other tables show informa-tion about patients with addictions, such as typeof addiction, by age group.

Army Reporting System

A special discharge system that exists inWest Germany’s army hospitals was begun in1960 by a government agency called the Insti-tute of Defense Forces’ Medical Statistics. Thereporting system was established to learn moreabout army hospital utilization and morbiditypatterns among soldiers. Since West Germanarmy hospitals and patients are quite differentfrom other West German hospitals and patients,the reporting system’s statistics are not at allrepresentative of nationwide patterns of hospitaluse. The reporting system covers all army hospi-tals. Individual hospitals complete reportingforms for each discharged patient and sendthe forms to the institute for coding and

Proce@3”59The reporting forms include items that iden-

tify the hospital, department, and ward. The pa-tient’s name, hospital number, army grade, armyactivity, and first enlistment are reported, as arethe patient’s birthplace, occupation, next of kin,religion, marital status, and sex. The date, time,and type of admission (first, readmission withsame illness or injury, readmission for other ill-ness or injury, determination of fitness grade,and other) are listed. Intrahospital transfers, thedepartments transferred from and to, and thenumber of days of inpatient treatment in eachdepartment are reported. The date of discharge,place to which discharged, and total number ofdays of inpatient care are also given.

A primary diagnosis, four additional diag-noses, and up to five operations can be reportedon the forms. The diagnoses are coded using asystem similar to the International Classificationof Diseases. The codes for operations were de-veloped specifically for the army hospitals. Ifthe patient died, the date, time, cause of death,and whether an autopsy was performed are

given. If the patient is disabled, the presumedcause of the disability and whether it was in-curred in the line of duty are reported. The typeof fitness for duty is also given. An overall sum-mary of the patient’s illness is written, and it issigned by the ward physician and the physicianin charge of the patient’s department.

The forms are completed for both long-staying and short-staying patients, and the statis-tics produced from the forms concern bothtypes of patient. Discharge statistics includedeaths and interhospital transfers but not intra-hospital transfers. Bed-day statistics refer to thenumber of bed days used during the year, butmean length-of-stay statistics are computedusing the number of bed days of discharges,which is divided by the number of discharges.The admission and discharge days are countedtogether as 1 bed day, and hospital stays of lessthan 24 hours are counted as 1 bed day.

Statistical reports are published monthly;another publication is prepared annually. Thestatistics are also supplied to the Federal Statisti-cal Office for inclusion in its annual publicationabout hospitals.

AGGREGATE HOSPITAL REPORTS

Official hospital utilization statistics in WestGermany are compiled by the Federal StatisticalOffice from aggregate hospital reports. All hospi-tals report, whether they are public, nonprofit,or profitmaking institutions. The hospitals re-ceive annual questionnaires from the State Sta.tistical Offices. Each State uses a somewhatdifferent questionnaire, and the definitions ofterms used to complete the questionnaires varyfrom State to State, but the Federal StatisticalOffice has established a committee to developuniform forms and terminology .47 Hospitalstaffs complete the questionnaires with informa-tion about the hospitals’ operation and utiliza-tion during the calendar year. Usually the infor-mation comes from daily summaries of thehospitals’ activities, the so-called “midnight sta-tistics YY55 The completed forms are sent to aea.health departments , which aggregate the in-coming data and report the results to the StateStatistical Offices. The State offices then

28

forward the data to the Federal StatisticalOffice, which is responsible for processing andpublishing them.

The Federal Statistical Office calculatesseparate utilization statistics for the acute carehospitals and special hospitals, which generallycontain long-staying patients. As a gToup, pa-tients in acute care hospitals had an average stayof 15.8 days in 1977, while patients in specialhospitals averaged 58.7-day stays.8 Howeversome types of hospitals that were part of theacute care group reported average stays that ex-ceeded 30 days, and some special hospitalsreported average stays of less than 30 days.

Transfers between hospitals are always con-sidered discharges and new admissions, buttransfers between departments within a hospitalare counted as part of a single admission. Deathsare combined with other discharges for the pur-pose of computing utilization statistics, but theyare also reported separately. A bed day iscounted for each patient in the hospital at mid-night. The total number of bed days thus refersto the number used during the year, not beddays used by patients discharged during theyear. The average length of stay is calculated bymultiplying the total number of bed days by 2and dividing by the total number of admissionsand discharges. The rates of discharges and beddays per unit of population generally are notcomputed, but State or nationwide rates can becalculated from the published statistics.60

The statistics from the aggregate reports arepublished annually in “Hospitals,’yg which isnumber 6 in the Health Care Statistics seriespublished by the Federal Statistical Office. The1979 edition of “Hospitals” presents 1977 data,which primarily concern hospital beds. For in-stance, the number of hospitals and beds areshown by State, type of hospital ownership, hos-pital size, hospital specialty, and hospital regionswithin States. The number of beds per 10,000population are given by State and type of hospi-tal ownership. The number and types of hospitalpersonnel are reported in another set of tables.Hospital utilization statistics are presented inthree tables: one for males, one for females, andone for both sexes. The number of patients hos-pitalized at the beginning of the year, admis-sions, total patients treated, discharges, deaths,

patients hospitalized at the end of the year, beddays, and average length of stay are reported ineach table by type of hospital ownership, hospi-tal specialty, and State. The average occupancyrates of hospitals are also reported by hospitalspecialty, hospital ownership, and State. Anadditional table presents data on hospital birthsand shows the number of women who gave birthand the number who experienced complications,the number of newborns and whether the new-borns were live or dead, the bed days and aver-

age lengths of stay of ~ maternity patients and—..—of those with complications, and the number ofinpatients who experienced miscarriages. Thisinformation is reported by State and hospitalownership.

The Federal Statistical Office publishes simi-lar tables in its monthly statistical publication,Economics and Statistics.61 The tables areusually less detailed than those in “Hospitals”but contain more recent statistics. The statisticsin both publications are used to document theexistence, location, and level of hospital use,which are necessary to know for administrativepurposes. However the information is not suffi-cient for detailed studies of hospital operation,including studies of cost effectiveness, thatare important for hospital management andplanning.55

HOUSEHOLD SURVEY

West Germany began experimenting withpopulation health surveys in 1963.5s Additionalhealth surveys were undertaken in 1966, 1970,and 1972. In 1973 a section on illnesses, acci-dents, and handicaps was added to the Micro-census, an ongoing household survey conductedby the Federal Statistical Office. The Micro-census has operated since 1957 and primarilycollects household demographic, social, andeconomic data. The data have been used for eco-nomic studies and to update the regular census.The Microcensus is conducted four times eachyear, but the health questions are included odyonce a year.

The Microcensus samples cover almost all ofthe West German population; only miiitarypersonnel and

. .institutionalized indi~duals are

29

excluded. The sampling ratio is between 0.25and 1.0 percent of the population. Study areasare chosen at random using as a sample frame allthe regions covered in the regular census. Everyhousehold within a chosen study area is part ofthe sample. One person is interviewed in eachhousehold and answers questions about thehealth of all the household members. Inter-viewers are lay volunteers, recruited and trainedby the State Statistical Offices.

The items included in the health section ofthe Microcensus have changed somewhat overtime but have always focused more on illnessand disability than on the utilization of healthservices. For example, the 1978 questionnaireincluded a list of questions for a householdmember who had suffered an illness, accident, orh-~dicap_during the 4-week period prior to the—-.interview. If a person had experienced morethan one health problem, the questions addressedthe most serious problem. Whether the illnesswas chronic, the length and type of illness, andwhether the person was still sick when the inter-view took place were asked. The length of timethe person was unable to work due to the illness,accident, or handicap was recorded. The ques-tionnaire also reported each household mem-ber’s height and weight, whether he or shesmoked, and if so, what and how much he or shesmoked.

Questions about the use of health servicesalso referred only to the most serious healthproblem experienced in the 4 weeks prior to theinterview. Whether the household member saw aphysician for the problem was noted, as was thetype of physician (general practitioner or spe-cialist), and whether the visit was to a hospital

outpatient department. Hospital stays of at least1 night were also reported. The definition of ahospital excluded institutions supervised by asingle doctor that do not offer regular medicaltreatment, such as homes for the elderly.

Microcensus statistics are published in theFederal Statistical Office Health Care Statisticsseries. They are also available in such publica-tions as Data from the Health Care System, pub-lished by the Federal Ministry of Youth, Family,and Health. While most published statistics donot concern hospitalization, some informationis provided. For instance, tables in Data fromthe Health Care System, 197762 show the per-cent of sick persons who had been hospitalizedby sex and age group; by sex and type of illness;by sex, age group, and ability to work; and bysex, type of illness, and ability to work.

It was expected that the Microcensus statis-tics would outline the health status of the WestGerman population and thereby provide infor-mation to develop need-based planning of thehealth care system. Some researchers and policy-makers have not found the statistics to be asuseful as was hoped. The use of nonmedicallytrained interviewers and the procedure of askingquestions about only one health disorder havebeen criticized. Changes in the questions that areasked about health have made time-trend studiesdifficult. Moreover switches in the time of yearthe questions are asked (from May to October)could introduce seasonal variation to the find-ings. It has been suggested that a separate healthinterview survey might produce more usefulhealth data, and discussion of such a separationhas been taking place.4T

U.S. NATIONAL HOSPITAL DISCHARGE SURVEY

In the United States a number of national, dix II. MSO in appendix II are brief descriptionsState, and local data systems collect hospital of the main national hospital and household sur-utilization statistics. This chapter is concerned veys that collect hospital utilization statistics.with the National Hospital Discharge Survey. The National Center for Health StatisticsThis survey is the major source of national esti- (NCHS) established the U.S. National Hospitalmates of short-stay hospital utilization. Other Discharge Survey in 1965.2 Previously NCHSimportant discharge reporting systems, which had collected some hospital use informationare more limited in scope than the National Hos- through its household Health Interview Survey,pital Discharge Survey, are discussed in appen- begun in 1958.63 Information about hospital

30

Table G. General hospital discharge reporting systems, by country and raporting system

I

General hospital dischargeraporting system

Agency or agenciasresponsible .............

Year begun ......................

Main publications . ..........

Denmark

Inpatiant registrationsystems

National Health Serv-ice, Association ofCounty Councils,local and regionalcomputer centers

1970

Serias publications inMedical StatisticsReports [6,1 91

Medical Report 11:Report on Hospitalsand Other Institutionsfor Treatment of theSick in Denmark[18], publishad until1978

Scotland

Scottish HospitalIn-PatientStatistics

Information SewicesDivision of tha Com-mon Services Agency,Scottish HealthService

1951-one region,1861-entire country

Scottish Hospital lrr-Patient Statistics [37]

Scottish HealthStatistics [401

West Garmany

Schlaswig-Holsteinhospital morbidity

study

State StatisticalOffice, SchlaswigHolstain

1969

Diseases of Inpatientsin Schleswig-Ho/stein [56]

Insurance fundstat isticalsystems

Sickness insurancefunds

-..

Annual reports ofFederal associationsof sickness funds,such as Illness-type,Illness-cause, andDeath Statistics [51 1

Survey of SocialSecurity [501

lNumbers in paranthesharefor references, which give full bibliographic information on the publications.

births and deaths was also reported on birth anddeath certificates. In 1962-63 NCHS developedthe Master Facility Inventory (MFI), a compre-hensive list of hospitals, nursing homes, andother inpatient health facilities in the UnitedStates.6A As well as being a source of nationalstatistics on the number, type, and geographicdistribution of inpatient facilities, the MFI wasexpected to serve as a sampling frame for sur-veys of specific types of facilities and their users.A continuing survey of hospital discharges,which uses the MFI as the sampling frame, wasin the planning stages when the MFI was devel-oped. In 1964 a sample of 95 hospitals wasdrawn from the MFI for a pilot study of hospitaldischarges.6s In 1965 a master sample of 690hospitals was drawn from the MFI, of which 315were inducted into the National Hospital Dis-charge Survey.

An additional 150 hospitals from the mastersample were inducted into the survey during thefirst years of its operation; by 1969 a total of465 hospitals was involved. In 1972 and every 2or 3 years since, the master sample has been sup-plemented by a “birth sample” drawn from listsof new hospitals added to the MFI since 1965.

United States

National HospitalDischarga Suwey

National Center forHealth Statistics

1965

Series 13 publicationsin Vital and HealthStatistics [66,70-731

Detailed Diagnosesand Surgical Proce-dures for ParierrtsDischarged FromShort-Stay Hospitals[76]

In 1978 there were 535 hospitals in the surveysample, and of these, 413 participated in thesurvey.

The survey was designed as a continuinggeneral purpose study of hospital utilization pat-terns. It was not established to answer anysingle question or to provide data to any particu-lar group. The collected statistics are available tothe public and are used by government agencies,health policymakers, university researchers, hos-pital supply companies, and a variety of othergroups and individuals.

The National Hospital Discharge Survey andthe discharge reporting systems in Denmark,Scotland, and West Germany to which it is com-pared are listed in table G. The table shows thatthe U.S. survey is like the Scottish system in onerespect: It is the responsibilityy of a single na-tional agency. No one national agency in eitherDenmark or West Germany has a similar respon-sibility. National data are compiled in bothcountries, but each has a number of reportingsystems that are operated by separate agencies.The National Patient Register in Denmark re-ceives data from the separate registration sys-tems, and the Sozialdatenbank in West Germany

31

receives data from the various sickness insurancefunds.

METHODS OF DATA COLLECTION

One way that the National Hospital Dis-charge Survey differs from the other threecountries’ reporting systems is that it uses a two-stage sampling design. Sampling is not part ofthe design of the reporting systems in Denmark,Scotland, or Schleswig-Holstein in West Ger-many. All hospitals covered by these systems areexpected to supply abstracts of information forall discharges except those that are specificallyexcluded from the systems, such as psychiatricdischarges in Denmark and Scotland. The sick-ness insurance funds in West Germany also col-lect some information on all the discharges cov-ered by their reporting systems, but they obtainmore detailed data on samples of discharges. Thesamples are drawn in a one-stage process fromthe universes of all discharges covered by par-ticular types of sickness insurance funds. In con-trast, a “s~mple of hospitals is drawn from theuniverse of hospitals covered by the U.S. survey,and then a sample of discharges is selected fromeach sample hospital.

The original sample of hospitals for the U.S.survey included all the hospitals in the universewith 1,000 beds or more. The hospitals in theuniverse with less than 1,000 beds were dividedinto primary strata by bed size (6-49 beds, 50-99beds, 100-199 beds, 200-299 beds, 300-499beds, and 500-999 beds) and region (Northeast,North Central, South, and West). Hospitalswithin the primary strata were further classifiedby type of ownership and more detailed geo-graphic divisions. In 1965 a controlled selectiontechnique was used to draw the master sampleof hospitals from these hospital classes. A sys-tematic random sample method was used to sup-plement the master sample. The sampling proba-bilities vary from certainty for the largest

hospitals to 1 in 40 for the smallest hospitals.Z~GGThe sample hospitals’ discharges are sampled

with probabilities that vary inversely with theprobability of selection of the hospital. In hospi-tals with 1,000 beds or more, only 1 percent ofdischarges are sampled; 40 percent of the dis-

charges are sampled in some of the smallest hos-pitals.67 The sample of discharges is randomlyselected, usually by using the last digit or digitsof the patient’s medical record numbe~,-If thehospital’s list of discharges does not show medi-cal record numbers, every kth discharge on thelist is selected for the sample, beginning with adischarge chosen at random.

An abstract form is completed for eachsample discharge. The information for the ab-stract is taken from the face sheet of the pa-tient’s hospital record. In about two-thirds ofthe hospitals the hospital staff completes theabstracts. In the remaining hospitals the formsare completed by U.S. Bureau of the Census per-sonnel, acting for NCHS. All hospitals send com-pleted abstracts to a census regional office forreview. Each form is checked for completeness,and then all are sent to NCHS. The NCHS staffcodes the diagnoses and surgical operations orprocedures listed on each abstract. When thecoding is done, the data on the forms are trans-ferred to computer tapes, and the tapes areedited and processed.

These data collection procedures differ fromthe procedures used in the other three countriesin the areas of central coding of medical infor-mation and central data processing. Dischargeforms are completed and coded by hospital per-sonnel in Denmark, Scotland, and Schleswig-Holstein. The one exception is the occupationitem, which is centrally coded in Scotland. In-formation about the coding procedures of theWest German sickness insurance funds was notobtained. Not all data processing is centralizedin Denmark and Scotland. Local and regionalcomputer centers process discharge data in Den-mark, but the centers also provide the NationalHealth Service with data tapes. In Scotland twoarea health boards and two local computer cen-ters process data, in addition to the nationalcomputer center.

COVERAGE

Not aIl U.S. hospitals are within the scope ofthe National Hospital Discharge Survey. Ex-cluded are institutional hospitals, such as prisonhospitals and university student health centers,

32

as well as all Federal hospitals, such as militaryand Veterans’ Administration hospitals. Hospi-tals with less than six beds and those in whichthe average length of stay of all patients is 30days or more are also excluded. The sample ofdischarges drawn from participating hospitalssometimes excludes patients treated in long-termcare units if the units keep records separatelyfrom the rest of the hospital. All other dis-charges are sampled, but the survey reportsusually exclude data for newborns.

The coverage of the discharge reporting sys-tems in the other three countries is comparedwith the coverage of the U.S. survey in table H.It is important to note that none of the report-ing systems in the other countries excludes hos-pitals on the basis of patients’ average length ofstay. In Scotland and Denmark psychiatric hos-pitals are excluded from the reporting systemsjbut almost all other long-term hospitals are in-cluded. The Schleswig-Holstein study coversacute care hospitals, but these hospitals aredefined by the type of treatment they provide,not by the patients’ average length of stay. Whilemost of the acute care hospitals in West Ger-many report average patient stays of less than 30days, not all do, and a few special care hospitalsreport average stays of less than 30 days. The

sickness insurance funds in West Germany obtaindata from all hospitals, those classified as acuteand special care.

Several different patterns of coverage existin regard to psychiatric patients. The general dis-charge reporting systems in Denmark and Scot-land not only exclude patients in psychiatrichospitals but also patients treated in psychiatricunits of other hospitals. Both countries havespecialized reporting systems that cover thepsychiatric hospitals and units. The Schleswig-Holstein study excludes all patients in psychi-atric hospitals, since the hospitals are classifiedas special care hospitals, but the study coverspatients discharged from psychiatric units inacute care hospitals. The West German sicknessinsurance funds collect information on anypsychiatric patient whose hospitalization wascovered by fund insurance, whether the patientis discharged from a psychiatric hospital or apsychiatric unit in another type of hospital. TheU.S. survey covers patients discharged frompsychiatric hospitals in which the average lengthof stay is less than 30 days. Patients dischargedfrom hospital psychiatric units are also coveredif the units are in hospitals that are within thescope of the survey and if they are not long-termunits with separate record systems.

Table H, Comparability of coverage of general hospital discharge reporting systems, by country and reporting system

Coverage

System covers..................

Systemdoesnot cover-

Denmark

National PatientRegister

Ninety-six percent ofall general and apacial-ized somatic hospitalsas of 1979

Five private generaland specialized so-matic hospitals as of1979

Psychiatric hospitals

Psychiatric units innonpsychiatrichospitals

Scotland

Scottish HospitalIn-PatientStatistics

Scottish Health Sew-ice hospitals

Private hospitals andprivate beds in Scot-tish Health Servicehospitals

Psychiatric hospitals

Psychiatric units innonpaychiatrichospitals

Maternity patients

Newborns

West Germany

Schleswig-Holsteinhospital morbidity

study

Seventy percent ofdischarges from acutecare hospitals inSchlaswig-Holstain

as of 1977

Thirty percent of dis-charges from acutacara hospitals inSchleswig-Holsteinas of 1977

Spatial care hospitals,including psychiatrichospitals, inSchleswig-Holstein

Insurance fundstatist icalsystams

Hospitalizations cov-ered by sickness insur-ance funds

Hospitalizations notcovered by sicknasainsuranca funds

Unitad States

National HospitalDischarge Survey

Sample of dischargesfrom sampla of short-stay hospitals

Long-stay hospitals

Fadaral hospitals

Hospitals with leasthan six beds

Institutional hospitals

Some long-term unitsin short-stay hospitals

33

Another important difference in coverage isthe exclusion of maternity patients and new-borns from the general reporting system in Scot-land. A special reporting system covers Scottishmaternity patients and newborns. Newborns arewithin the scope of the other reporting systems,but only in Denmark are they routinely countedas discharges in published reports.

Private hospitals are not fully represented insome of the systems. Hospitals that have not yetjoined the reporting systems in Denmark andSchleswig-Holstein are all privately owned. Thesmall number of private hospitals in Scotland areexcluded from the Scottish reporting system, asare patients discharged from private beds inScottish Health Service hospitals. The U.S. sur-vey and the West German sickness insurancefunds’ statistical systems cover private hospitals.The funds’ statistical systems are the only onesthat exclude uninsured patients, however, andthe U.S. survey is alone in excluding Federalhospitals and hospitals with less than six beds.

ITEMS COLLECTED

The abstract forms used for the 1977 Na-tional Hospital Discharge Survey contain theitems listed in table J. The hospital and patientare identified by numbers on the forms, whichare used only for reviewing and processing thedata. No information that would permit identi-fication of individual hospitals or patients isreleased from the survey. In Denmark, Scotland,and Schleswig-Holstein not only are hospitalsidentified on the forms, statistics for individualhospitals are tabulated. The tabulations are pri-marily for the use of the individual hospitals.Few of the reporting systems’ routine publica-tions present data separately by hospital.

Most of the other items collected by theU.S. survey are also collected in the other threecountries. The major exception is the item onrace, which is only collected in the United States.Other exceptions are the expected source ofpayment, which is only collected in the UnitedStates and Schleswig-Holstein, and the date ofsurgical procedure(s), which is only collected inthe United States and Scotland. In addition,‘the Schleswig-Holstein study does not obtain in-

formation about marital status or surgicalprocedures.

The content of the item on patient disposi-tion differs among reporting systems. For theU.S. survey, the types of dispositions includeroutine discharge, discharged home; left againstmedical advice; discharged, transferred toanother facility or organization; discharged, re-ferred to organized home care service; died; andnot stated. The information about patient dispo-sition in the other reporting systems includeswhether or not the patient was transferred toanother department within the hospital. Trans-fers to other facilities or organizations are alsospecified in more detail in the other reportingsystems. For instance, a transfer to another hos-pital is reported separately from a transfer to anursing home in all three countries. The Den-mark and Schleswig-Holstein system also reportwhether or not a patient who had died wasautopsied. The U.S. survey is, however, the onlyone of the four to collect information on trans-fers to home care services, and only Scotlandand the United States not e irregular discharges,such as leaving against medical advice.

Some items are collected by the reportingsystems in Denmark, Scotland, or Schleswig-Holstein, but not by the U.S. survey. For in-stance, the other reporting systems obtain in-stance, the other reporting systems obtaininformation about the source or type of ad-mission. The content of the item(s) varies. InScotland the categories of admissions includeemergency and from waiting list. In Schleswig-Holstein the categories include transfer fromanother department, transfer from another hos-pital, and newborn. In Denmark categories simi-lar to those in Scotland and Schleswig-Holsteinare used, and others are included, such asfrom nursing home and through outpatientdepartment.

Another item not included in the U.S. sur-vey, but identified in Denmark and Scotland, isthe hospital department in which the patientwas treated. In Denmark the hour of admissionis also included, as is the kind of accident suf-fered by patients admitted for treatment of acci-dental injuries. In Scotland the physician incharge of the patient’s case is identified, the pa-tient’s occupation is given, and the date the

34

Table J. Comparison of items collected in the United Statesl with those collected in Denmark, Scotland, and West Germany, byreporting system

Item

Hospital number . .. ... .. ... .... .. ... .. ... .. .. ... ... .. ... ... .. .. ... .. .. .. .. ... .. .. ... ... .... .. .. ... .. ...

C+Ise number .... .....o.o.. .. ... ... ... . .... . ... ... .. ... .. .. .. .. .. .... .. .. .... .. .. .... .. ... .. ... .. ... .. ....Date of admission .... ... ... ... ... . ... .. ... ... ... .. .. .... . ... .... .. .. ... ... .. .. .. ... .... ... .. .. ... .. .. .Date of discharge .... ... ... .... .. .. .. .... .. ... ... .. ... ... .. .. .. .. .... .. .. .. .. ... . .... ... . .. . .... ... ....Disposition of patiant ... .. ... ... . .... ... . ... .... . ... ... .. ... ... ... .. .. .... .. ... . .... .. ... ... .. ... ...Date of birth or age .... .... .. ... .. ... .. ... .. .... .. ... .. ... .. .... .. ... .. ... .. ... ... .. ... .... . .. ... . ... .Sex ... .. ... .. ... ... ... .. .. .. .. .... .. .... ... . .. .. .. .... .. .... .. .. . ... .. .. .. .. .... ... .. .. .. . .. .... .. .. .. .. .. .. ...

Race ., . ... . .. . ... .. .. . ..... .. ... .... .. .. .... .. ... ... ... .. .. .... . .... ... .. . .... .. ... .... .. .. . .. .. ... .. .... . ....

Marital status .... ... .. ..... .. ... .... .. ... . ... ..... .. . .. .. .. .... . ... .... .. ... .. .. ... . ..... .. .. .. ... ... . ...Ragion of residence ... .. .. .. .. .. .. .... .. .. .. .. .. ... ... .. .. .. . .. ... ... ... .. .. .... .. .. .... .. .. .... .. ....Expectad source of paymant ... .. .. ... . ... . ... .. ... ... .. .. .. .... .. .... .. .. ... ... . .... .. . ..... .. ..

Principal diagnosis .... ..... . .... ..... . .. .. . ... ... . .... . .. ... .... .. .... .. ... .. ... .. ... .. ... .. ... .. ... ..

Othar di~nows .... .. ..... ... .. .... ... .. .. ... ... ... ... .. .. .. .... ... .. .... .. . ... .... . ... ... .... . .... . ... .Principal surgical procedure .... . ... ... .. ... ... .... ... ... ... . .. .. ... ... .. ... .. ... .. .... .. ... .. ... .Othar surgical procedures .... .. ... ... . ... .... .. ... .. ... ... . .... .. ... .. .... .. ... . ... ... ... ... ... . .. .Data of surgical procedure(s) ...... . ... ... ... ... ... . ... .. ... ... .... .. .. ... .. .. .... ... .. .. ... . .. ..

11977 U.S. National Hospital Discharge Survey.

Denmark

National PatientRegister

1979

YesYes

YesYesYesYesYas

No

YesYeaNo

Yes

YesYesYasNo

Scotland

Scottish Hospital

In-PatientStatistics

1977

YesYesYesYesYasYesYes

No

YesYesNo

Yes

YesYasYesYes

West Germany2

Schleswig-Holstein

hospitalmorbidity study

1979

YesYesYesYesYesYesYesNoNo

YesYesYesYesNoNoNo

2Detailed information m-a not obtained about the items collected by the sickness insurance funds in West Germany.

patient was placed on the waiting list is noted.The Schleswig-Holstein study includes an itemabout the patient’s accommodation, that is, aone-bed room, two-bed room, or room with morethan two beds. The diagnoses reported in theSchleswig-Holstein study are also qualified asbeing final, provisional, or “state after” (whichrefers to a condition that occurred after or wasdue to the illness).

The principal diagnosis and additional diag-noses are coded somewhat differently by thereporting systems. As seen in table K, the princi-pal diagnosis is defined in various ways. In theU.S. survey the principal diagnosis is defined asthe condition established after study to bechiefly responsible for occasioning the admissionof the patient to the hospital.66 The Scottishreporting system uses the definition recom-mended in the ninth revision of the Interna-tional Classification of Diseases,39 and thedefinition used in the Schleswig-Holstein studyis similar. Both refer to the main condition orillness treated, which is not necessarily the con-dition responsible for admission. In Denmark

the physician decides which condition is mostimportant, and it is coded as the principal diag-nosis. The criteria that Danish physicians use todetermine the importance of conditions are notspecified. Thus the most important conditionmay or may not be the condition responsible foradmission or the main condition treated.

All the reporting systems use the Interna-tional Classification of Diseases (ICD) to codediagnoses, but each utilizes a different variation.In Denmark and Schleswig-Holstein, the eighthrevision of ICD is used, but the National PatientRegister uses a special Danish adaption. TheScottish system and the U.S. survey have begunusing the ninth revision of ICD, but in theUnited States the clinical modification (ICD-9-CM)68 is employed. Three- or four-digit codesare utilized in Scotland and Schleswig-Holstein,four- to five-digit codes in the United States, andfive- to six-digit codes in Denmark. In Denmarkand Scotland medical records staffs code data;specially trained NCHS staff code the U.S. sur-vey data. In Schleswig-Holstein physicians usu-ally code the diagnoses.

35

Table K. Coding of diagnoses in general hospital discharge reporting systems, by country and reporting system

Coding of diagnoses

Definition of principal diagnosiscoded .... .. .... .. ... ... ... . .. .. .. ... . .... . ...

Code used .. .. . ... .. ... . ... .. ... .... .. . ..... . ..

Detail of code .. ... .. .. ... . .. .. . ... ... ... .. ..

Coding done by . .. ... ... ... ... . ... .. ... ... .

Denmark

National PatientRegister

The condition thephysician decides ismost important

International Classifi-

cation of Diseases,

eighth revision,Danish adaptioti

Five to six digits

Medical secretaries inindividual hospitals

Scotland

Scottish HospitalIn-PatientStatistics

The main conditiontreated or investigatedduring the hospital

stay

International Classifi-

cation of Diseases,

ninth revision, as of1980

Four digits

Medical records staffin individual hospitals

West Germanyl

Schleswig-Holsteinhospital morbidity

study

The main illness forwhich the patient wasunder treatment

International Classifi-

cation of Diseases,

eighth revision

Three to four digits

Usually physicians,sometimes other hos-pital personnel, inindividual hospitals

United States

National HospitalDischarga Survey

The condition estab-1ished aftar study tobe chiafly responsiblefor occasion ing the

patient’s admission totha hospital

International Classifi-

cation of Diseases,

ninth revision, clinicalmodification, as of1979

Four to five digits

National Cantar forHaalth Statistics staff

lDetafied information was not obtained about the coding of items by the sickness insurance funds in West Germany.

DEFINITIONS AND PROCEDURES

The statistics most commonly produced bydischarge reporting systems concern discharges,bed days, and average lengths of stay. Some dif-ferences in the way these statistics are computedexist among the reporting systems. The U.S.National Hospital Discharge Survey defines a dis-charge as the termination of a period of hospi-talization by death or by the disposition of thepatient to his or her place of residence, a nursinghome, or another hospital.GG The reporting sys-tems in Denmark, Scotland, and Schleswig-Holstein also regard deaths and releases of pa-tients to their homes or other institutions asdischarges, but in addition these reporting sys-tems label transfers from one department orspecialty to another within a hospital as dis-charges. The effect of including intrahospitaltransfers in the number of discharges probablyvaries from country to country. Only theScottish reporting system publishes statisticsaboutof all

36

intrahospit~ tr-ansfers.In 1976, 3 percentthe discharges reported by the Scottish

system were transfers from one specialty toanother within a single hospital.37

In one respect, the discharge reporting sys-tems count bed days the same way: Each systemsums up the bed days accumulated by dis-charged patients during a yeas-long reportingperiod. This procedure does not count the beddays of patients still in the hospital at the end ofthe reporting period, but if a discharged patient’shospitalization extended through more than thel-year reporting period, all the bed days used inthe previous year or years are counted. It is im-portant to be aware that this is not how beddays are usually computed for the annual ques-tionnaires on utilization that are completed byhospital personnel in most countries. Instead,the total days of care supplied by the hospitalduring the year is usually reported. The totaldays of care includes bed days used by patientswho are still hospitalized at the end of thereporting period and excludes bed days used inprevious reporting periods. The two proceduresfor computing bed days result in nearly equiv-alent bed-day statistics for a year when most ofthe patients reported are hospitalized for short

periods, but the procedures are likely to resultin different bed-day statistics when many long-staying patients are covered.cg

The bed days of a discharge are computed inthe U.S. survey by counting all the days fromthe date of admission to the date of discharge.The day of admission is counted as 1 bed day,but the day of discharge is not. Stays of lessthan 1 day are counted as 1 bed day. The report-ing systems in Denmark and Scotland follow thesame procedures in counting bed days, but until1979 both the admission and discharge dayswere counted as bed days in Scotland. InSchleswig-Holstein a bed day is counted for eachmidnight the patient was in the hospital. Thisprocedure usually results in counting the admis-sion day as 1 bed day, the discharge day andhospital stays of less than 1 day as O bed days.

Average length of stay is calculated in theU.S. survey by dividing the total number of beddays of patients discharged during a year by thenumber of patients discharged. The same for-mula for average length of stay is used by thereporting systems in Denmark, Scotland, andSchleswig-Holstein, but the resulting statisticsare not completely comparable with the U.S.statistics because of the dlf ferent ways dis-charges and bed days are computed. The mostimportant variation is in the pre-1979 Scottishstatistics on the average length of stay. Countingthe discharge day as a bed day increases theaverage stay by a full day. However countingintrahospital transfers as discharges decreasesthe average length of stay. In Scotland thedecrease in the average stay for all patients wasonly a fraction of a day in 1976, but the de-crease could be greater in Denmark or Schleswig-Holstein if intrahospital transfers were morecommon. The average length of stay reportedfor Schleswig-Holstein is also somewhat reducedby the failure to count 1 bed day for hospitalstays of less than 1 day.

INFORMATION PUBLISHEDOR AVAILABLE

Statistics from the National Hospital Dis-charge Survey have been published in NCHS’SVital and Health Statistics series 13 reports since1966. Three reports are usually published from

survey data collected during each calendar year.One type of report presents summary statisticson hospital utilization. The summary reports for1965-73 contain only nonmedical statistics,70but subsequent reports include some statisticson diagnoses and surgical operations. More de-tailed information about hospital utilization bydiagnosis is presented in a second report,71 anda third report supplies more detailed data onsurgical operations. 72 In addition to theseannual reports, special analyses of the surveydata are sometimes presented in separate publi-cations, such as in a recent report on hospitalutilization of persons with alcohol-relateddiagnoses.73

A recent annual report, “Utilization ofShort-Stay Hospitalsj Annual Summary for theUnited States, 1978,”66 contains the followingdetailed

1.

2.

3.

4.

5.

6.

7.

tables:

Number, percent distribution, and rateof patients discharged from short-stayhospitals, by sex and age.

Number, percent distribution, and rateof days of care, average number ofhospital beds occupied daily, and aver-age length of stay for patients dis-charged from short-stay hospitals, bysex and age.

Number and percent distribution ofpatients discharged from short-stay hos-pitals by age and length of stay, accord-ing to sex.

Number and percent distribution ofpatients discharged from short-stay hos-pitals by color and age of patient, ac-cording to sex.

Number and percent distribution ofdays of care for patients dischargedfrom short-stay hospitals by color andage of patient, according to sex.

Average length of stay for patients dis-charged from short-stay hospitals, bycolor, age, and sex.

Number of patients discharged fromshort-stay hospitak and days of care,by sex, age, geographic region, and bedsize of hospital.

37

8.

9.

10.

11.

“ 12.>–’

13.

14.

15.

16.

17.

18.

Rates of patients discharged from short-stay hospitals and of days of care, bygeographic region, age, and sex.

Average length of stay for patients dis-charged from short-stay hospitals, bygeographic region, age, and sex.

Average length of stay for patients dis-charged from short-stay hospitals, bysex, age, geographic region, and bedsize of hospital.

Number of patients discharged fromshort-stay hospitals and days of care,by type of ownership of hospital andage and sex of patient.

Average length of stay for patients dis-charged from short-stay hospitals, bytype of ownership of hospital, age ofpatient, and sex.

Number of patients discharged fromshort-stay hospitals, rate of discharges,and average length of stay, by categoryof first-listed diagnosis and age.

Number of discharges and averagelength of stay for patients dischargedfrom short-stay hospitals, by categoryof first-listed diagnosis, sex, and color;and rate of discharges by category offirst-listed diagnosis and sex.

Number of patients discharged fromshort-stay hospitals, rate of discharges,and average length of stay, by categoryof first-listed diagnosis and geographicregion.

Number of patients discharged fromshort-stay hospitals and average lengthof stay, by category of first-listed diag-nosis and bed size of hospital.

Number of all-li;ted diagnoses for pa-tients discharged from short-stay hospi-tals, by diagnostic category and age,sex, color, geographic region, and bedsize of hospital.

Number of all-listed operations for pa-tients discharged from short-stay hospi-tals, by surgical category, age, sex, andcolor.

19.

20.

21.

22.

Rate of all-listed operations for patientsdischarged from short-stay hospitals, bysurgical category, age, and sex.

Number of all-listed operations for pa-tients discharged from short-stay hospi-tals, by surgical category and geographicregion.

Rate of alMisted operations for patientsdischarged from short-stay hospitals, bysurgical category and geographic region.

Number of all-listed operations for pa-tients discharged from ‘short-stay ho;pi-tals, by surgical category and bed sizeof hospital.

Tables 1 and 2 present statistics for the fol-lowing age groups: under 1 year, 1-4 years, 5-14years, 15-24 years, 25-34 years, 35-44 years,45-54 years, 55-64 years, 65-74 years, and 75years and over. In other tables only the agegroups of under 15 years, 15-44 years, 45-64years, and 65 years and over are used. In tables3-12 statistics are given separately for the cate-gories of females including deliveries and femalesexcluding deliveries, but other tables show onlyone category for females. Statistics on color aregiven for two main groups: white and all other,The all-other group includes all categories otherthan white. In tables 4-6 an additional categoryis reported—color not stated—and the patients inthis category accounted for more discharges andbed days in 1978 than did the patients in the ano-ther category. In tables 16, 17, and 22 thehospital bed-size categories are 6-99 beds,100-199 beds, 200-299 beds, 300-499 beds, and500 beds or more. In tables 7 and 10 the cate-gories are 6-99 beds, 100-499 beds, and 500beds or more. The geographic regions reportedin the tables are Northeast, North Central,South, and West, which correspond to theregions used by the U.S. Bureau of the Census.

Tables 13-16 present statistics on first-listeddiagnoses. The first-listed diagnosis is the oneidentified as the principal diagnosis or else theone listed first on the face sheet of the medicalrecord. All-listed diagnoses, reported in table 17,are the first-listed diagnosis and up to four otherdiagnoses listed on the face sheet of the medicalrecord.G6 The statistics on diagnoses are pre-sented for broad groupings of diseases and

38

{

injuries, which correspond to classes I-XVII ofthe Eighth Revision International Classificationof Diseases, Adapted for Use in the UnitedStatesy4 (ICDA), the classification system usedfor the survey during 1970-79. Some statisticsare also presented for subcategories. For in-stance, statistics are given for class VI, Diseasesof the Nqvous System and Sense Organs (ICDA320-389), and for the subcategories of Diseasesof the Central Nervous System (ICDA 320-349),Cataract (ICDA 374), and Diseases of the Earand Mastoid Process (ICDA 380-389).

All-listed operations, reported in tables

18-22, are the first three operations listed on theface sheet of the medical record, excluding cer-tain procedures and treatments not generallyconsidered surgery .66 The statistics on opera-tions are reported for classes 1-17 of the ICDAsection, Surgical Operations, Diagnostic andOther Therapeutic Procedures; and statistics aregiven for some subcategories of the classes.

The annual reports that concentrate on hos-pital utilization by diagnosis present statisticsfor a more extensive list of subcategories withineach ICDA class than do the summary reports.For instance, while statistics are presented for4 subcategories within class IX, Diseases of theDigestive System, in the 1978 summary re-port, 66 statistics are given for 15 subcategories

of the class in the 1975 report on hospital utili-zation by diagnosis.T 1 Similarly, the report onsurgical operations presents statistics for detailedlists of subcategories within the classes ofoperations.72

In addition to Vital and Health Statisticsseries 13 reports, NCHS published data in 1979from the National Hospital Discharge Survey ina report titled Detailed Diagnoses and SurgicalProcedures for Patients Discharged From Short-Stay Hospitals: United States, 1977.75 The re-port presents statistics for each ICDA code. Forinstance, statistics are given for over 150 codesfor class IX, Diseases of the Digestive System.The statistics are shown by age and sex of pa-tients discharged, conditions diagnosed, and sur-gical procedures performed. Other publicationsof this type are expected to be produced usingdata from subsequent years of the survey’soperation.

Statistics from the survey are also publishedin such reports as Health, United States’6 andThe Nation’s Use of Health Resources.y7 Un-

published data are available in the form of datatapes and special tabulations, which are preparedto meet specific requests for information. Re-strictions placed on the release of the data areonly those related to the confidentiality of insti-tutions and individuals.

The main sources of published data from thereporting systems in the United States, Denmark,Scotland, and West Germany are listed in table G.Most of these publications present hospital utili-zation statistics by diagnosis. Typically the num-ber and rate of discharges and bed days and theaverage length of stay are given for categories ofdiagnoses by age and sex. The diagnoses aregrouped somewhat differently in each publica-tion, but all use the International Classificationof Diseases as the basis for the groupings. Thenumber of age groups also varie:; ; the statisticson diagnoses may be given for as few as threeage groups or as many as seven.. Discharge andbed-day rates are computed using different defi-nitions of the population. For instance, the U.S.rates are calculated using the civilian noninstitu-tionalized population, in Scotland the totalpopulation is used, and the West German sick-ness insurance funds present rates per 10,000members.

Diagnostic statistics are also given by othertypes of categories. Geographic regions consti-tute a common category, but. there is consider-able variation among other types of categoriesfor which data are presented. The U.S. publica-tions are the only ones to show statistics ondiagnoses by color and bed size. In Denmark andSchleswig-Holstein diagnostic statistics are givenby type of hospital department. The sicknessinsurance funds in West Germany show diag-nostic statistics by type of membership in thefunds, and in Scotland diagnostic statistics aregiven by source of admission and type of patientdisposition.

Statistics on different types of surgical oper-ations are not available in West Germany but arepublished elsewhere. Stat istical comparisons arehampered not only by dif ferent groupings of theoperations but also by the use of different clas-sification systems to code operations. The UnitedStates is the only one of.’ the countries to use theICD codes for operations.

It should also be pointed out that not allthe publications present national data. In Den-mark the last national data published in the

39

discontinued series of medical reports, MedicalReport II, were for 1974-75. Only data fromlocal areas of the country have been publishedthus far in the Medical Statistics Reports series.In West Germany the main sources of data areeither the Schleswig-Holstein publications, whichonly cover one State, or the publications fromthe several associations of sickness insurancefunds, each of which only covers hospitaliza-tions insured by a particular type of fund. TheScottish publications, like the U.S. publications,present national data.

SUMMARY

The U.S. National Hospital Discharge Surveyand the reporting systems in Denmark, Scotland,and West Genmany are similar in some ways and

different in others. Abstracts of information fordischarged patients are completed in each re-porting system, and the abstracts contain manysimilar items. Information about patients’ diag-noses is collected in each system, and each uses avariation of the International Classification ofDiseases to code the diagnoses. The reports pub-lished by the systems usually provide statistics

on diagnoses by age and sex. However the re-porting systems cover different sets of hospitalsand patients. The procedures used to collectdata vary, and the procedures for computing sta-tistics are dissimilar. Although the reporting sys-tems’ similarities allow cross-national compari-sons of hospital utilization by diagnosis, thesystems’ differences require that the statistics becarefully adjusted before the comparisons aremade.

HEALTH SERVICES SYSTEMS

In addition to understanding different dis-charge reporting systems, those who intend tocompare hospital utilization data among coun-

tries should have some knowledge of the coun-tries’ health services system characteristics.Certain characteristics are likely to significantlyaffect hospital use rates. For instance, the num-bers and types of available long-term-care facili-ties can affect hos,pital use. Patterns in the provi-sion of ambulatc)ry and home care can beimportant, and the costs of receiving hospitaland other health ctare services should be consid-ered. These aspects of the health services systemsin Denmark, Scotland, West Germany, and theUnited States are (discussed briefly in this sec-tion. Further information about the healthservices systems in each country can be found invarious publications. 4,16,48,78-84

LONG-TERM-CARE FACILITIES

Cross-national comparisons of hospital utili-zation data need to take into account differ-ences in the types o f facilities that providelong-term care. When long-term care is primarilythe responsibility of thle hospital system, higher

bed-day rates and higher average lengths of stayare likely to be reported than when other typesof long-term-care facilities exist.

The number of beds per population in long-term hospitals is one indicator of the extent towhich the hospital system supplies long-termcare. Table D shows that the United States hasfewer beds per 1,000 population in long-termhospitals than does Denmark, Scotland, or WestGermany. However, as seen in table B, theUnited States also has a smaller percent of thepopulation age 65 years and over (the majorusers of long-term-care facilities) than do theother three countries. If long-term hospital beds

per 1,000 population age 65 years and over arecompared, the United States remains low withabout 13 beds per 1,000 persons age 65 yearsand over; while Denmark has about 17; WestGermany, 26; and Scotland, 40.

These statistics do not include beds in long-term units of short-term hospitals. All fourcountries have some beds in such units, and thenumber has been increasing in Denmark andScotland. In Denmark the units usually havebeen established for aged and chronically ill in-dividuals who require more intensive medicalsupervision than that available in nursinghomes.8G Some units in Scottish hospitals treat

40

elderly ~atients who require extensive medicaland nursing care, while other units provide alevel of care similar to that available in nursinghomes in other countries.s6

The statistics on long-term hospital beds inScotland also do not include beds in facilities forthe mentally deficient, but those facilities areconsidered part of the hospital system. In 1977-78 there were 19 hospitals for the mentallydeficient in Scotland, and they contained 6,635beds.T The statistics do include beds in joint-userhospitals, which are hospitals where local socialservices authorities and the health service sharefacilities, and beds in contractual hospitals,which are private institutions that make agree-ments with the health service to provide care. In1977-78 there were 22 joint-user and contractualhospitals in Scotland, and they contained 1,531beds, almost all of which were for long-termcare,

Bed statistics for West Germany’s long-termhospitals include beds in institutions called theKurkmnkenhauser, which do not have closecounterparts in the other three countries. TheKurkrankenhauser maybe equivalent to rehabili-tation centers, extended care facilities, or resthomes. They are usually owned by pension fundsand are primarily located in resort areas.4GJSZIn1977 the Kurkrankenhauser accounted for 57percent of the discharges from West Germanspecial care hospitals and had an average lengthof stay of 30.1 days.s

Each country has some long-term care facili-ties outside the hospital system. The UnitedStates has a large number of beds in such facili-ties. In 1976, 20,468 nursing homes operated inthe United States, and they had a total of1,414,865 beds, which was 6.5 beds per 1,000population, or 61.7 beds per 1,000 populationage 65 years and over.g There were also 6,280other inpatient institutions with 375,805 beds inthe United States in 1976, including facilities forthe mentally retarded, the emotionally disturbed,dependent children, unwed mothers, alcoholics,and others.

Comparable data on long-term-care facilitiesin the other countries are not available, but Den-mark is said to have a good supply of beds ininstitutions outside the hospital system.ST Theinstitutions include nursing homes; convalescent

homes; rehabilitation centers; facilities for thementally retarded, the blind, the deaf, andothers with handicaps; and old age homes. Mostfacilities for the handicapped are the responsi-bility of the national government, but other in-stitutions are either provided or supervised bymunicipal social welfare authorities. The rela-tionships between the hospitals and these insti-tutions have been problematic because the latterare administered by different committees at thelocal level and different ministries at the na-tional level. However there is growing recogni-tion of the need to reduce the burden on hospi-tals of long-staying patients who do not requirehospital treatment, and each county is nowexpected to set up a joint hospital-welfare com-mittee to facilitate collaboration between thetwo systems of care.

Fewer types of long-term care facilities existoutside the hospital system in West Germany.A nursing home system exists but is consideredinadequate.s8 Approximately 1 percent of per-sons age 65 years and over are in nursing homes,but it is estimated that 2 percent need nursinghome care. Old age homes are more prevalentthan nursing homes; approximately 4 percent ofthe elderly reside in them. These homes do notroutinely supply medical care, though, and planscall for them to be replaced by sheltered housingin the community.

As mentioned earlier, Scotland does nothave a nursing home system. Some long-term pa-tients receive care in homes run by local socialservices authorities or by voluntary organiza-tions. In 1972, 390 of these homes containedover 13,000 beds,sg and the number of beds hasbeen steadily increasing. Most are residentialfacilities and provide only minimal medicalservices.

Thus the four countries” differ widely in theextent to which their hospital systems areresponsible for long-term care. The Scottish hos-pital system includes the most long-term-carefacilities, and the West German hospital systemincludes a larger proportion of such facilitiesthan do the hospital systems in Denmark or theUnited States. The U.S. hospital system proba-bly includes the smallest proportion of long-term-care facilities, but further data are neededto study this point.

41

AMBULATORY AND HOMECARE SERVICES

Hospital use may be affected by severalaspects of ambulatory and home care services.The supply of physicians and the way they areorganized are likely to have an effect. The avail-ability of nurses for ambulatory care and homenursing programs is expected to be important,as is the degree of development of home supportservices.

The number of physicians per 10,000 popu-lation does not vary greatly among the fourcountries. In 1977 Scotland had the lowest num-ber, 16.7 physicians per 10,000 population;goWest Germany had the highest, 20.3 per 10,000population.46 The United States reported 17.9physicians per 10,000 population in 1977 ;76Denmark had 19.5 physicians per 10,000 popu-lation in 1976.90

In the United States 15 percent of profes-sionally active physicians were in general orfamily practice in 1977, and the rest reported aspecialty practice. Most physicians, 64 percent,were office based; that is, they spent the greatestamount of their time in practices based in pri-vate offices. Another 27 percent were hospital-based; that is, salaried hospital physicians; and9 percent were primarily involved in teaching,administration, research, and other non-patient-care activities. About 24 percent of physiciansnot employed by the Federal government werein group practices in 1975, an increase from18 percent in 1969.76

In the United States ambulatory and hospi-tal care are generally provided by the samephysician. Physicians in office-based practicesusually can admit their patients to hospitals andattend them in the hospitals. Physicians inhospital-based practices also provide a certainamount of ambulatory care. Some see ambula-tory patients in part-time private practices, andsome provide ambulatory care in hospital out-patient departments and emergency rooms.

In Denmark approximately 30 percent ofphysicians were in general practice in 1975, andthe rest were employed by hospitals and pro-vided specialized care.8T The number and per-cent of specialists has been increasing over thelast 25 years, but the number of general practi-

tioners has remained relatively constant. Generalpractitioners are remarkably evenly distributedgeographically. Every area with a population of2,330 plus or minus 10 percent has a generalpractitioner in its midst. 16

Traditionally, hospital and ambulatory carehave been quite separate in Denmark. Untilrecently hospitals maintained very few outpatientdepartments, and hospital physicians still haveonly limited possibilities for private practice.Most ambulatory care is provided by generalpractitioners, who cannot follow patients thathave been referred to a hospital. A referral froma general practitioner is required before a hospi-tal will admit a patient, except in an emergency.During the last 15 years most general practi-tioners in Denmark have joined group practices.The groups usually establish themselves in pri-vate health centers or clinics that contain sharedlaboratories and other diagnostic facilities sothat most diagnostic and therapeutic problemscan be handled without referring a patient to ahospital. All surgical cases except those involvingvery simple procedures are referred to hospitals.

In 1977, 57 percent of physicians in Scot-land were hospital based, 37 percent were ingeneral practice, and 6 percent were in publichealth or held administrative positions.40 As inDenmark, almost all specialists are employed byhospitals. General practitioners engage in privatepractice under contracts with the Scottish HealthService. In most cases general practitioners pro-vide only ambulatory care services, but there aresome exceptions. General practitioners in ruralareas can admit patients to cottage hospitals andlook after them during their hospital stays. Inurban areas some general practitioners workpart-time in hospitals, but usually they serve aspart of a specialized unit staff and do not carefor their own patients.gl As a rule, specialistssee only hospitalized patients, but again thereare some exceptions. Specialists see ambulatorypatients referred to hospital outpatient depart-ments, and some specialists maintain part-timeprivate practices in which they treat ambulatorypatients. A small number of physicians notaffiliated with the health service provide ambula-tory care and follow their patients who are ad-mitted to a private hospital. In the majority ofcases, though, patients receive ambulatory careand hospital care from different physicians.48

42

Recently general practitioners in Scotlandhave been joining group practices and movinginto health centers.gI Primary care teams ofphysicians, nurses, and midwives have developedin these settings. The health centers are alsoequipped with more diagnostic and treatmentfacilities than solo practitioners have been ableto support in the past, and the availability of thefacilities may decrease the number of hospitalreferrals made by general practitioners.

In 1977 approximately 47 percent of allphysicians in West Germany were in privatepractice, 45 percent were employed by hospi-tals, and 8 percent worked in other institutions,such as public health departments, industries,and research organizations.A6 About 48 percentof full-time hospital physicians were specialists,and 47 percent of all physicians were specialists.A large number of the hospital staff who werenot specialists were in training, frequently spe-cialist training. The number of specialists has in-creased in recent years, while the number ofgeneral practitioners has remained constant.

Ambulatory and hospital care are usuallyprovided by different physicians in West Ger-many. Very few hospitak have outpatient de-partments, and only 7 percent of all physicians,the “Belegiirzte,” follow patients both in andout of the hospital.sz Most hospital care is sup-plied by physicians employed by the hospitals;most ambulatory care, by physicians in privatepractice. Physicians in private practice usuallydo not belong to group practices.sl Howevermany share laboratory factlties and other equip-ment or maintain their own laboratories andequipment; thus it is unnecessary for them torefer patients to hospitals for many tests andminor procedures.

Differences in the supply, specialization, andorganization of physicians probably affect hos-pital utilization among the four countries. Whilephysician services may substitute for hospitalservices, a larger supply of physicians also couldlead to increased hospital use since more physi-cians can evaluate more patients and find morehealth disorders that need hospital treatment.The larger tie proportion of specialists, hospitalbased or not, the more hospitalizations theremay be, since the complex medical equipmentand facilities located in hospitals are likely to beused more by specialists than by general practi-

tioners. Large numbers of hospital-based physi-cians, whether or not they are specialists, mayalso increase the emphasis on hospital care.However the growth in group practices could de-crease hospital use since more extensive diag-nostic and treatment facilities can be supportedby most group practices than by most solo prac-tices. Further study is needed of these possiblerelationships.

The effects of nurses being involved inambulatory and home care, and of the availa-bility of other home support services also requirefurther study. When nurses play a significantrole in the provision of ambulatory care services,they may substitute in part for physicians andthus increase access to the health services sys-tem. However, whether increased access leads toan increase or decrease in hospitaI use requirescareful investigation. The availab~lty of homenursing and other home support services proba-bly reduces the need for hospital and other in-patient care. These services should allow patientsto complete their convalescence at home afterhospital treatment for an acute illness, and helpmaintain the chronically ill and disabled outsideinstitutions. However it is possible that users ofhome services have different characteristics thando users of inpatient facilities.

Most nurses in Denmark, Scotland, WestGermany, and the United States work in hospi-tals and other inpatient institutions. Howeversome nurses in each country provide ambulatoryor home care services. In the United Statesnurses have a long history of involvement inambulatory and home care. Public health nurs-ing, school “nursing, private duty nursing, andhome visit nursing all-existed before 191578 Atthat time private duty nursing, which providedhome care as well as hospital care, outnumberedall other nursing categories. The proportion ofprivate duty nurses declined over time, though,and the proportion of nurses employed in hospi-tals increased. In 1974, 75 percent of theregistered nurses in the United States worked inhospitals and nursing homes. Another 4 percentwere in nursing education, 7 percent worked inpublic health and schools, and the remainderwere in occupational health, private duty, doc-tors’ offices, and other fields.gz

Recently there has been renewed interest inthe United States in nursing roles outside

43

hospitals. The role of the nurse practitioner hasbeen created to help with the shortage of physi-cians in certain areas of the country. Nurse prac-titioners are trained to perform tasks previouslyperformed by physicians. In 1979 there were anestimated 16,240 nurse practitioners in theUnited States, and the majority provided pri-mary care.76 There is also increasing interest inhome nursing as part of comprehensive homecare programs. The home care programs are seenas possible alternatives to costly long-term insti-tutional care.98

In 1975 approximately 74 percent of thenurses in Denmark were employed in hospitals,and the rest were in social welfare; that is, theyworked as public health nurses or in nursinghomes, oId age homes, and the like.8T Publichealth nursing did not exist in the country until1937, when a program was started to train nursesas infant home visitors who would provide regu-lar well-baby checkups. Beginning in 1946 infanthome visitors also supplied school nursing serv-ices, and in the 1950’s experimental programscombined home nursing for adults and childrenwith infant home visiting and school nursing.1GToday specially trained public health nursessometimes provide all these services, sometimesonly school or infant care. Some registerednurses without special training also supply homeand school nursing care. However there is ashortage of nurses in Denmark. There are notenough registered nurses in general or enoughspecially trained nurses for the public healthposts. Therefore the home nursing services arenot readily available in all areas.

In 1977; 92 percent of Scotland’s nursingpersonnel worked in hospitals, but almost allother nurses were in community services.40Community nurses are primarily home nursesand health visitors. The health visitors are publichealth nurses with special training in social serkices, mental health problems, and interviewingskills. The role of the community nurse devel-oped in the nineteenth century when voluntary‘organizations began hiring nurses to visit people’shomes to help the sick and teach proper childcare. Now employed by the health service, thecommunity nurses continue to provide a signifi-cant amount of health care. In 1973 homenurses made over 3 million visits, 2 million ofwhich were to patients age 65 years or over, and

heaIth visitors made an additional 1.9 millionhome visits, 18 percent of which were to theelderly.sg

Almost all the nursing personnel in WestGermany work in hospitals. There are very fewpublic health nurses in the country who provideambulatory care services. Physicians in publichealth departments and private practices supplyservices, such as well-baby examinations, thatpublic health nurses supply in many other coun-tries. Some home nursing services do exist. Fivemajor voluntary agencies have organized homenursing services, and a“ few pubIic agencies,profitmaking agencies, and religious organiza-tions also have done SO.SSHome nursing servicesare primarily available in urban and industrialareas, but even there insufficient personnel existto supply all the necessary services. Comprehen-sive social services centers are being developed tohelp meet the needs of the population, especiallythe aged. The centers are staffed with nurses andsocial workers and offer a wide range of supportservices to local areas.

In addition to home nursing, other inhomesupport services are avaiIable in each country.These include homemaker or home-help servicesand meals-on-wheels programs. Home help con-sists of assistance with household management,such as cleaning, washing, shopping, as well aspersonal assistance with dressing, bathing, andthe like. Meals-on-wheels programs supply hotmeals to persons, usually the elderly, who areunable to shop for or prepare food and whohave no one to help them on a regular basis.

In Denmark local social welfare authoritiesare required by law to provide home help toneedy elderly and disabled pensioners.ss Localsocial services authorities in Scotland haveestablished numerous home-help and inhomemeal services.sg In West Germany social servicescenters provide home-help and inhome mealservices, as do a variety of other voluntary andgovernment agencies. At present the services areusually available only in urban areas, but furtherexpansion is planned.ss In the United Stateswelfare and voluntary agencies provide homesupport services, and there is some Federalfinancing of services covered by Medicare andthe amendments to the Social Security Act of1975. The number of homemaker-home-health-aides is much smaller than needed, though, and

44

the Medicare reimbursement policies are so com-plex and restrictive that they inhibit the growthof services.88,93

To summarize, each of the four countriesexhibits different patterns in the availability andorganization of ambulatory and home care serv-ices. The United States is unique in that ambula-tory and hospital care are generally provided bythe same physician. The United States also hasthe highest percent of specialist physicians, thelowest percent of hospital-based physicians, andthe highest proportion of nurses working outsideinpatient care facilities. Denmark has the highestpercent of hospital-based physicians, an espe-cially even distribution of general practitioners,and widely available home-help services. Scot-land reports the lowest number of physicians per10,000 population, but it has well-establishedcommunity nursing and home support programs.West Germany has the highest number of physi-cians per 10,000 population, the lowest percentof specialist physicians, and very few nursesworking outside hospitals.

COSTS OF RECEIVINGHEALTH CARE

In this section the patients’ cost of receivinghospital care is compared with the costs of re-ceiving other forms of health care. The focus ison whether persons in each of the countries havebarriers to or incentives for hospital use. Sincephysicians usually decide when to admit and dis-charge patients, there is also a brief discussionof how physicians are paid and whether themethod of payment could provide economicincentives for hospital use.

In 1976, 89 percent of the U.S. civilian non-institutionalized population was covered bysome type of health insurance, while 11 percent,or about 23 million people, had no insurance.93Private hospital insurance, which covered 76 per-cent of the population, was the most common.Some persons who carried private insurancewere also covered by government Medicare andMedicaid programs. An additional 4 percent ofthe population was covered only by Medicare,and 6 percent was covered exclusively by Medic-aid. Almost all those enrolled in Medicare areage 65 years or over, while Medicaid covers cer-

tain low income individuals. Frequently personsmust make copayments for insured health serv-ices, and some services are generally excludedfrom insurance coverage.

In 1977 the proportion of hospital expensespaid directly by U.S. patients was quite small:6 percent.94 Private insurance covered 37 per-cent of the expenditures for hospital care;Medicare, 24 percent; Medicaid, 9 percent; andother Federal, State, and local government pro-grams, 22 percent. The remaining 2 percent wasaccounted for by philanthropy and industry.Nevertheless, persons using hospital servicescould incur significant out-of-pocket expenses.A 1975 survey showed that the average annualout-of-pocket hospital expense to persons withan expense was $264. For 41 perce”ntof personswith a hospital expense, the amount paid directlywas less than $50, but for 12 percent it was over$500.95

U.S. physicians are usually paid on a fee-for-service basis. However hospital-based physiciansreceive salaries from the hospitals, and a smallproportion of office-based physicians are in pre-paid group practices and are paid on a cavitationbasis. Cavitation is the payment of a fixedamount each year per person without regard tothe amount of medical care the person receives.In 1977, 39 percent of the total cost of physi-cian services was paid directly by patients;37 percent was paid by private insurance; 24 per-cent was paid by government programs.g4 Theaverage annual out-of-pocket expense for physi-cian services, among persons with an expense,was $107 in 1975.95

Most U.S. nursing homes are private profit-making institutions. Approximately 41 percentof the total expense of nursing home care waspaid directly by patients in 1977, and govern-ment programs covered 57 percent of thecosts.gq Data on the cost of nursing home careto those with an expense is not available fromthe 1975 survey. Direct payments for drugsamounted to 83 percent of the total cost ofdrugs in 1977.94 Private health insurance cov-ered 8 percent of the total cost of drugs, andgovernment programs covered 9 percent. In1975 the average annual expense for prescrip-tion drugs was $59 for persons with an expense,and the average annual expense for optical serv-ices among persons with an expense was $67.95

45

In 1977 dkect payments accounted for 92 per-cent of the total expense for eyeglasses and ap-pliances. Private insurance covered 2 percent ofthe total cost of eyeglasses and appliances thatyear, and government programs covered 6percent.94

These statistics indicate that the out-of-pocket costs of receiving health care in theUnited States could be a barrier to hospital usefor some; an incentive for others. The cost ofhospital care is likely to be difficult to pay forpersons without insurance or for insured personswho must make substantial copayments. How-ever, among those with comprehensive insurancecoverage of hospital expenses, the higher propor-tion of the costs for other health services thatmust be paid out-of-pocket could encouragehospital use.

In Denmark the entire population is requiredto take part in the health insurance system.Since 1973 the system has been administered bythe county councils and has been financed by agraduated income tax. Two types of insuranceexist. Under the first plan there are no directcharges for physician services, but persons mustagree to see only one general practitioner duringthe year and to see specialists only if referred bythe general practitioner. Under the second planpersons may see any general practitioner or spe-cialist they wish at any time, but they arecharged directly by the physician and are reim-bursed only in part by health insurance. Until1976 all persons with an income below a certainlimit, some 80 percent of the population, hadthe first type of coverage, and those with higherincomes had the second type. Since 1976 therehas been free choice between the plans for alLIG

The expense of public hospital treatment inDenmark does not require insurance coveragesince hospital care is provided without any directcharges to the patient. Hospitals receive theirfunds from the county governments and patientsmust attend a hospital in the county where theyreside to receive free care. There were small feesfor hospital use until 1973, but health insurancecovered the fees for the most part.ST

Care in convalescent homes is also free ofcharge. However, to reside in an old age home oranother facility operated by the local social wel-fare authorities, an individual must give up his orher pension, except for a small amount for daily

necessities. If an indkidual has income in addi-tion to the pension, most of that income mustbe used to pay for maintenance expenses in thewelfare facility.85

Hospital physicians are salaried by the hospi-tals and do not charge inpatients for their serv-ices. General practitioners are reimbursed by theinsurance system using both cavitation and fee-for-service principles. About half of the incomemost general practitioners receive from the in-surance system is based on the number ofpersons on their lists, and half is based on theservices the general practitioners have pro-vided.l 6 Drugs are divided into three categories.The count y government pays 75 percent of thecost of one category, the necessary drugs, andpays 50 percent of the cost of the second cate-gory, the less important drugs. The cost of otherdrugs must be paid directly by the patient.sz

In sum, there are no cost barriers to receivinghospital care in Denmark, and there is littleeconomic incentive for patients to choose hospi-tal care over ambulatory care. However freelong-term care in hospitals might be preferred bypatients to the loss of their pensions and theother costs of treatment in a social welfarefacility.

In Scotland health insurance exists, but iscarried only by a small proportion of the popu-lation. Most health care is financed by the healthservice from general government revenues and isprovided to patients without direct charge. Hos-pital care can be obtained without charge inhealth service hospitals, but some patientschoose to pay a small fee for more privateaccommodations. Other patients prefer to betreated by a private physician and pay a specialfee for the privilege.4s Patients who use privatehospitals or private beds in health service hospi-tals are charged for care, but the number of pri-vate hospitals and beds is quite small. The feesfor special treatment in the health service hospi-tals and for private hospitalizations are usuallycovered, at least in part, by private insurancepolicies.

Ambulatory care is provided without chargefor the most part. Small charges are made forsome medicines, dentures, eyeglasses, and otherappliances, but physicians’ services are generallysupplied without cost to the patient. Generalpractitioners are paid by the health service on a

48

cavitation basis, with various modifications.There are special adjustments to encourage phy-sicians to practice in underserved areas and in-creased payments for treatment of the elderly,night calls, and other practices the healthservice wishes to encourage.g 1 Specialists aresalaried by the health boards but are oftenallowed to engage in part-time private practicein which they charge patients directly. In addi-tion a small number of physicians in full-timeprivate practice charge their patients directly fortreatment. Private insurance funds cover thecharges for private ambulatory care in manycases.

Thus there are no significant cost barriers toreceiving hospital care in Scotland, nor are thereincentives for patients to choose hospital carerather than other kinds of health care. Mostambulatory care is free to the patient, and so ismost long-term care, since it takes place inhospitals.

In West Germany 96 percent of the popula-tion is covered by insurance from a local orspecialized sickness insurance fund. Many per-sons covered by insurance from a sickness insur-ance fund also carry supplementary privateinsurance, and a small percent of the populationonly carries insurance from a private insurance~omPaY.48,81, 82 me sic~e55 in5urance funds

cover the costs of hospital care necessary for thetreatment of an illness or injury. If the patientwishes to have more private hospital accommo-dations or to be treated in the hospital by thephysician of his or her choice, there is a directcharge, but often it is covered by the supplemen-tary insurance policies. The sickness insurancefunds cover the costs of long-term care in hospi-tals, including the Kurkrankenhauser. The costsof nursing home treatment are included in thestandard coverage of the sickness insurancefunds in some States, and the coverage can beobtained on an optional basis in several otherStates.

The costs of ambulatory care for the treat-ment of an illness or injury are covered almostentirely by the sickness insurance funds. Thephysician from whom treatment is received mustbe registered with the funds, but almost all phy-sicians in private practice are registered. Patientswho make visits to nonregistered physiciansusually carry private or supplementary insurance

to cover the costs of these visits. Patients mustmake small copayments for prescription drugsand appliances , and not all of the costs bf pre-ventive health services are covered by insurance,but the sickness insurance funds are movingtoward more complete coverage of preventivecare.

Hospital physicians are usually salaried, butif they provide ambulatory care outside thehospital, they receive fee-for-service reimburse-ment. Physicians in private practice are reim-bursed on a modified fee-for-service basis. Thesickness insurance funds pay prearranged lumpsums to local physician associations, which inturn pay the physicians’ shares of the lump sumbased on the number and type of services thephysicians have provided to insured persons.48

In West Germany, as in Denmark and Scot-land, there is little indication of cost barriers orincentives that influence patients who choosehospital care. Nursing home care could be morecostly for West German patients than hospital orambulatory care, but health services are gener-ally available without significant out-of-pocketcosts.

In addition to the probable effect of eco-nomic barriers and incentives on patient choicesin the United States, U.S. physicians may havemore economic incentive to hospitalize patientsthan do physicians in the other three countries.The use of fee-for-service reimbursement in theUnited States for most physicians’ services thatare provided in hospitals makes it financiallyrewarding for physicians to admit patients andperform expensive treatments. Salaried hospitalphysicians have no such incentive. When cavita-tion alone is used as a basis of payment foroffice-based physicians, and the office-basedphysicians do not follow patients in the hospi-tals, there may be an economic incentive forphysicians to refer patients who require time-consuming care to hospitals. The office-basedphysician’s income is not increased by providingcomplex services, and it is not decreased byhaving the hospitals provide the services. Fee-for-service payment for office-based physicianswho do not follow patients in hospitals couldcreate economic incentives for the office-basedphysician to provide as many services as possibleoutside the hospital. In Denmark, Scotland, andWest Germany, office-based physicians generally

47

I

do not follow hospitalized patients, but none ofthe countries uses either cavitation alone or purefee-for-service reimbursement. In spite of themodifications, there may be some incentive foroffice-based physicians in Scotland to refer pa-tients to hospitals and for office-based physi-cians in West Germany to avoid hospital referrals.

SUMMARY

This section has surveyed characteristics ofthe health service systems in Denmark, Scotland,West Germany, and the United States. Certaincharacteristics in each country are likely to in-crease hospital utilization. In the United Statesthe characteristics include economic incentivesto physicians and patients for hospital use andthe high percent of physicians in specialty prac-tices. In Denmark the high proportion of

hospital-based physicians may increase hospitaluse. In Scotland the use of cavitation to payoffice-based physicians and the absence of anursing home system probably increase hospitaluse, and in West Germany the large number ofphysicians per population and the lack of suffi-cient alternative facilities for long-term care arelikely to increase hospital use.

On the other hand, each health servicessystem has some characteristics that should de-crease hospital use: for instance, the large num-ber of alternative facilities for long-term care inthe United States, the well-established programsfor home care in Denmark and Scotland, and thesmall percent of physicians who are specialistsin West Germany. Further research is needed tounderstand the interactions of these factors andthe effects they have on hospital use. Increasedunderstanding of the effects of health servicessystem characteristics should result in more use-ful comparisons of hospital utilization statistics.

SUMMARY AND CONCLUSIONS

The comparability of hospital utilizationstatistics in Denmark, Scotland, West Germany,and the United States was discussed in thisreport. The main focus was on general hospitaldischarge reporting systems, which collect ab-stracts of information about individual dis-charges. For Denmark, Scotland, and West Ger-many, other types of reporting systems werealso discussed, including those that cover specialhospitals or groups of patients (such as psychi-atric or maternity patients), annual hospitalreports of aggregate utilization data, and house-hold surveys that collect information abouthospital use.

Although the United States has many impor-tant hospital data systems, only the NationalHospital Discharge Survey was described here.Other U.S. sources of national hospital utiliza-tion statistics are briefly reviewed in appendix II.The National Hospital Discharge Survey waschosen for comparison with the general hospitaldischarge reporting systems in the other threecountries because it is the major source of na-tional estimates of short-stay hospital use for theUnited States.

Several similarities were found in the com-parison of the four countries’ reporting systems;for instance, many of the same items of informa-tion are collected in each system, and each usesa variation of the International Classification ofDiseases to code diagnoses. However differencesalso exist, particularly in the types of hospitalsand patients covered in the reporting systemsand in the definitions and procedures used bythe systems to compute utilization statistics.

The report also contained a brief review ofthe health services systems in the four countries.Information was given about characteristics ofthe health services systems that are likely toaffect hospital utilization rates. The characteris-tics include the availability of separate long-term-care facilities, patterns in the provision ofambulatory and home care services, and thecosts to patients of receiving various kinds ofhealth care. Each country’s health services sys-tem was shown to have some characteristics thatare expected to increase hospital use and othersthat are likely to decrease it.

The information presented indicates thatdischarge reporting systems in other countries

4a

could be valuable sources of data for compara-tive studies. However the differences in the re-porting systems require further evaluation, andprocedures need to be developed to adjust thedata to take the differences into account. Workis underway in this area. As mentioned in theintroductory section, a 10-country study is beingdone to estimate the effects of differences in thereporting systems on the data the systems pro-duce. The study covers the four countries dis-cussed in this report and the six countries whosedischarge reporting systems are described in anearlier report. 1 Data from each country is ad-justed to take the differences in the reportingsystems into account.

Further research is also needed into theeffects health services system characteristicshave on hospital utilization rates. This type ofresearch is valuable in its own right. Healthpolicymakers are deeply concerned with con-trolling hospital use and associated high costs.Understanding the systemic factors that affecthospital utilization rates should assist policy-making decisions. When the broad effects ofhealth services system characteristics are under-stood, it will also be possible to make moredetailed comparisons of hospital utilization sta-tistics. Specific questions–such as whether dis-charge rates for respiratory disease are related to

rates of automobile ownership, and what therelationship is between hospital staffing ratiosand average length of stay—can be studied cross-nationally once controls are introduced for thesystem differences that affect discharge rates(such as percent of specialists) or differencesthat affect length of stay (such as the presenceor absence of a nursing home system).

The cross-national research already donethat uses data from discharge reporting systemsgives an indication of the promise of future re-search. R. F. Bridgman uses data from areas ofeight countries, including Schleswig-Holstein inWest Germany, to study the relationship be-tween the level of socioeconomic developmentand hospital utilization.96 In other studies hos-pital caseloads are compared cross-nationally,g 7the relationship between hospital use and hospi-tal expenditures is examined,gg and the effectof the number of surgeons on surgical rates isexplored.gg Further research using data thathave been adjusted to take differences in thestatistical systems into account, and that controlfor the broad effects of health services systemcharacteristics, should help answer many addi-tional questions about hospital use that concernthe United States and other countries of theworld.

000

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27Committee on the Danish National Morbidity Sur-vey: The Sickness Survey of Denmark. Copenhagen.

50

Committee on the Danish National Morbidity Survey,1960.

28Committee on the Danish Nation~ Morbklity Sur-

vey: The Hospital Survey of Denmark. Copenhagen.Committee on the Danish National Morbidity Survey,1959.

29Scottish Home and Health Department: Scottishhospital morbidity data, 1961-68, by E. Lockwood.Scottish Health Service Studies. Pub. No. 20. Edinburgh.Scottish Home and Health Department, 1971.

30Heasman, M. A.: Scottish Hospital In-Patient Sta-tistics. Mea! Care. 8(4) Supp.: 113-120, July-Aug. 1970.

31 Heasman, M. A.: Scottish Hospital In-Patient Sta-tistics–sources and uses. Health Bull. 26(4), Oct. 1968.

32Parkin, D. M. et al.: Scottish Consultant Review ofIn-Patient Statistics (SCRIPS). A survey of users’opinions. Health Bull. 34(5):, 273-278, Sept. 1976.

33 Hexman, M. A.: SCRIPS: Success or failure? Acritical study of the Scottish Consultant Review ofIn-Patient Statistics, in G. McLachlan, cd., A Questionof Quality: Roads to Assurance in Medical Care. Lon-don. Oxford University Press for the Nuffield ProvincialHos itals Trust, 1976. pp. 171-185.

f3 Clwke, J. A.s scofl~d, in G. A. Koo1, cd., Hospital

Statistics and a Minimum Basic Data Set. Report on aEuropean Communities Seminar. Edinburgh. Nov. 2-4,1976. pp. 43-48.

35 Hutcheon, A. W., and Wilson, G. M.: An attempt toimprove the standard of diagnostic entries and records ina medical unit. Health BulL 34(4): 221-227, July 1976.

36 Heasman, M. A., Director, Information ServicesDivision of the Common Services Agency, ScottishHealth Service: Personal communication.

37 Information Services Division of the Common Serv-ices Agency, Scottish Health Service: Scottish HospitalIn-Patient Statistics, 1976. Edinburgh. Scottish HealthService, 1978.

38 Last, J. M.: Data collection requirements for patientmanagement. Med. Care. 8(4) Supp.: 159-168, July -Aug.1970.

39World Health Organization: Manual of the Interna-tional Statistical Classification of Diseases, Injuries, andCauses of Death, Based on the Recommendations of theNinth Revision Conference, 1975. Geneva. World HealthOr anization, 1978.

$OInformation Services Division of the CommonServices Agency, Scottish Health Service: ScottishHealth Statistics, 1977. Edinburgh. Her Majesty’s Sta-tionery Office, 1978,

41Wilson, J. M. G., Senior Research Fellow, Informa-tion Services Division of the Common Services Agency,Scottish Health Service: Personal communication.

42 Ferguson, J. B, P., and Murray, A.: Survey of theusc of form S.M.R.M. (Scottish Medical Record–Maternity) as a normal delivery discharge letter. HealthBull. 28(3): 30-35, July 1970.

43 Information Services Division of the CommonServices Agency, Scottish Health Service: Scottish Men-tal Health In-Patient Statistics, 1976. Edinburgh. Scot-tish Health Service, 1978.

4 Farmer, P. J., Information Services Division of theCommon Services Agency, Scottish Health S-ice:Personal communication.

45 Office of Population Censuses and Surveys: GeneralHousehold Survey, 1977. London. Her Majesty’s Sta-tionery Office, 1979.

46 Senftleben, H. U., Office of Health, District Com-mittee of Main-Kinzig-Kreis: Personal communication.

47 Schach, E., Research Associate, Computer Center,University of Dortmund: Personal communication.

48 Simanis, J. G.: National Health Systems in EightCountries. DHEW Pub. No. (SSA) 75-11924. SocialSecurity Administration. Washington. U.S. GovernmentPrinting Office, 1975.

49 Pflanz, M., Former Professor and Head, Institute ofEpidemiology and Social Medicine, Hanover MedicalSchool: Personal communication.

50Der Bundesminister fir Arbeit und SozialordnungUbersicht iiber die Soziale Sicherung, 1974. Bonn. DerBundesminister fiir Arbeit und Sozialordnung, 1975.

51Bundesverba,ud der Ortskrankenkassen: Statistik derOrtskrankenkassen: Krankheitsarten-, Krankheitsura-schen-, und Sterblichkeits-Sta tistik, 1977. Bonn. Bun-desverband der Ortskrankenkassen, 1979.

52Bundesministenum fiir Jugend, Familie, undGesundheit: Das Gesundheitswesen der BundesrepublikDeutschland. Band 5. Ausgabe 1974. Stuttgart undMainz. W. Kohlhammer GMBH, 1974.

53Huschenbeth, I.: Health statistics in the FederalRepublic of Germany: Present activities, in P. Armitage,cd., National Health Survey Systems in the EuropeanEconomic Community. Luxembourg. Commission of theEuropean Communities, 1977. pp. 42-47.

54Heinemann, A., Director of the Hospital DiagnosticStatistics Reporting System, Statistical Office ofSchleswig-Holstein: Personal communication.

55Griesser, G.: General statistics and hospital informa-tion, in G. A. Kool, cd., Hospital Statistics and a Mini-mum Basic Data Set. Report on a European Communi-ties Seminar. Edinburgh. Nov. 2-4, 1976. pp. 63-79.

56Statistisches Landesamt Schleswig-Holstein: DieKrankheiten der Krankenhauspatienten in Schleswig-Holstein, 1976. KieL Statistisches Landesamt, Schleswig-Holstein, 1978.

57Kukla, R., Rhineland Provincial Union: Personalcommunication (obtained and translated by H. U.Senftleben).

58 Landschaftsverband Rheinland: Zahlen, Fakten undTendenzen, 1978. Koln. Landschaftsverband Rheirdand,June 1979.

59Thomas, Mr., ~stitute of Defense Forces’ MedicalStatistics: Personal communication (obtained and trans-lated by H. U. Senftleben).

60Naegele, Mrs., Federal Statistical Office: Personalcommunication (obtained and translated by E. Schach).

61 Statistisches Bundes~t: Wirtschaft und Statistisk.

Heft 2, 1977.62Der Bundesminister fur Jugend, Familie, und Ge-

sundheit: Daten des Gesundheitswesens, 1977. Bonn. DerBundesminister fur Jugend, Farnilie, und Gesundheit.

51

63 National Center for Health Statistics: Reporting ofhospitalization in the Health Interview Survey. Vital andHealth Statistics. PHS Pub. No. 1000-Series 2-No. 6.Public Health Service. Washington. U.S. GovernmentPrinting Office, July, 1965.

64National Center for Health Statistics: Developmentand maintenance of a national inventory of hospitals andinstitutions. Vital and Health Statistics. PHS Pub. No.1000-Series l-No. 3. Public Health Service. Washington.U.S. Government Printing Office, Feb. 1965.

65National Center for Health Statistics: Participationof hospitals in the pilot study of the Hospital DischargeSurvey, by A. M. Brown, I. Altman, and D. J. Thomp-son. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 19. Public Health Service. Washington. U.S.Government Printing Office, Oct. 1966.

66Nation~ Center for Health Statistics: utilization Ofshort-stay hospitals, annual summary for the UnitedStates, 1978, by B. J. Haupt. Vital and Health Statistics.Series 13-No. 46. DHEW Pub. No. (PHS) 80-1797. PublicHealth Service. Washington. U.S. Government PrintingOffice, Mar. 1980.

67National Center for Health Statistics: Quality con-trol in the Hospitrd Discharge Survey, by K. W. Harrisand K. L. Hoffman. Vital and Health Statistics. Series 2-No. 68. DHEW Pub. No. (HRA) 76-1342. Health Re-sources Administration. Washington. U.S. GovernmentPrinting Office, Dec. 1975.

68Commission on Professional and Hospital Activities:International Classification of Dtkeases, 9th Revision,Clinical Modification (ICD-9-CM). Ann Arbor. EdwardsBrothers, Inc., 1978.

69American Association of Medical Record Librarians:Glossary of Hospital Terms. Chicago. American Associa-tion of Medical Record Librarians, 1969.

70National Center for Health Statistics: Utilization ofshort-stay hospitals, summary of nonmedlcal statistics,United States, 1973, by W. F. Lewis. Vital and HealthStatistics. Series 13-No. 23. DHEW Pub. No. (HRA) 76-1774. Health Resources Administration. Washington.U.S. Government Printing Office, July 1976.

71National Center for Health Statistics: Inpatientutilization of short-stay hospitals by diagnosis, UnitedStates, 1975, by L. Glickman. Vital and Health Statis-tics. Series 13-No. 35. DHEW Pub. No. (PHS) 78-1786.Public Health Service. Washington. U.S. GovernmentPrinting Office, Apr. 1978.

72National Center for Health Statistics: Surgicaloperations in short-stay hospitals, United States, 1975,by A. L. Ranofsky. Vital and Health Statistics. Series 13-No. 34. DHEW Pub. No. (PHS) 78-1785. Public HealthService. Washington. U.S. Government Printing Office,Apr. 1978.

73National Center for He~th Statistics: UtKlzation of

short-stay hospitals by persons discharged with alcohol-related diagnoses, United States, 1976, by M. Sanchez.Vital and Health Statistics. Series 13-No. 47. DHHS Pub.No. (PHS) 80-1798. Public Health Service. Wash@ton.U.S. Government Printing Office, May 1980.

74National Center for Health Statistics: Eighth Revi-sion International Classification of Diseases, Adapted forUse in the United States. PHS Pub. No. 1693. PublicHealth Service. Washington. U.S. Government PrintingOffice, 1967.

75National Center for Health Statistics: Detailed Diag-noses and Sur~”cal Procedures for Patients DischargedFrom Short-Stay Hospitals: United States, 1977, byB. J. Haupt. DHEW Pub. No. (PHS) 79-1274. PublicHealth Service. Washington. U.S. Government PrintingOffice, Sept. 1979.

76Nationa1 Center for Health Statistics: Health,

United States, 1979. DHEW Pub. No. (PHS) 80-1232.Public Health Service. Washington. U.S. GovernmentPrinting Office, 1980.

77National Center for Health Statistics: The Nation’s

Use of Health Resources, 1979, by B. J. Haupt. DHEWPub. No. (PHS) 80-1240. Public Health Service. Washing-ton. U.S. Government Printing Office, 1980.

78Anderson, O. A.: The Uneasy Equilibrium. NewHaven. College and University Press, 1968.

79Sidel, V. W., and Sidel, R.: A Healthy State. NewYork. Pantheon Books, 1977.

80Levitt, R.: The Reorganized National Health Sem-ite, 2d ed. London. Croom Helm, 1977.

81Maynard, A.: Health Care in the European Commu-nity. London. Croom Helm, 1975.

82Hu, T., cd.: International Health Costs and Expendi-tures. DHEW Pub. No. (NIH) 76-1067. National Insti-tutes of Health. Washington. U.S. Government PrintingOffice, 1976.

83Blanpain, J. et al.: National Health Insurance andHealth Resources: The European Experience. Cambridge.Harvard University Press, 1978.

84Leichter, H. M.: A Comparative Approach to PolicyAnalysis: Health Care Policy in Four Nations, Cam-bridge. Cambridge University Press, 1979.

85 Fiirstnow-S@ensen, B.: Care of the Old, 3d ed.Copenhagen. Ministries of Labor and SociaJ Affairs,1970. -

86National Center for Health Statistics: Inpatienthealth facilities as reported from the 1976 M FI survey,by J. F. Sutton and A. Sirrocco. Vital and Health Sta-tistics. Series 14-No. 23. DHEW Pub. No. (PHS) 80-1818. Public Health Service. Washington. U.S. Govern-ment Printing Office, Jan. 1980.

87Koch, J. H. et al.: Health Services in Denmark.

Copenhagen. Amtsr8dsforeningen i Danmark, 1976.88K~n, A. J., and Kamerman, S. B.: Social &YViCt?S

in International Perspective. DHEW Pub. No. (SRS) 76-05704. Social and Rehabilitation Service. Washington.U.S. Government Printing Office, 1977.

89Kane, R. L., and Kane, R. A.: Long-Term Care inSix Counti”es. DHEW Pub. No. (NIH) 76-1207. NationalInstitutes of Health. Washington. U.S. GovernmentPrinting Office, 1976.

90World Health Organization: World Health StatisticsAnnual, 1978. Vol. III, Health Personnel and HospitalEstablishments. Geneva. World Health Organization,1979.

52

91 Brotherston, J.: Primary care financing: A Scottishperspective, in C. D. Burrell and C. G. Sheps, eds., Pri-may Health Care in Industrialized Nations. Annals ofthe New York Academy of Sciences, vol. 310. NewYork. New York Academy of Sciences, 1978. pp. 252-256.

92National Center for Health Statistics: Health Re-sources Statistics, 1976-77, by C. M. Croner. DHEWPub. No. (PHS) 79-1509. Public Health Service. Wash-ington. U.S. Government Printing Office, 1979.

93 Nation~ Center for He~th Statistics: ~ealth,United States, 1978. DHEW Pub. No. (PHS) 78-1232.Public Health Service. Washington. U.S. GovernmentPrinting Office, Dec. 1978.

94Gibson, R. M., and Fisher, C. R.: National healthexpenditures, fiscal year 1977. Sot. Secur. Bull. 41(7):3-20,July 1978.

95 Nation~ Center for He~th Statistics: person~ out-

of-pocket health expenses, United States, 1975, by C. S.Wilder. Vital and Health Statistics. Series 1O-NO. 122.DHEW Pub. No. (PHS) 79-1550. Public Health Service.Washington. U.S. Government Printing Office, Nov.1978.

96Bridgman, R. F.: Hospital Utilization: An Interna-tional Study. Oxford. Oxford University Press on behalfof the Regional Office for Europe of the World HealthOr anization, 1979.

$7Pearson, R. J. C. et al.: Hospital caseloads in Liver-pool, New England, and Uppsala: An international com-parison. Lancet. 2:559-566, Sept. 1968.

98Andersen, R., and Hull, J. T.: Hospital ut~lzationand cost trends in Canada and the United States. Med.Care. 7(6): 4-22, Nov.-Dee. 1969.

99 Bunker, J. P.: Surgical manpower: A Comparison ofoperations and surgeons in the United States and in Eng-land and Wales. N. Engl. J Med. 282(3): 135-144, Jan.1970.

100Commission on Professional and Hospital Activities:Length of Stay in PAS Hospitals, by Diagnosis, UnitedStates, 1976. Ann Arbor. Commission on Professionaland Hospital Activities, Oct. 1977.

101Health Care Financing Administration: Medicare:Inpatient use of short-stay hospitals, 1977, by C. Hel-bing. Health Care Financing Notes. DHEW Pub. No.(HFCA) 03022. Health Care Financing Administration.Baltimore. Health Care Financing Administration.

102Health Care Financing Administration: HFCA pro-gram statistics. Health Care Financing Review. 2(l): 79-85, Summer 1980.

103Nation~ Institute of Ment~ He~th: private psychi-

atric hospitals, 1974-75, by M. J. Witkin. Report Serieson Mental Health Statistics. Series A-No. 18. DHEWPub. No. (ADM) 77-380. Alcohol, Drug Abuse, and Men-tal Health Administration. Washington. U.S. Gover-nmentPrinting Office, 1977.

104National Institute of Mental Health: Psychiatricservices and the changing institutional scene, 1950-1985,by M. Kramer. Report Series on Mental Health Statis-tics. Series B-No. 12. DHEW Pub. No. (ADM) 77433.Alcohol, Drug Abuse, and Mental Health Administra-tion. Washington. U.S. Government Printing Office,1977.

105National Institute of Mental Health: The design ofmanagement information systems for mental healthorganizations: A primer, by R. L. Chapman. ReportSeries on Mental Health Statistics. Series C-No. 13.DHEW Pub. No. (ADM) 76-333. Alcohol, Drug Abuseand Mental Health Administration. Washington. U.S.Government Printing Office, 1976.

106National Institute of Mental Health: Reinstitu-tionalization: An analytical review and sociologicalperspective, by L. L. Bachrach. Report Series on MentalHealth Statistics. Series D-No. 4. DHEW Pub. No. (ADM)76-351. Alcohol, Drug Abuse, and Mental Health Ad-ministration. Washington. U.S. Government PrintingOffice, 1976.

107~erican Hospit~Association: Guide to the Health

Care Field, 1979 ed. Chicago. American Hospital Associ-ation, 1979.

108American Hospital Association: Hospital Statistics,1979 ed. Chicago. American Hospital Association, 1979.

109National Center for Health Statistics: Current esti-mates from the Health Interview Survey: United States,1978, by J. D. Givens. Vital and Health Statistics. Series1O-NO. 130. DHEW Pub. No. (PHS) 80-1551. PublicHealth Service. Washington. U.S. Government PrintingOffice, Nov. 1979.

110Andersen, R. et al.: Two Decades of Health Sero-ices: Social Survey Trends in Use and Expenditures.Cambridge. Ballinger, 1976.

111Aday, L. A. et al.: Health Care in the U.S.: Equita-ble for Whom? Beverly Hills. Sage Publications, 1980.

000

53

-.

APPENDIXESCONTENTS

I. Contributors to Study ............ .......................................................................... ............................... 55

II. Sources of National Hospital Utilization Statistics in the United States in Addition to the Na-. .tional Hospital Discharge Suwey ...................................... ...................................................... ......... 56

General Hospital Discharge Reporting Systems .................................................... ...................... 56Special Hospital Reporting Systems ........................................... ...................... ............ .............. 56Aggregate Hospital Reports ................................................... .................................................... 57Household Surveys ...... ...................................................................... .......... ............................... 57

54

APPENDIX I

CONTRIBUTORS TO STUDY

DENMARK

Karen DreyerDeputy Director of DivisionNational Health Service of Denmark

Dr. Finn Kamper-J@gensenDanish National Institute of Social Research

Dr. Jens SchmidtInstitute of Psychiatric Demography&hus Psychiatric Hospital

SCOTLAND

P. J. FarmerInformation Services DivisionCommon Services AgencyScottish HeaIth Service

Dr. M. A. HeasmanDirectorInformation Services DivisionCommon Services AgencyScottish Health Service

Dr. J. M. G. WilsonInformation Services DivisionCommon Services AgencyScottish Health Service

WEST GERMANY

A. HeinemannDirector of Hospital Diagnostic Statistics

Reporting SystemState Office of StatisticsSchleswig-Holstein

R. KuklaRhineland Provincial Union

Mrs. NaegeleFederal Statistical Office

Dr. Manfred PflanzInstitute of Epidemiology and Social MedicineHanover Medical School

Elisabeth SchachComputer CenterUniversity of Dortmund

Dr. H. U. SenftlebenOffice of HealthDistrict Committee of Main-Kinzig-Kreis

Mr. ThomasInstitute of the Defense Forces’ Medical Statistics

Mr. WortmannFederation of Local Sickness Funds

UNITED STATES

Mary MoienDivision of Health Care StatisticsNational Center for Health Statistics

Iris ShimizuSurvey Design and Methods StaffNational Center for Health Statistics

Al SirroccoDivision of Health Care StatisticsNational Center for Health Statistics

55

APPENDIX II

SOURCES OF NATIONAL HOSPITAL UTILIZATIONSTATISTICS IN THE UNITED STATES IN ADDITION TO

THE NATIONAL HOSPITAL DISCHARGE SURVEY

In addition to the National Hospital Dis-charge Survey, many local, State, and nationalstatistical systems in the United States collecthospital statistics. The following are brief de-scriptions of some of the major sources ofnational hospital statistics.

GENERAL HOSPITAL DISCHARGEREPORTING SYSTEMS

Abstracting Services

Approximately two-thirds of the hospitals inthe United States subscribe to an abstractingservice. The hospitals supply data about each oftheir discharges to the services, which, for a fee,process the data on computers and provide the

~ hospitals with various tabulations. The largest,abstracting service is the Professional ActivityStqdy (PAS), begun in 1953 by the Commissionon Professional and Hospital Activities (CPHA).It ‘covers 1,460 hospitals, or about 31 percent ofall the discharges from nongovernmental short-stay hospitals in the United States. Informationabstracted for PAS includes patient characteris-tics, length of stay, diagnoses, tests, treatments,and physician. In addition to the tabulationsprovided to the subscribing hospitals, PAS dataare published in the CPHA series, Length of Stayin PAS Hospitals,l 00 and data tapes are availableto researchers on a contractual basis.

Medicare Claims File

Health insurance is provided by a variety ofpublic and private agencies and organizations in

NOTE: A list of references follows the text.

56

the United States, many of which compile datafrom hospitalization claims. Medicare is a na-tional public health insurance program thatcovers most people age 65 years and over, thosewith chronic renal disease, and those who meetthe disability provisions of the Social SecurityAct. The Medicare Claims File is maintained bythe Health Care Financing Administration(HCFA), Department of Health and HumanServices (DHHS). Information from 20 millionMedicare claims has been collected since the filewas begun in 1966. Twenty-percent systematicsamples of claims have also been drawn andcoded for medical diagnosis. HCFA publishessome hospital statistics from the file in its peri-odicals Health Care Financing Noted 01 andHealth Care Financing Review. 1°2 Hospital utili-zation statistics by diagnosis are available ontape.

SPECIAL HOSPITAL REPORTINGSYSTEMS

Mental Health NationalReporting Programs

The National Institute of Mental Health(NIMH), DHHS, conducts several major surveys:the Inventory of Mental Health Facilities, theAnnual Census of Patient Characteristics for

State and county mental hospitals, and samplesurveys of selected mental health facilities. Eighttypes of facilities are covered by the NIMH sur-veys: psychiatric hospitals, psychiatric servicesin general hospitals, community mental healthcenters, other multicomponent mental healthfacilities, residential treatment centers for

emotionally disturbed children, outpatient men-tal hm.h.hfacilities, mental health day-night facili-ties, and transitional mental health facilities. Forthe inventory data are collected on services pro-vided, caseload, staffing patterns, and expendi-tures of the individual mental health facilities.State and county mental hospitals and commu-nity mental health centers are surveyed annuallyfor the inventory; other mental health facilitiesarc surveyed biennially. For the annual censusdata ar&eollected on the age, sex, and diagnosticcharacteristics of resident patients and admis-sions in State and county mental hospitals. Inthe sample surveys detailed information is col-lected on patient characteristics in certain typesof mental health facilities; the type of facilitiescovered varies. NIMH publishes data in its Re-port Swks on Mental Health Statistics103-106and has data tapes available.

Federal Hospital Reporting Programs

Several Federal agencies operate statisticalsystcms that receive data about hospitalizationsin particular types of Federal hospitals. TheBureau of Medical Services, DHHS, operates anInpatient Data System that receives data abouthospitalizations in the eight general hospitals runby the Public Health Service. The Indian HealthService (IHS), DHHS, has an Inpatient Data Sys-tcm that contains information on hospital serv-ices provided to American Indians and Alaskannatives in the 50 IHS hospitals and other hospi-tals that have contracts with the IHS. The Vet-erans’ Administration (VA) maintains the Pa-tient Treatment File, which contains a medicalrecord abstract for each discharge from the 172VA hospitals and discharges whose hospital carewas provided under the auspices of the VA. Inthe Department of Defense the various ArmedForces operate hospitals for their personnel inthe United States and abroad, and they collectstatistics on the use of these hospitals.

AGGREGATE HOSPITAL REPORTS

Annual Suwey of Hospitals

Beginning in the 1940’s the American Hos-pital Association (AHA) has conducted an

Annual Survey of Hospitals. The survey coversalmost all hospitals in the United States and theU.S. territories. Each hospital is mailed a ques-tionnaire requesting information about its serv-ices, utilization, personnel, and finances. Over90 percent of the hospitals usually respond tothe questionnaire, and estimates are made ofdata for nonreporting hospitals. Statistics fromthe survey are published annually in the AHApublications Guide to the Health Care Fieldl 07and EIospita/ Statistics 08 and are available ontape.

HOUSEHOLD SURVEYS

National Health Intewiew Suwey

The National Center for Health Statistics hasbeen operating the National Health InterviewSurvey since 1957. The survey covers the civflannoninstitutionalized population of the UnitedStates. A multistage probability design is used todraw samples of households, and all adult mem-bers of the households are interviewed. The in-terviews are conducted each week throughoutthe year. Approximately 120,000 persons in40,000 households are interviewed each year.Information is gathered about the demographiccharacteristics of the household members, theirhealth status, and their use of health services.Data from the survey are published in series 10of Vital and Health Statistics,l 09 and are avail-able on tape.

National Suweys of Health Sewices

The Center for Health Administration Studiesat the University of Chicago conducted nationalhousehold surveys of health care utilizationand expenditures in 1953, 1958, 1963, 1970,and 1976. The surveys covered the noninstitu-tionalized population of the United States. Self-weighting probability samples of householdswere drawn for each survey, and the last threesurveys also oversampIed certain persons andfamilies of special concern in health policy for-mation. The 1976 survey oversampled ruralsouthern black persons, persons of Spanish herit-age living in the Southwest, and persons experi-encing episodes of illness. For the 1976 survey7,787 persons were interviewed in 5,432

57

households. Information was collected about so- Two Decades of Health Services: Social Surveycial and demographic characteristics, health sta- Trends in Use and Expenditures 10 and Healthtus, and access to the health care system. Major Care in the U.S.: Equitable for Whom?111 Datasources of the results of the 1976 survey are: tapes from each survey are also available.

000

58

VITAL AND HEALTH STATISTICS Series

S, n’i.{ f, f’i-(.iAmJmSmtd Colkction Ftocedums. –Reports which describe the general programs of the NationalCknter for Health Statistics and its offices and divisions and data collection methods used and inchsdeclcfiniticsns md other material necessary for understanding the data.

S, rli., 2. Data khkztian and Methods Research. –Studies of new statistical methodology incIuding e:iperi-rmmtal tests of new survey methods, studies of vital statistics collection methods, new analyticaltcchniqucs, objective evaluations of reliability of collected data, and contributions to statistical theory.

S, F1,s J. Ar+tictil Studies. –Reports presenting analytical or interpretive studies based on vital and healthstatistics, carrying the analysis further than the expository types of reports in the other series.

S,ri, I -1. Documcn[s and CcJmmittce Repofts. –Final reports of major committees concerned with vital andhc.dth statistics and documents such as recommended model vital registration laws and revised birthad death certificates.

S, ri,.{ 1(1, Datu From the Health Interview Surql. –Statistics on illness, accidental hjuries, disability, use ofhospital, medical, dental, and other services, and other health-related topics, all based on data collectedin a continuing national household interview survey.

.Wii, ~, 1I. I.+it,l From the Health Examination Survey and the Health and Nutrition Examination Suruey. -Datafrom direct examination, testing, and measurement of national samples of the civilian noninstitu-tlondizcd population provide the basis for two types of reports: (1) estimates of the medically definedprw.dence of specific dkeases in the United States and the distributions of the population with respectto physical, physiological, and psychological characteristics and (2) analysis of relationships among thevmious measurements without reference to an explicit finite universe of persons.

S, i-i, \ 12. Ikta From the- Institutionalized Population Surueys. –Discontinued effective 1975. Future reports fromthese surveys will be in Series 13.

S, ,r~,\ J .?. Data on Health Resources Utilization. —Statistics on the utilization of health manpower and facilitiesproviding long-term care, ambulatory care, hospital care, and family planning services.

S, ri, ., 1.1. .lkiu on HcAh Resources: Manpower and Facilities. –Statistics on the numbers, geographic distri-bution, and characteristics of health resources including physicians, dentists, nurses, other healthoccupations, hospitak, nursing homes, and outpatient facilities.

S, l-i,s ~tl, Du~a 07z itfor~ali~y. –Vmious statistics on mortality other than as included in regular annual or monthlyreports. Special analyses by cause of death, age, and other demographic variables; geographic and timesmics analyses; and statistics on characteristics of deaths not available from the vital records based onsample surveys of those records.

S,ric., ZI, DaLa on Natality, Marriage, and Divorce, —Various statistics on natality, marriage, ~d divorce otherthan as included in regular annual or monthly reports. Special analyses by demographic variables;gcogr~phic and time series analyses; studies of fertility; and statistics on characteristics of births notavailable from the vital records based on sample surveys of those records.

Si i-it \ 22. Duitf From the National hlortality and Natality Surveys. –Discontinued effective 1975. Future reportsfrom these sample surveys based on vital records will be included in Series 20 and 21, respectively.

Strii. ! 23. Ddtti From the National Suruey oj. Family Growth. —Statistics on fertility, family formation and dis-scdution, tkrdly planning, and related maternal and infant health topics derived from a biennial surveyof a nationwide probability sample of ever-mamied women 15-44 years of age.

k’or AIi>t of titles of reports published in these series, write to: Scientific and Technical Information BranchNational Center for Health StatisticsPublic Health ServiceHyattsville, hfd. 207S2

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