DATA EVALUATION AND METHODS RESEARCH	 Series 2 

Number 80 

TheStatusof 

HospitalDischargeData 

in Six Countries 

Availability, comparability, and quality of cross-national hospital 

discharge data. Descriptions of discharge reporting systems in six 

developed countries, with emphasis on coverage, types of data collected, procedures and definitions used in data collection and analysis and statistics routinely available. Discussion of health services 

system characteristics possibly affecting rates of hospital utilization. 

DHEW Publication No, (PHS) 80-1354 

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 

Public Health Service 

Office of Health Research,Statistics, and Technology


National Center for Health Statistics


Hyattsville, Md. March 1980

Library of Congress Cataloging in Publication Data 

Kozak, Lola Jean. 

The status of hospital discharge data in six countries. 

(Vital and health statistics: Series 2, Data evaluation and methods research; no. 80) 

(DHEW publication; (PHS) 80-1354) 

\ Bibliography: p. 

Supt. of Dots. no.: HE20.6209: 2/80 

1. Hospital utilization–Australia–Statistical services. 2. Hospital utilization–Canada– 

Statistical services. 3. Hospital utilization–England-Statistical services. 4. Hospital utilization— Finland-Statistical services. 5. Hospital utilization–Franc e–Statistical services. 

6. Hospital utilization–Sweden–Statistical services. I. Andersen, Ronald, joint author. 

II. Anderson, Odin Waldemar, 19 14-joint author. III. Title. IV. Series: United States. National Center for Health Statistics. Vital and health statistics: Series 2, Data evaluation and 

methods research; no. 80. V. Series: United States. Dept. of Health, Education, and Welfare. 

DHEW publication; (PHS) 80-1354. [DNLM: 1. Patient discharge. 2. Hospital–Utilization– 

Australia. 3. Hospital–Utilization–Canada. 4. Hospitals–Utilization–Europe. W2 A N148b 

no. 80] 

RA409.U45 no. 80 [RA971.6] 312’.07’23s


ISBN 0-8406 -0186-7 80-607009

NATIONAL CENTER FOR HEALTH STATISTICS 

DOROTHY P. RICE, Director 

ROBERT A. ISR4EL, DepuzY Director . 

JACOB J. FELDMAN, Ph.D., Associate Director for Analysis 

GAIL F. FISHER, Ph.D., Assoaate Director for the Cooperative Health Statistics System 

ROBERT A. ISRAEL, Acting Associate Director for Data Systems 

ROBERT M. THORNER, SC.D.,Acting Associate Director for International Statistics 

ROBERT C. HUBER, Associate Director for Management 

MONROE G. SIRKEN, Ph.D., Associate Director forMathen@ical Statistics 

PETER L. HURLEY, Associate Director for Operations 

JAMES M. ROBEY, Ph.D., Associate Director for ProgramDevelopment 

PAUL E. LEAVERTON, Ph.D., Associate Director for Research 

ALICE HAYWOOD, Information Officer 

OFFICE OF INTERNATIONAL STATISTICS 

ROBERT M. THORNER, SC.D.,Acting Associate Director 

Vital and Health Statistics-Series 2-No. 80 

DHEW Publication No. (PHS) 80-1354 

Libra~ of CongressCatalog ChrdNumber 80-607009 
ACKNOWLEDGMENTS 

This report was financed by Purchase Orders PLD-07840-77 and PLD-08633-

78 from the National Center for Health Statistics and by the Center for Health 

Administration Studies of the University of Chicago. 

The report was made possible by numerous colleagues from several countries 

who provided us with the benefit of their considerable knowledge and experience, 

supplied us with published and unpublished materials, and gave us references to 

other reports and informants. These people are listed in appendix I. We are particularly indebted to our coordinators in each of the six countries, who bore the 

brunt of our continuing requests and critiqued drafts of the report: J. M. Martins 

and Marlene M. Lugg in Australia; W. A. Mennie, J. B. Davis, and A. Dobrodzicki 

in Canad”a;Donald Macmillan, Andrew F. Long, and J. M. Yates in England; A. S. 

HW5 and Eero Linnakko in Finland; Ari6 Mizrahi and M. (). Gascon in France; 

and Bjdrn Smedby in”Sweden. To the extent that this report by people “on the 

outside looking in” faithfully reflects the situations in the six countries studied, 

we gratefully acknowledge our informants and coordinators. Of course, for any 

errors of fact or interpretation we must bear sole responsibility. 

We also wish to thank Gretchen Fleming and Stan Merrill, who assisted with 

translation of materials, and our project officers, Robert M. Thorner and Jacob J. 

Feldman, whose support and suggestions far exceeded the usual project officer 

role. 
CONTENTS 

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

Characteristics of Six Countries ..............................................................................................................


Australia .................................................................................................................................................


Genersl Hospital Discharge Reporting Systems .................................................................................


Other Discharge Reporting Systems ..................................................................................................


Aggregate Hospital Reports ...............................................................................................................


Household Surveys ............................................................................................................................


Canada ...................................................................................................................................................


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


Other Discharge Reporting Systems ..................................................................................................


Aggregate Hospital Reports ...............................................................................................................


Household Surveys ............................................................................................................................


England and WaIes ..................................................................................................................................


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


Other Dischaxge Reporting Systems ..................................................................................................


Aggregate Hospitaf Reports ...............................................................................................................


Household Surveys ............................................................................................................................


Finland ...................................................................................................................................................


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


Other Discharge Reporting Systems ..................................................................................................


Aggregate Hospital Reports ...............................................................................................................


Household Surveys .....................................................................................................................4......


France ....................................................................................................................................................


General HospitaJ Discharge Reporting System ..................................................................................


Other Discharge Reporting Systems ..................................................................................................


Aggregate Hospital Reports ...............................................................................................................


Household Surveys ............................................................................................................................


Sweden ...................................................................................................................................................


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


Other Discharge Reporting Systems ..................................................................................................


Aggregate Hospital Reports ...............................................................................................................


Household Surveys ............................................................................................................................


Summary ............................................................................................................................................. ...


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


Sources of Utilization Statistics in Addition to the General Hospital Discharge Reporting Systems...


Health Services Systems ....................................................................................................................


Conclusion ........................................................................................................................................


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


Appendixes 

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


II. Major References Concerning Hospital Utilization, by Country ................................................


111. Additional Sources of Information About Hospital Utilization, by Country .............................


... m


1


4 

8 

8 

14 

16 

17 

18 

18 

21 

22 

25 

25 

25 

29 

30 

31 

32 

32 

34 

34 

35 

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40 

41 

41 

42 

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46 

47 

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47 

56 

58 

63 

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74 

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v 
----------------------------- ---

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LIST OF TEXT TABLES 

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

B. Selected vitsl statistics by country ................................................................................................. 

c. DMribution of beds in hospitsls and related institutions, by country ............................................ 

D.	 Percent distributions of beds in general hospitals by selected characteristics, accortilng to 

country ................................................................................o........................o.o.....o..o..o...o.............. 

E. Utilization statistics in generaf hospitals by country ....................................................................... 

F. General hospital discharge reporting systems in operation, by country .......................................... 

G. Coverage of general hospital discharge reporting systems, by country ............................................ 

H,	 Whether or not selected items are coflected by gcneraf hospital dkchargc reporting systems, by 

country .......................................................................................................................................... 

J. Coding of diagnoses in general hospital discharge reporting systems, by country ........................... 

K.	 Sources of hospitsl utilization statistics in addition to the general hospital discharge reporting 

systems, by country ....................................................................................................................... 

4 

5 

5 

6 

7 

48 

50 

54 

55 

57 

SYMBOLS 

Data not available


Category not applicable---–-—---------—----


Quantity zero ----------------------------------

Quantity more than O but less than 0.05 

Fi~c does not meet standards of 

reliability or precision-----—----------—--­

. . . 

. 

0.0 

* 

vi 
THE STATUS OF


HOSPITAL DISCHARGE DATA


IN SIX COUNTRIES


Lola Jean Kozak, Ronald Andersen, and Odin W. Anderson,


Center for Health Administration Studies, Graduate School of Business, University of Chicago


INTRODUCTION 

In recent years there has been a growing concern about problems in the organization and financing of health services in the United States. 

Debates over possible solutions to these problems have stimulated interest in the health 

services systems of other countries in the developed world. Examination of other health 

services systems might uncover new approaches 

to the difficulties experienced in this country. 

Further, many of the current proposals for 

change in the U. S. health services system have 

previously been implemented in od-ier countries. 

Thus the extent to which the changes have 

actually produced the desired results can be 

investiga.ted through the study of these countries. 

The initial studies of health services systems 

in other countries were primarily descriptive. 

They outlined the major characteristics of the 

systems and pointed out broad similarities and 

differences between systems. These studies were 

an essential first step in cross-national research. 

They increased understanding of how health 

services systems function and pointed to the 

range of variation which currently exits in such 

systems. The information collected also led to 

the generation of many hypotheses about why 

differences exist in such aspects of health 

services systems as expenditure and utilization 

patterns, health levels, and patient satisfaction. 

Now it has become important to move on to 

more stringent kinds of cross-national research.l 

The hypotheses which have been suggested need 

to be subjected to rigorous tests, and conceptual 

models of the structure and functioning of 

health services systems need to be developed. 

Some studies that begin to undertake these tasks 

include Kohn and White’s study of health services utilization in seven countries2 and Anderson’s study of the health services systems in the 

United States, England, and Sweden.3 Much, 

more work of this type remains to be done. 

One of the major difficulties in moving beyond the descriptive phase of research has been 

the problem of gathering sufficient comparable 

data on specific chziracteristics of different 

health services systems. To overcome the problem, some researchers have designed ad hoc data 

collection procedures and have collected for 

themselves the information they wanted from 

different countries. This approach can insure 

consistency and comparability of data, but it is 

quite complex, time consuming, and costly, and 

therefore the number of health services systems 

that can be compared is limited. Other researchers draw data from preexisting cross-nationaI 

sources such as the summaries of health statistics 

prepared by the World Health 0rganization$4 

These sources present a different set of problems. Though they are relatively quick, simple, 

and inexpensive to use, and though they make 

possible studies of lame numbers of health services systems, the data available in them are often 

not comparable enough to allow rigorous empiri1 
cal tests of hypotheses concerning systems. In 

addition, because the summaries generally report 

only a limited set of aggregate measures on each 

country, it is impossible to inquire into many of 

the important relationships within systems. 

Data regularly collected by health agencies 

within individual countries may help solve some 

of these problems. Such data are not as accessible as statistics in cross-national summaries are. 

However, it is generally much easier and less 

costly to use existing statistics than it is to develop and carry out special data collection procedures. Also, though there is a loss of flexibility 

in the use of preexisting statistics rather than of 

data from specially designed studies, a much 

wider range of data may be expected to be available from individual countries than that which 

can be incorporated in international summaries. 

Finally, while statistics collected by individual 

countries cannot be expected to achieve the 

comparability of statistics especially collected 

for comparative purposes, they should be somewhat easier to compare than are the statistics in 

cross-national summaries. 

The summaries usually include the definitions used in compiling statistics, but this is 

often not enough information to acquaint the 

researcher with important differences in the 

types of entities included together in single categories. More detailed information on classifica­

~ion procedures is usually available from the 

agencies in the individual countries involved in 

data collection. Moreover, the wider range of 

data available from individual countries may 

allow comparable categories to be constructed 

by the researcher. Of course, the development of 

comparable categories is also essential to the 

policymaker and administrator who wish to 

monitor performance of different systems and 

consider programmatic implications based on 

observed differences. “Real” differences must be 

distinguished from “apparent” differences for 

such monitoring to be a useful exercise. 

The potential that data regularly collected 

by individual countries have for cross-national 

comparnons has led to interest in greater knowledge about the status of such data. This study 

will address itself to one aspect of that interest. 

It will examine the availabilityy, comparab~ty, 

and quality oi hospital discharge data in selected 

countries of the developed world. 

Hospital statistics were chosen for study for 

severaI reasons. First, hospitals hold a central 

position in most health services systems. They 

deal with the most serious health disorders, and 

generally they absorb by far the largest portion 

of total health expenditures. Thus hospital utilization commands much interest in different 

countries. Health agencies collect a considerable 

amount of hospital utilization data, and frequently they are interested in comparing the 

patterns of use in their hospitals with those patterns in other countries. 

In addition, it is likely that hospital discharge data are less problematic to compare than 

other types of health statistics are. All developed 

countries label basically the same type of institution as a hospital. Even though hospitals may 

be divided into different subgroups from one 

country to the next, the same general set of categories of hospitals exists cross-nationally. In 

contrast, when international comparisons of 

health personnel are attempted, researchers find 

categories that are widely used in some countries 

but insignificant in others, such as midwives; or 

they find categories, such as the feldsher in the 

Soviet Union, that lack any counterpart in many 

other health services systems. People making 

comparisons of health costs and expenditures 

must contend with radically differing health 

financing programs, different accounting methods, and exchange rates that are currently fluctuating and are problematic in the health care 

sector even in more stable periods. Thus if any 

data regularly collected in individual countries 

are useful for cross-national health sector comparisons, they should be hospital utilization 

data. Difficulties are found in comparing hospital statistics, but they can be expected to be 

even greater with other kinds of health statistics. 

To assess the status of hospital discharge 

data, hospital ‘statistical systems were examined 

in six developed countries: Australia, Canada, 

England and Wales, Finland, France, and Sweden. These countries were chosen for study for 

two major reasons. First, statistics concerning 

their health services systems have frequently 

been compared with U. S. health statistics. Second, the countries display a range of health services systems characteristics that can be expected 

to affect the ways health statistics are collected. 

Sweden and Finland have drawn much 

2 
American interest because of their continuing 

success in reducing infant mortality rates. This 

success has sometimes been interpreted as an indication of a superior health services system. 

Hospitals in both countries are almost entirely 

publicly owned and operated, but they are the 

concern of local units of government rather than 

part of a single national health service. Canada 

and Australia are of interest to the United States 

because of the many similarities between their 

health services systems and the U. S. system. In 

both Canada and Australia the provision of 

health care is not a responsibility of the National 

Government but rests legally with the States or 

Provinces. Both countries have adopted national 

health insurance programs but continue to have 

important private segments within their health 

systems. The National Health Service in England 

and Wales, which provides almost all of the 

health services in the country, has probably 

been studied by U. S. health researchers more 

intensely and for a longer period of time than 

has any other health system. It continues to be a 

provocative contrast in health services organization to the U. S. system and to systems in many 

other developed countries. The French health 

services system is a more typical example of the 

health services systems in Western Europe and, 

has therefore been gaining increased attention 

from comparative researchers in recent years. 

The French system contains a mixture of public 

and private services. Public hospitals are generally run by local communes, but a significant 

number of private hospitals also exist. A health 

insurance system was developed decades ago, 

and it was gradually expanded until it now covers almost all of the population. 

This work is intended as an exploratory 

state-of-the-art study. Very modest funding 

support precluded travel to the countries 

included for data gathering purposes. We were 

thus limited to the use of published reports and 

unpublished materials that could be acquired 

from governmental agencies, private health organizations and research institutions, universities, and written and telephone communication 

with informed people in each country. Consequently, our selection of countries was also tempered by our previous knowledge of the systems, by our expectations that we could gain 

fairly ready access to sufficient information to 

prepare our report, and by our hope that we 

could prevail on colleagues within each country 

to provide us with the insights and direction we 

would need to accomplish our task. 

After the countries to be studied had been 

chosen, inquiries were sent to people knowledgeable about hospital use statistics in each 

country. Each contact was asked a series of 

questions including what agency or agencies 

were responsible for the collection of hospital 

statistics, what procedures were followed in the 

collection and analysis of data, what institutions 

and patient groups were covered by the statistical system or systems and what ones were excluded, what items of information were collected on hospital inpatients, and how the information was coded and grouped. Questions were 

also asked concerning what guidelines were followed in the calculation of utilization statistics– 

whether there was any separation of short-term 

from long-term patients and how discharges and 

transfers were handled, for example; what kinds 

of information were regularly published or available on hospital use; and how health services 

systems characteristics affected hospital utilization statistics. 

The primary focus of these questions was on 

any national statistical system in which data 

were collected by means of abstracts filled out 

on individual patients at the time of discharge. 

Such a system offers the most detailed information on hospital utilization. However, information was also requested on other sources of 

national hospital statistics, such as annual hospital reports or nationwide household surveys that 

included statistics on hospital utilization. 

Each person originally contacted was also 

asked to recommend other individuals in the 

country who had knowledge of hospital statistics and who would be willing to assistwith the 

study. Further inquiries were then sent to the individuals who were recommended. In addition, 

letters were sent to researchers in the United 

States and other countries not chosen for detailed study to obtain background information 

about the range of hospital statistical systems in 

operation and to request further recommendations on sources of information available on the 

six countries studied in detail. 

Over 50 persons in 10 countries responded 

to the requests for information. hlany not only 

3 
made comprehensive replies to the original sei 

of questions but also answered a number of followup questions on points that were not clear to 

us. In addition, they commented on early drafts 

of the report. We were also fortunate that a 

number of our informants visited the Center for 

Health Administration Studies during the period 

this report was being prepared. We were thus 

able to discuss details face to face with R. B. 

Scotton of Australia, Donald Macmillan and 

Kenneth Lee of England, Hannu Vuori of Finkqd, Simone Sandier of France, and Bj6rn 

Smedly and Monica Jonsson of Sweden. A list of 

fi contributors is given in appendix I, and the 

information they supplied is noted throughout 

the report. 

In addition to the information ‘received 

through personal communications, material on 

the discharge reporting systems in the six coun­

, tries was obtained from a review of published 

sources. For each country, publications that described or evaluated the hospital statistical systems were consulted, and samples of the regular 

reports that include hospital statistics were examined. The literature reviewed is listed in the 

references and appendixes. The project began in 

fall 1977. This report was completed in December 1978. 

CHARACTERISTICS OF SIX COUNTRIES 

Before examining hospital discharge data in 

each of the six countries, a few characteristics of’ 

the countries and their hospitals should be 

Table A, Spatial distribution 

Country 

Australia,,,,,,.,.,.,,,..,,,,,,,,,,,.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,.,.,,.,,,,,,,,,,,,, 

noted. First, in table A it can be seen that the 

countries differ widely in the size of their populations. Australia and Canada contain a fourth to 

a half as many people as France and England 

and Wales, which have relatively large populations; and Sweden and Finland have the 

smallest populations, with Finland 11 times 

smaller than France. The amount of area included in each country also varies greatly, with 

Canada, the largest, more than 65 times larger 

than England and Wales, the smallest. The number of persons per square kilometer is very low 

in Australia and Canada and quite high in England and Wales. The percent of the population 

living in urban areas is more similar from country to country, but it should be noted that 

Australia has the most highly urbanized population even though it has the lowest density, and 

that almost half of the population of Finland 

still ljve-sin rural areas. 

Selected vital statistics from each country 

are arrayed in table B. The statistics show that, 

Australia and Canada have younger populations 

than do the European countries studied. Australia and Canada have the highest birth rates, 

and the percent of their populations under 5 

years of age is higher than in all other countries 

except France. Finland and Sweden have the 

lowest infant mortality rates, and Sweden$s 

population has achieved the longest life expectancies, with the difference particularly notable 

for males. 

Table C presents information on the availability of beds in hospitals and related health institutions in each country. These statistics 

require further explanation. For Australia the 

of populations by country 

Araa in 

squara 

kilometers 

13,546,000 7,6S6,848 

Persons Percant of 

per population 

squara in urban 

kilomatar areas 

1.s 86 

2.3 70 

325.5 78 

14.0 51 

SS,8 

18,2 :; 

Canada o...................,,, ...... ...........,,, ,,,. ,,,,, ,,,,, ,, ,.,,,, ,,,.,,. .,, .O.,, .,.,. ,,, O,,,.,.,,,,,,,, ,,,, ,.,. 22,479,000 9,976,139 

England and Wales................... ................ .................................... .................... ... 49,185,000 151,126 

Finland ...... ....... ........................................... ................................ ...........,,. ,,,,, ,,, . 4,731,000 337,00s 

France ............... .. .. .............. ........................................ ............... ...................... .. 52,975,000 547,026 

Sweden ........................................................................................................... .... 8,193,000 449,864 

NOTE: Data are for most recent year available, 1971-76. 

SOURCES: References 4, S, 7-13. 

4 
Tak B. Salectef fital statistics by country 

1 

1 I 1 1 

ParCent of Infant Avaraga Iifa Parcent Death 

Birth rata population mortal ity expectancy of popu la- rata per 

Country per 1,000 under 5 rate par in yaars tion 65 1,000 

population years of 1,000 live years and populaaga births --1-1 Male Female over tion 

I 

I Australia ............................................................... 17.2 9.0 14.3 68.0 75.1 8.5 8,1 

Canada .......................... ........................ ................ 15.7 8.0 15.0 69.6 77.1 8.1 7.3 

England and Walas ................................................ 11.9 7,0 14.2 69.3 75.6 14.0 12.1 

Finland ........................ ........................................ . 14.0 6.0 9.6 67.0 75.7 10.6 9.4 

I Franca ................... ............................................... 

Svwdan ............................................ ..................... 

14.1 

12.7 

8.0 

7.0 

12.5 

8.6 

69.0 

72.2 

76.9 

78.1 

13.6 

15,0 

10.6 

10.8 

I 

NOTE: Data are for most recent year available, 1971-77. 

SOURCES: References 5, 7-13. 

Tabla C. Distribution of beds in hospitals and ralated institutions, by country 

General and Nursing 

Country Total specialized Psychiatric homes and 

institutions related hospitals institutions 

Beds per 1,000 total population 

Australia ................................................................................................................ I 2.5 6.5 2.0 14.0 

tinada .. ..... .. .... .. ... . .... ... ... ... .. .. ... ... ... . ... .. .... . .... .. . ... ..... . .... . .. .. ... ... ... . .. ... ... .... ... .. .... .. . 15.5 7.2 2.1 26.2 

England and Wales . . .. ... ... .. .. .... ... . .. .. . ... .. .. .. .. .. .. .. ... . .. .... .. .. .. .. .. .. ... .. ... ... ... .. ... . .. .. .... .. . 11.9 5.5 33.4 

Finland . ..... ... .. . .... .. .... . ..... .. .. .. .. . ... .. .. .. .. ... ... .. .. . .. ... .. ... ... .. .. .... .. .. ... . .... .. ... . ... . .... .. .. .. .. 22.1 11.2 ?2 46.7 

France ....................,,, ,.,,.. 0..,., ...,, ..................... ....................................................... 16.9 8.0 2,2 56.7 

Swedan .................................................................................................................. 17.1 8.9 4.5 ‘3.7 

lNursing homes.


2Nursing homes, hostels, and homesfor theaged.
 3private nursing homeS and pla~eS in residential accommodations provkiedby or on behalf of local authorities.


4Beds for chronically ill in social welfare institutions.


5H08picea, retbement homes, and annex sections Of public hospit~s.


6Cottage hoaPitaIa, conv~escent homes, and nonpsychiatric nursing homes.


NOTE: Data are for most recent year available, 1973-77. 

SOURCES: References 6, 9, 10, 13-20. 

general and specialized hospitals category consists of all hospitals approved by the Commonwealth Department of Health. Almost all of 

these approved hospitals provide short-term 

care. For Canada, the same category is composed of general hospitals, allied special hospitals, and tuberculosis institutions. Allied special 

hospitals are divided into two groups: The first 

contains rehabilitation, convalescence, extended 

care, and chronic care hospitals, and it accounts 

for 11 percent of all the country’s hospital 

beds .14 The second group is called “other hospitals” and it contains hospitals, such as orthopedic, cancer, and cardiology hospitals, that 

provide treatment for a limited range of diseases 

or injuries; or hospitals for a particular age or 

sex group, such as pediatric and maternity hospitals. These “other hospitals” account for approximately 4 percent of all Canada’s hospital 

beds. Tuberculosis. institutions contain fewer 

than 1 percent of Canada’s hospital beds. 

The statistics in tabIe C for psychiatric, general, and specialized hospitals in England and 

Wales refer to National Health Service hospitals 

only, but private institutions are included in the 

category of nursing homes and related institutions. In Finland the general and specialized 

hospitals category includes beds in health centers, hospitals of institutions, and tuberculosis 

hospitals, as well as general hospitals. Health 

5 
centers have been opening in Finland since 

1972, and beds in health centers have, to a large 

extent, replaced beds which previously existed 

in small rural hospitals. Presently health centers 

account for 2.3 beds per 1,000 population. 

Hospitals of institutions are units attached to 

institutions such as prisons, military garrisons, 

and homes for the aged. Close to 60 percent of 

the beds in hospitals of institutions are in units 

registered as hospitals, and they are similar to 

other general hospital beds.g Over 80 percent of 

the unregistered beds are attached to homes for 

the aged. Registered and unregistered hospitals 

of institutions account for 3.5 beds per 1,000 

population. Tuberculosis institutions contain O.5 

bed per 1,000 population. 

In France the statistics on general and specialized hospital beds include beds in short-stay, 

intermediate-stay, and tuberculosis hospitals or 

sections of hospitals. There are other long-stay 

units in many French hospitals in the annexes 

and hospice sections, but they are not considered part of the “hospital sector” since they provide care similar to that given in nursing homes, 

in other countries.1 Q 1 Intermediate-stay sections contain beds for rehab~ltation, convalescence, and other similar care. They account 

for 0.8 bed per 1,000 population. Tuberculosis 

units account for O.5 bed per 1,000 population. 

In Sweden there are nursing homes that specialize in the care of the mentally ill. These are 

included along with psychiatric hospitals in the 

category of psychiatric institutions. 

It can be seen in table C that England and 

Wales has the lowest bed-to-population ratio 

whether only the general and specialized hospitals or all health institutions are considered. Australia and Canada also have lower bed-to-population ratios than do the other countries studied. 

Finland and Sweden have the most general and 

specialized hospital beds, the most psychiatric 

beds, and the most total beds per population. 

In table D the distribution of beds in different kinds of general hospitals and general hospital units is presented. Concerning the ownership 

of hospitals, it is important and to be aware that 

Table D. Percent distributions of beds in general hospitals by selacted characteristics, according to country 

Hospital 

ownership 

Type of general Typs of unit within general hospitals hospital 

Country All 

beds Local Other Other 

Public Privata 1 Teaching or Other Maternity Psychiatric long- shortrural tarm term 

I Percent distributions 

Australia ................................ 100 23 645 ’13 93 9,113 12 981

Canada................................... 100 2;: . . . z 9 4 so 

England and Wales ................. 100 98 . . . . . . . . . 7 9 13: 

Finland .................................. 100 21 740 39 141 z 

Franca ................................... 100 % 3: 524 83 73 1,0: : 1511 77 

Sweden .................................. 100 99 1 20 4 76 4 6 1316 74 — 

lIncludes both profit and nonprofit hospitals unless otherwise stated. 

21ncludes nonprofithospitals as well as government-owned hospitals. 

3Short-term beds in private hospitals. 

4FuII teaching hospitals only. Spublic university hoapiteS centers. 

6Nonmetropolitan or country hospitak 

7Loc~ hospit~gand hospital units in health centers. 

8Public local hospitals. 9Doe~ not include Victoria. 

10Maternity, obstetrics, and gynecology units. 

1lGeriatric units. 

12Tubercu10sia and~~onicdig~a~e
 unit~.


13Tubercu10sis
 and geriatric units. 

la’ruberculo~ig units. 

151ntermediate.gtay units: convalescence, rehabilitation, etc. 

NOTE: Data are for most recent year available, 1972-77. 

SOURCES: References 6, 9, 10,13-15, 19, 23-25. 
in Canada, though 99 percent of hospitals are 

called public, only about 40 percent are operated by units of government.zz An equal number are run by nonprofit lay groups, and 20 

percent are operated by religious organizations. 

Only institutions run for profit are referred to 

as private hospitals in Canada. Canada thus contains the highest percent of nongovernment general hospitals, though Australia and France ako 

have a sizable number. The general hospitals in 

the other three countries are near monopolies 

of the government. 

To obtain an approximate picture of the 

level of complexity of the general hospitals in 

the different countries, the percents of beds in 

two subtypes of general hospitals are presented. 

Teaching hospitals are assumed to provide, on 

the average, a more complex level of medical 

services than do the other general hospitals; and 

rural or local hospitals, which are usually small 

and unspecialized, are assumed to provide a less 

complex level of services than is average. It can \	 be seen in table D that the countries have about 

the same percent of beds in teaching hospitals, 

but Finland and Australia have many more local 

or rural hospitals than do France and Sweden. 

Canada and England and Wales also have hospitals that would be classified as local or rural, 

but the number of beds accounted for by such 

hospitals was not available in the materials assembled for this study. The last section of table 

D concerns the distribution of general hospital 

beds in types of specialized units that are often 

treated differently in hospital statistical systems. 

The final introductory table, E, presents 

utilization statistics from general hospitals in 

each country. It can be seen that England reports the Iowest level of hospital use whether 

the number of discharges or the number of bed 

days per population is considered. Finland 

reports the highest level of use, again whether 

the number of admissions or of bed days per 

population is considered. Along with Finland, 

France and Sweden rdso have a much higher 

number of bed days per population than Australia, Canada, or England. 

Two figures relating to average length of stay 

are given. The first includes all general hospital 

patients. The second, which is expected to be 

more meaningful for comparative purposes, is 

the reported average length of stay excluding 

the largest number of nonacute patients or units. 

Using either set of statistics, patients in Australia 

and Canada can be seen to average the shortest 

lengths of stay. If all Sweden’s general hospital 

patients are considered, Sweden records the 

longest average stay; but if only acute specialties are compared, Sweden, along with England 

and Wales, has an average”length of stay intermediate between the other four countries. Finland and France report appreciably longer average stays, even in their short-stay hospital units. 

Table E. Utilization statistics in general hospitals by country 

Admissions Avarage length 

or Bad days of stay 

Country discharges per 1,000 

per 1,000 population Genaral Short-stay 

population T hospitals units 

Australia ................................................... 1975-76 190 1,586 8.0 

Gnada......................................................................... 1975 160 1,589 9.5 i:: 

England and Wales .......................... ............................. 1976 109 1,414 12.9 29.5 

Finland ...................... .. ...... ................ .......................... 1976 198 2,880 14.0 311.6 

Franca .......................................................................... 1976 162 2,430 15.0 412.2 

Sweden ,,,., ,,,, ,,,. 0................... .......... ............................. 1975 168 2,580 15.4 59.9 

Ishort.term units in general hospitals. e~cl~di~g &Sabl@ Health Service hospitals. 

,,,,0,,,,,,,..,,,.. 

2NonP~y~hiatri~ specialties ~~unge~ in NJatiOnd 

3Excludes hospitals of institutions.


‘%hort-stay departments in public and private hospitsds.


5Nonpsychiatric hospitals excluding chronic sick.


6@neral and allied special hospital~–othar statistics for generelhospitals ofdy. 

7Exciude~ “nonspecialized hospitals of health centers. 

SOURCES: References 9-11, 13, 14, 17, 18, 26-28. 

Bed 

occupancy 

rate 

(parcent) 

69 

677 

76 

775 

84 

82 

7 
Many other general characteristics of the 

countries could be examined, and further information about health services systems are 

presented in the summary section of this report. 

First, however, the hospital discharge data collected in each country are described. 

Every country was found to have in operation a statistical’ system or systems for the collection of information on individual patients 

discharged from hospitals. The systems that collect discharge data on general hospital inpatients 

are described in detail in the first section of the 

chapter for each country. Discharge reporting 

systems covering other types of hospital patients 

are discussed second. Hospital reports that include aggregate data on hospital use are investigated in the third section of each chapter, and 

the fourth section deals with nationwide household surveys. 

AUSTRALIA 

Australia is made up of six States and two 

Territories. The States are New South Wales 

(population 4.8 million), Victoria (3.6 million), 

Queensland (2.0 million), South Australia (1.2 

million), Western Australia (1 .1- million), and 

Tasmania (0.4 million). The two Territories have 

much smaller populations. The Northern Territory contains 97,000 persons, and the Australian Capital Territory has a population of 

198,000.7 

Most hospital statistics are collected and 

compiled by authorities in the individual States 

rather than by national authorities. The States 

have established separate hospital morbidity 

data reporting systems, and each State’s system 

is somewhat different, although efforts have 

been made to standardize the procedures for 

data gathering and analysis, The States also collect the bulk of the administrative hospital statistics available in Australia-the statistics concerning the facilities within hospitals, staffing, 

financing, and utilization of hospitals. 

National authorities have had some involvement in the collection of hospital statistics. For 

instance, a nationwide survey of hospital facilities and services was conducted in 1972-73 by 

the Hospitals and Health Services Commission. 

A hospital” discharge reporting system’ was established in 1975 as part of Medibank, the National health insurance program, but diagnostic 

information has not been collected by that system. Also, a national morbidity survey that includes data on hospital use was started in 1977 

by the Australian Bureau of Statistics. 

General Hospital Discharge 

Reporting Systems 

National general hospital statistics were first 

collected in Australia in the 1950’s as part of a 

voluntary health insurance program established 

by the National Health Act. However, hospital 

services not covered by the insurance program 

were not included in the statistics, and substantial numbers of services were not covered until 

the passage of the Health Insurance Act in 1974. 

The 1974 Health Insurance Act created Medibank, which at first provided compulsory coverage of almost all general hospital and doctors’ 

services. Hospitals were expected to begin forwarding statistical information to the newly 

established Health Insurance Commission as 

soon as their States signed cost-sharing agreements with the Commonwealth and started receiving hospital benefits. On July 1, 1975, South 

Australia, Tasmania, and the Territories began 

receiving benefits and forwarding data to the 

Commission. Victoria and Western Australia 

joined the program as of August 1, 1975; 

Queensland, September 1, 1975; and New South 

Wales, October 1, 1975.26 

In 1976 the Medibank scheme was revised so 

that it entered into competition with private insurance funds. The majority of the Australian 

population were allowed to opt out of Medibank 

and obtain private health insurance. However, 

all the public and private hospitals approved by 

the Commonwealth Department of Health continued to have the responsibility to report statistics on users to the Health Insurance CommisaThe term “discharge” is used by the authors to 

refer to both live discharges and deaths, though in Australia the term “separation “ is used to refer to both. See 

the section “definitions and procedures” for further 

information. 

8 
sion .b On November 1, 1978, Medibank was 

again revised and became a totally voluntary system. The effect of this change on the collection 

of statistics is not yet clear.29 

The Health Insurance Commission uses statistics from the Medibank system in their 

management of the insurance system—for reveiwing claims, processing claims, and preventing 

fraud and overservicing.zG The statistics are also 

expected to serve as a national data base for research into trends in the delivery, use, and cost 

of hospital services. The Commission routinely 

provides some hospital statistics to the Commonwealth Department of Health and the State 

health authorities, It also attempts to meet special requests for statistics from government 

agencies, professional associations, university researchers, and others who agree to ,uphold the 

privacy provisions of the Health Insurance Act, 

However, so many request have come to the 

Commission in the first years of the system’s 

operation that it has been unable to meet all of 

them. 

Within each State and Territory in Australia, 

there also exists a separate system for the collection of hospital morbidity statistics.’ These statistical systems have existed for various periods 

of time. For instance, Queensland’s has been in 

operation since the 1930’s, while the New South 

Wales system, first organized in 1968, did not 

cover all the State’s general hospitals until January 1,1978. 

Most of the systems are cooperative projects 

of the Australian Bureau of Statistics (ABS) and 

the State health authorities. In New South Wales 

the ABS and the Health Commission of New 

South Wales collect zind analyze morbidity data. 

In Queensland, the Department of Health collects data from public hospitals and the ABS collects from private hospitals, The South Austrabunle~~ ~therwi~e noted, the remainder of this de. 

scription of Medibank statistics is drawn from information furnished by D, R, Harvey, Assistant General 

Manager, Data Management, Health Insurance Commise.ion.25 

cunless otherwise noted, fi’e description of’S“tate 

hospital morbidity statistics is drawn from the second 

paper of the Working Party on Hospital Morbidity Statistics of the National Committee on Health and Vital 

StatisticscSo 

lian Hospitals Department and ABS have responsibilityy for the South Australian system, and in 

Western Australia, ABS and the Public Health 

Department are involved in the system. In 

Tasmania and the Territories, .ABS performs all 

the data collection, processing, and analysis and 

then makes the hospital statistics available to the 

health authorities. 

Until 1972 the Victorian Hospitals and Charities Commission and ABS collected and published data from nonmaternity public ward 

patients in Victorian public hospitals. However, 

the Hospital Computer Services at the Monash 

University Computer Center has now developed 

an alternative data system to which most public 

hospitals in Victoria have subscribed. 

At least two important changes are expected 

in the hospital morbidity statistics systems in 

the near future. The first affects only South 

Australia, where the hospitals department is being joined with the public health department 

into a health commission. The commission will 

have a comprehensive planning and research section, which is expected to make considerable 

changes in the hospital data collection systems 

by the end of 1979.81 By 1981 other changes 

will have taken place in the systems in most of 

the States. The ABS has announced that it will 

withdraw from the States’ hospital morbidity 

systems by that time, continuing to receive only 

completed computer tapes from the State health 

authorities .29 Since the ABS has had major 

responsibilities for collection and analysis of 

hospital morbidity data in most States, its withdrawal will necessitate general reorganization of 

most systems. 

The State health authorities are the primary 

users of the statistics from the morbidity studies 

in every State except Victoria. Health authorities utilize the statistics in health planning and 

assessment of health care delivery at the State, 

regional, and hospital levels. Research is also undertaken into problems in health care defivery, 

such as cost containment, integration of services, 

development of an equitable distribution of resources, and discovery of effective ways to 

manage the care of the chronically ill. 

The individual hospitals which participate in 

the reporting systems also receive tabulations of 

the data on their patients. In every State but 

9 
Queensland the return of information to the 

hospitals is routine. In Queensland, hospitak’ requests for data are filled. The hospitals vary considerably in their use of the data they receive. 

Some use it for management purposes, but that 

necessitates a rapid feedback process, and, with 

the exception of Victoria, most States have had 

delays of several months between the close of a 

collection year and the receipt of the tables by 

the individual hospitals. Planning of individual 

hospital services and areawide planning are also 

based on these data, but often only the large 

teaching hospitals use the data in this way. In 

fact, smaller hospitals in some States make no 

use of the data at all. 

Other government and private agencies and 

individuals, such as university researchers, also 

obtain sets of tables or computer printouts of 

the morbidity data from the collecting agencies 

or from the State health authorities for specialized studies of health services. 

Methods of data collectz’on.-The Medibank 

reporting system is in continuous operation. 

Hospitals collect information from each individual patient’s hospital record and forward data to 

processing centers located in every State and 

Territory. As well as compiling information on 

admissions and discharges, the hospitals report 

data on long–staying patients from time to 

time. Thus the count of bed days can include 

those of all patients hospitalized during the year 

rather than just those of separated patients, as is 

the case when data are obtained only from discharge slips. At the processing centers the data 

are computer processed and stored in hospital 

statistical files containing patient records filed 

according to hospital. The file is continuously 

updated and readily accessible. 

In the State hospital morbidity studies, statistics are collected from participating hospitals 

by means of discharge forms filled out on every 

inpatient. The forms are sent to each State’s 

data collection agency, which is usually the ABS 

but may also be the health authority or the 

computer service. The data collection agencies 

transfer the information on the discharge forms 

to computer tapes and edit and process it. Routine tabulations and statistics for special studies 

are then obtained from the tapes. 

Coverage. – In the Medibank system, all public and private general hospitals are expected to 

report information on their patients to the 

Health Insurance Commission. During the reporting year July 1, 1976, to June 30, 1977, all 

but three private hospitals with a total bed 

capacity of 10 forwarded data to the Commission. There were 53 public hospitals with a total 

of 351 beds not reporting during the period, but 

“they accounted for less than 1 percent of Australia’s hospital beds, and in some instances the 

occupancy levels in these small hospitals may 

have been zero for the year. 

The private hospitals did not forward data 

on all their users. Hospital admissions paid for 

by workmen’s compensation or other third 

party insurance, such as automobile accident insurance, were not reported upon. Also excluded 

in the reporting system were Veterans’ Affairs 

hospitals and mental hospitals. Mental patients 

receiving treatment in general hospitals, however, were included, ~d in recent years an increasing amount of inpatient psychiatric treatment has been taking place in general hospitals. 

State hospitals providing long-term care and 

nursing homes were also excluded from the reporting system. 

Information about an estimated 72 percent 

of the discharges from Australia’s general hospitals is collected through the State morbidity 

studies. Most of the patients not covered are 

those hospitalized in private hospitals. No private hospitals are included in the statistical systems of Victoria, South Australia, Tasmania, or 

the Territories. However, the Australian Capital 

Territory contains only one 50-bed private hospital, and the Northern Territory has none at all; 

so their public hospital reporting systems are 

largely complete. Queensland receives statistics 

from private hospitals, but because these must 

be pooled to meet confidentiality constraints, 

individual institutions cannot be compared nor 

interarea usage tables produced. Western Australia and New South Wales collect statistics 

from their private hospitals, though reporting 

from private hospitals in New South Wales only 

began in 1978. 

All admissions to public hospitals are reported upon in the morbidity studies with the 

exception of the systems in Victoria and South 

Australia. Victoria’s Hospital Computer Services 

covers 70 percent of the admissions to public 

hospitals in that State. In South Australia, all 

10 
public hospitals except one large maternity hospital are expected to report on their admissions. 

In the 1976-77 reporting period, however, 19 

small public hospitals also failed to forward any 

data to the authorities, leaving 62 hospitals in 

the system.~ 1 

Thus in New South Wales, Queensland, Western Australia, and the Northern Territory, hospital morbidity statistics cover 100 percent of the 

inpatients in general hospitals. In the Australian 

Capital Territory 93 percent coverage is estimated; in Tasmania, 72 percent coverage; in 

South Australia, 65 percent coverage; and in 

Victoria, 50 percent coverage. 

Hospitals in the reporting systems generally 

do not report on health of newborns. Western 

Australia is an exception, however. Information 

on all newborns there is reported to the Midwives Data Collection System and merged with 

the hospital morbidity data at the end of each 

year.2g 

Statistics on inpatients in Veterans’ Affairs 

hospitals are reported to the Department of 

Veterans’ Affairs rather than to the usual State 

authorities. The Department has provided the 

collected data for ABS since 1974 and had 

already been giving information to some individual States prior to that time .82 Western Australia, Queensland, and Tasmania include the 

data from the Department of Veterans’ Affairs 

in their published hospital morbidity and utilization statistics. 

Inpatients in psychiatric hospitals are not 

included in any hospital morbidity data reporting system except the one in New South Wales. 

There a separate morbidity data collection system for psychiatric inpatients was merged with 

the general hospital morbidity study on January 1, 1978, The other general hospital morbidity studies include data on psychiatric patients 

who are hospitalized in general or specialized 

wards that are part of general hospitals. 

Items collected. –The information collected 

in the Medibank statistical system is in two 

parts. The first concerns the hospital and includes the hospital number, type, region, postcode (postal area), and number of beds. The 

second concerns individual patients and consists 

of the patient’s health insurance number, date 

of Iodgment with Medibank, date of processing 

by Medibank, billing date by the hospital, accommodation status, admission and discharge 

dates, admission and discharge codes, bed days, 

surname and initials, postcode, date of birth, 

and sex. No information is available on patient 

diagnoses or treatments. 

The statistics collected in the morbidity 

studies are different in each State and Territory, 

but the differences have been reduced in the last 

decade. Australia’s NationaI Health and Medical 

Research Council (NH&MRC) adopted a minimum basic data set for discharge abstracts in 

1967, and it has been gradually accepted by the 

States since that time. Variability remains, however, both in some of the items on the forms and 

in the definitions or specifications used for 

items. 

The NH&MRC’s set consists of the following items :30 

Hospital and patient identifiers. 

Admission date, separation date, and mode 

of separation (discharge, transfer, death with 

autopsy, death without autopsy). 

Patient’s ‘address, date of birth, sex, marital 

status, and country of birth. 

Principal diagnosis, underlying problem, 

other conditions and complications, principal operation and other operations, and external cause of any accident, poisoning, or 

violence. 

The identifying items used in the morbidity 

studies of the States and Territories are quite 

similar. All have the suggested hospital and patient identifiers. South Australia, Tasmania, and 

the Australian Capital Territory also include 

ward identifiers, and Western Australia collects 

the patient’s name along with his or her number. 

All the morbidity studies also collect admission and separation dates and mode of separation. New South Wales and Western Australia 

obtain more detailed information on the mode 

of separation than do the other States and Territories. They divide discharges into categories 

such as by hospital or own risk and separate 

transfers into nursing home, psychiatric unit or 

hospital, or other hospital. The Australian Capital Territory (ACT) also subdivides transferred 

into other ACT hospital or other hospital. 

11

Other utilization items are included on the 

forms in several States. Western Australia collects time of admission as well as date. New 

South Wales, Victoria, and Western Australia 

report the source of the referral to the hospital— 

such as “outpatient department, emergency, or 

other hospital. South Australia, Western Australia, and the Territories ask mode of admission, which is divided into categories such as 

vehicular accident, workmen’s compensation, 

shipping, and, in ACT, elective, urgent, or other 

hospital. 

The attending medical officer is identified 

in New South Wales, Western Australia, Tasmania, and the Northern Territory. New South 

Wales and Western Australia also identify the 

operating medical officer. The general practitioner is identified on the forms in Victoria and 

ACT. ACT also identifies the specialist involved 

in treatment. The type of accommodation is 

recorded in Victoria and South Australia. An 

item listing the place to which the patient is referred is on the forms in New South Wales, 

Victoria, Western Australia, and Tasmania, including the categories private doctor, outpatient 

department, home, nonreferral, and so on. 

Length of stay is recorded in Victoria, a discharge number in Queensland, and the state of 

health at separation in Tasmania. 

The items on the NH&MRC data set concerning the patient’s social and demographic 

characteristics are included in all the morbidity 

studies. In addition, information on the patient’s 

race is collected in South and Western Australia, 

New South Wales, and the Northern Territory. 

In the latter two, race is divided into Aboriginal 

and non-Aboriginal. South Australia uses the 

categories Aboriginal, white, other, and not 

stated. The patient’s occupation is also collected in New South Wales, Queensland, South 

and Western Australia, and Tasmania. 

The principal diagnosis, principal operation, 

and external cause of accident, poisoning, or 

violence are recorded in every morbidity study, 

but there is considerable variation regarding the 

other medical items. Only South Australia, Western Australia, and Tasmania collect data on the 

underlying problem; Western Australia collects 

up to five such problems. All the States and 

Territories except Victoria and Queensland collect “other conditions.” ACT can record one 

“other condition”; the Northern Territory and 

New South Wales, two; Tasmania, three; Western 

Australia, five; and South Australia, nine. Complications are reported everywhere except 

Queensland and the Northern Territory, and the 

number that can be reported varies from two in 

ACT to nine in New South Wales and South 

Australia. Operations other than the principal 

one ,can be recorded everywhere but Queensland. Generally there is a space for recording one 

other operation, but in Western Australia up to 

four can be given, and in South Australia, eight. 

Finally, Tasmania, Western Australia, and ACT 

report information on the site of any accident as 

well as listing the external cause. 

The diagnoses reported on the discharge 

forms are coded using the full four-digit codes of 

the eighth revision of the International Classification of Diseases.33 Operations are classified 

by the three-digit codes of the General Register 

Office of England and Wales. The ninth revision 

of the International Classification of Diseases 

(ICD-9), and its supplementary classifications on 

operations are expected to be introduced for 

coding in 1979. Coding is sometimes done centrally by the agency that collects the discharge 

forms and sometimes by the individual hospitals. 

Both practices can exist in the same State. In 

South AustraIia and Western Australia, for instance, most of the larger teaching hospitals 

code their own discharge forms. Most of the , 

smaller hospitals write out diagnoses and operations on the forms and send them to the Australian Bureau of Statistics to be coded. The princi-’ 

pal diagnosis is defined as the disease or injury 

that best characterizes the period of hospitalization; and the principal operation, if there are 

more than one, is the operation that best characterizes the stay in the hospital. 

Definitions and procedures, –When calculating utilization statistics from the data collected in either the Medibank system or the 

State morbidity studies, no division is made between long-term and short-term patients. ,In 

most cases, however, it is possible to obtain data 

on short-term patients from the systems by 

using length of stay as the criterion of shortterm care. Almost all of the hospitals that report 

to either system are primarily concerned with 

the care of short-term patients, but a small 

number of patients in these hospitals have stays 

12 
of several months or even several years, These 

patients have an impact on the statistics concerning bed days and average length of stay. 

In both systems, transfers from one hospital 

to another are counted as discharges. Transfers 

within a single hospital from one ward or department to another are considered part of a single 

admission. Discharges and deaths are combined 

and are referred to as “separations” in most 

Australian publications. 

In the Medibank system, a patient who does 

not stay overnight in the hospital before discharge is said to have used O.5 bed day. In the 

State morbidity studies, a stay lasting less than 

24 hours is counted as 1 bed day.34 In the Medibank system, bed days are calculated in two 

ways–’’occupied” bed days, the number of bed 

days used in the year whether or not the patients were discharged during the year, and 

“completed separation” bed days, which are limited to days used by discharged patients. In the 

State systems, only “compIeted separation” 

bed days are calculated. In both systems, average length of stay is obtained by dividing the 

number of bed days of discharged patients by 

the number of discharges. 

Information published or available. –Some 

statistics from the Medibank reporting system 

were published in the Health Insurance Commission’s 1975-76 annual report.Z6 The Commonwealth Department of Health also has begun 

publishing some Medibank statistics in its annual 

reports, but the statistics primarily concern 

claims paid rather than utilization of services.15 

The 1975-76 report presents the number of 

discharges, bed days, and average length of stay 

by hospital type, patient status, and State. Two 

types of hospitals are referred to in the tables— 

recognized hospitals, which are under the ad-. 

ministrative control of State health authorities; 

and private hospitals, which are independently 

administrated. In recognized hospitals there are 

two possible patient statuses–hospital patient 

and private patient. Hospital patients are those 

in standard wards treated by the hospital staff. 

Private patients are those paying for more 

privacy in their room accommodations and 

treated by fee-for-service physicians. All patients in private hospitals have private sta&s. 

Other tables in the report include bed days per 

1,000 population, discharges per 1,000 population, and occupancy rates by hospital type and 

State. 

A draft of hospital statistics for 1976-77 

compiled by the Health Insurance Commission 

includes additional tables based on the data collected: percent distribution of discharges and 

bed days by hospital type and patient status for 

each quarter by State, number of discharges for 

the year according to average length of stay by 

hospital type and State, number of approved 

hospitals and beds according to leveI of bed occupancy by hospital type and State, and number 

of discharges, related bed days, and average 

duration of stay by age and sex in each State. 

Queensland, Western Australia, and Tasmania routinely publish data from their morbidity studies. New South Wales also expects to 

begin an annual publication in the near future. 

Each State’s publication contains a somewhat 

different set of tables. 

In the bulletin Patients Treated in Hospitals, 

Queensland, 1975,35 published in 1977, the 

number of patients treated in hospitals is broken 

down by disease and sex; by disease, sex, and 

duration of stay; by disease, sex, and age group; 

by disease, sex, average period of treatment, and 

type of hospital; by disease and usual residence; 

and by disease, sex, and occupation. Deaths are 

categorized by disease and sex. Operations are 

classified by body location and sex; and major 

accident cases are given by age, sex, and external 

cause of injury. 

Western Australia’s Hospital In-Patient Statistics, 1976,36 published in 1977, contains 

somewhat similar tables. The number of patients 

is broken down by age and duration of stay. The 

age and sex distribution, total bed days, and 

average stay are given for each principal condition, as is the percent distribution of patients 

in various disease categories. The principal operation and external cause of injuries are both subdivided by sex, age, and duration of stay. 

The most recent Tasmania bulletin, Hospital 

Morbidity, 1976,37 was pub fished in 1978. It 

includes tables in which the principal diagnosis is 

broken down by age and sex; by average length 

of stay and age; and by number of patients, total 

days in the hospital, average len.@h of stav, and .-

sex. The principal operation is b~oken” do~ by 

the same set of variables in a second group of 

tables, and accident patients are reported by 

13 
external cause and sex. This publication also 

contains time-series tables on number of patients, on total days in the hospital, and on average length of stay for principal conditions and 

external causes of injuries. 

The other States and Territories produce and 

distribute sets of unpublished tables that generally concentrate on the principal diagnosis, the 

principal operation, and the external cause of injuries. Statistics are commonly given on the 

number of discharges, the total number of bed 

days, and the average length of stay for patients 

in each category of the classification of diseases, 

operations, or external causes. Age and sex distributions for each category are also available 

from most studies. 

In addition, statistics in morbidity tables in 

the Northern Territory are generally broken 

down by ethnic group and hospital. Usual residence, status at discharge, and deaths are variables in some tables. The ACT tables also include 

statistics on patients’ usual residence and status 

at discharge. Further, the number of patients 

and their average length of stay in each category 

of principal diagnosis and operation are given 

for each doctor in ACT. In Victoria, the Hospital Computer Services tables give additional 

breakdowns on patients’ payment status. One 

set of tables in South Australia lists all the discharges from the hospitals by principal diagnosis, giving 14 items of information on each 

discharge. A similar listing of discharges by external causes is also produced. Other South Australian tables include, in addition to the usual 

variables, the type of admission, pensioner entitlement, insurance benefits, occupation, place 

of residence, and country of birth. 

The New South Wales reporting system produces a great number and variety of tables and 

indexes. Statistics are often broken down by 

individual hospitals or regions as well as being 

given for the State as a whole. Usual residence, 

source of funds and hospital insurance, country 

of birth, medical officer, and race (Aboriginal or 

non-Aboriginal), as well as sex and age, are used 

as variables. Bed occupancy statistics are reported along with the number of discharges, 

total bed days, and average days of stay. In a 

relative stay index, comparisons are made between the actual and expected number of cases, 

numbers of bed days, and average length of stay; 

and the significance of the deviation between 

the actual and the statistics is shown. There are 

also length of stay percent distributions; “leakage” tables, cross-tabulations of usual residence 

by region of hospitalization; and separate tables 

on patients in the hospital for more than 2 

months. Finally, there are indexes which list all 

the data collected from the records of any patient who has a selected disease or operation or 

who has stayed over 2 months in the hospital. 

In Western Australia, sets of unpublished 

tables very similar to those produced in New 

South Wales are available along with the data 

included in the regular publication .*9 

Other Discharge Reporting Systems 

Data collection. –Separate discharge reporting systems are also maintained to collect statistics on patients in Veterans’ Affairs (VA) 

hospitals and in psychiatric institutions. The VA 

system covers discharges from all repatriation 

general hospitals. The Department of Veterans’ 

Affairs operates one such hospital in the capital 

city of each Australian State .3* The hospitals 

are responsible for the treatment of veterans for 

conditions attributed to their military service. 

They also provide care to the general community to the extent that excess capacity is available after the entitled veterans are served. All are 

teaching hospitals for undergraduate medical 

students, and all provide medical, surgical, and 

psychiatric services. No maternity service is 

available. The Department also operates auxiliary “hospitals that provide long-term medical 

and nursing home care and emphasize active rehabilitation. Both types of hospitals are included 

in the morbidity data collection system run by 

the Department. Two of the general hospitals 

have computerized, online admission and discharge systems, but most collect the data on 

discharge forms and then transfer it to punchcards that are fed into a computer.30 

Most psychiatric care in Australia takes place 

in hospitals and clinics directly operated and 

owned by State mental health authorities .d In 

durdess otherwise noted, the description of psychiatric statistics is taken from reference 38, an Australian 

Bureau of Statistics paPer.38 

14 
New South Wales, the hospital commission recently took over responsibility for psychiatric 

facilities when it merged with the department of 

health, which had previously operated them?g 

In the Territories there are no separate institutions for mental patients. 

All State mental health agencies collect discharge data on all inpatients under their control. 

In addition, some States receive data from 

private psychiatric hospitals and from psychiatric wards in general hospitals. The general 

hospital psychiatric patients often must be reported twice, both to the general morbidity and 

to the mental health statistical systems. This 

duplication has been eliminated in New South 

Wales, however. The separate psychiatric statistical system was discontinued there as of January 1, 1978, and uniform morbidity data were 

henceforth collected from all hospital patients 

whether physically or mentally ill. 

In Victoria and Western Australia, computerized registers of psychiatric patients have 

been created by the mental health authorities. 

In Victoria the register includes data on every 

person who was residing in one of the Mental 

Health Authority’s psychiatric facilities on 

July 1, 1961, or who has been admitted since 

that time .40 The Western Australia register has, 

since 1971, contained information on all psychiatric inpatients, whether in mental or general 

hospitals, and on all who make outpatient and 

day visits to hospitals for psychiatric care.zg 

Items available, –The information collected 

on patients discharged from repatriation hospitals closely follows the minimum data set recommended by the National Health and Medical 

Research Council (NH8cMRC) for general hospital patients. The only recommended item not 

included is “underlying Condition ,“ but the VA 

Department does collect information on up to 

four “other conditions.” In addition to the recommended items, the Department records the 

patient’s name and a ward identifier, whether 

the patient is Aboriginal or non-Aboriginal, the 

mode of admission, and the place to which the 

patient is referred after discharge?” 

The data collected are used on a monthly 

basis to produce the diagnostic and surgical indexes used in many research programs. Unpublished statistics are also forwarded to the Australian Bureau of Statistics and to several State 

health authorities. In addition, statistics are published in the Repatriation Commission’s annual 

report. The 1976-77 report, published in 1977#1 

presents data divided by sex and given separately for each treatment category (general 

medical, surgical, tuberculosis, psychiatric and 

nursing care, or long-term) within each VA hospital. Statistics presented include total number 

of patients treated, total inpatient days; average 

days of treatment per patient; average number 

of beds occupied daily; number of admissions; 

median age of patients admitted; number of readmission; readrnissions as a percent of total admissions; number of discharged, including 

deaths; and mean length of stay of patients discharged. Also presented is a time-series table on 

the percent distribution of patients treated in 16 

disease categories. 

Data collected by the psychiatric discharge 

reporting systems are generally similar from 

State to State, but differences remain even 

though NH8cIvIRChas adopted a minimum data 

set for mental health statistics. 

The NH&MRC set includes the following 

utilization items: date of admission or registration, name of the institution or facility, source 

of referral (self or relatives, private psychiatrist, 

other medical practitioner, outpatient sector, 

and so on), type of admission (whether first 

admission), classification at admission (voluntary, formally recommended, or forensic), number of previous admissions, details of leaves 

(type of leave, date out, date in, days absent), 

total days absent on leaves, number of day patient and outpatient attendance, any changes in 

classification during stay, date of discharge or 

death, and outcome of episode (died in hospital, 

left against medical advice, referred to private 

psychiatrist, referred to geriatric unit, and so 

on). 

The recommended social and demographic 

items include the patient’s name, sex, age, date 

of birth, status, any pension entitlement, birthplace, year arrived in Australia if not born there, 

education, and occupation of patient and of the 

main income earner in the patient’s household. 

The medical items recommended are the principal condition treated, any alcoholism or other 

drug dependency; and the cause of death, antecedent causes, and other significant conditions 

contributing to death. 

15 
In no State do the utilization items collected exactly match those recommended by the 

NH&MRC, but many of the differences are 

superficial. For instance, items on type of admission, previous admissions, classification at admission, and changes in classification frequently 

are designed in different ways, but similar in for-. 

mation is generally collected about these points. 

The major departures from the recommended 

form come on such items as detaik of leaves, 

which are omitted from every St ate’s forms except Queensland, and numbers of day-patient 

or outpatient visits, which are reported only in 

Queensland, South Australia, and Tasmania. In 

addition to the recommended items, New 

South Wales, Victoria, South Australia, and 

Tasmania include an item identifying the patient’s doctor. 

The recommended social and demographic 

items are all collected on the discharge forms 

used in Tasmania and Queensland. The forms 

used in Victoria and Western Australia omit age, 

but it can be ascertained from the date of birth. 

South Australia, Western Australia, and New 

South Wales do not collect data on pension entitlement, and New South Wales also omits the 

items on when the patient arrived in Australia 

and his or her education. Additional items collected besides those recommended include 

address (in every State), next of kin (in all but 

New South Wales), religion (in all but Tasmania 

and New South Wales), race (in Western Australia and New South Wales), person(s) with 

whom the patient was living (in Victoria and 

Queensland), number of children (in South Australia) and age at admission (in Queensland). 

Except for the cause of death, which is not 

reported in New South Wales, all recommended 

medical items are collected on the discharge 

reporting forms. In Victoria the additional item 

“method used” is on the form if suicide was 

attempted. In Queensland detailed questions 

must be answered on the patient’s condition: 

whether there is any mental retardation and, if 

so, to what extent; whether organic brain impairment or epilepsy is present; the extent of 

alcoholism; the type of drug dependency; the 

means if there was a suicide attempt; and any 

physical condition associated with the psychiatric diagnosis. In South Australia a list of questions is asked about the treatment the patient 

received. Whether electroconvulsive therapy, 

major or minor tranquilizers, antidepressants, 

lithium, social work, and/or psychotherapy are 

received by the patient is noted; and biochemistry, EEG, and X-ray tests are reported. 

The data collected on the forms are handled 

in the same general way as the data on the general morbidity forms are. Statistics such as number of admissions, number of discharges, average 

period residents were in the institution, and percent bed occupancy are computed by the mental 

health authorities. The distribution of patients 

within diagnostic categories is examined and 

broken down by the various utilization, social, 

and demographic variables that are collected. 

The information is used in epidemiological and 

other similar research. Statistics are also published in most States, either in bulletins specifically devoted to mental health statistics, as in 

Victoria and Western Australia, or along with 

other kinds of health statistics, as is done in 

South Australia. 

Aggregate Hospital Reports 

No national health agency in Australia, governmental or private, regularIy collects reports 

of aggregate statistics from hospitak on their 

facilities and utilization. The need to establish 

a routine reporting system to collect such information has been identified by national authorities, but it remains unmet .42 Meanwhile, some 

national hospital utilization data have been collected in a variety of studies from time to time. 

The Hospital and Health Services Commission conducted a survey of hospital facilities and 

services in 1972-73. Victoria did not participate 

in the study, but 99 percent of the remaining 

hospitals in the country did. Personnel in each 

hospital filled out a questionnaire that requested 

information on number of beds, average number 

of beds occupied, and average length of stay during the year ending June 30, 1973. These statistics were to be reported separately for seven 

types of services: medical and surgical combined, geriatric, pediatric, psychiatric, obstetric, 

neonatal, and other. Also to be reported were 

the number of births, number of operations, 

attendance in the outpatient departments and 

emergent y rooms, and radiology and laboratory 

services provided by the hospital during the year. 

16

Results from the survey were published in 1974 

in A Report on Hospitals in Australia.24 The 

average occupancy rates by State and hospital 

type, beds per 1,000 population for each State 

and type of hospital service; average number of 

births per year by size of hospital, percent of 

total operations performed by size of hospital, 

and the like are presented in the report. 

The Uniform Costing Committee of the Hospital and Allied Services Advisory Council 

(HASAC) began collecting standard financial 

statements from all public hospitals in Australia 

in 1971. The data from the statements are presented in reports to HASAC, the latest one 

being Uniform Statements of Costs, Source of 

Funds of Hospitals and Nursing Homes and Government Assistance to Allied Services in Australia in the Year Ended 30 June ’74.23 Jncluded 

in it are statistics on the number of public hospitals in each State and their total available beds, 

the number of inpatients treated, total bed days, 

daily average of inpatients, bed occupancy rate, 

and average length of stay for inpatients treated 

during the year. 

In the past, the Official Year Book of Australia,43 published by the Australian Bureau of 

Statistics, included hospital statistics such as the 

number of beds in each State, admissions, inpatients treated, discharges and deaths, and 

average daily number of inpatients. The 1975-76 

yearbook reported, however, that ABS would no 

longer publish Australia-wide data on public and 

private hospitals and nursing homes. According 

to the yearbook, limited State information on 

these institutions would continue to be published by State offices of ABS. (See, for example, reference 44.) ‘ 

In addition to the publications by the State 

offices of ABS, State health authorities in New 

South Wales, Victoria, Western Australia, the 

Northern Territory, and the Austr~ian Capital 

Territory routinely publish statistics on the 

utilization of public hospital facilities .39 The “ 

other State health authorities also collect information on public hospitals, but they do not 

publish it, The State publications are generally 

similar.45-47 The report of the Health Commission of New South Wales, Statistical and Financial Data, Public Hospitals,48 can be used as an 

example of the type of statistics usually presented. As the title indicates, the report presents 

a considerable amount of data on hospital 

income and expenditures. Some information on 

hospital personnel and outpatient treatment is 

also presented. The main utilization statistics 

given are bed days, daily average of occupied 

beds, and average length of stay. Data are presented for individual hospitals and regions as 

well as for the State as a whole. The statistics 

from hospitals in metropolitan areas versus 

country areas are separated in some tables; and 

medical, surgical, and obstetric hospitals are 

sometimes separated from convalescent hospitals, nursing homes, and the like. Within hospitals, statistics on newborns are given separately, 

and information on obstetric patients is often 

separated from data on other inpatients. 

Household Surveys 

A new source of national data on hospital 

use is the yearlong national health interview survey conducted by the Australian Bureau of Statistics. Commencing on July 1, 1977, the study 

was undertaken to provide basic data on the 

health status of the population. Data were expected to be used by the Federal and State Governments and by other health and welfare organizations for planning new facilities and services 

and for measuring the utilization of existing 

facilities. 

Data collection. –A total of 15,000 private 

households were randomly selected for the survey, using a stratified, multistage area sample 

design. Appro&mately 12,000 of the households 

were drawn from regions of specific interest to 

the health authorities of the States and Territories, with the remaining 3,000 chosen from 

outside the designated regions, ABS interviewers 

obtained information on all members of the 

households selected. Individuals aged 14 and 

over were interviewed personally, and information on children under age 14 was gathered from 

their mothers. Certain groups of people, such as 

the occupants of motels and hotels, diplomatic 

personnel, and n~n-Australians on vacation in 

the country, were excluded from the study. 

More importantly, persons residing in hospitals, 

nursing homes, and other health institutions 

were also excluded. 

Items available. –In addition to the items on 

hospitalization, the survey contained questions 
on current or recent illnesses; chronic illnesses; 

accidents; general well-being; use of doctors, 

dentists, and other health workers; use of medicines; immunization history of children; and the 

type and extent of health insurance. The following social and demographic items were also collected: age, sex, geographic locality, country of 

birth, duration of residence in Australia and in 

the region where living, major activity, maritalstatus, occupational group, educational status, 

gross income per person and per income unit, 

fluency in English, and number of household 

members. 

The first question concerning use of hospitals was about whether or not the person had 

been admitted to any hospital, psychiatric hospital, nursing home, or convalescent home 

within the last year. The number of admissions, 

length of stay, and name and address of the 

facility in which each occurred was requested. 

The general reason for the most recent admission was asked. Response categories included 

having a baby, surgery, having tests done, observation only, or, if none of these others 

applied, a sickness, illness, or injury. No other 

medical information was obtained about the 

hospitalizations since it would overlap with the 

data collected in the State hospital morbidity 

studies and was expected to be less accurate 

than the morbidity study data, which are copied 

from medical records.3A 

The survey was divided into quarters, and 

seIected data from the first quarter, which ended 

September 30, 1977, were published in a preliminary bulletin in April 1978.49 That bulletin 

did not include statistics on hospital utilization, 

but it was to be followed by two other preliminary bulletins. The final reports of the study 

were expected to be published on the national, 

State, and regional levels in 1979. 

CANADA 

The Canadian hospital discharge reporting 

systeme is integrated with the insurance system 

eThe term “discharge “ is used by the authors to 

refer to both live discharges and deaths, though in 

Canada the term “separation “ is used to refer to both. 

See the section “definitions and procedures” for further 

information. 

and is a collaborative effort of the health authorities of the 10 Provinces and the Federal Government. These diverse actors have been cooperating for 18 years on individual discharge 

reports and for several decades longer on annual 

hospital reports. Through their cooperation, 

Canada has been successful in developing a nationwide reporting system even though the 

National Government does not have the primary 

responsibilityy for hospital care. 

General Hospital Discharge 

Reporting System 

In April 1957 the Federal Parliament of 

Canada passed the Hospital Insurance and Diagnostic Services Act, which established a FederalProvincial cost-sharing program to cover the 

expense of hospital care in general and allied 

special hospitals. Five Provinces began operation 

of the program on July 1, 1958, and the rest 

joined it over the next 3 years. Quebec, the last 

to join, entered the program January 1, 1961.50 

One of the requirements of the hospital insurance program was that each Province collect 

information about each individual hospitalized 

patient. The information was needed to check 

whether patients were eligible to be covered by 

the program and to serve as the basis of payments to hospitals for services rendered on a 

patient-day basis.51 

While the insurance program was going into 

effect, the Royal Commission on Health Services, known as the Hall Commission of 1961, 

was investigating Canadian health services. One 

of the recommendations of the Commission was 

that the Dominion Bureau of Statistics compile 

nationaI hospital morbidity statistics.52 Some 

Provinces had already developed discharge reporting systems, and the rest soon followed. 

They found the systems to be economically 

feasible, since individual reports were already 

required for the insurance program. National 

morbidity data were first compiled for 1960 and 

were first published in 1964. 

Until 1969 national data were tabulated by 

both the Department of Health and Welfare and 

the Dominion Bureau of Statistics, now called 

Statistics Canada. In 1969 the two sets of statistics were reviewed, and it was decided that the 

small differences between them could not justify 

18

continuing both. Statistics Canada assumed sole 

responsibility for producing the statistics and 

has continued reporting them annually.zo The 

reports include the publications Hospital Morbidity 62; Hospital Morbidity, Canadian Diagnostic List53; and Surgical Procedures and 

Treatments.54 Data collected in 1974 were published in 1977. 

The morbidity statistics are used for planning purposes on both the national and provincial levels .55 The data serve as a basis for assessing hospital needs and for forecasting future bed 

requirements. For example, some quality control can be exercised by monitoring the data to 

be sure that complex surgical procedures do not 

take place in hospitals that lack appropriate 

facilities or supporting staff .56 However, the statistics are not sufficiently detailed to allow their 

use for other kinds of hospital management.50 

Epidemiological studies are also undertaken 

with the data. Changes in the incidence of certain diseases following the introduction of new 

kinds of treatment have been investigated, and 

historical trends in hospital morbidity have been 

examined.56 Other special studies using the data 

have been done by a variety of government departments, universities, and research agencies. 

Attempts have been made to link the hospital 

data with other health and demographic statistics into comprehensive data systems for some 

areas.5 7 

Methods of data collection. –The data are 

collected on admission-discharge forms completed by each hospital and submitted to each 

Province’s hospital insurance commission. Most 

items are filled out in the hospitals, but the 

coding of the medical items is generally undertaken by the Provincial officials. The forms used 

differ from Province to Province. There is a common core of information collected in all 

Provinces, but somewhat different definitions or 

classifications of these common items are used. 

Efforts are under way to further standardize the 

collection of the items used on the national 

level. 

The Provinces produce data files on tape 

from the forms and tabulate the data to meet 

their needs. Some statistics are published in 

most Provinces. In Saskatchewan and Nova 

Scotia, for example, the annual reports of the 

hospital insurance commissions include morbidity tables, and in Manitoba the commission publishes data in a statistical supplement to its 

annual report. Other Provinces, like British 

Columbia and Ontario, publish separate reports. 

Some Provinces also have unpublished tabulations that they can release for research purposes. 

Statistics Canada routinely obtains copies 

of the data files from the Provinces and converts 

them to a standard format. The agency also performs a series of manual and computer checks 

on the tapes .52 The tapes are examined for 

errors and completeness. Some errors or omissions cause the records to be rejected; others are 

corrected automatically. Blank records or records which are exact duplicates of others, for instance, are rejected. If age or sex is missing, however, it is filled in by choosing a value randomly 

from a table of age and sex groups. The value inserted must be consistent with the diagnoses and 

operations reported on the record. Once each 

Province’s tape has been edited, it is merged into 

the national data set used to produce the routine 

publications. 

Coverage. –Data are collected from all general and allied special hospitals in Canada, 

whether public, Federal, or profitmaking. Tuberculosis and mental hospitals are not included but 

have separate reporting systems. Psychiatric patients receiving treatment in a general or allied 

special hospitaI are reported to both the mental 

health and the hospital morbidity sections of 

Statistics Canada. This duplication made interpretation of the psychiatric statistics difficult in 

the past. Now, however, most of the units and 

facilities making two reports have been identified, and unduplicated statistics are being produced. Nursing homes and other long-term facilities not defined by the Provinces as hospitals 

are not included in the reporting system. 

Statistics from the hospitals in the two 

Canadian Territories, the Yukon and the Northwest Territories, are also excluded. Together 

the Territories have approximately 65,000 population and 50 hospitals, including nursing stations, with 590 hospital beds.zo The exclusion 

has not had a serious impact on the statistics. 

Furthermore, data from the Territories are expected to be included with the Provincial data 

in the national summaries in the near future. 

All inpatients in the hospitals covered by the 

system, with only minor exceptions, are re19

ported. Some Provinces exclude from their re-, 

ports those patients whose bills for treatment 

are not paid by the national h“ospitalinsurance 

program. Approximately 98 percent of the 

population is insured by the system. However, 

some hospital treatment may be the responsibilityof the Workmen’s Compensation Board or 

some other agency. It should also be noted that 

patients are reported by the Province in which 

they reside rather than by the Province in which 

they receive treatment.5z 

items collected. –Information colle~ted~n “all” 

of the Provinces includes the patient’s name, 

age, address, dates of admission and discharge, 

attending physicians, primary and secondary discharge diagnoses, and primary and secondary 

surgical procedures, if any .fIO The definition of 

the primmy diagnosis is not the same in zdl. 

Provinces. Some record “that condition which 

required the most medical resources’’;Gz others 

report the condition that precipitated the admission to the hospital. The secondary diagnosis 

may be either a complication that arose during 

the hospitalization or a second disease treated, 

The primary surgical procedure is the most important operation relating to the primary diagnosis, and the secondary operation is related to 

the secondary diagnosis.sb 

Diagnoses and surgical procedures are generally coded according to the eighth revf~i~fi-of 

the International Classification of Diseases, 

adapted (ICDA-8 ). There have been some exceptions, however. For instance, in 1974 Alberta 

used the second edition of the hospital adaptation of the International Classification of Diseases (H-ICDA), which could not be perfectly 

transferred into ICDA-8 at all levels of detail.Ez 

It is expected that all Provinces will start using 

the ninth revision of the International Classification of Diseases in 1979. Diagnoses are coded to 

four digits, but three-digit ICDA-8 codes are the 

most detailed ones published. Diagnoses are 

further collapsed into a 188-category classification referred to as the Canadian Diagnostic List 

and are available as well by the 16 ICDA-8 

Chapter Headings. 

Definitions and Procedures.–In the analysis 

of the data from the morbidity study, no divisions are made between long-term and shortterm hospital patients.ss While most long-term 

care institutions are excluded from the study, 

the allied special hospitals which are included .. 

contain long-staying patients. Furthermore, 

long-term units which are part of generzil hospitals are included in the study. 

A “discharge” is defined in the Canadian 

‘hospital system as the departure of a live inpatient. The total of all persons released either 

alive or dead is defined as “separations,” and, in 

Canada, it is the number of “separations” that 

is usually u;ed in the calculation of utilization 

statistics. However, either discharges of live patients or deaths can be separately identified and 

analyzed. 

Transfers between hospitals are included in 

the count of discharges and new admissions. 

Trimsfers of inpatients moved from an active 

treatment unit to a chronic long-term care unit 

within a single hospital are also counted as discharges and new admissions. All other intrahospital transfers are considered part of a single 

hospital admission. 

Data on newborn infants are reported in the 

study, but utilization statistics for adults and 

children are tabulated separately from those for 

newboyns. 

Information published or available, –The 

main table in Hospital Morbidity52 presents the 

number of discharges,f the discharge rate per 

100,000 population, and the average stay per 

discharge by the ICDA-8 list of diagnoses, sex, 

age group, and Province. The age groupings used 

are as follows: under 1 year, 1-4 years, 5-1.4, , 

15-19, 20-24, 25-34, 35-44, 45-64, 65-74, and 

75 years and over. A second major table lists 

the number of discharges and bed days, the rates 

per 100,000 population of discharges and bed 

days, and the average stay per discharge by the 

16 ICDA-8 chapters, sex, age group, and Province. The number of discharges and the average 

stay per discharge for newborns are shown in a 

third table by diagnosis and sex. 

An introductory analysis section of the publication contains several additional tables. There 

are summary tables that give utilization statistics 

by sex and age group and by sex and Province. 

Trend tables show utilization statistics from 

1970 to 1975, in one table given by age group, 

in another, by the total for all ages. The 20 leading causes of hospitalization, based first on the 

number of discharges and then on the number of 

f’1’he term “discharge“ is used by the authorsto 

refer to both live discharges and deaths. 

20 
bed days, are given in one table for males and 

in another for females. The percent distribution 

of discharges and bed days by age group and 

ICDA-8 chapters is also presented in a table. 

Finally, a table shows discharge rates over a 

5-year period standardized to remove the effects 

of demographic changes in the population, by 

ICDA-8 chapter and sex. 

Hospital Morbidity Canadian Dia@ostic 

List53 contains tables similar to those in Hos@ 

tal Morbidity. It differs in that the main table 

and the table concerning newborns present statistics by diagnosis using the 188 categories in 

the Canadian Diagnostic List rather than all the 

three-digit ICDA-8 categories. 

The publication Sur@”cai Procedures and 

Treatments54 also follows a format similar to 

that used in Hospital Morbidity; but instead of 

presenting data on all discharges, Surgical Procedures and Treatments is limited to statistics 

for discharged cases that had an operation or 

for the total number of primary operations per­ ..—— formed. Tables’ typically show discharges, rates 

per 100,000 population, and average stay per 

discharge for operations and treatments, by the 

ICDA-8 list, age group, and Province. In addition 

to all the published data, a great deal of detailed 

information is produced which is not published 

but which can be obtained from Statistics 

Canada. 

Other Discharge Reporting Systems 

In the 1930’s Dominion Bureau of Statistics 

organized an annual hospital reporting program 

in cooperation with the Provinces. It was decided at that time to create separate reporting 

programs for mental and tuberculosis hospitals, 

since these hospitals were generally operated 

only by the Provincial health authorities.51 

Annual reports were required from these specialized hospitals. Additionally, programs were initiated in the 1930’s to gather admission and discharge forms on the individual patients treated 

in the hospitals. Both kinds of reports have continued to be collected to the present, though the 

tuberculosis statistics have become less important as the number of tuberculosis inpatients has 

decreased dramatically.. 

Data collection. —Several special definitions 

are used for the collection of mental health statistics in Canada.Eg Mental hospitals are differentiated from psychiatric hospitals. The latter 

provide only short-term intensive psychiatric 

treatment, while the former provide treatments 

for all types of mental patients. Both participate 

in the reporting system, as do public, private, 

and Federal institutions for the mentally retarded, homes for the aged and senile that treat 

elderly patients with mental disorders, hospitals 

for addicts, treatment centers for long-term inpatient care of emotionally disturbed children, 

hospitals for epileptics, and psychiatric units in 

general hospitals. In recent years some information has also been gathered on psychiatric 

patients in nonpsychiatric wards of general 

hospitals. 

Admissions are divided into three types: 

first admissions who have had no previous psychiatric care in any psychiatric inpatient facility, 

readmission who have had previous psychiatric 

inpatient care, and transfers-in, who are received 

directly from another inpatient psychiatric facility .’ There are also three types of discharges—discharges (not including patients on probationary 

leave), deaths , and transfers-out, who are patients moved directly to another inpatient psychiatric facility. A category called “patients on 

the books” is frequently referred to. This category consists of patients in residence in the institutions plus those on leave or boarded out but 

still not officially discharged. 

Items available. –The admission and discharge forms completed on each inpatient include items for identification of the institution 

and the case number, age, date of birth,. sex, 

marital status, and education of the patient. The 

admission information consists of the date of 

admission; source of referral-which can be self, 

therapist, community agency, etc.; method of 

admission—voluntary, emergency, involuntary, 

and so on; i’f transferred in, the name of the 

facility from which transferred and the date of 

admission there; if a readmission, the name of the 

previous facility and date of discharge from it. 

The primary and secondary admitting diagnoses 

are listed and coded according to ICDA-8. The 

discharge information consists of the date of 

leaving the institution and the official date of 

discharge. If transferred out, the institution to 

which sent is recorded. Disposition, to self or 

family, community agency, outpatient facility, 

21

and so on, is recorded, and final primary and 

secondary diagnoses and the cause of death are 

given, again coded by ICDA. 

Statistics Canada regularly publishes data 

collected on the admission and discharge forms 

in Volumes I and II of its Mental Health Statistics series. “Volume I: Institutional Admissions and Separations ~)59 Contfis one inclusive 

set of tables for all institutions and takes from 

that set one for public psychiatric units and one 

for institutions for the mentally retarded. Each 

set incIudes a group of tabulations concerning 

first admissions. The type of institution and the 

age, sex, Province, diagnostic class, region of 

residence, and marital status of first admissions 

are given, with each table showing a crosstabulation of two to four of these variables. A 

similar set of tables is published for readmission, but it includes the number of previous 

admissions by diagnostic class and time off the 

books by sex and diagnostic class. Discharges 

are described using all the variables except 

region of residence and marital status. In addition, tables on the length of stay of discharges 

are presented by Province, sex, age, and diagnostic class. Deaths are broken down in the sane 

way as discharges, and cause of death is divided 

by diagnostic category and sex. Transfers-in 

are examined by diagnostic class and type of 

institution. 

In “Volume II: Patients on Books of Institutions,j$GOStatistics Cmada uses data from the 

admissions and discharge forms to calculate ‘how 

many patients are on the books in each institution each year. Sets of tabIes are presented in 

this volume for all mental health institutions, 

public mental hospitals, and institutions for the 

mentally retarded. In each set the number of 

patients on the books at the end of each reporting year is broken down by at least three variables at a time. Variables used include type of 

institution, sex, age, Province, time since admission, and diagnostic class. A separate set of 

tables shows time-series data on the total number of patients on the books and the rate per 

100,000 population of patients on the books. 

The percent distribution of patients on the 

books by time since admission, sex, Province, 

type of institution, selected diagnosis, and the 

degree of mental retardation of patients in institutions for the retarded are also reported. 

The statistics collected and published on 

tuberculosis hospitals were for years quite similar to those collected from mental health institutions. As inpatient treatment for tuberculosis 

declined, however, the statistics changed. In the 

1960’s, it was recognized that inpatient information by itself was obsolete as an indicator of the 

prevalence of tuberculosis or of the treatment 

measures in use.61 Thus, in 1966 reports began 

to be collected on persons receiving drug treatment as well as on inpatients, and published 

statistics included both categories of tuberculosis patients. In recent years, institutional statistics drawn from annual reports made by the 

tuberculosis hospitals have been published by 

Statistics Canada together with the morbidity 

data. Data published on inpatients includes number and rate per 100,000 population divided by 

age group, sex, Province, diagnosis, and origin 

(Indian, Eskimo, and others). 

Aggregate Hospital Reports 

In 1931 Statistics Canada, then called the 

Dominion Bureau of Statistics, established a 

hospital statistics reporting system in collaboration with the Provincial health authorities. The 

Provinces agreed to distribute and collect annual 

hospital questionnaires and to report the data 

gathered to Statistics Canada so that national 

summaries of hospital statistics could be prepared. In 1952 the program was changed in two 

major ways.s 1 The Canadian Hospital Association took on the responsibility for developing a 

Canadian Hospital Accounting Manual, which 

was to be used by hospital personnel in reporting the hospital’s financial operations on the 

annual report forms. The use of this manual, 

which has been updated several times by the 

hospital association, has Ied to national uniforrnity in hospital accounting. The second major 

change was the separation of reports on the 

financial operation of the hospitals from reports 

on hospital activity, utilization, personnel, and 

educational programs. In 1958-59 the national 

hospital insurance program was introduced. At 

this time, the two reporting forms were again 

revised to meet the informational requirements 

‘of the insurance program’s cost-sharing programs. Since the advent of national hospital insurance, the annual reports have been the joint 

I 

22 
concern of the Health Insurance Directorate of 

the Department of National Health and Welfare 

and the Health Division of Statistics Canada. 

As well as being used as a basis for insurance 

payments to hospitals and for routine publications, the data collected by the annual reports 

serve a variety of other purposes. On the national level, the data are used for long-term planning of the health services system as well as for 

ongoing evaluation and research. The Provinces 

have the responsibility for regulating and operating all except Federal hospitals. The Department of National Health and Welfare, however, 

acts as a consultant to the Provinces, professional associations, hospitals, and the like to 

assistin the improvement of health care .62 

On the Provincial level, the data are also 

used for planning, evaluation, and research.bo 

The Provincial health authorities make comparisons of hospital:: assess the kinds of care available in them, estimate future hospital costs, plan 

new hospital programs, and assert some kinds of 

ongoing administrative controls on the basis of 

the data collected. Individual hospitals also use 

the data for planning and administrative 

purposes. 

Data collection.–Two annual return forms, 

parts I and II, are completed by the administrative personnel in each Canadian hospital according to detailed sets of instructions and definitions prepared by Health and Welfare and Statistics Canada.68~64 Part I must be certified by 

the hospital authority when completed; part II 

must be certified by the authority and an auditor. In addition to the standard national form, 

Provincial health authorities sometimes add 

items of their own to the required report. Additional reports are submitted by some hospitals as 

part of a quarterly Federal survey of hospital 

indicators. 

The annual returns are submitted to the Provincial health authorities, who edit .—. them —. —..

and— send copies to Statistics Canada an-d Health and 

Welfare. Statistics Canada personnel do further 

manual editing and then code the forms and 

transfer them to computer tapes-for further editing of errors and inconsistency. Statistics Canada 

produces three annual publications from the 

annual returns. Unpublished data, subject to certain confidentiality provisions, are also available 

from Statistics Canada. 

Part I annual return forms are expected from 

all public, proprietary, and Federal general and 

allied special hospitals. Mental and tuberculosis 

hospitak have ‘separate reporting systems. 

Almost 100 percent of the hospitals that are expected to report do so. In 1975 only 16 hospitals did not submit the return, and 14 of them 

had fewer than 20 beds. Most, in fact, were 

nursing stations averaging four beds.1A Part II 

returns are required only from non-Federal public hospitals. The quarterly system is a voluntary 

one, and in 1978 it covered 56.6 percent of the 

hospitals, or 72.3 percent of the beds in public 

general and allied special hospitals.s 1 

Hospitals with fewer than 50 beds do not 

make as detailed breakdowns of the information 

reported as do the larger hospitals, and they are 

excluded from a number of published tables. 

Hospitals in the Yukon and the Northwest Territories do report annually, and their data are included in the summary statistics for all of 

Canada. When statistics are broken down by 

Province, however, the Territories are frequently 

not reported separately but are instead included 

in the Canadian total. 

The annual returns require counts on all 

“adults, children, and healthy newborns treated 

in hospitals. The newborns are separately identified, and statistics are computed separately for 

the category of adults and children and the category of newborns. Similarly, while bassinets or 

cribs for newborns are reported, these are separated from other hospital beds. 

Hospital units are identified in the annual returns as either long- or short-term. A short-term 

unit is defined as one “provided for patients 

who at the time of admission require extensive 

diagnostic and treatment services and/or skilled 

nursing care and comprehensive medical attention.” Long-term units are “provided for patients who at the time of admission require regular medical assessment, treatment services and 

continuing nursing care. MI4 In 1975 the average 

length of stay in public hospitals was 8.76 days 

for short-term units and 154.55 days for longterm units. 

Items Available.–The utilization data collected in part I of the annual returns consist of 

information on bed days, movement of inpatients, and services provided to inpatients. The 

annual return instructions require that a distinc23 
tion be made between “patient days during the 

reporting year” and “total days’ stay” of discharges.63 The former is the total volume of 

inpatient care, in bed days, of the hospital 

during the year. The latter is the sum of the bed 

days used since admission by all patients discharged from the hospital during the year. For 

both measures the admission day is counted as 1 

bed day, but the discharge day is not. Again, 

transfers between hospitals are counted as 

discharges and new admissions; transfers within 

a single hospital from an active treatment unit to 

a chronic long-term care unit are counted as discharges and new admissions; but all other intrahospital transfers are considered part of a single 

hospital stay. 

Measures of the movement of inpatients consist of several itemsG3: number of patients in the 

hospital at the beginning of the reporting period, 

number of patients under care during the year; 

discharges; deaths, not including stillbirths; number of patients in the hospital at the end of the 

reporting period; and total days’ stay of discharges. Since 1976 figures on inpatient movement have been reported separately for psychiatric short-term units, other short-term units, 

rehabilitation and convalescent units, extended 

care and chronic units, and other long-term 

units. Bed days are also reported separately for a 

more detailed list of short-term units (medical, 

surgical, intensive care, obstetrical, pediatric, 

psychiatric, and other). Jn addition, bed days are 

broken down by type of room accommodation– 

standard, semiprivate, and private-and by the 

agency which has responsibility for payment for 

the stay. 

Hospital services reported include the number of autopsies done, number and type of laboratory test, radiology examinations and treatments, units and types of blood transfused, visits 

to surgical suites, deliveries in the obstetrical 

suite, and number of physical-medicine and rehabilitative treatments given. Housekeeping services are reported, including weight of laundry 

done in the year and so on. Information is also 

given on outpatients, day patients, and hospital 

personnel. 

The Statistics Canada publication Hospital 

Statistics: Volume I–Be&, Services, Personnel, 14 presents utilization statistics by type of 

hospital-general full-teaching, general nonteaching with long-term units, rehabilitative, pediatric, and so on. The inpatient movement statistics are given by Province, type of hospital, and 

bed size of hospital. Number of admissions and 

percent distribution of bed days are given by different types of wards (medical, surgical, and so 

on) for each Province and according to types 

and size of hospitals. Mean and median length of 

stay in each type and size of hospital are given 

for long- and short-term units. Percent distributions of laboratory tests and radiology examinations are given by type of test for each Province 

and according to types and sizes of hospitals. 

Occupancy rates and rates of admissions, total 

bed days, and average daily number of patients 

per 1,000 population are given for each Province 

and, in the case of occupancy rates, for types 

and sizes of hospitals. 

The publications of the Department of 

National Health and Welfare present less detailed 

breakdowns of statistics by type of hospitals but 

report numerous statistics, including number of 

admissions, bed days, average length of stay, 

percent occu ancy, bed turnover, and bed turnover interv< .62 Average length of stay is calculated by dividing the number of live discharges 

and deaths into total days’ stay of live discharges 

and deaths. The percent occupancy is the ratio 

of the average daily patient census to the number of available beds. Bed turnover is obtained 

by dividing the number of admissions in a year 

by the number of beds setup that year, and bed 

turnover interval is computed by dividing the 

number of admissions into the number of unoccupied bed days. 

Other statistics on hospital utilization are 

also available in the annual Statistics Canada 

publications entitled Hospital Statistks: Volume 

III– Indkators27 and Mental Health Statistics: 

Volume III–Institutional Facilities, Semites, 

and Finances. 65 The former reports data from 

the voluntary quarterly survey of hospitals and 

presents a wide variety of statistics on utilization 

and costs. The data in the volume on mental 

health are drawn from special annual reports 

made by psychiatric facilities and from parts of 

the annual return made by general and allied 

special hospitals with psychiatric units. The publication is mainly concerned with facilities, per24 
sonnel, and financial information, but includes 

some utilization statistics such as the average 

number of patients in institutions, the numb’er 

of patients on the books, and patients treated 

each year over time. 

Household Surveys 

National household surveys have not been an 

important source of data on hospital utilization 

in Canada. However, the “Canadian”Sicknesi Survey was conducted in 1950-51 by the Department of National Health and Welfare and the 

Dominion Bureau of Statistics (Statistics Canada). It was undertaken ta investigate ill health, 

health care, and expenditures for health care 

over a 12-month period in about 10,000 households and included questions on the number of 

hospitalizations, bed days, and operations. A 

complete report of the survey, Illness and Health 

Care in Canada: Canadian Sickness Survey 1950-

51,66 was published in 1960. 

A new national health survey, undertaken in 

1978, included a physical examination component and a household interview component. The 

survey was intended to be continuous, but 

because of budget reductions it was terminated 

after 11 months of operation. The data that 

were collected are being processed, but no results are available at present,5 I 

ENGLAND AND WALES 

England and Wales developed one of the 

earliest hospital discharge reporting systems, the 

Hospital In-Patient Enquiry (HIPE). HIPE was 

established by national health authorities and 

collected data on a 10-percent sample of discharges. In the 1960’s health authorities became 

interested in collecting information on 100 pe; 

cent of hospital discharges and started the Hospital Activity Analysis (HAA), which did so. In 

addition, hospitals in England and Wales have 

long submitted to national authorities annual 

hospital returns (also knows as SH 3‘s) on their 

activities and utilization. Information on hospitalization has also been collected in an ongoing 

series of household surveys. 

General Hospital Discharge Reporting 

Systems 

The ‘ establishment of the National Health 

Service (NHS) in 1948 provided the opportunity 

to implement a nationwide hospital discharge reporting system. In 1949 the Department of 

Health and Social Security and the General 

Register Office, now the Office of Population. 

Censuses and Surveys (OPCS), began the Hospital In-Patient Enquiry. At first they collected 

statistics on aIl discharges from teaching hospitals and on all discharges from general hospitals 

in two areas of EngIand. The difficulties in handling the statistics on all discharges with the data 

processing equipment then available led to a 

change in 1953 to collection of information on 

only a 10-percent sample of discharges. The 

number of hospitals covered gradually expanded 

until in 1958 all the nonpsychiatric NHS hospitals were reporting upon a 1O-percent sample of 

their discharges.GT 

HIPE was established to provide England 

and Wales with epidemiological and administrative information about hospital utilization. The 

information was expected to be helpful for 

comparative studies of community morbidity 

and use of health resources, and it was thought 

that the data would aid in hospital service pkmning.Gs Experience with the system, however, 

led to a reevaluation of the purposes for which it 

was suited. It became clear that community 

morbidity and hospital morbidity are not the 

same. Only for those conditions which almost 

always require hospital treatment, such as appendicitis, can community morbidity patterns 

be gauged by studying hospital use. The level,of 

hospital use is found to be related to availability 

of facilities as well as to the level of existing 

community morbidity. Although accurate measures of community morbidity cannot be ascertained, comparative studies of hospital morbidity and of regional patterns of hospital utilization are possible, and such studies have been 

made by academics and government health authorities. 

The Department of Health and Social Security made intensive use of the HIPE data ‘for 

administrative and planning purposes, but regional imd local authorities rarely did so.Gg The 

25 
length of time required to process the data” was 

cited as one reason why it was not used more 

regionally and locally, and the use of a sample 

rather than total returns limited the usefulness 

of the data for local planning. Data on individual 

hospitals were not returned to the hospitals, so 

the HIPE could not be used by the hospitals for 

management purposes. 

The perceived deficiencies of HIPE led to 

interest in development of a new reporting system, the Hospital Activity Analysis (HAA). To 

resolve the problem of delays between collection of data and availability of results, HAA is 

organized regionally instead of nationally. Also, 

information is collected on all discharges instead 

of on the 10-percent sample and is returned directly to hospitals and consultants to make HAA 

a useful management tool for administrate ors and 

clinicians. 

The Department of Health and Social Security sponsored the establishment of HAA, but 

it was operated by the Regional Hospital Boards 

until 1974. The 1974 reorganization of NHS 

abolished the Regional Hospital Boards. The 

Regional Health Authorities, which assumed responsibility for operating hospitals after the 

reorganization, also assumed the operation of 

HAA. The first hospitals began collecting data 

on all their discharges in 1965, and the number 

doing so gradually increased until, in 1976, data 

on 97 percent of the discharges from general 

hospitals, excluding maternity patients, were 

being reported to the ,Regional Health Authorities.70 

As with HIPE, not all the expectations that 

accompanied the establishment of HAA have 

been fulfilled .6g~T1YTZThe time required to make 

the data available has not decreased as much as 

was hoped. In some regions returns have been 

available as soon as 6 weeks after the submission 

of data, but in other regions up to 2 years have 

elapsed before returns were available. It is 

thought that delay will decrease as regions gain 

experience with the system, but it is likely to 

remain a problem because doctors in some hospitals are slow in filling out discharge summaries. 

Use of the HAA data for hospital and clinical management has also not been as widespread 

as expected. Both administrators and physicians 

complain that HAA contains insufficient information. No statistics on resource use except bed 

use are available from HAA, and administrative 

data are not integrated with the HAA data. Physicians desire more clinical. information than is 

available using the current codes for diseases, 

which are insufficiently detailed and report only 

diagnoses and operations. The accuracy of the 

statistics is also questioned. Many consultants 

find. errors on their own patients in the returns 

and thus tend to disregard the data altogether. 

Special studies of the system have found it 

“grossly inaccurate”T3 in one instance and 

“almost as good as clinical notes”TA in another, 

In addition, there are many complaints that the 

complex and lengthy way in which data are presented interferes with comprehension. Finally, 

the idea of using statistical material rather than 

individual perceptions of problems as the basis 

for decisionmaking about clinical practice or resource use is not thought to be generally accepted by administrators and physicians.T 1 

HAA has not fulfilled the expectations for 

use in hospital management but has proved useful for local and regional planning purposes. The 

data have also been used in special studies to 

investigate resource use and comparative hospital practices. 

Methods of data collection. –The 10-percent 

sample of discharges for HIPE has been drawn 

in several ways.G8 Before the establishment of 

HAA, hospitals usually reported on every 10th 

entry on a discharge register, starting from a 

randomly selected entry. Sometimes an admission register was used for the sampling, and 

every discharged patient whose permanent registration number ended in a certain digit was 

occasionally reported on, Other times, data were 

reported on every patient discharged whose day 

of birth ended in a specified digit, excluding the 

digits 1, 0, and 9. With the implementation of 

HAA random samples have been drawn by computer from the 100-percent returns. 

It was found that in some hospitals the rules 

for sampling were violated over the years, and 

most national samples have not contained a full 

10 percent of the total discharges. Usually, some 

hospitals failed to turn in their full allotment of 

forms. In 1975, 9.25 percent of all discharges in 

England and Wales and 9.19 percent of the discharges in England alone were reported on. To 

get annual estimates, the number of discharges 

reported was multiplied by a correction factor. 

26 
In 1975, the correction factor for England and 

Wales was 10.807, and for England alone it was 

10.887.T~ 

Since the data for HIPE are now drawn from 

I the 100-percent returns of HAA, both HIPE and 

HAA begin with the completion of the same reporting form, designated HMRI (1P). It is recommended that the form be part of each patient’s case notes.T 6 As such, part of the form is 

filled in when the patient is admitted and the 

rest during the course of the patient’s stay, with 

final information added at the time of discharge. 

Clerks, secretaries, nurses, and doctors are involved in completing various parts of the form, 

and since completing the form is part of the routine recordkeeping, it is thought that greater 

reporting accuracy results. Not all hospitals follow this recommended procedure, but all do 

report the same basic data to their Regional 

Health Authority. 

Before the establishment of HAA the reporting forms were forwarded to OPCS, and all were 

coded in one central office. Coding is now done 

in the regions, sometimes by clerical personnel 

of hospitals,, other times in subregional coding 

centers, and still other times by the regional 

authorities .70 Variation in coding practices has 

followed this decentralization. While some items 

may be more accurately coded at the local level 

because local records are available for rechecking, other items are found to be less accurate. 

This coding variation makes the compilation of 

national summaries more difficult. 

Coded data are transferred to magnetic tape 

and analyzed by’ the regional authorities, who 

prepare the output needed at the regional and 

local levels and draw the 10-percent sample for 

HIPE that is sent to OPCS, OPCS processes the 

sample, editing it for logical errors, and prepares 

the tabulations required by the Department of 

Health and Social Security and other national 

users. 

Coverage. –The HIPE and HAA reporting 

systems cover most hospital discharges in England and Wales, but there are some exceptions? 7 

First, the few private hospitals outside NHS do 

not report on any of their patients. In addition, 

convalescent hospitals and psychiatric hospitals 

operated by NHS are not included in the 

systems. 

NHS hospitals do not report discharge information on all patients they treat. Private patients are usually not reported and neither are 

psychiatric patients in psychiatric departments. 

Psychiatric patients treated in general wards are 

reported, however. Patients in convalescent 

wards are not reported. Preconvalescent units do 

not complete discharge forms, but their patients 

are reported upon by the units into which the 

patients are first admitted. The admitting unit is 

responsible for recording the final discharge data 

after preconvalescent care is completed. Hospital 

staff treated as inpatients are also a special category. If they are treated in the hospital for an 

illness that normally would not require hospitalization, they are not included in the reporting 

system. If a special department is required for 

the staff patient’s care, however, his or her 

record is included in the system. 

Maternity patients and healthy newborns are 

not reported in the usual manner either. Special 

discharge forms are used to report their hospital 

stays. At present only a 10-percent sample of 

the stays are reported, and the sample is still 

sent directly to OPCS.70 In some areas, experiments have been made with 100 percent reporting, but these have not yet become widespread. 

Items collected.–The form HMRI (1P), 

which is generally used to collect data for HIPE 

and HAA, includes the following utilization 

items: hospital name, patient’s unit number, 

date the patient was placed on the waiting list 

to be admitted, date of admission, source of admission (from waiting list, booked—that is with 

admission fixed in advance, immediate, transfer), number of days after admission before the 

first operation, date of the first operation, number of operations, date discharged, identification 

of the consultant under whom discharged, and 

type of discharge (to home, to another NHS 

hospital, to convalescent home, or death).77 

Also included are social and demographic items 

on the patient’s home address, sex, age, date of 

birth, place of birth, marital status, and category. The category can be normal NHS, full 

paying, amenity (an NHS patient who pays a 

small charge for extra privacy), preconvalescent, 

convalescent, or staff. 

Medical items include diagnosis, operation, 

and, for an accident patient, the place of the 

accident. The first &agnosis reported is the 

specific or principal specific condition treated 

27 
during the hospitalization. The underlying cause 

immediately responsible for the patient’s ;ymp -

tomsT5 is given second, and four other relevant 

conditions or complications can be listed. The 

—.

diagnoses ——___ are recorded using the eighth revision 

,=. ._ ._ _—. _ of the International Class~fication of Diseases 

(ICD-8). Injuries are classified by using the 

ICD-8 Nature of Injury codes. The first operation reported is the operation most closely related to the principal condition for which the 

patient was treated, Up to three other operations or investigations can be recorded. Operations are coded according to a classification 

system developed by OPCS. An accident is recorded as road traffic accident, home, work, 

other, or not applicable. 

The forms pertaining to maternity patients 

include most of the same utilization, demographic, and social items. In addition, the date 

and details of delivery, complications, and previous pregnancies are recorded for the mother. 

Items reported concerning the newborn include 

sex, birth weight, single or multiple birth, 

whether transferred to a special-care unit, any 

diseases or abnormalities and the outcome, and 

whether stillborn, died within 24 hours, died 

after 24 hours, or discharged alive .68 

Definitions and procedures. –The calculation 

of utilization statistics from the data collected 

in ~IPE and HAA is done without separating 

data on long-term patients from data on shortterm patients. Most of the information collected 

concerns short-term patients, but there are some 

exceptions such as the patients treated on geriatrics units and on units for the younger disabled. 

In computing the number of discharges, 

deaths and transfers to other hospitals are 

counted along with regular discharges. Transfers 

from one unit or department to another within 

single hospital are considered part of a single 

Edmission. 

The discharge rate for the country as a 

whole is estimated from the 10-percent sample 

collected by HIPE. The total number of discharges is estimated from the sample and then 

divided by the estimated population at risk at 

midyear. 

Among the other statistics calculated for the 

country as a whole from the HIPE data are mean 

and median duration of stay. The mean for a 

year is obtained by dividing the aggregate duration of stay of all patients in the sample by the 

number of patients reported hospitalized in the. 

sample. The median is the length of stay of the 

middle case when all in the sample are ranked in 

order of duration of stay. It is touted as a good 

indication of the average length of stay since it 

is not affected by the abnormally long- and 

short-staying cases. 

“The “ayerage number o~-b~d~Red-&ily is 

also computed. It is the estimated aggregate 

duration of stay of all inpatients divided by the 

number of days in the year. Waiting time, that 

is, the period of time on a waiting list, and mean 

and median waiting time are also computed. 

Information published or available.–The statistics from HIPE have been published in the Department of Health and Social Security’s annual 

series, Hospital Inpatient Enquiry. 75*77 Some 

data from HIPE has also been presented in the 

Central Statistical Office’s publication Social 

Trends78 and, before 1973, in the annual report 

of the Department of Health and Social Security. Since 1973, statistics that were included 

in the annual reports have been published separately in Health and Personal Social Service 

Statzktics.17~18 The desired schedule for publishing has ‘been to make preliminary tables 

available late in the year after the statistics were 

collected, and to publish the main volume the 

following spring, 2 years after collection, However, this schedule has not been met since 1972; 

it has taken about 3 years to publish the main 

tables.TO Unpublished tabulations and standard reference tables m-e produced to meet special inquiries, and ad hoc tabulations of some 

kinds are prepared on request from DHSS or 

academic research centers. 

The, main tables in the report on HIPE present utilization, demographic, and social information on diagnostic groups. The sample numbers and estimated annual total discharges for 

each diagnostic group are given, as are the 

sources of admission, mean and median durations of stay, average beds used daily, beds per 

million population, discharge rates, and mean 

‘and median waiting times. In each diagnostic


group the distribution of patients by region of 1

residence, sex, age group, and marital status is


given. Deaths from different diagnoses and


hospital fatality ratios for different diagnostic


groups are given. Most tables contain cross-


28 
tabulations of several of these statistics. one 

table, for instance, shows diagnostic categories 

divided by sex and age groups and presents 

sample numbers, deaths in the hospital, mean 

duration of stay, discharge rates, and average 

beds used daily for each group in each category. 

Similar tables are presented using the department where the patient was treated as the main 

variable. For each department sample numbers 

are given along with waiting times, average beds 

used daily, percent distribution of discharges, 

duration of stay, sex, age group, region of treatment, and diagnostic group. Tables also examine 

injuries divided b-y age and sex groups, re-@on of 

treatment, &d place of occurrence. Sample 

numbers, estimated total discharges, and mean 

duration of stay are given on injuries. 

Operations are reported for different sex 

and age groups and regions of residence. The 

operation rates; mean and median durations of 

stay and mean and median waiting times for persons having operations; beds used per 100,000 

population for different operations; and sample 

numbers of operations are published. 

Statistics concerning maternity patients are 

sometimes reported together with statistics on 

other discharges in the tables presented in the 

HIPE report. In addition, some statistics are presented separately on maternity patients. The 

estimated total number of maternity discharges 

is given for different types of obstetric care and 

regions of residence. Total births, estimated 

total deliveries in the hospital, percent of births 

delivered in the hospital, and mean postnatal 

stay are also given by region of residence. 

The tables of HIPE statistics presented in 

other routine publications are generally abstracted from the HIPE report. Statistics from 

HAA are not published as a rule, but sets of 

unpublished tables are distributed to regional 

and local authorities. Individual hospitals or 

hospital consultants can request specialized analyse~ along with the rout~e fe~dback. Health 

researchers can also obtain routine or special 

tabulations from the regional authorities. 

Other Discharge Reporting Systems 

Statistics have been collected on psychiatric 

inpatients since 1949 although they are not reported on by the HIPE or H!+ systems.Tg The 

General Register Office and the Ministry of 

Health conducted separate studies until 1964, 

when the Mental Health Enquiry (MHE), operated by the Department of Health and Social 

Security, was created. In addition to individual 

reports on each psychiatric admission and discharge, complete censuses of all psychiatric inpatients were undertaken in 1963 and 1970-71. 

Information about the number and characteristics of inpatients is obtained by updating the 

censuses through the use of the admission and 

discharge reports. 

The Department of Health and Social Security is itself the major user of the data collected.T2 It uses the information for national 

planning and for evaluation of psychiatric services. The statistics are also expected to be useful 

for medical research into mental illness and its 

treatment. They have’ been used by researchers 

to some extent but have become less helpful 

with the change in treatment patterns for mental 

illness. Instead of having prolonged hospital 

treatment, many patients are hospitalized for 

repeated short periods. The lack of a method to 

link records of patients from one hospital stay 

to the next makes it quite difficult to obtain 

from MHE the information necessary for investigating current questions about psychiatric treatment. 

Data collection.–In addition to mentally ilI 

patients in psychiatric hospitals and psychiatric 

units of general hospitals, mentally retarded patients are reported on by MHE. For both 

mentally ill and mentally retarded, one form is 

filled out at admission and another at discharge. 

Forms are sent to the Department of Health 

and Social Security, which codes and analyzes 

the data. Output on punchcards or magnetic 

tapes is returned to the regions for any further 

analysis the y might wish to make. 

]tenzs auailable.–The information collected 

on the MHE admission and discharge forms is 

generally similar to that on the HIPE forms.7g 

In addition to the usual utilization and sociodemographic items, several specialized items are 

reported. One of these is type of admission, 

which can be coded as direct from community; 

from general hospital nonpsychiatric unit; from 

psychiatric bed in a nursing home or hospital; 

from prison, approved school, etc.; or other. 

Transfers, whether from another hospital or 

29 
from another unit within one hospital, are considered new admissions. The legal status of patients is also coded, as is the source of referral 

(family doctor, courts, outpatient clinics, and so 

on). Previous psychiatric hospitalization is 

noted, as is the mental category (mental illness, 

psychopathic disorder, subnormality, severe subnormality, other). The 1.Q. and mental age of 

the mentally retarded are also recorded. 

Under diagnosis, the psychiatric condition 

for which the patient was admitted is reported 

first. An underlying or associated cause of the 

patient’s condition is recorded second; and epilepsy, drug dependency, or alcoholism, if present and not reported in the other diagnostic 

spaces, constitutes a third reported item. The 

diagnoses are coded using ICD-8. 

Finally, included on the discharge form are 

items concerned with outcome. Whether the patient is placed on probationary leave, requires 

no further treatment, is referred to psychiatric 

outpatient care, is transferred to a mental nursing home, or is referred for other types of aftercare is reported. The cause of death given on the 

patient’s death certificate is recorded for deaths. 

Statistics from the admission and discharge 

forms are routinely published in the Department 

of Health and Social Security’s Statistical and 

Research Report Sera”es,79 and selections from 

the reports in this series are presented in other 

publications such as Health and Personal Social 

Service Statistics} 7Y18The tabulations published 

in the Statistical and Research Report Series 

generally concern numbers and rates of admissions, discharges, and inpatient populations. Admissions are reported by age and sex, hospital 

region, type of hospital or unit, source of referral, legal status of the patient, and diagnostic 

group. Discharges are also reported by most of 

these and by duration of stay and outcome. The 

age, sex, region, and duration of stay of resident 

populations are studied. Separate tables examine 

first admissions, admissions that are not first 

admissions, and all admissions. Admissions and 

discharges of patients in psychiatric units of 

general hospitals are presented separately as 

well as together with those of patients in psychiatric hospitals. Tables on mentally retarded 

patients are presented separately from those on 

the mentally ill. 

Aggregate Hospital Reports 

Hospitals in England and Wales have long 

collected informatio~ about bed availability, bed 

occupancy, admissions, and discharges on each 

ward and in each specialty. When the National 

Health Service was founded in 1948, all NHS 

hospitals began reporting the information to the 

Department of Health and Social Security in 

annual hospital returns (the SH3’S). The annual 

returns have been collected every year since 

then. 

Statistics from the annual returns are used 

for planning and management purposes on the 

national, regional, and local levels. While not as 

useful for some purposes as the more detailed 

data from HIPE and HAA, the information on 

the annual returns is generally more current .69 

Although there are procedural differences between the discharge reporting systems, the 

annual return data are also used to estimate the 

completeness of HIPE statistics. 

Data collection, –Generally, hospitals compile information daily (between midnight and 

9:00 a.m.) on beds used, admissions, discharges, 

and the like.76 These “midnight bed state returns” are combined to obtain the data required 

on the annual return. The annual returns are 

sent to the Department of Health and Social 

.Security, which processes them and produces 

regional and national summaries from them. 

Returns are submitted by all NHS hospitals, 

including psychiatric and convalescent hospitals. Private hospitals do not report. The NHS 

hospitals do not report staff patients with conditions that would not normally require hospitalization, and healthy newborns are not 

counted as separate discharges. Day patients, 

outpatients , and other patients receiving only 

partial care from the hospital are reported, but 

they are not counted in with other discharges. 

Transfers between specialized units, as well as 

between hospitals, are counted as discharges and 

new admissions on the annual returns. 

Items available.–The annual return SH3 ‘ 

form filled out by each NHS hospital reports 

separate figures for each clinical specialty. The 

average daily number of beds occupied in each 

specialty is the total of the daily number of inpatients in the specialty divided by the number 

30 
of days in the year. The average duration of stay 

in the year is also reported. It is estimated for 

short-stay cases by dividing the total number of 

bed days by the total number of discharges. For 

long-stay cases it is obtained by subtracting the 

admission date from the discharge date. Also 

reported are the average daily number of beds 

available, discharges and deaths, the size of the 

waiting list at the end of the year, and the 

annual bed turnover rate. 

Statistics from the forms are published in 

a variety of routine publications such as Health 

and Personal Social Service Statistics, ~’918 Regional Statistics, 12 and Annual Abstract of 

Statistics.80 The publications generally report 

utilization measures for all specialties, together 

first and then individually or in groups. The 

most detailed information on different specialties is found in Health and Personal Social 

Service Statistics. 

None of the publications reports specific 

definitions of long- and short-term patients, and 

in most published tables these types of patients 

are reported together. However, some statistics 

for acute specialties are reported separately in 

Rep”onal Statistics, and in Health and Personal 

Social Service Statistics there is a,category called 

“nonpsychiatric; excluding geriatrics and units 

for younger disabled.” This category had an estimated average length of stay of 9.5 days in 

1976, while all nonpsychiatric specialties combined averaged 12.9 days.17 

Household Suweys 

Many other studies have been done concerning the use of hospital services in England and 

Wales. Most of these have been ad hoc investigations, but the Social Survey Division “of the 

Office of Population Censuses and Surveys has 

conducted a continuous study since 1971. This 

General Household Survey (GHS) has examined 

five main subject areas: population, housing, 

employment, education, and health. It was undertaken to supply the Central Government 

with information to assist in resource allocation 

decisions. Results have regularly been sent to 

about a dozen Government departments, and 

researchers outside the Government have shown 

increasing interest in them. 

Data collection. –The data for GHS are collected from a large sample of households in 

England, Wales, and Scotland. In 1975 about 

15,000 households were included. Interviews are 

conducted with all adult members of these 

households, and information about children 

under 16 is obtained from the adults. Institutionalized individuals are excluded from the 

study. The sample is drawn in a two-stage 

process, first sampling electoral wards and then 

selecting addresses within each ward from the 

electoral register. The samples are stratified by 

type of area-between metropolitan and nonmetropolitan areas, by socioeconomic group of 

the head of the household, and by the proportion of the householders who are owneroccupiers. 

Items available.–A great deal of information 

is collected about the social and demographic 

characteristics of the individuals who make up 

each household studied in GHS. Age, sex, marital status, length of time at present address, 

type of housing, skin color, country of birth, 

family size, type of employment, income, educational level, and region are investigated. The 

utilization of ambulatory and inpatient health 

services is studied, as is the incidence of acute 

and chronic sickness. Concerning hospitalizations, individuals are asked to report any inpatient care in the 3 months preceding the time of 

the interviews. They are asked whether they 

were NHS or private patients and how long a 

time they spent in a hospital. If they are currently on a waiting list to be hospitalized, they 

report how long they have been on it. For each 

hospital visit, medical information requested 

includes questions concerning what the doctor 

told the patient was wrong with him or her and 

whether any other treatments such as radiotherapy, physiotherapyy, heat treatments, and the 

like were received. 

OPCS has published the survey results in a 

series entitled General Household Survey. In 

1978 data collected in 1975 and 1976 were published in the fifth and sixth numbers of this 

series.s1~f3z The information in the publications 

on hospitalization has been limited to tables on 

the number of medical and surgical inpatient 

visits per 1,000 persons in a 3-month reference 

period and the average number of inpatient 

31

nights per visit, both separated for different age 

and sex groups. Unpublished statistics are also 

available, subject to certain restrictions, in the 

form either of tables or of magnetic tapes of the 

data. 

FINLAND 

Finland’s discharge reporting systems are the 

most inclusive of any in the six countries studied. Information is collected on all discharges 

from all hospitals registered by the National 

Board of Health, which includes all the public 

and private, general and specialized, and local 

and regional hospitals. All registered hospitals 

also complete aggregate annual reports for the 

National Board of Health that include information on utilization, and most hospitals forward 

data on utilization to the Finnish Hospital 

League. In addition, three national household 

surveys including data on hospital use and users 

have been undertaken to investigate health 

services utilization. 

General Hospital Discharge 

Reporting System 

In Finland there is one discharge reporting 

system, but it has three distinct parts, one for 

general hospital patients, the second for tuberculosis hospital patients, and the third for patients 

in mental hospitals and psychiatric units of general hospitals. Somewhat different discharge 

forms are used for the three types of patients, 

and statistics about the three types are usually 

tabulated and presented separately. The parts of 

the system will therefore be discussed as though 

they were separate systems. The part for general 

hospitzd patients will be described in this section, and the second and third parts will be discussed in the section “other discharge reporting 

systems.“ 

The National Board of Health of Finland 

started operating a discharge reporting system 

covering general hospitak in 1960. The ~oard 

began with an advantage not present in most 

other countries. Legislation existed that gave it 

the authority to collect information on all 

health activities supported, even in part, by tax 

money. Hospitals could thus be required rather 

than requested to supply discharge statistics.l G 

Nevertheless, during the first years of the system’s operation, only general hospitals in certain 

districts of the country were required to report 

on their patients. In 1967 the system was expanded to cover all registered general 

hospitals.ss 

The reporting system was established to provide data for use in national planning and evaluation of hospital services, and it has proved 

useful for these purposes. The data were also 

expected to be used for research into health 

services and epidemiological questions. While 

data have not been used for research purposes to 

the extent expected, usage has increased in the 

last few ye.ars.84 

Methods of data collection.–The discharge 

statistics are obtained from forms filled out on 

every patient at the time of discharge. Information can be written in on the patient’s separation 

form, or it can be entered in coded form. Most 

forms are coded by hospital personnel, and in 

the larger hospitak data are usually also transferred from the forms to magnetic tapes before 

they are sent to the National Board of Health. 

The larger hospitals often perform their own 

analyses of the data. Additionally, the National 

Board returns routine information about individual hospitals’ activities to the hospitals free 

of charge or at a nominal cost. 

The National Board of Health stores the information from the discharge forms in a computerized data bank. Data are arranged in four 

ways: by patient identification number, by local 

area, by institution, and by diagnosis. Information is published on how the data bank can be 

used to answer specific questions but there has 

been little interest in producing regular statistical publications based on the discharge 

reports.l 6 

Coverage.–The inpatients in all general hospitals, public and private, are covered by the discharge reporting system. The inpatients treated 

in health centers are zdso covered, and discharge 

statistics concerning them are usually combined 

with the statistics on the general hospital patients. Inpatients in registered hospitals of institutions, like military and prison hospitals, are 

covered by the reporting system, but their hospital use statistics are not usually combined with 

the statistics from the general hospitals and 

health centers. Hospitals of institutions that are 

32 
not registered with the National-Board of Health 

are not covered by the reporting system. The 

nonregistered hospitals account for 6,916 beds” 

out of the country’s total “of 72,492 beds, and 

almost all the patients they contain are longstaying.g 

The nonregistered hospitals of institutions 

are not, however, the only facilities that treat 

long-term patients. Finland does not have a nursing home system for the treatment of the chronically ill. Many patients who would be in such a 

system in other countries, for instance in Australia and Canada, are treated in the general 

hospitals and health centers in Finland and are 

covered by the discharge reporting system. 

Further, the boundary between residential facilities and health care facilities is not clear in Finland, and some institutions that primarily provide residential care are included in the hospital 

system and covered by the reporting system.85 

Items collected. –Basic information on the 

discharge forms includes utilization of services, 

social and demographic characteristics of patients, and patients’ medical problems. Utilization information begins with identification of 

the hospital and department where treated. The 

,	 type of place that referred the patient to the 

hospital and the place to which the patient was 

referred when discharged are also included, as 

are admission and discharge dates. 

From 1967 through 1974 the social and 

demographic items collected included sex, date 

of birth, marital stattis, occupation, and area of 

residence. In 1975 date of birth was dropped as 

‘a separate item since it was already included on 

the form in the identification number of each 

patient. Marital status was also dropped. Coding 

of all occupations—which proved difficult, time 

consuming, and not very reliable—was changed 

to coding of only a few “risk” occupations. Area 

of residence remained on the form, and an item 

was added to identify patients who paid extra 

for the use of semiprivate beds.8A 

The medical information collected was also 

revised in 1975, Omitted were items on the patient’s condition when discharged, results of 

treatment, and ‘operations and treatments received while in the hospital. It was thought that; 

information on the patient’s condition at discharge could be obtained indirectly from the 

item on the place to which the patient was referred. The coding of the items on results of 

treatment had been found to be stereotyped, 

and the information collected had not been useful. The coding system for the item concerning 

operations and treatments had been problematic, and the information that resulted had again 

not been very useful, so the item was dropped 

until a new coding system could be devised. Lefj 

on the form were items concerning the main 

diagnosis, two other diagnoses, and the underlying cause of death. An item on the urgency of 

the patient’s condition was also added. 

The main diagnosis is defined as the main 

reason for being in the hospital. The second 

diagnosis is the underlying illness or an additional illness. The third diagnosis may be 

another additional illness, or it may be used to 

code the external cause of accidents. The coding 

system used is a five-digit adaptation of the 

eighth revision of the International Classification of Diseases. It is the same adaptation that 

is used in Sweden. Commonly, office personnel 

on each ward fill in the diagnosis in accordance 

with information from the patient’s “medical 

records. However, cause of death is usually recorded directly by a physician. 

Definitions and procedures. –When utilization statistics are computed from the discharge 

reports in Finland, all short-term and long-term 

patients are considered together. The country 

has no designation of “short-term” for hospitals 

or beds. Because some hospitals are designated 

as being for chronic patients, an approximation 

of short-term discharges can be obtained by 

looking only at discharges from institutions for 

nonchronic patients, which on the whole are 

general hospitals. However, many long-staying 

patients are treated in general hospitals?s 

The day of admission and day of discharge 

are counted as one when the discharge statistics 

are calculated. Deaths are included in the number of discharges, but they are identified so that 

they can be examined separately. Transfers between hospitals are counted as discharges and 

new admissions. Intrahospital transfers, which 

are not common, are regarded as one admission 

if the transfer concerns the treatment of the 

same disease. Healthy newborns are not counted 

as discharges. 

The length of stay, calculated for each patient by computer, is determined by subtracting 

33 
the date of admission from the date of discharge. Mean length of stay is obtained by dividing the number of bed days by the number of 

inpatient visits to hospitals. Computer programs 

also exist to calculate many other utilization 

statistics, such as visits and bed days per unit of 

population, occupancy rates, and visits per bed. 

Information published or available.–While 

no statistics from the discharge reporting system 

are re~larly published, much information is 

potentially available in the system’s computer 

data bank. For instance, utilization rates can be 

obtained for different age and sex groups, and 

medical information can be separated by age and 

sex. Hospital use in different areas of the country can be examined, and case mixes of different 

levels and kinds of hospitals can be compared. 

Most studies using the data bank have concerned hospital visits rather than patients, but 

since each hospitzdized individual has a unique 

identification number, it is also possible to conduct person-centered research. Repeat hospitalizations can be located, whether in the same or a 

different hospital, and complete hospital histories of individuals can be studied. 

Some users have found the data bank slow 

and expensive. As a result some hospital regions 

have started to maintain their own regional discharge data registers, which contain the information required by the National Board of Health 

and other data of interest to the region. Most 

regional registers are processed by computers 

owned by the central hospital in a region. At 

present experiments are under w,ay to explore 

the kinds of data systems that will be most helpful to the regions. It is thought that there would 

be great value in a system that could link the 

population register and information on the 

health facilities of a region with treatment information. The Finnish Hospital League is 

working with central hospitals to investigate the 

problems and possibilities of such a system.8G 

Other Discharge Reporting Systems 

The National Board of Health established 

discharge reporting systems for tuberculosis and 

psychiatric inpatients before it began gathering 

data on general hospital discharges. Beginning 

in 1956 the discharges of all patients in tuberculosis sanatoriums were reported to the 

National Board of Health, and in 1958 a register 

of all new cases of tuberculosis was also begun. 

The discharges of all patients in mental hospitals 

were reported starting in 1957, and in 1963 an 

annual census of patients in mental hospitals 

began supplementing the discharge data.16 

Procedures similar to those used in the general hospital discharge reporting system are used 

to collect and analyze the data on the tubercular 

and mental patients. The discharge forms used 

contain the same items that are on the generaI 

hospital discharge forms but require additional 

information. Special items to be filled in on patients in tuberculosis hospitals concern the 

observation of tubercle bacilli, results of tuberculin tests, history of tubercular illness, resistance to tubercular. drugs, and drugs used in treatment.87 The psychiatric forms included 

numerous special items” until the beginning of 

1977, when the forms were revised. Extra items 

concerning the treatment specialty, socioeco-’ 

nomic status of the patient, and type of admission remain on the psychiatric forms at present. 

All the statistics collected on tubercular and 

mental patients are stored in the National Board 

of Health’s central data bank. Again, many kinds 

of information are potentially available, but 

routine publications are not produced. 

Aggregate Hospital Reports 

Data collection. –Summary statistics on hospital utilization are collected by the yearly 

reports all hospitals send to the National Board 

of Health. Some summary statistics have been 

collected and published in Finland since the 

1940’s. However, it was 1963 before the first 

nationwide statistics were compiled.8s Since 

then the National Board of Health and the Finnish Hospital League have both been involved 

in collecting annual reports from the hospitals 

and in publishing the results. 

The National Board uses the statistics collected to supplement the discharge reporting 

system. National planning and evaluation of 

health services are aided by use of the annual 

reports. The reports are also used to check the 

completeness of the discharge reporting system. 

Data from the annual reports are published in 

the “Yearbook of the National Board of 

Health.”g The national health administration’s 

34 
yearbook is part of a series of annual reports 

that have been published for 124 years. Many 

volumes were called “Public Health and Medical 

Care,” but the most recent one is entitled 

“Health Services.” It was published in 1978 and 

covers health data of many kinds from the years 

1971 through 1977. It is written in Finnish and 

Swedish, but the tables are labeled in English, 

and an English summary is included. 

The Finnish Hospital League is an organization of the communal hospitals of Finland. 

Communes are the local administrative units of 

the country, and they operate 95 percent of the 

country’s hospital beds .89 The Hospital League 

was established in the 1960’s, to facilitate hospital administration. It attempts to develop ways 

in which hospitals can be more efficient and economical, and it serves as an advocate for hospitals in regard to national health care policy. To 

help pursue these goals, the Hospital League collects and analyzes statistics from annual reports 

of its members’ hospital activity. The statistics 

are presented in a yearly publication entitled 

Hospital Economics. 28 The latest issue, published in 1977, presents statistics collected in 

1976. The publications are written in Finnish, 

but some have English keys to tables. 

The National Board’s statistics are more inclusive than those collected by the Hospital 

League. The National Board’s statistics include 

data on private hospitals and hospitals of institutions, registered and nonregistered; information on these facilities is excluded from the 

data published by the Hospital League in Hospital Economics. The Hospital League also excludes all but a handful of the hospital beds in 

health centers. In past years all the health center 

hospitals submitted annual reports to the National Board, but since 1977 only those under 

the direction of specialists have done so. Data 

from other health center hospitals are now sent 

to the Board as parts of other accounts of health 

center functioning.g 

Items available. –The utilization statistics 

collected are quite similar in the National 

Board’s and the Hospital League’s aggregate 

reporting systems. The type of utilization statistic most frequently reported in published 

materials is bed days. This measure is thought to 

be especially appropriate for national planning 

purposes since it is not greatly affected by different practices concerning transfers and readmission for the same condition .85 It is also the 

measure used by the National Government to 

calculate reimbursements due to hospitals. Since 

in the Government calculation the day of admission and the day of discharge are regarded as 2 

bed days, many published statistics follow this 

rule.9 However, statistics are also presented that 

count the days of admission and discharge together as one. Whether the former “Finnish 

system” or the latter “international system” is 

used to calculate statistics is noted in the published tables. 

Other utilization measures reported by the 

National Board and the Hospital League include 

number of admissions, average length of stay, 

and occupancy rates. Number of hospitals and 

number of hospital beds are also reported. 

Further, number of inpatient treatments, such as 

X-ray exams, operations, and laboratory tests, is 

compiled. 

Most of these statistics are given per unit of 

population for types of hospitals, for each of the 

Z l-hospital regio~s of the ~ountry, and for specialized departments within hospitals. A detailed 

list of specialized departments is used. It includes internal medicine and surgery, both 

broken down into sub specialties; gynecology; 

obstetrics; pediatrics; ear, nose, and throat diseases, ophthalmology, radiotherapy, neurology, 

skin and venereal diseases; lung diseases; psychiatry; and contagious diseases. Both the National 

Board and the Hospital League study changes 

over time in various of these statistics. 

The National Board and the Hospital League 

also study other aspects of hospital operation 

besides utilization. Statistics on personnel, outpatient visits, and financial patterns are shown in 

the annual reports. These statistics are sometimes cross-tabulated with the utilization measures. For instance, the League studies various 

kinds of hospital costs per bed day. 

Household Surveys 

The Research Institute for Social Security is 

the research unit of the Social Insurance Institution, which administers the country’s national 

health insurance program. The Research Institute regularly collects data on health care covered by insurance, but hospitalization is not 

35 
financed by insurance so it is not included.16 

However, in addition to the regular studies, the 

Research Institute has conducted three special 

national household surveys of health care use, 

and these have included data on hospital utilization. 

The special studies were formulated to evaluate the effects of changes in the health services 

system. The first two, undertaken in 1964 and 

1968, investigated the impact of the national 

health insurance program, which began operation in 1964. Since 1968 changes have occurred 

in the services covered by insurance, and ambulatory care has been reorganized, resulting in the 

growth of health centers. Therefore, another 

survey was conducted in 1976. The results of 

the 1976 suiwey are not yet available, but the 

1964 and 1968 studies are described in a series 

of research reports and are summarized in a 

book published in 1974, Health Services Use and 

Health Status Under National Sickness Insurance. 90 

Data collection.–For the .1964 and 1968 

studies, independent samples were drawn from 

F-hkm&s” population register. The samples did 

not include individuals in institutions or children 

under 15, but information on the latter was obtained during the interviews. Approximately 

7,000 families were in each sample–23,516 individuals in 1964 and 17,910 in 1968. In 1964, 

8.9 percent of the sample could not be interviewed; in 1968, 3.1 percent. The interviews 

were conducted by public health nurses, and respondents were asked about health service use 

for a period of approximately 5 months. Similar 

data collection procedures were used in the 

1976 study?l 

Items available,–Most questions in the surveys concerned the use of physician services, 

drugs, and dental services; but the number of 

bed days experienced by members of each family was also recorded, Social and demographic 

characteristics reported in the survey included 

the age, sex, marital’ status, and occupation of 

each individual; family size; the educational 

background of the family head; family income; 

and family expenses for health services. Medical 

information included any complaints of acute or 

chronic disorders. 

The most frequently used measure of hospital utilization in published reports based on the 

surveys is the number bed days per 100 adults 

per 100 days. Age and sex distributions of these 

standardized bed days were computed. Stand-’ 

ardized bed days are also presented by family’ 

income, by distance to the nearest physician, 

and by number of physicians in the commune. 

In each case, chronic and nonchronic illnesses 

are reported separately. 

FRANCE 

In France hospital statistics on public hospitals are usually collected separately from statistics on private hospitals. Most of the statistics 

are drawn from annual reports on facilities and 

utilization. Public hospitals have completed 

these annual reports for years, and more recently private hospitals have begun making 

them. However, the statistics from the two sets 

of reports are generally analyzed and published 

separately. Many public hospitals also participate in a morbidity study, but the study does 

not include any private hospitals even though 40 

percent of all admissions are to private hospitals.lo A national household survey conducted 

in 1970 is dne of the few sources of data on 

both categories of hospitals. 

General Hospital Discharge 

Reporting System 

In 1968 the Ministry of Health and Social 

Security decided to establish a morbidity study 

in the public hospitals in France. The Ministry 

sent a memorandum to administrators in public 

hospitals requesting that they begin recording 

the diagnoses of all patients discharged from 

.their hospital sectors as of January 1, 1969. 

Further memorandums revising the instructions 

for collecting and submitting the morbidity data 

were sent out in 1973 and 1975. Additional 

changes in the study are planned for 1979-8 O.gz 

The Ministry expected that the statistics collected in the morbidity study would be useful 

for planning and regulating the hospital sector at 

the national level and that local hospital administrators would be able to learn more about the 

needs of their clientele from the statistics. It was 

also thought that the data would be useful for 

medical and epidemiological reiearch.gs 

36 “ 
Methods of data collection. –The memorandums sent by the Ministry to the public hospitals did not instruct them to collect individual 

discharge forms for each patient. Instead, each 

department in the hospitals was expected to 

compile a set of tables at the end of the year 

that reported in aggregate form data on all 

patients it had discharged during the year. The 

Ministry left it to the administrators in individual hospitals to make decisions on the specific 

procedures to be followed in compiling the 

tables. Thus a variety of personnel were involved 

in data collection. In some hospitals the chief 

physician of each department completed the 

tables, and in others interns or other subordinate 

physicians did so. In still other cases, nursing 

personnel and administrative personnel were in 

charge of the tables. There is concern that these’ 

different kinds of personnel did not always follow similar procedures in completing the tables 

or report the statistics with equal accuracy.gs 

After the tables were completed, they were 

usually sent to the Ministry for processing. The 

Ministry performed validity checks, corrected 

for underreporting, and confirmed reports of 

rare diseases. However, the tables collected in 

university hospitals were checked and corrected 

by the hospitals themselves before the data were 

sent to the Ministry. Some university hospitals 

also transferred the data from the tables to magnetic tape, processed it, and obtained tabulations for their own uses. These hospitals then 

forwarded the magnetic tapes to the Ministry. 

After making checks where necessary, the Ministry transferred the data from the rest of the 

hospitals to magnetic tapes and created a data 

file of information from all participating hospitals. 

After 1978 these procedures were no longer 

followed. Instead, the Ministry is introducing 

the use of individual discharge reporting forms 

in the participating hospitals.9 z Once the new 

forms are in use, the Ministry will receive either 

the forms or magnetic tapes containing information from these hospitals. 

Coverage. –Public hospitals in France are 

divided into four major categories: centres 

hospitaliers rggionaux (regional hospital centers), centres hospitaliers (hospital centers), 

hdpitaux (hospitals), and h6pitaux locaux (local 

hospitals). The centres hospitaliers r@onaux, 

centres hospitaliers, and h~pitaux were asked to 

participate in the morbidity study, but the 

hbpitaux locaux were not .93 The h~pitaux 

locaux primarily provide treatment @ longstaying patients, but some maternity patients are 

also “treated in them. The centres hospitaliers 

r&ionaux, centres hospitaliers, and h$pitaux 

were expected to report on all discharges except 

those from psychiatric units or from hospice and 

annex sections. The hospice and annex sections 

provide a level of care similar to that given in 

nursing homes in other countries.92 

At the end of the first year of the morbidity study reports were received on only 33 percent of the discharges that were expected to be 

covered. Only 26 percent of the hbpitaux discharges were reported, but 37 percent of the 

centres hospitaliers discharges and 42 percent of 

the centres hospitaliers r&ionaux discharges 

were covered. In some hospitals, concerns about 

violating the confidentiality of patient records 

impeded cooperation with the study, and in 

others, insufficient personnel were available to 

complete the records. However, by 1973 the 

proportion of the discharges expected to be covered that were reported had risen to 50 percent. 

The h~pitaux and centres hospitaliers showed 

marked improvement in their rate of information return, reporting on 55 percent and 57 percent respectively, in 1973. The centres hospitaliers r@-ionaux continued to report on only 42 

percent of their discharges .94 

Discharges from psychiatric hospitals and 

private hospitals are not covered by the morbidity study. The exclusion of private hospital discharges is very important. Not only do private 

hospitals account for a substantial percent of 

all discharges, but also significant differences 

have been found between the patients treated in 

public versus private hospitals. Private hospitals 

treat more surgical patients but fewer medical 

patients than public hospitals do. They also treat 

fewer children of under 2 years of age or adults 

of over 65 years of age than public hospitak, 

and they treat a larger percent of women, especially women in their childbearing years 25 Thus, 

looking at public hospital morbidity alone does 

not lead to an accurate picture of the age, sex, 

or diagnostic characteristics of all French hospital patients. 

When the rate of reporting from covered 

37 
hospitals is considered together with the planned 

exclusions, one finds that less than 30 percent 

of France’s hospital sector patients are actually 

being reported in the morbidity study. Furthermore, there is considerable variation in the rate 

of reporting in different regions of the country. 

No region reports on more than 79 percent of 

the discharges from its public hospital sector, 

and the rate is as low as 22 percent in one 

region.g4 

Items collected. –When the morbidity study 

began, hospitak were requested to report only 

diagnosis, sex, and whether the hospital stay 

was terminated by normal discharge or death. 

In 1973 they were asked to begin submitting 

tables of diagnoses by age groups and were instructed to calculate the number of days of hospitalization for each diagnosis?s Thirteen age 

groups were to be used: O-28 days, 28 days to 1 

year, 1-4 years, 5-9, 10-14, 15-24, 25-34, and so 

on up to 85 years and over. By 1975 concern 

had developed that certain types of services in 

many of the participating hospitals were failing 

to report or were underreporting their discharges. Thus, hospitals were asked to indicate 

which of their services were reporting and which 

were not so that corrections for consistent 

underreporting could be made in the national 

data. 

Plans are under way to collect a great deal 

more information on each discharge when the 

individual reporting forms are put into use. 

Among the items to be collected are the following: identification of the hospital; mode of 

transportation to the hospital; date of admission; type of admission (direct or transfer); if 

transfer, hospital transferred to and from which 

transferred; type of service in which treated; 

date of discharge; and type of discharge (transfer 

or discharge). Also collected are the patient’s 

date of birth, sex, nationality, area of residence; 

the socioprofessional category of the head of the 

household or the person financially responsible 

for the patient; the principal diagnosis; and, in 

accident cases, the cause of the accident.gz 

Until 1973 the most serious disease diagnosed for each patient was the one to be reported. Since 1973 the direction has been to 

code the principal disease treated or studied during the period of hospitalization. However, this 

direction has not always been followed. Sometimes the diagnosis reported has still been the 

most serious disease. At other times the diagnosis that led to admission or the one for which 

the most expensive care was given has been reported~s Further, for a growing number of discharges the diagnoses have either not been 

reported at all or have been insufficiently specified to be included in the analysis. By 1973, 

10.2 percent of discharges fell into this indeterminate group .94 The diagnoses have been coded 

using the D list of 300 diseases from the eighth 

revision of the International Classification of 

Diseases. Traumatic injuries have been coded 

according to the nature of the injury. The fourdigit codes of the ninth revision of ICD will be 

used by some hospitals in 1979 and by all beginning in 1980.92 

Definitions and procedures. –In the data collected in the morbidity study, no distinction is 

made between long- and short-term patients. 

Most discharges reported are from short-term 

units, but intermediate units containing convalescent patients and patients being rehabilitated are also covered, and these patients averaged hospital stays of 72 days in 1974.10 

The number of discharges reported by each 

hospital is supposed to include only discharges 

which take place from January 1 through December 31 of a particular year. However, some 

hospitals include in their yearly total patients 

stiIl in the hospital on December 31 and report 

their length of stay as the period from their admission to December 31. Other hospitals, while 

not counting patients until they are discharged, 

compute lengths of stay which began in the 

previous year by counting only the period from 

January 1 through discharge date~z 

Deaths are counted as discharges, but they 

are often analyzed separately. Many French patients return to their homes when they are about 

to die, which lowers the rate of hospital deaths. 

Transfers between hospitals are counted as discharges. Transfers from one service to another 

within a single hospital are supposed to be 

treated as part of a single hospital stay, but 

nearly half of the hospitals that participate in 

the morbidity study do not follow this procedure.gz Instead they report stays for each hospital service separately, so that if a patient is transferred three times, three different stays are 

recorded. Women hospitalized for normal deliv38 
cries are excluded from some analyses, but they 

are included in the total number of discharges 

unless they are specifically said to be excluded. 

Information published or available.–Statistics from the morbidity study were first published in bulletins of the Ministry of Health and 

Social Security in 1971. They have appeared in 

the Bulletin de statistiques sociales (1971), the 

Bulletin de statistiques Sante~Se>un”te”Soca’ale 

(1972; 1973, 1974), Sant/ S/curit/ Sociale, 

Statistiques et commentaires (1975-77), and 

Sant[ et Secun”tk Sociale: Tableaux idition 

1975-1976. The statistics in the 1977 publication were collected in 1974. 

Most of the published data concern distributions of discharges in diagnostic groups. For 

instance, in the 1977 publication,g6 one table 

presented the number and relative frequency of 

discharges in 22 diagnostic categories by sex. 

Others reported the percent distribution of discharges in diagnostic categories in each age 

group by sex. The proportion per 100 discharges 

that had injuries was reported for each age group 

in categories of types of injuries by sex, and 

similar breakdowns were published for cardiovascular diseases, diseases of the digestive system, respiratory diseases, and complications of 

pregnancy and delivery. The number of deaths 

per 100 discharges in each major category of 

disease was also reported by sex. The average 

length of stay for patients in different diagnostic 

groups was given, and the percent of discharges 

in each of the six principal diagnostic groups was 

reported by sex for 1974 and 1970. 

Other Discharge Reporting Systems 

Data collection. –Statistics on psychiatric 

hospitalizations are periodically collected by the 

psychiatric section of the National Institute of 

Health and Medical Research (Institut National 

de la Sant6 et de la Recherche M~dicale– 

INSERM). These statistics cover adult services 

in psychiatric hospitals and psychiatric services 

in general hospitals. 

Procedures used to collect data cm psychiatric patients are similar to those used in the 

general hospital morbidity study.g T Each service 

keeps a record of certain information about its 

hospitalizations, and at the end of the year the 

information is transferred to a set of tables that 

is sent to INSERM. The chief physician for each 

service is responsible for completing the tables. 

Items available.–The information sent to 

INSERM by the psychiatric services allows 

INSERM to compile five types of tables. First, 

the number of hospital patients on December 31 

of the reporting year is available by sex, age, 

diagnostic category, patient status (present in 

the hospital on December 31, on trial discharge 

or extended leave, or absent from the hospital 

for other reasons on December 31), and length 

of stay. Second, the number of admissions during the year is given by sex, age, diagnostic category, and type of admission (first admission to 

any psychiatric service, transfer from another 

psychiatric service, admission for the second 

time or more, and unknown). Third, the number 

of discharges is shown by sex, age, diagnostic 

category, type of discharge (transfer to another 

psychiatric service, discharge other than transfer, and escape), and length of stay. Fourth, the 

number of deaths, which is not included in the 

number of discharges, is given by sex, age, diagnostic category, and length of stay. Finally, the 

/ number of hospital cases treated during the year 

is shown by sex, age, diagnosis, and type of hospitalization (hospitalization begun before January 1 of the year and ended during the year, hospitalization begun and ended during the year, 

hospitalization begun during the year but not 

ended by December 31, hospitalization begun 

before January 1 and not ended by December 

31, and total hospitalizations). 

Statistics from the tables are published by 

INSERM and are included in bulletins of the 

Ministry of Health and Social Security. An example of the information published is that in 

Sant& S6cun”tG Sociale, Statistiques et commentaires. 97 A group of tables is presented in 

this publication concerning each of the five categories of psychiatric patients: those who were 

patients on December 31, admissions, discharges, deaths, and all those who were treated 

during the year. The number in each category is 

shown by sex and age group (under 15 years, 

15-19,20-24,25-34,35-44, 45-54,55-64,65-74, 

75-84, 85 years and over) and by sex, age group, 

and diagnostic category. For each category the 

number and percent distribution of patients is 

also given by sex and diagnostic category. In 

addition, the number and percent distribution of 

39 
hospital patients on December 31 are presented 

by patient status and sex; the number and percent distribution of admissions are given by type 

of admission and sex; the number and percent 

distribution of discharges are given by type of 

discharge and sex; the number of hospital cases 

treated during the year is given by sex, diagnosis, 

and type of hospitalization; and the rate of 

deaths of psychiatric patients per 1,000 deaths 

in the general population is given by age and sex. 

Aggregate Hospital Reports 

Before the hospital morbidity study was organized, the Ministry of Health and Social Security collected hospital data from questionnaires sent to the administrators of public 

hospitals. These questionnaires were first distributed in 1961, and the Ministry has continued 

to collect them annually from all public hospitals every year since that time.gs The Ministry 

also collected some data on private hospitals in 

1962 and 1968. Then, beginning in 1972, 

private hospitals also began filling out annual 

questionnaires and forwarding them to the Ministry. While most of the data now reported by 

private hospitals are similar to those reported by 

public hospitals, the statistics from the two sets 

of questionnaires have generally been analyzed 

and reported separately .99 

Almost all French hospitals complete and 

return the annual questionnaires, making the 

questionnaires a much better source of hospital 

statistics than the morbidity studies. Less than 

1 percent of private hospitals failed to report in 

197399 ; and all public hospitals, including local 

and psychiatric hospitals, made returns.100 Patients treated in the annex and hospice sections 

of hospitals are reported on in the returns. 

The statistics from the annual questionnaires have been published since 1963 in various 

Ministry of Health and Social Security bulletins. 

Data from 1972 on have been published in issues 

of Sante” Se”cun”te” Sociale, Statistiques et com -

mentaires.99$100 Some information from the reports was also included in Sante” et S6cun”t; 

Sociale: Tableaux ;dition 1975-1976.10 

The statistics that are reported primarily 

concern hospital beds. The number of beds in 

different kinds of hospitak, in the various sections of hospitals, and in the geographic regions 

and departments are reported; and percent 

changes in the distribution over time are calculated. Also reported are the beds per 1,000 

population, admissions per bed, and occupancy 

rates. 

Utilization measures reported include admissions, admissions per 1,000 population, bed 

days, and average length of stay. Admissions include transfers, whether between hospitals or 

between services within a hospital. Sometimes 

discharge rates are also reported, and when they 

are, deaths are given separately from other discharges. Average length of stay is obtained by 

dividing the number of bed days by the number 

of admissions.9s Percent changes in the number 

of admissions and bed days are frequently reported. Changes from one year to the next and 

from 1961 until the year under study are frequently reported. 

The beds and patients in the annex and 

hospice sections of public hospitals are usually 

reported on separately from other beds and patients. Statistics concerning intermediate-stay 

sections (rehabilitation units, convalescence 

units, and the like) and psychiatric sections of 

public hospitals are also usually separated from 

those on short-term sections. The short-stay 

sections are divided into three groups: general 

medicine and medical specialities, general surgery and surgical specialties, and gynecology and 

obstetrics, and statistics are reported separately 

for each group. Information on public hospitals 

is further subdivided into the four categories of 

hospital establishments: the centres hospitaliers 

r< “onaux, centres hospitaliers, h~pitaux, and 

F hopitauxlocaux.100 

Utilization statistics on private hospitals are 

presented in somewhat different categories from 

those used for public hospitals. Information is 

reported separately on me’dicine and medical 

specialties, surgery and surgical specialties, maternity with no surgical treatment, maternity 

with surgical treatment, convalescent services, 

rehabilitative services, tuberculosis services, and, 

finally, psychiatric services. These categories are 

further subdivided into those in profit and in 

nonprofit hospitals.gg 

The statistics published on psychiatric patients are similar to those reported on general 

hospital patients, but again somewhat different 

reporting categories are used. Psychiatric services 

40

in public general hospitals are reported separately from those in public psychiatric hospitals, 

and both are separated from those in private 

psychi&ic institutions, which. are themselves 

divided into profit and nonprofit categories. 

Psychiatric utilization statistics are also given 

separately for males and females; for adults and 

children; and for first admissions, transfers, and 

readmissions,l O 

Household Surveys, 

No regular household surveys on health are 

conducted by the French Government, but ad 

hoc studies have been made. One of the most extensive of these, undertaken in 1970, was a 

study of the consumption of medical care.g5 

The study was a joint project of the National 

Institute for Statistics and Economic Sjudies 

(@stitut National de la Statistique et des Etudes 

Economiques–INSEE) and the Research Center 

for Observation and Study of.Living Conditions 

(Centre de Recherche pour l’Etude et l’Observation des Conditions de Vie–CREDOC). 

The study was based on a sample of 7,393 

families in the metropolitan areas of France. Except for persons living in institutions, who were 

excluded from the sample, and persons living 

alone, who were underrepresented, the sample 

was considered representative of the French 

population. Information on many aspects of 

medical care was obtained from the families, 

including data on a tot~ of 1,235 hospitalizations during a 6-month period. 

. The data have been published in several 

CREDOC publications including “L’hospit#iia~ 

tion et sa place clans les d~penses m6dicales en 

1970,”9b and “Influence des facteurs socio­

~conomiques sur I’hospitalisation .“101 

The hospitalizations studied were divided 

into three major types: those in public general 

hospitals, those in private general hospitals, and 

those in specialized hospital establishments. The 

latter included psychiatric hospitals, convalescent centers, sanatoriums, and other long-term 

establishments. 

Utilization information gathered on these 

establishments included average length of hospital stay, median length of stay, number of days 

of hospitalization per person per year, and discharge rate, that is, the percent of the population with a hospital stay. These figures are not 

comparable with the statistics from the annual 

questionnaires, because transfers between services within a single hospital were counted as one 

stay in the survey but as new admissions in the 

annual statistics.95 ‘ 

Along with the utilization measures, a number of sociodemographic variables were collected. These include age, sex, education, family 

size, occupational group of the head of the family, family income, and source of payment for 

hospital care. The effects of these characteristics 

on hospital utilization, singly and in combination, were studied.101 

In addition, information w s reported on the 

medical problem which acco ! nted for the hospitalization and on the number and types of 

surgery experienced by the hospitalized patients. 

This information was examined for different age 

and sex groups and for different kinds of hospital establishments. 

Further information was being collected in 

1978 in a new household survey sponsored by 

CREDOC. Data on a representative sample of 

2,000 to 3,000 public and private hospitalizations were expected to be collected in this 

survey.1‘z 

SWEDEN 

In Sweden a variety of studies have been 

undertaken to collect statistics on hospital 

utilization. No single study produces comprehensive data’ on all hospitals and types of patients, but in combination the studies make 

available a wide range of information. Discharge 

abstracts concerning hospital patients are collected in three separate programs. One program 

covers the somatic patients (those physically ill 

or injured) in approximately three-fourths of the 

country’s hospitals. The second covers all patients in psychiatric hospit~s and in psychiatric 

units of general hospitals. The third covers all 

obstetrical patients and newborn infants 

throughout the country. In addition, utilization 

statistics are compiled by the National Board 

of Health and Welfare from annual re~orts sent . 

to it by”the country’s hospitals. Household surveys provide further information. 

41

General Hospital Discharge 

Reporting Systems 

Three levels of org&ization in health care 

are especially important in Sweden, The first 

level is the county. Sweden is divided into 23 

counties and 3 independent communes, and the 

counties and communes range in population 

from 54,287 to 1,491,345.18 In each county a 

county council is elected, which, along with 

other duties, has direct responsibilityy for most 

health care delivery in the county. The second 

level is the region. For purposes of health planning, the counties and communes are combined 

into seven health regions, which range in population from 642,314 to 1,547,946. Third is the 

national level. The National Board of Health and 

Welfare (NBHW) is the principal national governmental agency for supervising and promoting 

health care. 

In 1964 NBHW began an experimental program to collect discharge statistics from somatic 

hospitals. At first only hospitals in one of the 

seven health regions, the Uppsala region, were 

involved in the program. However, local authorities in other areas of the country soon became 

interested in collecting similar statistics, and 

they began setting up programs that made use of 

forms and procedures similar to those used in 

the NBHW program. By 1969 approximately 60 

percent of the discharges from Sweden’s physical disease hospitals were reported,l OS The 

NBHW’S experimental program ended that year. 

NBHW was willing to continue to assist hospitals in development of statistical programs and 

to analyze the discharge data, bu~ it stopped 

financing the programs ,87 In 1970 the county 

councils that were interested took over the financial responsibilities. Interest in the programs 

continued to grow, so that in 1978 approximately three-fourths of all discharges from 

somatic hospitals were reported.104 

There were several reasons for the establishment of the reporting systems. First, it was expected that the resulting data base would be 

useful in hospital planning on local, regional, 

and national levels. Also, it was thought that 

the data base would make possible hospital 

morbidity studies and other research into the 

use of health care services in the country .87 

During the initial experimental period of 

data collection in the Uppsala region, emphasis 

was placed on returning detailed diagnostic 

breakdowns to the individual hospitals and 

hospital departments participating in the 

study.1 04 This provided a validity check of the 

data and was ako expected to enhance the cooperation of the participants with the program. 

In 1969 production began on publications 

reporting data from the program. These publications, along with unpublished data from the 

program, were sent to a variety of individuals 

and authorities having an interest in health 

care.8T Executives and politicians at different 

levels of the country’s health care system received them, as did other local, national, and 

international authorities. Various ‘enterprises in 

the country’s drug industry, individuals involved 

in consultative and marketing activities, and 

scientific institutions and research workers also 

obtained reports. 

The data have been used for a number of 

d ecialized studies. An international comparison 

of hospital caseloads has been done using the 

Uppsala region’s statistics.105 The variations between Swedish hospitals in average length of 

stay for certain conditions have also been investigated,] OG and a linkage study of hospital 

stays for particular conditions over a 4-year 

period has been completed. Studies of drug 

complications and of surgical procedures are 

also being done. 

Methods of data collectz’on. -A form is filled 

out on each patient discharged from hospitals 

participating in the reporting system. The individual hospital departments are responsible for 

competing the forms. Departmental personnel 

fill in verbal descriptions of diagnoses but also 

code the diagnoses and operations along with 

other required information. Some hospitals 

transfer the information from the forms to magnetic tape and process it for their own use. 

Either the forms or the tapes are sent to the 

county councils. The councils create on tape 

data files that contain the discharge information 

from all reporting hospitals in the county. They 

may perform their own specialized analyses of 

the data. They also submit the tapes to NBHW. 

NBHW performs a series of checks on the tapes 

and then processes the data and adds them to its 

42 
information bank. Statistics are produced from 

the information bank for publications and other 

uses. 

Coverage. –In the Uppsala region and the 

three county Sk&e area, all somatic hospitals 

participate in the reporting system. Both public 

and private hospitals report; and nursing homes, 

some of which are equivalent to hospitals in 

the United States, are also included. Tog&ther 

the Uppsala and Sk%e areas account for 28 percent of the population of Sweden, and they are 

considered representative of the country as a 

whole.1 07 

Coverage of the discharges in the remainder 

of the country is less comprehensive. Since participation in the reporting system is voluntary, a 

few county councils have decided not to finance 

it in any of their hospitals. Other county councils are interested in statistics only from the 

major hospitals they operate, especially the 

teaching hospitals. Thus the country’s small hospitals and nursing homes are underrepresented in 

the data sent to NBHW from the country as a 

whole.1 04 Patients in psychiatric hospitals and 

psychiatric units in somatic hospitals are excluded from the reporting system, as are obstetrical patients and their newborn babies. 

Items collected. -The discharge forms developed by NBHW 103~s7 and used in most hospitals 

contain items which identify the hospital, department, patient, and medical record. The dates 

of admission and discharge are reported, as are 

the form of admission (from domicile, acute; 

from domicile, nonacute; from inpatient care, 

acute; from inpatient care, nonacute) and the 

form of discharge (to domicile; to inpatient care; 

dead, post mortem performed; dead, no post 

mortem performed). Whether or not the patient 

was previously treated for the same illness in the 

department earlier in the year is noted. The date 

of birth, sex, marital status, and insurance fund 

number are also required. 

Up to eight diagnoses can be recorded. The 

first-named diagnosis is the condition whose investigation or treatment was the main reason for 

keeping the patient in the hospital.103 Diagnoses 

are coded according to five-digit codes from the 

eighth revision of the International Classification 

of Diseases, adapted in Latin and Swedish for 

hospital use, As many as 16 operations can be 

reported. They are reported according to diagnosis–operations for the main diagnosis are 

reported first; for the second diagnosis, second; 

and so on. When more than one operation is 

undertaken for treatment of a single diagnosis, 

the operations are given in order of importance. 

The anesthesia used for each operation is also 

coded. The surgical codes are taken from a list 

of four-digit categories compiled by NBHW from 

the codes for operations and procedures developed in England by the Office of Population 

Censuses and Surveys, 104 ~d the anesthesia is 

coded according to a three-digit Swedish classification. Th~ immediate and underlying causes 

of death a e reported. Finally, special information is giv [ n on patients in lung departments or 

sanatoriums-whether or mot they had been 

treated previously for tuberculosis and whether 

tubercle bacilli were present or absent. 

Definitions and procedures. –Both long- and 

short-term patients discharged from hospitals 

participating in the study are reported on, but 

they can be separately identified. All units in 

Swedish hospitals are designated as either longor short-term. The designation is made on the 

basis of the intensity of care given in the unit. 

Therefore, separating discharges by the unit in 

which they were treated isolates short-term discharges. In addition, some utilization statistics 

for patients discharged from long-term hospitals 

are calculated separately from the statistics for 

discharges from short-term hospitals. 

In the calculation of utilization statistics, 

deaths are counted as discharges, but they can 

be examined separately if desired. Transfers, 

whether to another hospital or to a different department within a single hospital, are generally 

counted as discharges and new admissions. They 

can be examined separately. 

The number of bed days used by a discharged patient is obtained by subtracting the 

admission date from the discharge date. The 

entire period of stay is counted even if the admission occurred before the year under consideration. The average length of stay is calculated 

by dividing the total number of bed days by the 

total number of discharges. 

Information published or available. –In 1969 

NBHW began publishing data from the discharge 

rep orting sys tern in the Patient statistics sen”es, 

43 
Publication numbers” 1,109 2,10s 6,109 8,110” 

10}11 11}12’_J-~}l$~ndlfjl14 of fiis~erie~ ~on. 

tain data from somatic hospitals in the Uppsala 

region. The last three publications in the series, 

numbers 17,115 18,116 and 19,107 report data 

from both the Uppsala region and the three­

.county Sk%e area. Statistics collected from 

hospitals in other areas have not been regularly 

analyzed thus far,s’ and the most recent statistics reported from the Uppsala region and Sk~ne 

were collected in 1973. NBHW is currently discussing the form and content of future publications. 

One set of tables that has been published 

presents 10 items of information on each diagnostic category in the five-digit classification. 

The first item is the total number of patients 

with the diagnosis as either their main or secondary diagnosis. The remainder of the items are 

on patients for whom the diagnosis was the main 

cause of hospitalization. These items consist of 

the number of days in the hospital and the number of discharges, which is also given for the 

following categories: males, persons under 15 

years of age, persons 70 years and,over, persons 

with the diagnosis operated on, persons treated 

earlier in the year in the same department for 

the diagnosis, persons transferred to other hospitals ok departments, and deaths.1°7 

In another publicationll 6 diagnoses are 

grouped into a list of 99 categories. In each category information is given on patients whose 

main diagnosis was included in the category. 

This information includes total number of discharges; number of discharges that had been 

acute admissions (patient had entered the hospital at a time not agreed upon at least 24 hours 

before admission); number of bed days, number 

of days on leave, average duration of stay, numbers of patients aged 0-14 years, 15-44, 45-64, 

65-74, and 75 and older; number treated earlier 

in the year in the same department for the same 

main disease; number transferred from another 

hospital or department; number transferred to 

another hospital or department; number of 

deaths; number with the diagnosis operated on; 

number of bed days for patients having operations; and number of preoperative bed days for 

patients having operations. Subtables of the 

same items of information in the 99 categories 

are given for each hospital department—internal 

medicine, surgery, pediatrics, and so on. Subtables are also given for each kind of department 

by county. 

In addition, tables have been published I 

which report the total number of discharges; 

discharges per 10,000 population; bed days; ‘ 

bed days per 10,000 population; and average 

length of stay for all hospitals and for shortterrn hospitaIs in the Uppsala region, in the 

Sk&e area, and in the individual counties in 

each area. These tables present utilization statistics separately for males and females for a 

detailed list of age groups: O-1, 1-4, 5-9, 10-14, 

15-19, and so on up to 80-84, and 85 and 

older.lls 

Other kinds of analyses have been done at 

times, and the unpublished data in the information bank can be used for special research purposes. The publications are in Swedish, but 

tables of contents, summaries, and texts for all 

the significant tables are also given in English. 

Other Discharge Reporting Systems 

The National Board of Health and Welfare 

has also developed a psychiatric discharge reporting system and a medical birth registration 

system. The development of a system to report 

on psychiatric inpatients preceded the collection of discharge statistics on somatic inpatients.103 NBHW was authorized to start COI-, 

letting psychiatric data in 1962. At that time 

psychiatric treatm~nt was primatily the responsibility of the National Government. In 1967 the 

count y councils took over the provision of such 

care, but NBHW still received discharge data 

directly from psychiatric hospitals until 1969, 

when the county councils took over the task of 

collecting and processing the data. The councils 

deliver information on tapes to NBHW, and an 

agreement has been reached between NBHW and 

the councils which reduces the amount of information routinely submitted.117 

The medical birth registration system ,grew 

out of the discharge reporting system for the 

.Uppsala area. When NBHW began the system, 

maternity patients were reported upon in the 

same manner as other patients. In addition, a 

separate discharge form was filled out on each 

newborn discharged from the hospitals. In 1969 

a single, distinct form was put into use to report 

44 
I on both the mother and infant. In 1973 NBHW , expanded the reporting system to cover births , occurring in all areas of the country.1 1g 

Data collection.–The psychiatric reporting 

system obtains data in two ways.119 First, when 

a psychiatric patient is discharged from a hospital, a copy of his or her record card is sent to the 

appropriate authority, which is now the county 

c&nc~L Second, information is collected about 

patients resident in psychiatric facilities on December 31. NBHW was loaned the record cards 

of the patients resident at the end of the year 

annually until 1969, but since then the information has been collected only in certain years. 

Generally speaking, all psychiatric inpatients, whether in psychiatric hospitals or in 

psychiatric departments of general hospitals, 

have been included in the reporting system. 

However, there have been some exceptions. 

Until 1967 departments for children, which accounted for approximately 400 beds out of the 

total 28,000 psychiatric beds, were not ineluded.120~llT Until 1973 mental nursing 

homes, institutions which provide care for less 

serious mental disturb ances,, were not included. 

Since then publicly owned mental nursing 

homes, containing 6,314 beds, have reported; 

but private ones , containing 2,748 beds, have 

not.]04 

In the medical birth registration system, 

statistical forms are supposed to be filed on all 

deliveries. Almost all births in Sweden take place 

in hospitals and are reported by hospital personnel, In the case of a home birth, the form should 

be completed by the medical personnel attending the birth. Studies have been done on tl-fe 

co-mpleteness of the reporting system—about 1.0 

percent of newborns, but only 0.5 percent of 

newborns who died, were not reported in 

1973.121 

Items available. –The “information collected 

on psychiatric patients is similar to that collected on the somatic patients.s7 The hospital, 

department, patient, and medical record are 

identified by number. Date of admission and 

type of admission (voluntary, court order, back 

from probationary discharge, and so on) are 

reported, as are the date and type of discharge 

(probationary discharge, to institution for mentally handicapped, to psychiatric department, 

and so on). Previous admissions in the same 

department earlier in the year are noted, as are 

age, sex, marital status, insurance fund number, 

and diagnoses. Diagnoses are coded using the 

same ICD classifications as with somatic 

patients. 

In the calculation of utilization statistics,ll g 

discharges on probation and deaths are regarded 

as discharges. Transfers to other hospitals are 

counted as discharges and new admissions, but 

transfers within a hospital from one ward to 

another are generally considered part of a single 

admission. The duration of stay is obtained by 

subtracting the date of admission from the date 

of discharge and includes time on leave and in 

family care. 

Six publications of psychiatric statistics 

have been produced by NBHW. Four are in the 

Patient statistics series: numbers 3,1 Z“ 4,] 22 

9,123 and 14.117 one report preceded the series. 

The latest report, “Psychiatric In-Patient 

Care 1973: Statistics of the National Board 

of Health and Welfare,” is in the Statistical 

reports seriesll 9 published by the National Central Bureau of Statistics. It presents information 

on the number of psychiatric discharges, number 

per 100,000 population, and mean and median 

lengths of stay. Statistics on discharges often 

exclude the number of deceased and transferred 

patients, but separate tabIes present information on the deceased. Separate statistics are also 

presented for adult patients and for children and 

adolescents. Patients in mentaI nursing homes 

are also examined separately from those in psychiatric hospitals or psychiatric departments of 

general hospitals. Discharges are reported over 

time (1962-73) and by average length of stay, 

sex, mean age, age at discharge, diagnosis, and 

type of discharge. 

In the medical birth registration system, ‘ 

numerous specialized items of information are 

collected.1 z I Attributes of mothers that are reported incIude parity, diagnoses during pregnancy, obstetric diagnoses, and operations. Characteristics reported on newborns are birth order, 

birth weight and length, gestation+ age, sex, 

whether a single or multiple birth, and any malformations, diagnoses,. neonataI procedures, or 

deaths. These items are in addition to the usual 

information: identification of the patient, department; and hospital; admission &d discharge 

dates; marital status and age of mothers. The 

45 
diagnoses are coded according to the ICD classifications. 

Statistics on births in the Uppsala region 

from 1964 to 1968 were published in 1973 in 

number 12 of the Patient statistics series.118 

More recent information from the years 1973 

and 1974 was reported in 1977 for the whole 

country in the Statistical report serieslZ1 published by the National Central Bureau of Statistics. 

The emphasis in the published materials is 

on the newborn infant and especially on perinatal mortality and factors influencing it. For 

the most part, characteristics of mothers are related to characteristics of their babies rather 

than analyzed separately. Statistics usually. reported are number of births, percent distributions of births in various categories, and rate 

per 1,000 births of various events. The average 

length of hospital stays, number of births in . 

each hospital, and births per bed are also reported. Tables report births by type of hospital-that is, by level of specialization of the 

facility–but utilization measures are not usually 

cross-tabulated by other factors. 

Attempts are under way to see if the small 

amount of social information collected on the 

birth registration slips can be supplemented by 

information from other national registers.104 

Sweden has an income register that contains information on all citizens’ taxable incomes and 

a marital register that lists family relationships 

between individuals. Census data are collected 

on education and occupation but are not available because of confidentiality restrictions. 

Aggregate Hospital Reports 

Data collection. –Before the discharge reporting systems were created, the National 

Board of Health and Welfare compiled information on Swedish hospitals from annual reports 

that the hospitals were required to submit to the 

Board. The county councils had the responsibility for collecting these reports from individual 

hospitals. The councils, along with NBHW, used, 

the information for planning purposes and to 

monitor the provision of hospital services. 

One of the advantages to the hospitals of 

the discharge reporting systems is that they replace the annual report. Hospitals that file discharge slips on all their patients receive back 

from NBHW the same consolidated lists of patients by diagnoses that hospital personnel 

themselves previously had to compile for 

NBHW. The information from the discharge slips 

is combined with data in annual reports from 

hospitals not in the discharge systems, and the 

national summaries of hospital utilization are 

compiled. These summaries report on all discharges from all Swedish hospitals-public, private, general, specialized, and long- and shortterrn. 

Items available.–National summaries of hospital statistics are published regularly both by 

NBHW and by the Federation of County 

Councils. NBHW includes the hospital data in its 

annual report, “Pubfic Health in Sweden.”ls 

The data are also published in the Statistical 

reports series of the National Central Bureau 

of Statistics in “Hospital Service Statistics.”1 Z4>1z5 The Federation presents hospital 

statistics in its so-called LKELP publications and 

in its yearbook.126 

The published statistics are usually separated 

into categories of medical short-term, medical 

long-term, surgical short-term, psychiatric, and 

a few other general and specialized categories. 

Short- and long-term units are defined in terms 

of the intensity of care offered. The categories 

are further subdivided into more specialized 

groups. For instance, surgical short-term is 

broken down into surgery, gynecology and obstetrics, ophthalmology, and otolaryngology. 

The psychiatric category separates child and 

adolescent units from general psychiatric units. 

One group of beds called “technical beds” is not 

included in the above categories. This group includes beds in postoperative, intensive care, and 

special newborn care units. 

The information on hospitalization published for each of these categories includes the 

number of beds, number of bed days, occupancy 

rates,. number of admissions, average length of 

stay, and number on waiting lists. Rates per 

100,000 population for beds, bed days, and admissions are also given. Trend data are often 

presented either by showing data from a series 

of years or by calculating indexes that compare 

statistics from 2 years when 1 year’s statistics 

are given the value of 100. For example, the 

1976 admission index fo~sychiatric care was 

46

128 when 1970 equaled 100.] 2A Statistics for 

each of the categories of kinds of care are given 

by county and region as well as for the country 

as a whole, In calculating these statistics, deaths 

are counted as discharges, and both interhospital 

and intrahospital transfers are generally counted 

as discharges and new admissions, 

Household Surveys 

A small amount of information on hospital 

use has also been collected in Sweden as part of 

the continuous Survey of Living Conditions begun in 1974 by the National Central Bureau of 

Statistics.’ The survey covers six welfare components: health, employment, housing, education, finances, and social relations. Its purpose 

is to supply information for public discussions, 

planning, and implementation of social reforms. 

The survey collects data on a representative 

national sample of the Swedish population aged 

16-74 years. Each year 12,000 persons are 

selected for personal interviews that consist of 

some 400 questions. In 1974 the nonresponse 

rate was 17 percent.127 

Data from the survey are published in the 

Living Conditions series created by the National 

Central Bureau of Statistics. The first report on 

health, “Health and Medical Care Utilization 

1974,” was published in 1976. It contains information on longstanding illness, reductions in 

functional capabilities, incidence of restricted 

activity, outpatient visits, taking of medicines, 

dental status and dental care utilization, and 

hospital use. Diagnoses are not reported. The 

tables on hospital use include data on the number of persons hospitalized in a 3-month reference period and are shown by age and sex; by 

age, sex, and socioeconomic group; and by age, 

sex, and region of the country. 

SUMMARY 

The preceding descriptions of the major 

sources of hospital utilization statistics reveal 

similarities and differences in the data available 

in six countries. In this section several aspects of 

the data are highlighted and compared from 

country to country. The major emphasis again is 

on the general hospital discharge reporting systems. The operation of the systems is reviewed, 

with special attention to the coverage of each 

and the items of information collected by each. 

The other sources of hospital statistics in six 

countries are also summarized, and the advantages they possess over the general hospital 

discharge reporting systems f?x certain purposes 

are noted. In addition, selected characteristics 

of the health services systems of each of the 

countries that can be expected to have an 

impact on hospital utilization statistics are discussed. Finally, suggestions are made on the 

basis of the findings of this study for further 

research into the status of cross-national hospital 

statistics. 

General Hospital Discharge 

Reporting Systems 

This study is limited to nationwide general 

hospital discharge reporting systems, with two 

exceptions, the Hospital Activity Analysis in 

England and Wales (HAA) and the State morbidity studies in Australia. HAA is included even 

though it is organized on a regional basis, since 

its operation is basically uniform throughout 

England and Wales, and since it is closely interconnected with the national Hospital In-patient 

Enquiry. The Australian State morbidity studies 

are described since the national discharge reporting system does not contain any diagnostic 

information on hospital inpatients. 

Almost all the discharge reporting systems 

collect individual abstracts on 100 percent of 

the hospital patients they cover. HIPE, in 

England and Wales, is an exception, collecting 

abstracts on only a 10 percent sample of 

discharges, but 100 percent reporting is done in 

the country by HAA. France’s hospital morbidity study is another exception, at present reporting only aggregated data on inpatients. However, 

individual abstracts are expected to be in use by 

1980. The French study is also the only one in 

which substantial numbers of hospitals included 

in the reporting system failed to report. 

The reporting systems have been in existence 

for varying periods of time, as is summarized in 

tabIe F. Queensland, Australia, began operating 

a State hospital morbidity study in the 1930’s, 

and England and Wales started HIPE on an 

experimental basis in 1949. However, most 

47 
Table F. General hospital discharge raporting systams in operation, by country 

Country Reporting system Agency or agencies responsible 

Au@ralia ....................................................... Medibank statistical system Health Insurance Commission 

State morbidity studies	 State health authorities and State offices 

of Australian Bureau of Statistics; in 

Victoria: Hospital Computer Service 

Canada.......................................................... Hospital morbidity study Statistics Canada and Provincial hospital 

insurance commissions 

England and Wales...................................... Hospital In-patient Enquiry Department of Health and Social 

(HIPE) Security and Off ica of Population 

Censusesand Surveys 

Hospital Activity Analysis Regional Health Authorities 

(HAA) 

Finland ..,. .,..0,...........,..........................’.O.O..... Discharge reporting system National Board of Health 

France ..........................................................	 Public hospital morbidity Ministry of Health and Social Security 

study 

Sweden ......................................................... Discharge reporting system County cwncils and the National Board 

Year begun 

1975 

1930’.s-1970’s 

1860 

II 949.1958 

1965 

1960 

1969 

1964 

of Health and Welfare 

lBewn in some areas in 1949 and reached current coverage in 19s8. 

systems were not established until the 19 60’s, 

and a few, for instance Medibank in Australia 

and the French hospital morbidity study, are 

still in the process of change and development. 

Table F also shows that a range of types and 

levels of agencies is responsible for the general 

hospital discharge reporting systems. The most 

numerous are national health agencies, which are 

solely in charge of the systems in Finland and 

France and are cosponsors of the systems in 

England and Wales and Sweden. National statistical agencies are involved in operating the 

systems in Canada and England and Wales, and 

the national Health Insurance Commission in 

Australia handles the Medibank statistical system. 

On the regional level, health agencies are 

system sponsors in some of the Australian States 

and in England and Wales for HAA. State offices 

of the Australian Bureau of Statistics are also 

usually involved in the Australian State studies, 

and in Victoria a computer service collects and 

analyzes hospital data. The Provincial hospital 

insurance commissions are involved in the Cana­

~ dian system, and the county councils in Sweden 

are systems sponsors. 

The purposes for which the reporting systems we;e ‘established were generally similar 

from country to country. The primary purpose 

usually given was to collect data to be used in 

planning and evaluation of the health services 

system. Epidemiological research and research 

into problems in the delivery of health services 

were also expected to use the data collected by 

the systems. Use of the data for administrative 

purposes was also cited in some countries as a 

rationale for the development of the systems, as 

was its use for management of hospitals or for 

clinical practices in hospitals. 

The data from the system’s have not proved 

equally useful for all these purposes. Plans for 

use of the data for management have probably 

been the least fulfilled. The length of time 

consumed by data processing has reduced the 

potential of most systems to provide data for 

ongoing management, and other problems have 

also been discovered such as the lack of sufficient detail in the data collected r‘ 1? the 

reluctance of hospital personnel to use it. Other 

difficulties have been more common in one 

system than in another. For instance, in France 

the low and varied response rate to the hospital 

48 
morbidity study has rendered it less usefuI for 

many purposes than other systems. In Finland, 

because the central data bank has been slow to 

process data and expensive to use, less research’ 

than was expected has been generated. In 

Australia, the Health Insurance Commission has 

not been able to keep up with all the requests by 

researchers for Medibank data. 

Despite the problems, a good deal of use is 

made of the data collected by most systems. 

National health agencies are usually the heaviest 

consumers of the data, making use of it for 

administration, planning, and research. Regional 

health agencies also often draw upon the data 

collected by the systems for these purposes, and 

universities and other nongovernmental groups 

have undertaken a variety of studies using. the 

data. 

The data collected by the general hospital 

discharge reporting systems are published on a 

periodic basis by every country except Finland. 

Some systems produce annual publications from 

the data collected, including reports from several 

of the State morbidity studies in Australia, from 

the Canadian hospital morbidity study, and 

from HIPE in England and Wales. Series of 

published reports have also been made from the 

data collected by the French morbidity study 

and the Swedish reporting system. Statistics 

from Medibank have been published in recent 

annual reports of the Health Insurance Commission and the Commonwealth Department of 

Health. Generally, statistics are published 2 to 3 

yeay after they are collected. 

Unpublished tables compiled from the data 

collected by the reporting systems are frequently distributed on a routine basis to those 

who participate in the systems and to other 

interested parties. Each system also maintains 

computer files of the information collected, 

from which data for individualized purposes can 

be obtained. 

The coverage of the hospital discharge reporting systems is summarized in table G. This 

information is of critical importance for crossnational use of the data from the systems. The 

inclusion or exclusion of certain categories of 

hospitals or patients in different systems can 

reni%er-comparisons of the data misleading “unless 

corrections - are made to allow for the- &fferences. A brief inspection of the table makes 

clear that there are numerous differences in the 

patterns of coverage. 

First, the extent to which the general hospitals in each country are included in the.discharge 

reporting systems is variable. Nearly 100 percent 

of the general hospitals are covered by the 

Australian Medibank system, the Canadian system, the HIPE-HAA systems in England and 

Wales, and the Finnish system. In the Swedish 

system and the Australian State systems approximately three-quarters of the general hospital 

discharges are reported. In Sweden, data on all 

the hospitals are reported in two areas, the 

Uppsala region and the Sk&e area, which 

together account for 28 percent of the population. In Australia, three State systems and the 

Northern Territory’s system cover 100 percent 

of the general hospitals. These areas together 

account for 59 percent of the population of the 

country. In France, less than 65 percent of the 

general hospital beds are covered by the system, 

and approximately half of the discharges from 

the covered hospital beds have not been reported on. The level of reporting from covered 

hospitals is less than 100 percent in all areas of 

the country; it is as low as 22 percent in one 

region and ranges to a high of 79 percent. 

Patients discharged from private hospitals 

are more likely to be excluded from the discharge reporting systems than are patients from 

public hospitals. In France and England and 

Wales no private hospitals are reported on by the 

systems. In England and Wales, private patients 

in National Health Service hospitals are generally 

excluded, as well as patients in private hospitals. 

However, together these two groups of patients 

account for only” a small percent of all the 

discharges in the country. In France the exclusion of private patients is much more important 

since they account for half of the discharges and 

have different utilization, demographic, social, 

and medical characteristics as a group than do 

public hospital patients. 

In Sweden and Australia, some private patients are included in the studies, and some are 

excluded. The Medibank system in Australia 

covers all patients in private hospitals except 

those covered by workmen’s compensation or 

other like third-party insurance. Three State 

systems in Australia cover all private hospital . 

patients; the others exclude all such patients. In 

49 
Table G. Ccweraga of ganeral hospital discharga raporting systams, by country 

General hospital patients in -

Country 

Australia: 

Medibank., ......... 

States, ............... 

Canada...,,.,.,.., ....... 

England end Walesl 

Finland .................. 

France .................. 

Sweden ................. 

General hospitals 

All approved hospitals covered. 

All approved hospitals covered in 

New South Walas, Queensland, 

Western Australia, and the Northern Territory, Australian Capital 

Territory, 93 percent covered; 

Tasmania, 72 parcent; South 

Australia, 65 percent; Victoria, 

50 percent. Country as a whole 

72 percent covered. 

Ali covered in Provinces. Not covered in Yukon or Northwest 

Territory. 

All National Fiaalth Service general 

hospitals covered. 

All covered. 

Returns from centres hospitaliers 

r%gionaux, cantres hospitaiiers, and 

h~piteux. Covarage of thase varies 

from 79 percant to 22 percant in 

different regions. 

All somatic hospitals covered in 

Uppsala ragion and Sk%e area. 

Approximately 3/4 of ail somatic 

hospital patients covered in country as a whole. 

Public hospitals 

Covared. 

All covared except in 

Victoria, 70 percent 

dischargescovered; 

and South Australia, 

70 percent hospitals 

covared. 

Covared. 

Covared. 

Approximately 1/2 

of the patiants 

coverad, 

All covered in Uppsala region and 

Sk?ma. Most are cow 

arad in other araas, 

but small hospitals 

underrepresented. 

Privata hospitals 

or beds 

;overad, with some 

;xcaptions (See 

‘othar categories”). 

Covered in New 

South Walas, Queens 

land, Wastern Australia. Not covered 

dsewhera. (Northarn 

Territory has no 

private hospitals.) 

Covarad. 

Patients in privata 

hospitals or private 

beds of National 

Haqlth Service hospitals not covered. 

Covarad. 

Not covered. 

Covarad in some 

areas but may be 

excluded in others. 

Psychiatric units 

Covarad. 

Coverad. 

Not covared. 

Not covered.z 

Not covarad. 

Not covared. 

lI+ospital In-patient Enquiry end Hospital Activity Analysis. 

@i5charge ~ePort8 from general, ~5Ychiatric, and t~berc~lous hos~it~s in Finland are ~ partof a single reporting S@3111, but Separate statistics are produced for each. Statistics concerning general hospital discharges do not include discharges from psychiatric units of 

the hospitals, which are combined with psychiatric hospital discharges, 

!30 
Tabla G. Coverage ofgeneral hospital discharge repoming systems, by country-Con. 

General hospital patients in -

Country 

Austrel ia: 

Medibank .................... 

States, ........................ 

Canada ............................ 

England and Walesl ........ 

Finland ........................... 

France ............................. 

Sweden ,.,, ,,, ,,, ,,, .,,.,, ., ...,,. 

Long-term units 

Coverad. 

Covarad. 

Convalescent units 

not coverad. 

Covered. 

I ntermediata stay 

rehebilitation, con. 

vsslescent units, atc 

covered. 

Covered. 

Othar special-care 

units 

Covered, 

Newborns not 

covered. 

10.percent sampla 01 

maternity patients 

and nawbornscovered, report on spe. 

cielized forms. 

Newborns not 

cqvered. 

Covared. 

Maternity patients 

and newborns not 

covered, reportad in 

separate systam. 

Other categories 

Hospitalizetion in 

private hospitals 

paid for by third 

parties such as work 

men’s compensation 

not covered. 

Covared, 

Uninsurad hospitalizations and hospitalizations paid for 

by third parties such 

es workman’s compensation not 

covarad. 

Some staff patients 

not covered. 

Covered. 

Patients in hospital 

and annax sections 

not covarad. 

Coverad. 

Other hospitals 

Psychiatric, Vetarans’ Affairs, and 

State hospitals providing Iong-tarm 

care not covered. Nursing homes 

not covered. 

Veterans’ Affairs hospitals not coverad. Psychiatric hospitals not covered axcept in New South Wales. 

Allied special hospitals covered. 

Psychiatric and tuberculosis hospitals not covered. Nursing homes not 

covered. 

Psychiatric hospitals not covered. 

Local authority institutions for 

long-term cara not covered. Maternity hospitals raport on a 10-percant sampla of patiants on specialized forms. 

Registered hospitals of institutions 

and patiants in hospital beds in 

heelth centers covered. Nonregistered hospitals of institutions and 

psychiatric and tuberculosis hospitals not covered. 

Psychiatric and local hospitals not 

coverad. 

Psychiatric hospitals not coverad, 

51 
Sweden, since each county council decides 

which hospitals will be part of its reporting . 

system, some may exclude private hospitals.. 

Here again, there are so few private hospit~ 

patients that their exclusion does not significantly bias the data collected. 

In Canada, a small number of patients in 

public and private hospitals, those whose hospitalizations are not paid for by the national 

hospital insurance, are excluded from the reporting system. Almost all the population is 

covered by the insurance, but hospitalizations 

paid for by workmen’s compensation and those 

of the Canadian Forces, the Royal Canadian 

Mounted Police, and inmates of Federal prisons 

are excluded. 

Some public hospital patients in Australia, 

France, and Sweden are also excluded from the 

discharge reporting systems. Victoria, Australia, 

does not cover 30 percent of its public hospital 

discharges, and in South Australia, 30 percent of 

the public hospitals did not report data on their 

patients in a recent reporting year. In Sweden, 

some county councils chose not to cover all 

public hospitals, and the smaller public hospitals 

are generally the ones left out. In France, the 

small public local hospitals are all excluded from 

the ‘study, and, as previously mentioned, only 

half the discharges from the covered public 

hospitals are reported on. The highest-level 

teaching hospitals tend to be somewhat underrepresented among the hospitals covered by the 

French study. 

Within the general hospitals covered by the 

discharge reporting systems, certain categories of 

patients are not always reported on. The category most often excluded is that of patients in 

psychiatric units; reporting systems in all four of 

the European countries examined exclude these 

patients. However, the systems in Canada and 

Australia include the discharges from psychiatric 

units, and the New South Wales morbidity study 

includes data on discharges from psychiatric 

hospitals as well. Since psychiatric patients tend 

to be hospitalized for longer periods than 

patients with somatic problems do, their inclusion could confound such cross-national comparisons of the hospital utilization statistics as 

number of bed days per population and average 

length of_st~y. .—.—.. ‘– Also of irnpo~~=c;” f=-fi;rnatlonal cornparisons is the handling of data on maternity 

patients and newborns. Healthy newborns are 

not reported as discharges in the Australian 

State studies, the Finnish reporting system, or 

the Swedish reporting system. Sweden operates 

a separate birth registration study to gather 

information on newborns and their mothers, 

who are also excluded from the general hospital 

discharge reporting system. In England and 

Wales, data on maternity patients are also 

handled separately from discharge data on other 

NHS patients. Special reporting forms are used 

to gather information on the maternity patients 

and newborns, and only a 10 percent sample of 

maternity patients is examined. In Canada, 

information on newborns is gathered in the 

hospital morbidity study but is analyzed and 

reported separately from data on children and 

adults “discharged from”hospitals. In France, data 

on maternity patients are often presented separately from other discharge data. 

The extent to which long-term patients are 

covered by the reporting systems is extremely 

important to note when the data are used for 

cross-national comparisons. It might be assumed 

that since general hospitals are primarily for 

acute care, all general hospital discharge reporting systems would cover acute patients almost 

exclusively. Such is not the case. Though shortterm patients account for the majority of the 

hospital discharges in every system, the proportion of long-term, patients covered varies significantly from country to country, and the variation has an appreciable effect on the utilization 

statistics reported by the systems. 

The reporting system in Australia includes 

only a small number of long-term patients. 

Though the psychiatric units and geriatric units 

located in general ,hospitals are included in the 

systems, these units account for only 6 percent 

of the hospital beds covered by the reporting 

system.24 Nursing homes and State hospitals 

providing long-term care are excluded from the 

systems. If a 3O-day stay is used as the criterion 

by which to define a long-term patient, 4 percent of the discharges covered by the Medibank 

study in the 1976-77 reporting year were longterm. The average stay of all patients covered by 

the study in that year was 8.3 days.zs 

In Canada the patients covered by the hospital morbidity study had an average length of 

I


52 
stay of 11.1 days in 1975.s2 However, included 

in this figure were patients in psychiatric and 

other long-term units of general hospitals and 

the long-term patients in the allied special hospitals. The beds in long-term facilities account for 

24 percent of all the beds covered in the 

study.14 If the 30-day stay is used as the criterion for defining long-term patients, 5.5 percent of the discharges covered in the study in 

1972 were long-term patients.128 The hospital 

morbidity study does not separate statistics on 

long-term patients from statistics on shortterm patients, but from the annual reports it was 

learned that if the patients on short-term wards 

had been considered separately, their average 

length of stay would have been 8.8 days, 

In England and Wales, the HIPE and HAA 

studies exclude the long-term patients in convalescent and psychiatric units of National Health 

Service hospitals, but they cover patients in geriatric units and units for younger disabled patients. These units account for 22 percent of 

the beds covered by the studies, and the patients 

in them accounted for 4 percent of the discharges in 1974.17 HIPE and HAA do not make 

distinctions between long- and short-term patients, but data from the annual reports revealed 

that the average length of stay in nonpsychiatric 

NHS hospitals was 12.9 days in 1976 if the geriatric and younger disabled patient units were included. If they were excluded, the average 

length of stay was only 9.5 days. 

Finland’s reporting system covers longstaying patients in general hospitals, health centers, and registered hospitals of institutions. One 

study found that 24 percent of the beds in:general hospitals were used for patients staying 30 

days or more and that 50 percent of the beds in 

hospitals of institutions contained long-term patients.1 G Statistics are available from the Finnish 

reporting system that exclude hospital of institution patients, and these statistics gave the average length of stay as 11.6 days for 1975.85 If 

the hospital of institution patients were included, the average stay would be approximately 

14.0 days? 

In France, patients in psychiatric units of 

general hospitals and in the hospital annex section are excluded from the public hospital morbidity study, but patients in intermediate-stay 

units such as rehabilitation and convalescence 

units are covered. In 1974 these units accounted 

for 11 percent of the beds covered, 12 percent 

of the bed days, and 2 percent of the admissions. The morbidity study does not separate 

data on long- and short-term patients, but data 

from the annual reports can be used to estimate 

the impact of the long-term patients on the morbidity study statistics. Patients in the shortterm units covered by the study had an average 

length of stay of 12.2 days in 1974, but patients 

in all units covered averaged 13.7-day stays.10 

The Swedish discharge reporting systems 

cover long-term patients in general hospitals and 

long-term hospitals. Some of the published statistics from the Uppsala and Sk&e areas separate the long- and short-term hospitals. In those 

areas the long-term hospitals account for 39 percent of the beds covered and, in 1973, 43 

percent of the bed days and 4 percent of the discharges. They averaged a 160 J-day length of 

stay in 1973 while the short-term hospitals averaged 11.0 days.11s The short-term average still 

includes a sizable number of long-term patients 

cared for within the general hospitals. NBHW reported in its public heaIth publication that the 

average stay of patients in general hospitals is 

9.9 days when chronic care units are excluded. 

As well as the coverage of the discharge 

reporting systems, it is important to be aware of 

the kinds of information collected by each 

system. Table H gives a list of the items of 

information collected in the United States Hospitzd Discharge Survey and shows which of them 

are collected by the reporting systems in the six 

countries. 

Some items are common to all of the 

systems. The reporting hospital is identified in 

every system, and the patient is identified by 

name or number or both in every system except 

France;s public hospital morbidity study, which 

will begin doing so in the near future. The length 

of stay of each patient and whether he or she 

was discharged alive or dead is given in each 

system. The sex and age of patients is also 

always reported. In France patients are presently 

reported in grouped age categories, but by 1980 

hospitals will be reporting the date of birth of 

each individual patient. 

Diagnostic information is reported for patients in every system except Medibank, but the 

extent of it varies from the report of 1 diagnosis 

53 
Table H. Whether or not selected items ere col[ected by general hospital discharge reporting eystems, by country 

,+ — 

Country 

Austrdlw 

Modlbmsk ,,,,,,,..,.,,.,.,.,.,,,.,,, 

states ,,,s,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 

Cande2 ,,,, !,,, !,.,...,., .............0.0 

England and Wal@s3.,,.,,.., ........ 

Finland ,,,,...,., .......................... 

Franoe: 

During present study .......... 

Projected for 19S0 ............. 

%wlen., ............................o..o.. 

ldmmiflcs- Idcntlf Ica. 

tion of tlon of 

hOQitd patiant 

Yos Yas 

Yas Yas 

Yes Ya9 

Ya9 Yas 

Yas YES 

Yas No 

Yes Yes 

Yes Yes 

-1- Yes Yaa Yaa Yms Yss No No No 

Yes Yas Yaa Yes Yes 7yas Yes Yadl-10) 

Yes Ya: Yes Yas Yas No No Yas(2) 

Ye: Ya8 Yes Yes Yas No Yas Yale) 

YS4 Yas Yes Syss Yes No 8fJ0 Yas(3) 

4No 4N0 Yes 6Yas Yes No No Yes(l) 

Whethar Date of Date of Date of dl$ahmwd Maritd 

odmlsdon discharge dive or birth Sax Raw status Diagnoses 

or 822 d6sd — 

Yes Yes Yes Yes Yes No No Yes(l) 

Yes Yes Yes Yes Yes No Yes Y6S(B) — 

Owrations 

No 

Yedl.8) 

Ya8(2) 

Ya:[4) 

fiNo 

No 

No 

Yeme) 

lList ta~n from U.S, NIJHS H@t~ Di~harge Suwey+fedical Abstrsct. see reference 128. 

2BSS1C item reported to Statistics Canada by Provinces.


31tems ~olle~:ed by the HO~pit~ In.paflent Enquiry and the Ho6pital Activity ,%ldyd&


4Agmegate bed days ~epo~ed by each hospital for each diagnosis, 

%rcluded in rmtient identification number. 

6Groupod. -

?Race given in New South WaIes, South Australia, Western Australia, and the Northern Territory. 

8Dropped in 1975. 

in the French system and some Australian State 

systems to the ability to report up to 8 

diagnoses in Sweden and 10 in South Australia. 

Information on operations experienced. by patients may or may not be collected. Medibank 

and the systems in Finland and France do not 

report on them, but the other systems report at 

least one operation and usually more if applicable. 

Race and marital status are the least likely to 

be reported in the systems. The race of patients 

is not noted anywhere except in some State 

systems in Australia that obtain information on 

whether patients are Aborigines. The marital 

status of patients is available in the Australian 

State systems, HIPE and HAA in England and 

Wales, and the Swedish system; but Medibank in 

Australia, the Canadian system, the Finnish 

system, and the French system do not report it. 

The discharge reporting systems also gather 

various other items of information. The address 

of each patient or some other information on 

the area of residence of each is available almost 

everywhere. The country of birth of patients “or 

their nationality is reported in Australia by the 

State systems and in Engludand Wales. Nationality will be added to the French system by 

1980, The occupation of discharges is noted by 

most of the Australian State systems. Certain 

high risk occupations are also recorded in 

Ffiland, ”and the socioprofessional category of 

patients and of the head of the household of 

which the patients are a part will be recorded in 

France’s system in the future. Information 

about other social characteristics of patients 

such as the educational level, family size, length 

of residence, and religion, which may be important in assessing the functioning of the health 

services system, are not’ collected by these 

systems. 

Other items of information besides those 

listed in the table are also reported. Admissions. 

and discharges that are transfers are often 

identified. The type of accommodation patients 

had and whether they paid extra for privacy or 

other privileges in the hospital are also reported 

in several systems. The external cause of accidents is usually reported when applicable. Less 

frequently, the physicians who admitted or 

treated the patient are identified. Other items, 

including cause of death, whether or not an 

autopsy was done, anesthesia used during operations, and time on the waiting list before 

hospitalization, are also reported in a few 

systems. 

The types of personnel who complete the 

54 
I 

I


I discharge forms and, especially important, who


choose the diagnoses to be reported, their order 

I and the codes for them, vary as much within 

1 countries as they do between countries. Sometimes clerical personnel of hospitals complete 

I the forms; in other cases medical personnel– 

from nurses to the physicians who head hospital 

I departments–are in charge of them or are 

I	 responsible for filling out parts of them. Some 

of the larger hospitals code the forms themselves; others send the forms to local, regional, 

or national authorities for coding. Little infor­

!	 mation is available on the accuracy with which 

forms are comdeted and coded: and the studies 

which have b~en done, prima~ly in England, 

tend to be contradictory. -

The definitions of the principal or first 

diagnosis that are supposed to be followed by 

those who complete the forms are given in 

table J. Most are similar, referring to the main 

disease treated or studied during the hospital 

stay as the principal diagnosis. Some variation is 

known to exist in coding practices in different 

Provinces of Canada and in France, where the 

admitting diagnosis or the condition that re -

quires the most medical resources is sometimes 

reported in spite of instructions to the contrary. 

The eighth revision of the International 

Classification of Diseases is used at present 

(1978) to code the diagnoses in each system. In 

Finland and Sweden, a special five-digit adaptation of ICD-8 is used, which is comparable but 

more detailed. Alberta, Canada, started using 

the second edition of the Hospital Adaption of 

the International Classification of Diseases 

(H-ICDA) in 1974. It cannot be translated 

perfectly into ICDA-8. Most countries are 

making plans to begin using the ninth revision of 

the International Classification of Diseases in the 

next few years. 

The definition of the principal operation to 

be reported is generally the most important one 

related to the principal diagnosis. Canada uses 

the International Classification of Diseases codes 

to record operations, but Australia, England and 

Wales, and Sweden use the coding system developed by the General Register Office (now the 

Office of Population Censuses and Surveys) in 

England. or an adaptation of it. 

The discharge reporting systems also differ 

I 

Tabla J. Coding of diagnosas in ganaral hospital di ‘charge reporting systems, by country 

Country 

Australia (Stata studias) ,,.,,,,,,,,.,,,.,,.,,,, ............................


Canada .....................,...,,.,,.,.,,,.,.,,, ...................................


Finland ..,.........................................................................


Fra~a.,,,,.,,,,,,,,,,...,,,,,,,,.,,,,,,,,.,,,,,,,.,,,:,,,,..,.,..,,,,.,.,,,.,...,..


Swadan ............................................................................


I 

Coding of diagnokea 

Definition of principal diagnosis coded 

Disea& or injury which best characterized the 

period of hospitalization. 

In scma Provinces, tha condition which required the most madical resources. In others, 

the condition that precipitetad the admission 

to tha hospital. 

Specific or principal condition traatad 

during hospitalization or found to be tha 

underlying cause immediately raspcnsible for 

tha patient’s symptoms. 

Main raason for being in the hospital at the 

tima. 

Principal disease traated or studiad during 

hospitalization. 

The condition the investigation or traatmant 

of which was the main cause for keeping tha 

patiant in the hospital. 

Coda usad 

ICD-8 

I CDA-8, excapt in Alberta, 

which used H-ICDA 

ICD-8 

ICD-8, adapted in Latin 

and Swedish (fiva-digit 

codas) 

ICD-8 

ICD.8, adapted in Latin 

and Swedish (five-digit 

codes) 

55 
in some of the procedures they use to calculate 

utilization statistics from the data they collect. 

One important difference is in how they handle 

transfers. In all six countries a transfer from one 

hospital to another is considered a discharge and 

a new admission, but in some systems transfers 

from one service to another within a single 

hospital are also counted as discharges and new 

admissions. This is generally the case in Sweden. 

In France hospitals are instructed to consider 

intrahospital transfers as part of one admission, 

but approximately half still report them as 

discharges and new admissions. In Canada transfers from an active treatment unit to a chronic 

long-term care unit within a single hospital are 

considered discharges and new admissions, but 

other intrahospital transfers are counted as part 

of a single admission. 

A few of the systems differ in their treatment of inpatient stays of less than 1 day. In 

HIPE in England and Wales these stays are 

counted as using O bed days, and the Australian 

State systems count such stays as using 0.5 bed 

day, but Medibank and most other systems 

either count them as 1 bed day or count the 

admission and dk+charge day together as 1 day, 

which works out the same. Most systems calculate average length of stay by dividing the 

number of bed days used by patients discharged 

during the reporting period, including bed days 

which fell before the period, by the number of 

discharges. The Medibank system also obtains a 

bed-day count on all patients in the hospital 

during the reporting period whether or not they 

have been discharged, but this count excludes 

the discharges’ bed days that occurred before 

the reporting period began. In France some 

hospitals report only the discharges’ bed days 

that occurred in the reporting period, and others 

add the number of patients in the hospital on 

the last day of the reporting period together 

with the number of discharges that took place 

during the period. All systems count deaths 

together with other discharges when calculating 

statistics. 

Since the general hospital discharge reporting systems have all these differences, it might 

be thought that it is simply not possible to use 

them as a source of data for cross-national 

research. That conclusion is hardly justified. 

Indeed, the systems have much potential for 

comparative research, providing a wealth of 

similar and detailed data on the majority of 

general hospital patients in every country except 

France. It is because they have this potential 

that the variations between them have been 

discussed in such detail. Once the differences are 

understood, ways to adjust the data to take 

them into account can be devised. 

Sources of Utilization Statistics in 

Addition to’ the General Hospital 

Discharge Reporting Systems 

Other sources of hospital statistics also exist 

in each of the six countries. They are listed in 

table K. For some purposes, these sources may 

be preferred to the general hospital discharge 

reporting system, or researchers may need to 

combine information from them with data from 

the general hospital discharge reporting systems. 

The other dischtige reportti-g systems cover, 

with a few exceptions, patients excluded from 

the general hospital reporting systems. In Australia data from Veterans’ Affairs hospitals are 

included in the reports made by some of the 

State morbidity studies, and patients in psychiatric units may be reported to both the State 

morbidity studies and the State psychiatric 

studies. In Canada, too, psychiatric patients in 

general hospitals are reported to both the 

hospital morbidity study and the psychiatric 

discharge reporting system. In every country, 

the psychiatric discharge reporting systems are 

the primary source of data on psychiatric 

inpatients. In Sweden information about maternity patients and their babies must be obtained 

from the Medical Birth Registration, and in 

Finland and Canada information on patients in 

tuberculosis institutions must be gathered from 

the separate studies covering them. 

These reporting systems usually follow procedures similar to the general hospital reporting 

systems, and they collect similar items of information with some deletions and additions specific to the patients they cover. The systems 

covering the same kinds of patients are more 

comparable in coverage from one country to the 

next than are the general hospital discharge 

reporting systems, but certain factors still need 

to be noted when using the data from them for 

cross-national comparisons. For instante, when 

56 
I


Table K, Sources of hospital utilization statistics in addition to tha general hospital discharge reporting systems, by country 

I 

I Country 

~ Australia ................i.......................... 

Canada,,,,,,, ,,...,,,.,.,,,,, ,,,.,...,,,, ,0,..!.... . 

England and Wales............................ 

Finland,.,.,,..,,,,,.,,,,,,,,,,,,,,,,,..,,,,.,.,.,.. 

France ..,,,..,,.,.,.,.,,.,,. ........................ 

l-Th~ psychiatric and t~barc”losirj 

hospitals.- ­

Discharge reporting systems other than the 

general hospital discharge 

raporting ayatam 

Stata psychiatric systems 

Vatarans’ Affairs hospital 

system 

Psychiatric system 

Tuberculosis systam, 

Psychiatric systam 

Psychiatric systam 1 

Tulxwculosis ~ystam 1 

Psychiatric system 

Psychiatric system 

Medical Birth Registration 

~y~teyns are actually subsections 

Studias of hospital use 

Aggregate hospital reports 

National survay of hospitals in 1972 by 

Hospitels”and Haalth Sarvicas Commission 

National reports COIected f rom public 

hospitals since 1971 annually in the 

Hospital and Alliad Services Advisory 

Council 

Raports collected by Statas annually 

Annual raports collected since 1930’s by 

Statistics Canada and Health and Welfare 

Annual hospital raturns collected since 

194S by tha Department of Haalth and 

Social Security 

Annual hospital raturns collactad by tha 

National Board of Haalth nationwide 

since 1963 

Annual raports collacted by the Finnish 

Hospital League from communal 

hospitals 

Annual quastionnairas on facilities and 

use COIactad by the Ministry of Haalth 

from public hospitals since 1961 and 

from private hospitals in 1962, 196S, 

1972, and annually thereafter 

Aggregata raports collectad annually 

from hospitals not involvad’in general 

hospital discharge reporting system by 

county councils and tha National Board 

of Health and Welfare 

of the single discharge reporting !3@eISl 

Housahol’dsuweys 

National Health Suwey 

begun in 1977 

Suwey undertaken in 

1950-51 and 197S 

Continuous Genaral 

Household Survay 

begun in 1971 

Survays in 1884, 1888, 

and 1976 

Suwey undertaken in 

1970 and a suway 

presently under way 

Continuous Suwey of 

Living Conditions 

bagun in 1974 

that Sk?O CoVOra gOSlOrd 

comparing psychiatric data, whether or not the 

psychiatric systems cover institutions for the 

mentally retarded needs to be ascertained. The 

degree of development of alternative psychiatric 

care facilities in each country should also be 

examined. 

The collection of aggregate hospital reports 

preceded the development of discharge reporting 

systems in most countries, and the reports 

continue to be submitted annually by the 

general and specialized hospitals in each country. In Australia the national Hospital and Allied 

Services Advisory Council has collected annual 

reports from public hospitals since 1971, and a 

survey was done of all the hospitals in every 

State but Victoria in 1972. The Australian 

States also collect reports from hospitals annually, but again only public hospitals are included. In France both public and private 

hospitals submit annual reports to the Ministry 

of Health and Social Security, but somewhat 

different information is collected from each, and 

57 
most of the data from the two sets of reports tie 

analyzed and reported separately. 

In Sweden annual reports are submitted by 

some hospitals to the county councils, which in 

turn forward them to the National Board of 

Health and Welfare. The hospitals that take part 

in the discharge reporting system, however, no 

longer have to file these reports. All the hospitals in Canad,a and Finland and all the National 

Health Service hospitals in England and Wales 

make annual reports on their facilities, use, and 

personnel in addition to their pa~ticipation in 

discharge reporting systems. Only one nongovernmental agency, the Finnish Hospital League, 

is involved in the collection of reports, and 

the National Board of Health in Finland duplicates most of the information the Hospital 

League collects in its annual reports. 

The information in the annual reports is not 

as detailed in the area of characteristics of 

individual hospital inpatients as are the discharge 

reporting systems, but the reports have some 

advantages. Most include information on outpatients treated by hospitals, the number ,and 

distribution of beds in different hospital depart: 

ments, the numbers and kinds of hospital 

personnel, aggregate reports of use of such 

hospital services as laboratory tests and X-rays, 

and the financial aspects of hospital operation. 

The information allows study of such things as 

the cost of a patient day, the average number of 

laboratory tests per admission, and occupancy 

rates. 

Other advantages are specific to certain 

countries. For instance, in Canada the annual 

reports, unlike the hospital morbidity study, 

separate utilization statistics on long- and shortterm patients; and statistics from the annual 

reports are available for a considerably longer 

period of time than are those from the discharge 

reporting system. In England and Wales the 

annual reports are the only source of data that 

go back to the beginning of the National Health 

Service and that cover all patients in all NHS 

hospitals–the psychiatric and maternity hospitals as well as others. In Finland data from 

annual reports, unlike the data collected by the 

discharge reporting systems, are regularly published; and the reports cover all hospitals– 

psychiatric and tuberculosis hospitals, registered 

and unregistered hospitals of institutions, health 

centers, and general hospitals. In France the 

annual reports are completed by almost all 

hospitals, including the local hospitals excluded 

by the discharge reporting system. Hospitals 

report on their annex sections as well as on their 

short- and intermediate-stay sections, and more 

utilization statistics are published from these 

reports than are published from the discharge 

reporting system. In Sweden hospitals in all 

areas of the country are included in the summaries made from the annual reports and the 

discharge reporting system data, and more recent statistics are published from these combined sources than from the discharge reporting 

system alone. 

Household surveys also collect information 

on the hospital utilization of a national sample 

of patients in each country. In England and 

Wales and Sweden continuous household surveys 

collect data on many aspects of the welfare of 

the populations, including health data. In 

France, Finland, Canada, and Australia household surveys examining the health and health 

services utilization of the populations are either 

in progress or have recently been conducted. 

The surveys are not primarily concerned with 

hospital use; usually only a few questions about 

hospital use are included, and the published 

reports from the surveys usually contain only a 

brief discussion of and a few statistics on 

hospitalizations. Because the samples for the 

surveys do not include persons in hospitals or 

other institutions, the extent of hospital use is 

underestimated in them. However, the surveys 

do contain much information about the social 

characteristics of patients, including data on 

their economic status that is not available 

elsewhere. They are also a source of personoriented rather than visit-oriented data. Detailed 

analyses of hospitalizations are not often done 

at present except for the reports from the 1970 

survey in France in which the social characteristics of hospital patients were analyzed. Still, the 

potential vaIue of the surveys should not be 

overlooked. 

Health ServicesSystems 

In addition to understanding the statistical 

systems-. that gather hospital utilization data, 

58 
I those who intend to use h“ospital data crossnationally must have some kowledge of the 

health services systems in operation in the 

~ countries thev com~are. There needs to be an 

awareness of ;he relationships between hospitals 

and the other health services in each country 

and of other aspects of the health services 

systems that affect the rate of hospital use. 

Therefore, in this section certain characteristics 

of the health services systems in the six cotmtries studied will be examined. The discussion is 

not intended to be a comprehensive description 

of health services systems in any of the countries 

but rather will concentrate on selected characteristics that are expected to have an impact on 

the hospital utilization statistics. 

First of all, since chronic patients can have 

an important effect on hospital statistics, further 

attention will be given to the long-term care 

facilities available in each country and to the 

separation of long-term care from hospital care. 

Second, the patterns in the provision of ambulatory care will be examined. The availability of 

physicians and the separation between physicians providing inpatient care and those providing ambulatory care will be discussed, as will the 

availability of other kinds of health personnel 

and of programs for ambulatory care. Finally, 

the financial incentives or disincentives for 

hospitalization in each country will be explored. 

The number of beds per population in 

nursing homes and other similar institutions for 

long-term care were given in table C for each 

country. It was seen that Finland and France 

had the most beds, 6.7 per 1,000 population, 

Canada the next highest with 6.2, Australia with 

4.0, Sweden ,tith 3.7, and England and Wales 

with 3.4. It must be noted that these figures 

refer to only approximately equivalent beds. 

Often the level of care given by nursing homes 

and equivalent facilities is difficult to distinguish 

from the care given in long-term units of 

hospitals or in long-term hospitals. On the other 

hand, in many countries residential institutions 

that provide little if any medical services are not 

separated from nursing homes either. 

In Australia, general hospitals have long 

sought to exclude patients requiring chronic 

care,24 Separate institutions for chronic patients 

had been built in the cities earlier on. Some specialized in specific diseases such as tuberculosis 

or mental illness while others admitted patients 

with a variety of long-term illnesses and disabilities. Nursing homes were introduced to provide 

care for chronically ill aged persons. These 

homes have existed in Australia for many years 

but have been growing in importance and number since the Second World War. This does not 

mean that a complete separation of long- and 

short~term care exists. Outside the urban areas it 

has not been possible to build separate inpatient 

institutions for different types of patients, and 

so the small rural hospitals treat chronic as well 

as acute patients. Furthermore, where nursing 

homes exist, they are often not well distributed, 

making transfers difficult and resulting in some 

of the chronically ill remaining in general hospitals for long periods. 

In Canada, besides hospitals, there are nursing homes, hostels, and homes for the aged. In 

the past these institutions were quite limited in 

number, but over the past decade the number of 

beds in them has been rapidly expanding.zo The 

number of beds in long-term hospitals also began 

increasing in the 1960’s, but by the mid-19 70’s 

their growth had leveled off.] 28 Even with the 

expansion, most beds in long-term institutions 

are filled, and some chronically ill and aged persons are left in acute hospitals for lack of alternative facilities.58 } In England and Wales the term “nursing 

home” refers to a private institution that provides care for convalescent patients who can 

afford the fees.130 These nursing homes are not 

numerous, and most of the chronically ill cannot afford to stay in them. Local social service 

authorities provide most of the accommodations for the chronically ill and elderly. They 

license private and voluntary residential facilities and directly administer old-age homes. The 

number of places in these facilities has been 

growing for the last 20 years, and in some areas 

they are now sufficient to meet the needs of the 

chronically ill. In other areas, however, there 

is still a shortage. 

In Finland, over half of the care of chronically ill patients takes place within the general 

and specialized hospitals.16 The remainder is 

provided in public and private retirement homes 

and other social welfare institutions. The coordination between the social welfare institutions 

and the health institutions has been problematic 

59 
in the past,l ~1 making movement of patients between them difficult in many cases. 

In France many public hospitals have hospice sections that house chronically ill and 

elderly people, but these are not considered part 

of the hospital system of the country. They are 

categorized together with private retirement 

homes and independent public hospices that 

provide care for similar people. Within the hospital system there are geriatric units that also provide care for the elderly. 

Finally, in Sweden, the chronically ill may 

be cared for in a variety of institutions. Approximately 20 percent of the ,beds in general hospitals provide chronic care, usually in geriatric 

units.130 Small cottage hospitals and nursing 

homes are almost entirely devoted to the care of 

the chronically ill, and there are separate nursing 

homes for the care of chronic psychiatric patients. Homes for the aged are also numerous, 

but since only about 5 percent of their beds are 

used for the chronically ill, they were not included in the bed-to-population ratio. All facilities for long-term patients have been growing 

rapidly in the last two decades. 

These brief descriptions make clear that in 

none of the six countries are hospitals, even the 

geheral hospitals, devoted entirely to acute patients. In addition to the units specifically designated for chronic care, chronic patients often 

remain in acute hospital beds because insufficient long-term facilities are available or because 

there are difficulties in transferring patients to 

the existing facilities. However, it is also evident 

from these and earlier remarks that the proportion of long-term patients in hospitals and the 

extent to which acute patients can be separated 

from long-term patients vz+riesgreatly between 

Australia, where the separation appears most 

marked, and Finland, where it appears least 

marked. 

The ratio of physicians to the population 

also varies from country to country. England 

and Wales had the lowest ratio, 13.1 physicians 

per 10,000 population in 1974. It was followed 

by Australia with 13.9 physicians per 10,000 

(1972) and France with 14.7 (1975 ).6 In Finland, the number of physicians has been growing 

rapidly; the physician ratio there was 13.3 per 

10,000 in 1974 but reached 16.2 per 10,000 in 

1977} Canada’s ratio was higher, 17.1 physicians per 10,000 in 1975,6 and in Sweden, 

where there has also been a rapid increase in the 

number of physicians, there were 18.0 physicians per 10,000 in 1975.18 

The percent of physicians who are general 

practitioners is decreasing in alqost every country. France is the only country where over half 

of the physicians, 57 percent in 1973,22 are still 

in general practice. In Finland, approximately 

50 percent were general practitioners in 1976? 

and this was also the case in Canada. In Canada, 

however, many general practitioners concentrate 

their practices in single medical disciplines.z” 

In Australia, 44 percent of physicians were general practitioners in 197222; in England and 

Wales, 35 percent were general practitioners 

in 19731~z; and in Sweden only 12 percent of 

physicians remained in general practice in 

1969.22 

In Australia and Canada most physicians, 

general practitioners and specialists, are in private practice. They provide ambulatory care and 

usually follow their patients when they are 

hospitalized. Approximately one-third of Australian physicians and one-fourth of Canadian 

physicians are employed by hospitals and primarily provide inpatient care. They may, however, also see ambulatory patients in hospital 

outpatient clinics. 

In the other countries, ambulatory and 

inpatient care are more likely to be provided by 

separate physicians. In England and Wales, general practitioners provide only ambulatory care 

for the most part, though there are some 

exceptions. General practitioners in rural areas 

usually follow patients in the small Iocid hospitals, and approximately one-fourth of the general practitioners in urban areas do some parttime hospital work. However, most inpatient 

care is provided by specialists employed by the 

hospitals. These specialists see some ambulatory 

patients in hospital outpatient clinics, and some 

also maintain part-time practices in which they 

see ambulatory patients. In addition, a small 

number of physicians not affiliated with the 

National Health Service provide ambulatory care 

and follow patients in the private hospitals. 

In France, a similar pattern exists in the 

provision of physician services. About 70 percent of French physicians, general practitioners, 

and specialists are in private practice, and they 

60 
concentrate on ambulatory care services. As a 

rule they cannot follow their patients when they 

are admitted to public hospitals. The public 

hospitals are staffed by physicians employed by 

the hospitals who provide inpatient care. Again 

though, there are exceptions. Since local public 

hospitals do not have staff physicians, general 

practitioners in the rural areas provide the inpatient care in them. Also, some 40 percent of 

private physicians, mostly specialists, do parttime work in the other public hospitals. In 

addition, private physicians can admit patients 

to private hospitals, and physicians employed by 

public hospitals provide some ambulatory care 

in outpatient departments of the hospitals. 

In Finland and Sweden, the majority of 

physicians are employed by the hospitals. In 

addition to hagdling inpatient care, these physicians provide a significant amount of ambulatory care. In Sweden, half of all ambulatory 

visits take place in outpatient departments of 

hospitals. In Finland, in addition to visits to 

outpatient hospital departments, 60 percent of 

the hospital-based physicians conduct private 

practices in which they see ambulatory patients. 

About 10 percent of the beds in general hospitals are reserved for these doctors to admit their 

private patients. Generally, however, the same 

physician who treats the patient outside of the 

hospital will not follow the patient in the 

hospital. 

Ambulatory care in Finland and Sweden is 

also provided by medical officers employed by 

local authorities. In Sweden, district medical 

officers account for 30 percent of ambulatory 

care. Most officers are general practitioners. 

Over half work in health centers alongside 

specialists and other general practitioners. In 

Finland, local health officers supervise local 

hospitals and, more recently, the health centers 

in addition to providing ambulatory care. Only a 

small number of physicians in either country 

engage in full-time private practices, and these 

practices are limited almost entirely to ambulatory care. 

The effects of these patterns in the provision 

of physician services on the utilization of hospital services have not been sufficiently studied. 

However, certain hypotheses are suggestive. For 

instance, the employment of most physicians in 

hospitals could be expected to increase the 

emphasis on hospital care. If the hospital-based 

physicians do not usually foIlow the same 

patients on an ambulatory basis, the length of 

stay of inpatients could also be expected to be 

higher since physicians would be expected to 

take extra precaution that the patients had 

recovered before severing contact with them. 

When most physicians provide ambulatory care 

and follow their patients in the hospital, admission rates might be expected to be higher than in 

systems where ambulatory-care physicians do 

not have admitting privileges; but the length of 

hospitalizations would be expected to be 

shorter, since supervision of the patient does not 

cease upon discharge~ Physicians who provide 

only ambulatory care might have an incentive to 

refer patients to hospital physicians under the 

cavitation system of payment in England and 

Wales in which a single fee is paid to the 

physician per person per year regardless of the 

amount of care given, but ambulatory care 

physicians who are paid on a fee-for-service basis 

as in France would be expected to be more 

reluctant to refer patients. 

The availability of other types of medical 

and supportive services can also be expected to 

have an impact on the use of hospital services. 

Nursing services provided outside of hospitals 

and other home-help services are important in 

this respect, and each of the countries has 

developed some of these services. 

In England and Wales, Finland, and Sweden 

local authorities have long employed public 

health nurses to provide ambulatory care and 

home nursing. The nurses have been responsible 

for a wide range of primary care services, 

especially in rural areas where fewer physicians 

have been located. A sizable number of midwives also have been employed in these countries by local authorities. They are not usually 

involved in home deliveries since almost all 

births take place in the hospitals, but they 

handle much of the prenatal care. 

In England and Wales local authorities in 

many areas have well-developed programs for 

other home-help services. Domestic help, shopping assistance, night sitting, laundry services, 

and hot meals are among the services provided. 

In Finland, the health centers and community 

social welfare agencies have cooperated in the 

organization of home-help services. Some local 

61

parishes also employ deaconesses–religious sisters with nurses’ training–to provide home-help. 

In all three countries, attention is being given to 

the expansion of home-care services. 

Canada and Australia do not have as well 

established or widespread programs for ambulatory nursing services and home care, but interest 

in these types of programs is high and many are 

now being started. In Canada, in addition to the 

development of home-help services, some hospitals have initiated partial care services, such as 

day surgery, for ambulatory patients to reduce 

hospital use. In Australia, some voluntary organizations have been operating home nursing programs for years, and many of them are now 

being expanded. In addition, government home 

nursing and home-help programs have begun in 

recent years. For example, in Western Australia 

a Community Health’ Services Nursing Service 

was established in 1971 to cover underprivileged 

areas of the State. 

In France there appears to be the least 

development of public health nursing and 

home-help services. While some services do exist, 

they do not provide an alternative to hospitalization for many French patients. It should be 

noted, however, that French physicians continue 

to make many house calls on their patients, 

which is not common in the other countries. 

The way in which hospitalization and other 

health services are financed, and especially their 

cost to the patient, may encourage or discourage 

hospital use. The six countries use a variety of 

procedures to finance health services. In England 

and Wales, most services are paid for by the 

national government. In Finland the national 

government is responsible f or the largest share of 

health care costs; it provides subsidies to the 

local governments. The local governments use 

the subsidies and their own funds to finance 

most hospital and ambulatory care. The national 

health insurance covers other ambulatory care 

expenses such as visits to private physicians, 

traveling, and drugs. In Sweden the local governments pay for inpatient and outpatient hospital 

services. The national health insurance system 

pays the local governments small subsidies for 

hospital services and covers most other ambulatory care. In Canada and France, both hospitalization and other health services are covered by 

national health insurance programs. In Australia 

a combination of private and government insurance programs cover health services. 

Despite the differences, hospitalization is 

generally the best covered of the health services. 

In Australia all residents are eligible for free 

treatment in standard wards of public hospitals, 

attended by staff physicians. If they wish more 

private accommodations, to be treated by a 

private physician, or to use a private hospital, 

extra fees will be charged, but private insurance 

programs are available that will cover them. In 

Canada, hospitalization in standard wards is free 

to the patient in most instances, but some 

Provinces have established small fees, especially 

for daily care in extended care hospitals. The 

National Health Service in England and Wales 

also provides care on standard wards free to the 

patient, except for minor user charges on prescriptions, dental services, eyeglasses, and the 

like. In Finland hospitalization is free to the 

patient except for a small daily fee for “housekeeping services” such as meals and cleaning, 

which is presently $3.00. In Sweden there are 

no charges: hospitalization is provided without 

charge to the patient. On the other hand, in 

France the national health insurance covers only 

80 percent of the cost of most hospitalizations 

unless they are prolonged or especially costly. 

Private supplementary insurance, carried by 60 

percent of the population, covers part of the 

patient’s cost, but by law the patient is left with 

at least 5 percent of the cost. 

Physician’s fees and other treatment charges 

outside of the hospital are less extensively 

covered by the national health insurance in 

France than is hospital care. The patient is left 

to pay 25 to 30 percent of these fees out-ofpocket, though again supplementary insurance 

may cover all but 5 percent. In Sweden patients 

also pay a portion of the fees for physician 

services and for laboratory tests and other 

services required on an ambulatory basis. Since 

1970 there has been a limit to the extent of the 

patient’s expense, and it now stands at $4.00 per 

physician visit, including all the services required 

relative to the visit. In Finland ambulatory care 

can be obtained fi-om local health officers for 

small fees, $0.60-$0.75 at present, and the 

charge is expected to be completely eliminated 

by 1980. Ambulatory care from physicians in 

private practice is more costly; patients pay a 

62 
small deductible and 25 to 40 percent coinsurance for it. In England and Wales, ambulatory 

care is free except for the small user charges on 

prescriptions, dental services, eyeglasses, and the ..-._ like. In Canada physician services are covered by 

the national health insurance program, but some 

Provinces pay less than 100 percent of the fee 

schedule rate for the services, and physicians 

may bill patients for the difference, about 10 to 

15 percent of the fee. In Australia Medibank will 

pay 40 percent of the scheduled rate for medical 

fees, leaving patients with a maximum of $20.00 

to pay for any one service for which the scheduled fee is charged. Private insurance plans may 

pav 100 percent of the medical fees. 

Long-term care outside of hospitals is likely 

to be the most costly to the patient. In Australia 

nursing home care in all public and 70 percent 

of the private homes is paid for by the national 

Department of Health, but patients must contribute $6.70 for each day of care. In Canada 

the insurance program provides universal coverage of nursing home care in only three Provinces, 

and in them a daily fee of from $5.50 to $8.50 

per day is presently charged to the patient. In 

other Provinces patients are responsible for the 

entire cost of nursing home care, but subsidies 

are available for those who cannot afford the 

fees. In England and Wales the cost of care in 

the facilities provided by the local authorities is 

charged to the user on an ability to pay basis. 

However, in Finland and Sweden, the long-term 

care facilities can be used without charge to the 

patient. 

It can be seen that the patients in England 

and Wales have the least financial incentive to 

choose hospitalization over ambulatory care, 

and patients in Finland and Sweden have the 

least financial incentive to prefer hospitals to 

long-term care facilities. However, the charges 

for health services in all six of the countries are 

not for the most part serious barriers to obtaining care. Use of private medical services, and in. 

some places, use of long-term care facilities are 

the most likely to be affected by financial considerations 

Conclusion 

The hospital discharge statistics discussed in 

this paper have the p;tential to be a useful 

source of data for cross-national research. However, care must be taken in the interpretation of 

them. The coverage of the reporting systems and 

the procedures used in analyzing the data cm 

produce differences in the statistics that should 

not be mistaken for significant differences in the 

utilization of hospitals from one country to the 

next. 

Further exploration of aspects of hospital 

data regularly collected in different countries 

would be helpful to understand how to eliminate the irrelevant statistical artifacts. First of 

all, the question of the degree of impact on the 

statistics of differences in the coverage of the 

reporting systems needs to be examined in 

greater detail. It is clear that the differences are 

important, but with the study of additional 

data, estimates of the extent of the differences 

could be made. Then appropriate adjustments 

could be made in the statistics.. 

The accuracy of the data collected by 

different systems also should be studied in more 

detail. It is important to discover whether the 

completion of statistical reports is done with the 

same general level of accuracy in each of the 

reporting systems and what the level is. Information on the quality of the coding of data and on 

the efficiency of editing procedures also should 

be obtained. 

The effects of differences in the health 

services systems on the use of hospitals also need 

further study. A better understanding of different patterns of organization for the provision of 

physician services and of the importance of 

alternatives to hospital care is necessary to 

properly interpret cross-national differences in 

hospital use. 

The status of statistics on other aspects of 

hospitals, such as the facilities they contain, 

numbers and types of personnel, and costs, 

would also be useful to examine. These statistics 

are important in their own right and could 

increase understanding of utilization statistics. 

Information is needed on what types of statistics 

are available, how comparable they are, and 

whether they are of good quality. 

A final suggestion for further research is that 

the hospital discharge data in other countries 

should be surveyed. It is not certain that the six 

countries chosen for examination here have 

hospital statistical systems representative of 

63 
most industrialized countries, thotigh they do 

present examples of the major types of systems 

‘&d of the &fferences that can ‘exist between 

them. It may be discovered that some statistical 

systems are more or less common in other 

countries. Especially interesting would be the 

exploration of statistics in the other countries 

that contain a sizable number of private hospitals, since these hospitals are often excluded or 

treated differently in the systems studied here. 

Continuing research _into the status of routine health statistics collected by individual 

countries offers a significant return .g Many 

questions about health services systems are of 

deep concern to thk and other countries of the . 

world. Further research will provide a basis for 

the use of an enormous amount of data that 

have the potential to answer these questions. 

gFurther research on the status of international hospital statistics is under way. The discharge reporting systems in three additional countries have been examined 

by the authors, and discharge data from these three 

countries, the six countries discussed here, and the 

United States are being analyzed. In the analysis adjustments are made in the discharge data for differences in 

the patterns of coverage and in the definitions and procedures used by the reporting systems in the ten 

countries. 

000


64 
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APPENDIXES 

CONTENTS 

I. Contibutors tostidy ..................................................................................................................... 70


II. Major references conceminghospitaI utilization, by country ......................................................... 74


III. Additiond sources ofinfomation about hospital utiization, bycountq ...................................... 76


69 
APPENDIXI 

CONTRIBUTORS TO STUDY 

AUSTRALIA 

W. M. Barlett


Deputy Commonwealth Statistician


Australian Bureau of Statistics


Western Australia


W. Andrew Dibden


Director General of Medical Services


Hospitals Department


South Australia


Paul Gross


Acting Deputy Chairman


Hospitals and Health Services Commission


D. R. Harvey


Assistant General Manager


Data Management


Health Insurance Commission


T. N, Lanham


The Secretary


Hospitals and Charities Commission


Victoria


Marlene M. Lugg


Chief Health Statistician


Department of Public Health


Western Australia


A.M. Mackay


Supervisor


Health and Welfare Statistics


Australian Bureau of Statistics


G. Mackay-Smith


Director-General of Health Services


Department of Health Services


Tasmania


J. M. Martins


Deputy Director


Division of Health Services Research


Health Commission of New South Wales


O. M. May


Deputy Commonwealth Statistician and Govern­


ment Statistician for Queensland


Australian Bureau of Statistics


G. T. Miller


Department of Veterans Affairs


Mrs. Ohlsen


Department of Health Services


Tasmania


Beverley Schurr


Librarian


Embassy of Australia


Washington, D.C.


R. B. Scotton


Senior Research Fellow


Institute of Applied Economic


Research


University of Melbourne


G. R. Sleeman


Secretary


Mental Health Authority


Victoria


L. F. Young 

and Social 

Acting Director-General of Health Services 

Department of Health Services . 

Tasmania 

70 
CANADA 

J. B. Davis


Assistant Director


Program Development and Evaluation


Health Division


Statistics Canada


A. Dobrodzicki


Senior Analyst


Institutional Statistics Section


Health Division


Statistics Canada


Joe Hauser


Director


Health Division


Statistics Canada


H. I. MacKillop 

Director of Data Development and Evaluation 

Branch 

Ministry of Health 

W. A. Mennie


Director


Health Economics and Statistics


Department of National Health and Welfare


ENGLAND AND WALES 

Kenneth Lee


Lecturer in Health Economics


Nuffield Center for Health Services Studies


University of Leeds


Andrew F. Long


Lecturer in Quantitative Aspects of Management


Nuffield Centre for Health Services Studies


University of Leeds


Donald MacMillan


Nuffield Centre for Health Services Studies


University of Leeds


A. M. S. Mason


Senior Medical Officer


Department of Health and Social Security


Gordon McLachlan


Nuffield Provincial Hospitals Trust


Donald Patrick


Department of Community Medicine


St. Thomas’s Hospital


J. M. Yates


Research Fellow


Health Services Management Center


University of Birmingham


FINLAND 

Inkeri Barenthin


Uppsala University


A. S. Har6


Director


Department of Planning and Evaluation


National Board of Health


Esko Kalimo


Director


Research Institute for Social Security


Social Insurance Institution


Timo Klaukka


Research Institute for Social Security


Social Insurance Institution


Pekka J. Kopteff


Researcher


Inspector of Social Welfare


City of Vaasa


Reijo Koskela


Statistician


National Board of Health


Eero Linnakko


Planner “


The Finnish Hospital League


Pekka Pitkanen


Senior Planner


National Board of Health


71 
Hannu Vuori


Professor and Chairman


Department of Community Health


University of Kuopio


FRANCE 

M. T. Chapalain


Head of the Bureau of Studies and Planning


Ministry of Health and Social Security


M. O. Gascon


Assistant Manager


Hospital Morbidity Study


Ministry of Health and Social Security


F. Hatton


Health Services Research Division


Institute of Public Health and Medical Research


(INSERM)


D. Hossard 

Head of the Department of Health and Social 

Statistics 

Ministry of Health and Social Security 

Ari6 Mizrahi


Research Director


Research Center for the Observation and Study


of Living Conditions (CREDOC)


Simone Sandier


Research Directo~


Research Center for the Observation and Study


of Living Conditions (CREDOC)


SWEDEN 

Edgar Borgenhammer


Professor of Health Administration


University of G6teborg


Monica Jonsson 

Institute for the Planning and Rationalization of 

Health and Welfare Services (SPRI) 

Bjorn Smedby


Associate Professor


Department of Social Medicine


UppszdaUniversity


Gunnar Wennstrom


Head of Planning Department


The National Board of Health and Welfare


OTHERS 

Christa Altenstetter


International Institute of Management


West Germany


Hans H. Brieskorn


German Ministry for Research and Technology


West Germany


Hans Bruch


Pan American Health Organization


Washington, D .C.


Z. Brzezinski


Regional Officer for Epidemiology


Regional Office for Europe


World Health Organization


Michael A. Heasman


Common Services Agency


Scottish Health Service


Finn Karnper-Jorgensen


Institute of Social Medicine


Denmark


Steve Kelman


Assistant Professor of Public Policy


Kennedy School of Government


Harvard University


Kjeld Kjeldsen


Assistant Principal M.A.”


National Health Service


Denmark


Manfred Pfkmz


Professor and Head


Institute of Epidemiology and Social Medicine


Hanover Medical School


West Germany


Milton I. Roemer


School of Public Health


University of California


72 
Elisabeth Schach J.M. G. Wilson


Research Associate Information Services Division


University of Dortnwnd Common Services Agency


West Germany Scottish ‘Health Service


—000 

/ 

73 
APPENDIX II 

MAJOR REFERENCESCONCERNING HOSPITAL 

UTILIZATION, BY COUNTRY 

The following table lists the major references concerning hospital utilization for the six countries 

studied in this report. The numbers in ~arentheses are from the references followinrz the text. which 

give bibliographic-information 

Description of gtmaral 

Country hospital dkcharga reporting 

systems 

Australia .............. ...	 Report to the National Committee on Health and Vital 

Statistics by the Working 

Party on Hospital Statistics 

(30) 

Ccnada ................... Ramsey: 

The hoapitcl discharge abstract system of Seskatchawan Hospital Swvicas Plan 

{56) 

Thompson: 

The hospital diccharw ‘ 

abstract eyscem in British 

Columbia (55) 

in additick to that found here. 

Statistic$ from general 

hospital discharge report. 

ing cystems 

Medibank 

Annual Report of the Health 

I ncwance Commission 

(26,133) 

State Studies 

Queensland: 

Patients Treated in Hospitals in CIueendand (35) 

Western Au$tralia: 

Ho@tal in.Patient 

.$mtisrics (W 

Tasmania: 

Hc+i?ital MorbidW (37) 

Statistics Canada: 

Hospital Morb[dity (52), 

Hospital Morbidity, 

Canadian Dicgnaatic List 

(53) 

Suwical Procedwt?s and 

?-rcatm’snts (E4) 

Statistics from specialized 

dischaw reporting 

systams 

Veterans” Affairs 

4nnuai Raport of the Repatriation Commission (41 ) 

Psychiatric 

Annual reports in soma 

Stctes (1 34) 

Psychiatric 

Statistics Canada: 

Mental Health Statistics, 

Volume 1: Institutional Admissions and Separations 

(59) 

Mental Health Statistics, 

Volume 11: Patienta on 

Books of Institutions (60) 

Tulwculosis 

Statistics Canada: 

Tuberculosis Scctistics, 

Volume 1: Morbidity and 

Morta/ity (61) 

Statistics from 

?#gragetc hospital 

reports 

Hospitals and Health Sarvicm Commission: 

A Report on Hospitals in 

Austra/ie (24) 

Annual raport of tha Hocpital and Allied Sewicca Ad. 

viwy Cci.mcil Uniform 

Costing Committea (23) 

Annual reports of the State 

Officas of the Australian 

Bureau of Btatistl= (44) 

Annual reports of the State 

haalth cuthoritie$ (47,4S) 

Statistics Canadm 

Hospital Statistics: Vol. 

ume l-Beds, S.mites, 

PersOnri@ (14) 

Hospital $tat)st;cs: Voluma Ill-Indicators (27) 

Mental Haclth Statistics, 

Volume Ill-institutional 

Facilities, Sawkw end 

Finatias (65) 

Department of National 

Heclth end Walfara: 

Annual Report of the 

M/nister (62) 

Health Insurance and Re. 

swrces Dircctorcte and the 

Haalth Economics and Statistics Division: 

Supplementary statistical 

Compendium of the Hospital 

Insurance �nd Diagnostic 

Sewiw Prc$nmm (128) 

Statistics from 

household 

culvaya 

Australian 8urw 

of statl$tics bulletins: 

Australian Haelth 

Survey (49) 

Department of No. 

tionel Hmdth and 

Welfarn 

Illnass �nd Hacith 

tire in Wade: 

Canadian Sickness 

survey 7SWMI (66)

Statistic from tha 

1918 Cenada Health 

Survey not yet pub. 

Iishdd 

74 
Country 

England and Wales. 

Finland ................... 

France .................... 

Description of general 

hospital discharge rcportinl 

systems 

Alderson: 

Central Government rou. 

tine health statistics (68) 

Ashley: 

PreSnt state of statistics 

from hospital in.patient dat 

and their uw (69) 

Morris et al.: 

Cogstats: Some Notes on 

the Usaof Statkt;csin the 

Di4s!ona/ Managatmwt Of 

Hosp;tal Medical Services 

(72) 

Wilson: 

Hospital In-Patient En. 

quiry for England and Wales 

(671 

Kool : 

Hospital Statistics and a 

~;;mum Basic Data Set 

Nordic Medico-Statistical 

Committee: 

Computar.Based Patient 

Statistics: Part One-Hos~ita 

fn-Patknts (67) . 

Lecomta at al,: 

La Morbidit6 Hospitali&tw 

t4#thode d’Enqu$te (93) 

fordic Madlco.Btati~tical 

;ommittw 

f20mputar-Based Pa tient 

Metistics: Part One-Hospl. 

al in.Patients (67) 

Statistics from general 

hospital discharge report. 

ing systems 

Department of Health and 

Social Security, Office of 

Population C%nsuaasand 

Surveys, Welsh Office: 

Hospitcl in.Patient Enquiry: Preliminary Tables 

for England and Wales 

(75) 

Hospital In-Patient En. 

quiry: Main Tables for 

Englandand Wales (77) 

Statistics not routinely 

Statistics published in 

Sandi S&wri[6 SOcialeStatistiaues et commantaima 

(84, 85) 

Sant6 et S6curit6 .%ciale: 

Tableaux (10) 

National 8oardof Health 

md Welfare: 

Publications in the Patient 

Statistics Series (e.g., 107, 

115,116) 

Statistics from spacializec 

discharge reporting 

systems 

Department of Health and 

Social Security: 

Psychiatric hospitals and 

unitain England: in-patient 

statistics from the Mental 

Health Enquiry (79) 

Psychiatric and tuberculosis 

statistics not routinely pub 

Iished 

Pavchiatric statistics c!ub 

Iishedin 

Sant6 S6curit6 SOcialeStatistiques et commentairad 

(97) 

Psychiatric 

National Cwstral Bureau of 

Statistics 

Psychiatric i“.patiem ccre: 

natistlct of the National 

Soard of Health and Welfare 

[119) 

Matarnlty 

National Central SUrC.W of 

Statistics: 

Medical Birth Registration 

~tatiaticsof the National 

Board of Health and Walfara 

(121) 

Statistic from 

aggregate hospital 

reports 

Department of Health and 

Social Security: 

Health and Personal Social 

Services Statistics for 

.Eng/and (17) 

Welsh Office: 

Health and Personal Socia, 

Sawices Statistics for Wales 

(1s) 

National Board of Health: 

Yearbook of the National 

Board of Haalth (9) 

Finnish Hotpital League: 

Hospital Economics (28) 

Statistics published i“ 

Sant6 Securit6 ScwialeS&$ues et commentaims 

San& et S&writ6 Social.-: 

Tableaux (10) 

National Board of Health 

and Welfare 

Public health in Sweden 

(13) 

Federation of Swadish 

County Councils 

Statistical Yearbook for 

Counties (128) 

National Central Bureau of 

%atistic~ 

Hospital aawica statistiw 

statistics of the National 

Bocrd of Health and Welfara 

( 124,1 26) 

Statistics from 

houaehcdd 

autveys 

Office of Population 

Censuses and Surveys, SOcial Survey 

Dtvision: 

General House. 

Hold Survey (81 ,82) 

PuroIa et al.: 

Health Services 

Use and Health 

Status Under National Sickness Inwranm: An Evalu. 

stiva Resurvey of 

Fin/and (90) 

Lccomte et al.: 

L’Hospitalization 

!t sa placa clans Ies 

d@anaas madicale$ 

!n 1970(95) 

Mizrahi, A. and A.: 

Influence daa factaurs aOcic­

$conomiques sur 

‘hosoitaliaction 

:1011 

Wtional Ckntral 

hireau of Statistics: 

Health and Medi­

:al care utilization 

t 27) 

000


75 
APPENDIX III 

ADDITIONAL SOURCES OF INFORMATION ABOUT 

HOSPITAL UTILIZATION, BY COUNTRY 

AUSTRALIA 

American College of Hospital Administrators: 

The Delivery of Health Semites in Australia. 

Lectures from the International Fellows Seminar. Chicago. American College of Hospital Administrators, 1970. 

Harvey, D. R.: Medibank: Its Potential as a Provider of Statistics. Prepared for the Conference 

on Rationalisation and Development of Health 

Data Collection and Analysis Activities. Canberra, Feb. 1976. 

Hospitals and Health Services Commission: Second Annual Report 1974-75. Canberra. Australian Government Publishing Service, 1975. 

Lugg, M. M.: Health Data and Statistics Gaps 

in Australian Health Services Research and Pkmning. Background Paper for National Seminar 

on New Direction in Health Policies. Sydney, 

Apr. 22, 1975. 

Lugg, M. M.: A Report on Health Statistics 

Needs of Australia. Report of Special Consultant 

on Health Statistics to National Hospitals and 

Health Services Commission. Canberra, 1975. 

Martins, J. M.: Health Statistics Priorities for 

Australia. Paper for the Conference on Rationalisation and Development of Health Data Collection and Analysis Activities. Canberra, Feb. 

9-13,1976. 

Martins, J. M.: Some Features of the Evolution 

of Community Mental Health Services in New 

South Wales. Sydney. Health Commission of 

New South Wales, 1978. ,. 

New South Wales Office, Australian Bureau of 

Statistics: Statistics of In-Patients in PsychiaM”c 

Centers, 1974-75. 

CANADA 

Andersen, R., and Hall, J. T.: Hospital utilization and cost trends in Canada and the United 

States. Health Serv. Rev.: 198-222, Fall 1969. 

Department of National Health and Welfare: 

Review of Health Services in Canada, 1975. 

Ottawa. Health and Welfare, 1975. 

ENGLAND AND WALES 

Benjamin, B.: Hospital activity analysis: an information feedback for the consultant. The 

Hospital: 221-228, Mar. 1965. 

Bierman, P., et al.: Health services research in 

Great Britain. Milbank Mere. Fund Q. 46:9-102, 

Jan. 1968. 

Dodman, A., and Eastham, C.: Hospital activity 

analysis: an enquiry into the automated collection of data. The Hospital 622-265, Dec. 1965. 

Godber, G. E.: The Bn”tishNational Health Service. DHEW Pub. No. (NIH) 77-1205. Washington. U.S. Government Printing Office, 1976. 

McNay, R. A.: Hospital activity amdysis: experience in the area of the Newcastle Regional 

Hospital Board. The Hospital: 308-312, Sept. 

1969. 

Research in medical care. Br. Med. Bull. 30: 

Sept. 1974. 

76 
FINLAND 

I-E@ A. S.: Planning Methods Applied in the 

Development of Primary Health Care. Case 

Study Finland. PAHO/WHO Planning Project. 

Health Planning Methods. Ref. Document 77:1, 

1978. 

Lindholm, P.: A Regional Patient Information 

System. Helsinki. The Finnish Hospital League. 

Pcsonen, N.: The organization of medical care 

in Finland. Ann, Acad. Sci. Fenn. Helsinki. 

Suomalaienen Tiedeakatemia, 1964. 

Vauhkonen, O.: Health Care Utilization in 1975. 

Helsinki. The Finnish Hospital League, 1977. 

FRANCE 

Armitage, P.: National Health Survey Systems in 

the European Economic Community. Proceedings of a conference in Brussels. Luxembourg. 

Commission of the European Communities, 

Oct. 6-8,1975. 

Mizrahi, Andr6e, and Mizrahi, Ari6: hfkence de 

L ‘Age et du Sexe Sur Les Consummations Medicales D ‘Apres L ‘Enquete de 1970 Sur Les Soins 

Medicaux, Paris. CREDOC, 1973. 

SWEDEN 

American College of” Hospital Administrators: 

The Swedish Health Serva’ces System. Proceedings, Twenty-Second Fellows Seminar, Stockholm, 1969. Chicago. American College of Hospital Administrators, 1971. 

Andersen, R., Smedby, B., and Anderson, 

O. W.: Medical Care Use in Sweden and the 

United States~A Comparative Analysis of Sys­

—ooo 

tems and Behavior. Research Series No. 27. 

Chicago. Center for Health Administration 

Studies, University of Chicago, 1970. 

The Federation of Swedish County Councils: 

Health and Medical Care Services: The County 

Councils in Sweden. Stockholm. The Federation 

of Swedish County Councils, 1971. 

Hedengren, S.-O., cd.: The Swedish Health Services in the 2980’s. Stockholm. The National. 

Swedish Board of Health and Welfare, 1976. 

Navarro, V.: National and Regional Health Planning in Sweden. DHEW Pub. No. (NIH) 74-240. 

Washington. U.S. Government Printing Office, 

1974. 

Smedby, B.: Primary care financing in Sweden,’ 

in C. D. Burrell and C. G. Sheps, eds., Primary 

Health Care in Industrialized Nations. Annals 

of the New York Academy of Sciences. 310: 

247-251, 1978. 

INTERNATIONAL 

Douglas-Wilson, I., and McLachlan, G., eds.: 

Health Service Prospects: An International 

Survey. London. The Lancet and the Nuffield 

Provincial HospitaIs Trust, 1973. 

Fry, J., and F~ndale, W. A., eds.: International 

Medical Care: A Compan”son and Evaluation of 

Medical Care Services Throughout the World. 

Oxford Medical and Technical Publishing Co., 

1972. 

I-Iu, Teh-wei, cd.: International Health Costs and 

Expenditures. DHEW Pub. No. (NIH) 76-1067. 

Washington. U.S. Government Printing Office, 

1976. 

— 

77 

W.s. G0vERNk4Em FRINTINGOFFICE i9so 311-240/5 1-3 
VITAL AND HEALTH STATISTICS Series 

Series 1,	 Programs and Collection Procedures. –Reports which describe the general programs of the National 

Center for Health Statistics and its offices and divisions and data collection methods used and include 

definitions and other material necessary for understanding the data. 

Series 2.	 Data Evaluation and Methods Research. –Studies of new statistical methodology including experimental tests of new survey methods, studies of vital statistics collection methods, new analytical 

techniques, objective evaluations of reliability of collected data, and contributions to statistical theory. 

Series 3.	 Analytical Studies. –Reports presenting analytical or interpretive studies based on vital and health 

statistics, carrying the analysis further than the expository types of reports in the other series. 

Series 4.	 Documents and Committee Reports. –Final reports of major committees concerned with vital and 

health statistics and documents such as recommended model vital registration laws and revised birth 

and death certificates. 

Series 10.	 Data Fro m the Health Interview Survey. –Statistics on illness, accidental injuries, disability, use of 

hospital, medical, dental, and other services, and other health-related topics, all based on data collected 

in a continuing national household interview survey. 

S,ri,s 11.	 Data From the Health Examination Survey and the Health and Nutrition Examination Survey. –Data 

from direct examination, testing, and measurement of national samples of the civilian noninstitutiomdized population provide the basis for two types of reports: (1) estimates of the medically defined 

prevalence of specific diseases in the United States and the distributions of the population with respect 

to physical, physiological, and psychological characteristics and (2) analysis of relationships among the 

various measurements without reference to an explicit finite universe of persons. 

S(-rit’s 12.	 Data From the Institutionalized Population Surveys. –Discontinued effective 1975. Future reports from 

these surveys will be in Series 13. 

Series 13.	 Data on Health Resources Utilization. –Statistics on the utilization of health manpower and facilities 

providing long-term care, ambulatory care, hospital care, and family planning services. 

Series 14.	 Data on Health Resources: Manpower and Facilities. –Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health 

occupations, hospitals, nursing homes, and outpatient facilities. 

Series 20,	 Data on Mortality. –Various statistics on mortality other than as included in regular annual or monthly 

reports. SpeciaJ analyses by cause of death, age, and other demographic variables; geographic and time 

series analyses; and statistics on characteristics of deaths not available from the vital records based on 

sample surveys of those records. 

Series 21.	 Data on Natality, Marriage, and Divorce. –Various statistics on natality, marriage, and divorce other 

than as included in regular annuzd or monthly reports. Special analyses by demographic variables; 

geographic and time series analyses; studies of fertility; and statistics on characteristics of births not 

available from the vital records based on sample surveys of those records. 

&~ric.sZZ.	 Data From the National Mortaljty and Natality Surveys. —Discontinued effective 1975. Future reports 

from these sample surveys based on vital records will be included in Series 20 and 21, respectively. 

Swies 23.	 Data From the National Survey of Family Growth. –Statistics on fertility, family formation and dis. 

solution, family planning, and related maternal and infant health topics derived from a biennial survey 

of a nationwide probability sample of ever-manied women 15-44 years of age. 

For a list of titles of reports published in these series, write to:	 Scientific and Technical Information Branch 

National Center for Health Statistics 

Public Health Service 

Hyattsville, Md. 20782