CONTENTS
Objectives
and general characteristics 
INTRODUCTION
The Catalan healthcare system presents the main characteristics of a public healthcare model with universal coverage. It is financed by taxes and co-exists with a private healthcare system.
The proportion of the population with double healthcare coverage (public and private) in Catalonia is 23%. There is also a large group of centers run at different administrative levels, which, owing to the lack of social security backed healthcare resources in Catalonia, have been historically supported by the initiative of civil society. These act in complementary fashion to look after people from the public system.
In line with this, the Law Regarding Healthcare Planning in Catalonia (LOSC) established an organization model that separated the functions of financing and planning from those of service supply and management. Within this context, the Catalan Health Service (SCS) has the mission of planning public healthcare services and of hiring supplying organizations for the different healthcare networks, while at the same time guaranteeing the necessary levels of equity and efficiency.
This new organizational approach must be accompanied by new tools for planning and evaluation, and strong development of information systems, which permit the regulation of the market, thus enabling its operation to remain coherent with these principles. This information includes user identification, activity, costs and, in particular, information on morbidity. Within this context, the Basic Minimum Data Set (CMBD) stands out. As a systematic register of morbidity and healthcare activity, it is a vital tool for hospitals, supplying organizations and healthcare administrations, since it makes it possible to find out the pathology treated, the characteristics of the care provided and its development with time.
The history of the CMBD in Catalonia officially began with the Order of November 23, 1990, which established the obligation for all public and private hospitals in Catalonia to draw up a basic minimum data set regarding hospital discharge (CMBDAH) with information on acute-care hospitalization.
Since then, a concerted effort has been made by both hospitals and government to encourage improved data quality and availability. Furthermore, growing requirements for information about healthcare processes treated at the ambulatory level resulted in the inclusion of major ambulatory surgery and day hospital treatment in the CMBDAH from 1996 on.
In addition to information from acute-care hospitals, since 1998 the Basic Minimum Data from Mental Health Hospitals (CMBDCSM) Register has systematically compiled the information on the ambulatory activity of centers of this nature. As for social healthcare resources, and since 1999, data in which the Basic Minimum Data Set for Social Healthcare (CMBDSS) Register began to systematically record the activity of these centers.
At the beginning of 2001 and coinciding with the development of the CatSalut Systems Plan, the three CMBD Registers were amalgamated into the same unit.
The idea was to optimize resources and their use, and to unify criteria.
With the intention of diffusing the information concerning the activity of acute-care hospitals, the "Healthcare Activity" series has published the reports of the CMBDAH Register for 1993, 1994, 1995 and 1996-1999.
As a result of the new organization of the CMBD, the 2000 report now contains all the information of the CMBDAH Register and, for the first time, a summary of the CMBDSS and CMBDCSM Registers.
Always with absolute respect for the standards of confidentiality and use, the information contained in the CMBD Registers is available to all those managers, healthcare professionals and researchers who require it. It is the firm wish of both the Catalan Ministry of Health and the Catalan Health Service to encourage this use, since they understand it to be the best way of moving towards established goals, and of improving and maintaining the quality of the Register.
THE CMBD REGISTERS
Objectives
and general characteristics
The
fundamental objective of the CMBD Registers is to create comprehensive,
valid databases on the morbidity and activity of both internment hospitals
and ambulatory clinics of the Catalan healthcare network. These data
must be useful for understanding the pathology being treated, healthcare
planning, the assessment of resources and the purchase of services.
The CMBD Registers compile population-based information on the following healthcare activities:
Acute-care hospitals and specialized psychiatric hospitals
(CMBDAH Register):
conventional
hospitalization
major ambulatory surgical procedures (CMA)
day hospitals (HdD)
major ambulatory surgical procedures (CMA)
day hospitals (HdD)
Social
healthcare resources (CMBDSS Register):
hospitalization
in extended care, convalescence and palliative care units
functional
interdisciplinary social healthcare units (UFISS)
homecare
(PADES)
ambulatory
care in day hospitals and in diagnostic and follow-up units for cognitive
disorders and dementias
Ambulatory
psychiatric care (CMBDCSM Register)
These
are a source of accessible information for internal and external users
and have to meet the demands made by different fields. In all cases,
the release of data is subject to the current law regarding confidentiality
and the use of information.
The
CMBD Registers present coded data according to pre-established criteria,
in order to make them compatible and comparable with other information
systems.
The
following variables are common to all the Registers:
Discharge
identification variables:
•
hospital code
•
medical record number
Sociodemographic
variables:
•
date of birth
•
sex
•
place of residence
Administrative
variables:
•
source of payment
•
date of admission
•
admission status
•
date of discharge
•
discharge status
Clinical
variables:
•
diagnoses
THE
CMBDAH REGISTER
Organization and operation
Organization and operation
The CMBDAH Register compiles the healthcare activity data from acute-care hospitals (conventional hospitalization, major ambulatory surgical procedures and day hospitals) and specialized psychiatric hospitals in Catalonia.
Every three months, the hospitals send the data pertaining to their activity to the Register, either on diskette or by email.
Once received, the data are validated in accordance with the criteria presented in the reporting manual, and each hospital is sent the summary of the validation.
At the end of the year, the acute-care hospitals receive reports on their activity, and how it compares with other hospitals of similar characteristics. The data on conventional hospitalization and CMA are sent to the Spanish Ministry of Health and Consumption so that they can be included in the national CMBDAH Register.
Description
of the specific variables
The
individual characteristics of each of the CMBD Registers creates the need
to record not only the common variables but also, in the case of the CMBDAH
Register, the following variables:
Discharge
identification variables:
•
Healthcare number
Administrative
variables:
•
Transfer hospital
Clinical
variables:
•
Diagnoses (main diagnosis and up to 3 secondary diagnoses)
•
Procedures (up to 4 procedures)
•
Code E (external cause)
Perinatal
variables:
•
Length of pregnancy
•
Weight and sex of 1st newborn
•
Weight and sex of 2nd newborn
Quality
control
In
2000, the CMBDAH Register has received information from 83 acute-care
hospitals and 11 specialized psychiatric hospitals (ANNEX
1).
Of
the acute-care hospitals, 62 belong to the Hospital Network for Public
Use (XHUP) while the remaining 21 do not.
In 2000, the number of hospitals reporting to the CMBDAH has grown from 90 to 94. The new additions are acute-care hospitals that do not belong to the XHUP.
The information contained in the Register represents 100% of the discharges from the XHUP and half of the activity of the hospitals not belonging to the XHUP. The CMBDAH Register has recorded 95% of the activity of the specialized psychiatric hospitals.
In relation to 1999, the total activity reported to the CMBDAH in 2000 has risen 9.6% (TABLE 1). The most relevant increases have taken place in CMA activity (a rise of 32.2%) and HdD (a rise of 14.5%). Such growth is explained, on the one hand, by an increase in comprehensive information provided by the Register and, on the other, by a genuine surge in activity. Conventional hospitalization has undergone more moderate growth (a rise of 6.7%), while activity in specialized psychiatric hospitals has fallen off slightly.
When comparing information from different years, it should be taken into account that qualitative and quantitative changes have taken place in the Register's coverage.
TABLE 1. Number of discharges by activity
type and year. 1999-2000 Internal
validation
An
internal validation is carried out on the data received in order to establish
the quality of the information, to detect possible errors in each of the
variables and to check their coherence. This validation follows the criteria
established in the Instruction Manual for Reporting to the CMBDAH Register.
Codification of the clinical variables is done in accordance with the
ICD·9·CM, following the Guidelines for the Codification of Clinical
Variables of the CMBDAH of Catalonia. These guidelines seek to unify the
codification criteria of the healthcare episodes. They obey the criteria
established by the national reference group of the Spanish Ministry of
Health and Consumption, and were drawn up by CatSalut in joint collaboration
with the codification group of the Catalan Medical Documentation Society
of the Academy of Medical Sciences of Catalonia and the Balearic Islands.
During the internal validation process, two new variables were created on the basis of the original variables: the age of the patient (based on date of birth and date of admission) and the length of stay (based on date of admission and date of discharge).
It goes on to show the validity of the variables corresponding to conventional hospitalization and CMA in 2000.
Variables identifying the discharge
•
Validity greater or equal to 99.7% for all variables.
Sociodemographic
variables
•
Date of birth, age and sex: validity greater or equal to 99.9%.
•
Place of residence: validity of 95.4%.
Administrative
variables
•
Validity greater than 99.0% for all variables, except for the transfer
hospital variable (reporting is only required when the discharge status
is a transfer to an acute-care hospital, to a social healthcare hospital
or to a psychiatric hospital) validity of 83.8%.
Clinical
variables
•
Main diagnosis: validity of 98.7%.
Average
number of diagnoses (main and others) per discharge: 2.3.
•
First procedure: recorded in 76.4% of the discharges. Where this variable
was recorded, validity was 99.9%.
Average
number of procedures (all procedures) per discharge: 1.3.
•
External cause: validity of 82.2% for traumatology-related admissions.
Perinatal
variables
•
Validity greater than 93% for all variables.
In
general, the validity of the variables decreased with regard to 1999 as
a result of the incorporation of new hospitals. These hospitals need time
to adapt their data collection circuits to the Register's requirements,
and attain the same levels of quality as the hospitals that have been
reporting to the CMBDAH Register for years.
DESCRIPTIVE
ANALYSIS OF
THE CMBDAH REGISTER
The
CMBDAH Register compiles data from acute-care hospitals and specialized
psychiatric hospitals. The information from acute-care hospitals is
related to conventional hospitalization, major ambulatory surgery (CMA)
and day hospital activity (HdD).
This report includes the descriptive analysis of the 2000 CMBDAH Register. The information is presented in the following three blocks:
•
Conventional hospitalization, together with CMA
•
Day hospital
•
Psychiatric care
The
data for conventional hospitalization have been analyzed jointly with
those of CMA because major surgical procedures generally treated as
ambulatory may require admission, depending on the co-morbidity and
sociodemographic conditions of the patient or the amount of time needed
to reach the hospital. Given that one of the objectives of the CMBDAH
is to analyze hospital morbidity, a joint analysis must be made.
The data corresponding to day hospitals and specialized psychiatric hospitals are analyzed separately, since they involve types of activity that differ significantly with respect both to each other and to conventional hospitalization and CMA.
The discharge is the unit for measurement and analysis of the CMBDAH Register. Nevertheless, in certain sections of this report where greater emphasis is placed on the person who is receiving healthcare instead of discharges we will refer to "treated people". Information is also compiled and presented regarding all the discharges of a given patient. Only in this case will we refer to them as "patients".
Thus, despite the fact that both "treated people" and "patients" refer to those receiving care, each term has to do with a different analytical level.
These concepts will also be used when we refer to day hospitals (HdD), except as regards the "discharge" concept. In this case, instead of speaking of discharges we will use the term "sessions", since this type of activity involves no period of hospitalization.
When referring to the population of Catalonia in the research presented in this report (population pyramid and hospitalization rate per 1000 inhabitants), two sources of information have been used:
The population of Catalonia on January 1, 2000 as determined from the revision of the census, published in Royal Decree 950/2001 of August 3. This is the source that best adjusts to the real population of 2000. However, it is limited by the fact that it does not deal with age and sex.
The population of Catalonia according to the 1996 census, for the analyses requiring detailed information regarding age and sex. Yet this source does not show the population changes that have taken place in recent years and might therefore create a bias in the calculation of population indicators.
In the tables presenting the age, sex or length of stay variables, discharges are considered to be null and void when even one of these concepts is non-valid.
The
remaining variables deemed non-valid have been grouped in the "unknown"
category.
In the tables, percentages under 0.05% are presented as "0.0". A complete absence of recorded discharges is given as "-".
CONVENTIONAL
HOSPITALIZATION
AND MAJOR AMBULATORY SURGERY (CMA)
AND MAJOR AMBULATORY SURGERY (CMA)
Discharges
and patients
The number
of patients is calculated on the basis of the hospital code and the medical
record number. The medical record number makes it possible to identify
patients who have received care more than once in the same hospital. However,
it should be noted that the data compiled in the Register do not reveal
whether a treated person has received care in different hospitals. This
explains why the number of patients may be slightly overestimated and,
consequently, the average number of discharges per treated person underestimated.
The total number of discharges reported to the CMBDAH Register in 2000 was 814,657. These discharges corresponded to 667,769 patients (TABLE 2). The average number of discharges per treated person (1.22) showed differences with respect to age and sex (FIGURE 1). The average number of discharges per treated person grew with age except in women from 15 to 44 since obstetrical activity, which does not usually involve readmission, is very significant in this age group.
For all age groups, the average number of discharges per treated person was higher in men than in women (1.25 in men and 1.19 in women).
For patients admitted more than once, the average number of discharges was 2.46.
These patients (15.1% of the total) accounted for 30.4% of all discharges (TABLE 2).
FIGURE 1. Average discharges per treated
person by sex and age group. 2000
TABLE 2. Number of discharges
and treated people per year. 1999-2000 Age
and sex
Age is
calculated using two original variables: date of birth and date of admission.
Because of the non-validity of one of the two original variables, this
age variable was non-valid in 0.1% of the discharges.
The sex variable was non-valid for 0.03% of the discharges.
Of all discharges, 389,617 (47.9%) were men while 423,649 (52.1%) were women. The number of discharges in women has grown annually, both in absolute and relative terms. In relation to 1999, a 10.2% increase was seen in the number of women and a 7,6% increase in men.
This circumstance is explained by two factors: the aging of the population and greater comprehensiveness of information in the Register in relation to hospitals that began reporting to the Register in 2000; these hospitals showed above-average activity.
The average age was 51.6 (51.3 in 1999). This increase was due to the aging of the population and shown by the rise in the number of discharges of treated people over the age of 64, 9.2% more than in 1999.
Differences were seen with regard to sex. The average age of men (51.9 years) was greater than that of women (51.3 years). However, if obstetrical activity is discounted, the average age of women is 55.3.
Discharges of women from 25 to 39 years of age accounted for 23.90% of all female discharges and 12.5% of the total discharges.
The age group with the highest proportion of male discharges was that of 1 to 14.
FIGURE
2 shows the percentage distribution by age and sex for the
discharges of Catalan residents recorded in the 2000 CMBDAH Register,
and the Catalan population according to the 1996 census. The hospitalization
rate was calculated using these data (TABLE
3).
This rate, calculated from data made available to the CMBDAH, was 124.5 discharges per 1,000 inhabitants. However, if we count the activity of hospitals not belonging to the XHUP and which have not yet reported to the Register, this rate is approximately 140‰.
By age group, the highest hospitalization rate was that of infants under one year (521.3), followed by senior citizens over 84 years (434.6). In the case of infants under one year, 57.1% of the discharges involved boys and girls admitted to hospital during the first week of life. The lowest hospitalization rate of the group was that of children from age 10 to 14 (34.1), especially girls (TABLE 3).
FIGURE 2. Distribution of discharges of residents of Catalonia and of
the population of Catalonia, by sex and age group. 2000
TABLE 3. Distribution of discharges
by sex, age group and place of residence, and hospitalization rate of
Catalan residents. 2000 Place
of residence
The place
of residence variable includes the codes for province, town, district
(in the case of residents of the city of Barcelona) and country (in the
case of foreigners).
The degree of non-validity for this variable was 15.8%. Errors were largely attributable to the lack of information concerning the municipal district of residents of the city of Barcelona. If this factor is discounted, 4.6% is non-valid.
The information provided by this variable makes it possible to establish the territorial distribution of discharges by healthcare region and healthcare sector of residence.
The healthcare region and healthcare sector of residence were assigned to each discharge on the basis of the town code. As for the discharges of residents of the city of Barcelona, where the sector assignation required knowledge of the municipal district, and in view of the fact that this information has yet to be comprehensively recorded, assignation was not possible. For this reason, all sectors of Barcelona have been treated together.
TABLE 4 shows the number of discharges per healthcare region of residence and the distribution according to the healthcare region of the discharging hospital.
Of a total of 814,657 discharges, it was possible to assign the healthcare region of residence to 759,429 (92.2%). As for the remaining discharges, 18,118 (2.2%) resided outside Catalonia while the place of residence was unknown for 37,110 discharges (4.6%). However, 33,218 (4.1%) of these discharges only showed the code of one of the Catalan provinces and so therefore could be considered residents of Catalonia even though no healthcare region or sector was assigned. These discharges have not been included in the analyses presented in this chapter.
Of the 759,429 discharges involving residents of Catalonia, 632,445 (83.3%) were treated in hospitals in their own healthcare region of residence and 126,984 (16.7%) were treated in other regions. Of these discharges, 58,568 (7.7%) were residents of the healthcare regions of Barcelona Ciutat, Costa de Ponent and Barcelonès Nord i Maresme, and were treated in one of these neighboring regions.
The remaining 68,416 discharges (9.0%) corresponded to movement between other healthcare regions.
As for discharges for whom place of residence was recorded as being outside Catalonia (TABLE 4), 52.4% were from hospitals of the Barcelona Ciutat healthcare region and 16.4% from hospitals of the Lleida healthcare region, most of whom (2,373 discharges) were residents of the province of Huesca. In absolute terms, the hospitals of the Barcelona Ciutat healthcare region produced the highest number of discharges of residents from outside Catalonia. Nevertheless, in relative terms, Lleida was the healthcare region with the highest percentage of residents from outside Catalonia in relation to all hospital discharges (7.9%). For the healthcare region of Barcelona Ciutat, this percentage was 3.2%.
TABLE 4. Percentage distribution and number
of discharges of residents in each healthcare region in relation to the
healthcare region of the hospital. 2000Hospitalization rates
As indicators
of the use of hospitalization resources at the territorial level, hospitalization
rates have been calculated by healthcare region and sector of residence.
These rates have been calculated by the total of number of discharges
and by those financed by CatSalut (TABLE
5).
When assessing these rates, it should be recalled that the Register records 100% of the discharges financed by CatSalut. As stated in the Quality Control section, coverage was not 100% for discharges not financed by CatSalut, which for the most part involve private hospitals.
Since the age and sex structure of the territorial units analyzed was not homogeneous, in addition to the gross hospitalization rates, standardized hospitalization rates have also been calculated, according to the direct method, using the population of Catalonia as the standard (TABLE 5).
The standardized rates have been calculated according to the data recorded in the Register and the population according to the 1996 census, and the gross rates according to the population of 2000 and the 1996 census.
With respect to both healthcare region and sector, differences have been seen in the six indicators calculated (TABLE 5). Some of the lowest rates have been found where the population is most elderly and vice versa.
TABLE 6 synthesizes the territorial variation of the hospitalization indicators of discharges financed by CatSalut for 1999 and 2000, on the basis of the maximum/minimum rates and the weighed variation coefficient per town. The variation among regions was lower since at this level certain extreme cases in the sector were compensated. Contrary to what one would expect, the variation in standardized rates was greater than in gross rates. The indicators calculated with the population for 2000 showed less variation.
FIGURE 3 shows the standardized hospitalization rates of the discharges financed by CatSalut, by healthcare sector of residence. For comparison purposes, it also shows the rate for the whole of Catalonia and the interval of the variation coefficient taken per town. Of the entire group of sectors, 28 were found within the limits defined by the variation coefficient, 5 plus Barcelona Ciutat which was treated as a single sector were below it while the remaining 12 sectors were above it.
To evaluate the differences in hospitalization rates per healthcare sector of the discharges financed by CatSalut, one should bear in mind that publicly financed hospital healthcare in a territory is conditioned by the offer of other types of complementary healthcare.
More frequent in urban areas with high socioeconomic levels, the offer of private healthcare coverage by free-choice insurance companies can be accompanied by relatively low public hospitalization rates.
In certain rural areas, where low population density and good communications cannot justify the presence of a hospital, primary healthcare takes on a substitute role in certain aspects of care. In this case, hospitalization rates can be low.
From the viewpoint of healthcare policy, the presence of a hospital is justified in areas with low density of population and where communication is difficult, for example, in a mountainous region. In this case, hospitalization rates are higher than average because the offer of care provided by the close proximity of a hospital, however small, increases the demand.
The current situation caused by an aging population, in which the proportion of elderly, multiple-pathology treated people is on the rise, causes the frequency of admission of these treated people to depend, to a large extent, on the social healthcare resources available in the area.
TABLE 5. Hospitalization rates per 1000
inhabitants, by healthcare region and healthcare sector of residence.
2000
TABLE 6. Territorial variation
of the hospitalization indicators of discharges financed by CatSalut.
2000
FIGURE 3. Standardized hospitalization
rate and variation coefficient by healthcare sector of residence, of discharges
financed by the SCS. 2000 Source
of payment
The source of payment variable records the entity or institution that financed the patient's hospitalization. Of all discharges, 0.16% was non-valid in terms of this variable.
The source of payment variable records the entity or institution that financed the patient's hospitalization. Of all discharges, 0.16% was non-valid in terms of this variable.
80.8% of all discharges recorded in the Register were financed by CatSalut, a proportion that soars to 94.2% if only the XHUP hospital discharges are analyzed. The number of discharges financed by CatSalut in hospitals not belonging to the XHUP and which report to the CMBDAH Register was 9,960.
FIGURE 4 shows the distribution of discharges not financed by CatSalut, according to the source of payment.
As a result of the Register's increased coverage of hospitals not belonging to the XHUP, the number of discharges financed by free-choice insurance companies has gone up 47.9% over 1999. Moreover, privately financed discharges have risen 36.9% since 1999. Of these discharges, 4,304 took place in XHUP hospitals and 15,494 in hospitals not belonging to the public network.
FIGURE 4. Distribution of discharges not financed by the SCS, by source
of payment. 2000 Admission
and discharge status
The admission
status variable was non-valid in 0.3% of the discharges.
Of all discharges, 51.2% were planned and 48.8% involved emergencies. This distribution in XHUP hospitals was 47.7% and 52.5%, while in hospitals not belonging to the XHUP, these percentages were 71.7% and 28.3% respectively.
For the CMBDAH overall, planned discharges exceeded emergency discharges for the first time. This was due both to the increase in hospitals not belonging to the XHUP that began reporting to the Register in 2000, and to the growth of planned CMA activity.
With regard to the discharge status variable, 0.9% of discharges were non-valid. 93.5% of discharged treated people were able to go home (TABLE 7). The 22,077 deaths constituted approximately 38% of all deaths in Catalonia.
Discharges following emergency admission showed a higher percentage of deaths than discharges following planned admission, 4.7% and 0.9% respectively.
TABLE 7. Distribution of discharges by
discharge status. 2000 Length
of stay
Length
of stay is a variable calculated on the basis of the date of admission
and the date of discharge. 0.02% of all discharges were non-valid for
the calculation of length of stay (this percentage includes stays longer
than 6 months).
In 2000, the average length of stay for all discharges was 5.9 days (FIGURE 5), notably lower than in 1999 when it was 6.3 days. This decrease can be attributed to a large extent to improved hospital efficiency but the inclusion of CMA is also a significant contributing factor.
Average length of stay varies a great deal on account of other variables such as age, sex, diagnosis, admission status, source of payment and so on.
The average length of stay for men was 6.3 days, while for women it was 5.4 days. In general, there was a clear tendency for the average length of stay to increase with age, with the exception of infants under 1 year and women between 20 and 39 (TABLE 8 and FIGURE 6).
Women showed a shorter average length of stay than men in all age groups between 15 and 84. Since 1999, the average length of stay has decreased for all age groups and both sexes (FIGURE 6).
A high volume of hospitalization combined with a long average stay meant that certain age groups represented very high percentages of the total number of days spent in hospital. This was the case of those over 64, who accounted for 38.5% of the discharges (TABLE 3) and accumulated 49.3% of all days spent in hospital (TABLE 8). In 1999, these figures were 38.5% of all discharges and 49.1% of all days spent in hospital.
We should also take into account the significance of lengthy stays, because, although stays lasting longer than 30 days represented only 2.0% of discharges, they constituted 16.8% of the total of days spent in hospital. In 1999, these figures accounted for 2.2% of all discharges and 16.9% of all days spent in hospital.
If length of stay is analyzed according to admission status, it can be seen that emergency admissions were followed by an average stay of 7.8 days whereas planned stays lasted 4.1 days (8.0 and 4.4 days in 1996). The shorter average length of stay for planned discharges was basically due to increased CMA activity.
Discharges financed by CatSalut in 2000 were preceded by an average length of stay of 6.2 days, and those not financed by CatSalut, 4.8 days (6.5 days and 5.1 days in 1999, respectively). The shorter average length of stay of discharges not financed by CatSalut was fundamentally on account of the lower degree of complexity of the illness of the treated people.
FIGURE 5. Distribution of discharges by
days of stay. 2000
TABLE 8. Days of stay and average
length of stay by age group and sex. 2000
FIGURE 6. Average length of
stay by age group and sex. 2000 Diagnoses
The CMBDAH
records the main diagnosis of each discharge and up to three further diagnoses,
coded according to the ICD·9·CM.
The main diagnosis variable indicates the reason why a patient was admitted to hospital.
The other diagnoses include all illnesses or complications detected in the patient not considered as the main diagnosis, either already present at the time of admission or developed during the hospital stay.
The percentage of non-valid discharges for the main diagnostic variable was 2.1% of all discharges. Lack of specific information was the cause of non-validity in 0.8% of discharges. The term "non-specific diagnosis" involved those cases where, although correct, the information failed to present the maximum detail possible.
In 1.2% of all discharges there was no recorded information concerning the main diagnosis. The variable was either left blank or entered as an unknown diagnosis (code 799.9). The other causes of non-validity were attributable to coding errors not included in the ICD·9·CM and inconsistencies in relation to age and/or sex (0.1%).
Accordingly, in 1.3% of all discharges, there was no recorded information concerning the main diagnosis. In 1999 this percentage was 0.5%. This was one of the variables most affected by validity problems, as remarked in the section on "Internal validation".
62.7% of the discharges provided correct information regarding the first secondary diagnosis, while for the second the percentage was 42.5% and for the third, 29.5%.
Non-validity of the other diagnoses was due primarily to lack of specificity, which for the three secondary diagnoses was 0.1%. Non-validity as a result of error or inconsistency was 0.02%.
The average number of recorded diagnoses per discharge (main and other) was 2.33. In 1999 it was 2.37.
The main diagnosis has been analyzed according to two levels of classification:
•
Major ICD·9·CM diagnostic groups
•
Diagnostic categories of the Clinical Classifications for Healthcare
Policy Research (CCHPR) proposed by the Agency for Healthcare Policy and
Research (AHCPR), of the Department of Health and Human Services of the
United States.
Major
ICD·9·CM diagnostic groups
The ICD·9·CM
sets out more 13,000 diagnostic codes in 17 major groups, plus code V.
It includes those factors that affect state of health and contacts with
healthcare services.
TABLE 9 shows the distribution of discharges by main diagnosis, according to these 18 major groups.
The five major groups with the greatest number of discharges were those having to do with the circulatory, digestive and respiratory systems, diseases involving the nervous system and the sensory organs, and complications arising during pregnancy, delivery and puerperium. Together, these groups accounted for 51.4% of all discharges.
Diseases of the nervous system and sensory organs and diseases of the locomotive apparatus and connective tissue were the groups showing highest growth compared to 1999 (a rise of 17.66% and 17.5% respectively). In both groups, this upswing was due to increased surgical activity, which will be dealt with in the section on "Procedures". Discharges involving infectious and parasitic diseases have decreased since 1999 (TABLE 9).
Although each group comprises very different diagnoses and typologies of treated people, it should be mentioned that the longest average stays were for mental disorders, infections originating during the perinatal period and neoplasms. The shortest stays were for diseases of the nervous system and sensory organs and complications arising from pregnancy, delivery and puerperium.
The diagnostic groups accumulating most days in hospital were diseases of the circulatory system, neoplasms, diseases of the respiratory system and injuries and cases of poisoning, which constituted 50.6% of all stays.
Significant differences were seen with regard to the average age. The highest percentages involved diseases of the circulatory system, the nervous system and sensory organs, and neoplasms. The lowest corresponded, predictably, to perinatal and congenital diseases, followed by deliveries and infectious diseases (TABLE 9).
There were also differences in the distribution of discharges by cause of admission in relation to the age and sex of the treated person (TABLES 10 and 11).
Perinatal infections and respiratory ailments were significant for members of both sexes under the age of 5. Differences were seen with regard to sex and age. In women what most stood out were deliveries (15 to 44 years), neoplasms (45 to 54 years), diseases related to the locomotive system and connective tissue (55 to 64 years) and diseases of the nervous system and sensory organs (65 to 84 years).
Most notable in men were injuries and cases of poisoning (5 to 34 years), diseases of the digestive system (35 to 44 years) and diseases of the circulatory system (55 to 84 years).
TABLE 9. Distribution of discharges, average length of
stay and average age by main diagnosis, according to the major diagnostic
groups of the ICD·9·CM. 1999 and 2000
TABLE 10. Percentage of discharges of the three major diagnostic groups
accumulating most discharges in each age group, in men. 2000
TABLE 11. Percentage
of discharges of the three major diagnostic groups accumulating most discharges
in each age group, in women. 2000 Diagnostic
categories of the CCHPR
The Clinical
Classifications for Healthcare Policy Research (CCHPR) organize all the
diagnostic codes into 259 diagnostic categories, using a clinical criterion
above all. These 259 categories are then broken down into 17 groups.
ANNEX 2 sets out the detailed codes that make up each of the diagnostic categories.
TABLE 12 shows, for each diagnostic category, the total number of discharges and the percentage distribution, the average length of stay, average age, proportion of discharges among women and the mortality rate for 2000, as well as the number of discharges and percentage distribution for 1999 for comparative purposes.
It should be pointed out that the categories showing the greatest growth in 2000 were cataracts, pregnancy and/or normal delivery, abdominal hernia, traumatic disorders and dislocations of joints, osteoarthritis and varicose veins in the lower extremities. Categories showing a proportional drop included chronic obstructive and bronchiectasic pulmonary disease, infection due to the human immunodeficiency virus (HIV), gastrointestinal hemorrhage, malignant neoplasms of the bronchi and lung and intracranial injuries.
The following are the most noteworthy characteristics of TABLE 12 for the most relevant categories, compared with those of 1999.
TABLE 12. Diagnostic categories in accordance
with the CCHPR classification. 1999 and 2000 Procedures
The CMBDAH
Register presents up to 4 diagnostic or therapeutic procedures coded in
accordance with the ICD·9·CM.
The first is the diagnostic or therapeutic procedure, which is carried out during admission of the patient and most directly related to the main diagnosis.
This variable was recorded for 76.4% of all discharges, of which 0.3% was not specified and 0.06% either erroneous or inconsistent with age and/or sex.
As for other procedures, the percentages of notification were 35.2% for the second, 12.9% for the third and 6.7% for the fourth. The average number of procedures recorded per discharge was 1.31 (1.29 in 1999).
As with the main diagnosis, two workings of the first procedure are presented by different group level:
•
Major ICD·9·CM procedural groups
•
Procedural categories of the Clinical Classifications for Healthcare
Policy Research (CCHPR) proposed by the Agency for Healthcare Policy and
Research (AHCPR) of the Department of Health and Human Services of the
United States.
Major
ICD·9·CM procedural groups
The ICD·9·CM
gathers the more than 4000 procedural codes into 16 major groups.
TABLE
13 shows the distribution of discharges by first procedure
in terms of these major groups.
Operations on the digestive system, operations on the musculoskeletal system, eye operations and obstetrical procedures accounted for 45.5% of the discharges for which the first procedure was recorded. These procedural groups were always the most frequent, if one discounts the miscellaneous procedural group, which was made up almost entirely of non-surgical procedures.
With regard to 1999, the number of discharges with the first procedure recorded went up 10.8%. The procedural groups that increased with regard to this value were: eye operations, obstetrical procedures, operations involving the musculoskeletal system, the nervous system and both male and female genital organs. These rises were produced for reasons having to do with Register coverage or increased CMA or because of incentives introduced in the public system designed to increase the activity of certain procedures.
Even though each group includes very different procedures and typologies of treated people, the longest average stays plus discharges corresponded to operations on the hematic and lymphatic systems and the respiratory system, and the shortest to operations on the eyes, ear, nose, mouth and pharynx (TABLE 13).
In terms of age, the procedural groups with the highest average age were those involving operations on the eyes, urinary tract and cardiovascular system. The lowest average ages involved operations on the nose, mouth and throat, and obstetrical procedures (TABLE 13).
As occurred with the main diagnosis, differences in age and sex were seen in the distribution of discharges for the first procedure (TABLES 14 and 15).
Operations on the digestive system stood out in both sexes and for practically all ages, but principally in men between 45 and 74 years of age. Eye operations were most frequent in women over 65 and men over 75. Operations on the musculoskeletal apparatus were most frequent in women from 55 to 64 years of age and men over 84. In men, operations on the musculoskeletal apparatus were also significant but at younger ages (15 to 44), since these tended to be the result of injuries. The most frequent procedures in women of these ages (15 to 44 years) were obstetrical and involving the genital apparatus. Finally, a significant number of operations were performed on the nose, mouth and throat among children and adolescents between 1 and 14 years of age.
TABLE 13. Distribution of discharges, average
length of stay and average age of first procedure, in accordance with
the major procedural groups of the ICD·9·CM. 1999 and 2000
TABLE 14. Percentage of discharges
of the three major procedural groups accumulating most discharges in each
age group, in men. 2000
TABLE 15. Percentage of discharges
of the three major procedural groups accumulating most discharges in each
age group, in women. 2000 Procedural
categories of the CCHPR
The CCHPR
procedural classification organizes all of the procedural codes into 231
categories and 16 groups.
The level of comprehensive information provided in the procedural statement for the CMBDAH Register varied, according to whether these were surgical or medical. Surgical procedures were comprehensively collected, but medical procedures depended on the criteria of each hospital: while some presented all of them systematically, others did not present any. Given this varying level of comprehensive information and the fact that certain categories included both surgical and medical procedures, the analysis differentiated between each type of procedure, thus enabling us to determine the exact number of surgical procedures.
ANNEX 3 shows the detailed codes used for each of the procedural categories. Those considered surgical were distinguished from those considered medical.
TABLE 16 shows the total number of discharges for 2000 for each type of procedure and the percentage distribution, average length of stay, average age, proportion of discharges among women and mortality rate.
Of all discharges, 45.7% were recorded as surgical procedures and 30.6% as medical procedures. No procedure was recorded for 23.6% of discharges. This last group corresponded in large part to non-surgical treated people, and for this reason they have been included in TABLE 19 under medical procedures.
The most relevant differences between the two procedural groups, surgical and medical, had to do with the average length of stay and the mortality rate. The average length of stay of discharges with surgical procedures was shorter because, first of all, this group included CMA activity and, second, a large number had to do with non-complex pathologies. The mortality rate was notably higher for discharges in the medical procedural group.
In the analysis of the surgical procedure group, it should be stressed that, five of the six most frequent categories in 1999, exceeded the average growth of the overall surgical procedures, which was 12.7%. More specifically, operations involving the crystalline lens (24.9%), inguinofemoral hernia (15.8%), caesarians (19.3%), cholecystectomy and exploration of bile ducts (16.2%) and the ligature and tearing of varicose veins in the lower extremities (22.3%).
While the rise of caesarians is linked to more comprehensive information recorded in the Register from hospitals not belonging to the XHUP, the other four categories were justified by the efforts made by the public health system to finance interventions that bring about waiting lists.
The following are the most outstanding characteristics of TABLE 16 for the most relevant categories compared with those of 1999.
TABLE 16. Procedural categories in accordance with the CCHPR classification.
2000 Code
E (external cause)
The recording
of this variable is required when one of the diagnoses has been produced
by an external cause. This condition is obligatory in discharges involving
traumatology-related admission status. Discharges can also take place
on account of other, non-traumatological admission status types, and code
E is obligatory here too.
In 2000, 82.2% of traumatology admissions correctly identified the external cause (82.8% in 1999). For the remaining 17.8%, the code E variable was erroneous, either because it was not recorded (15.4 %) or because it had an erroneous or non-specific code (2.4%).
TABLE 17 shows the frequency of external causes recorded on the basis of the ICD·9·CM categories. Among traumatology admissions, the most frequent of these were prompted by accidental falls (22,090), followed by road traffic accidents (8,388). Most noteworthy among other causes were procedural complications (11,637) and adverse effects from pharmaceutical drugs (7,101).
TABLE 17. External causes of injuries and
poisoning. 1999 and 2000 Perinatal
data
Perinatal
data are recorded for the variables of length of pregnancy, weight and
sex of newborns.
Recording of these variables is required for all deliveries.
Of the 56,100 discharges for whom the perinatal variables should have been reported in 2000, 93.4% presented correct information on length of pregnancy, 95.5% on birth weight and 95.8% on the sex of the newborn.
The number of deliveries reported to the CMBDAH in 2000 rose 13.5% from 1999. This increase (42.2%) was due in large part to the obstetrical activity of the hospitals that began reporting to the CMBDAH Register in 2000.
The percentage of multiple births (1.9%) was the same as the previous year (even though the 1999 report erroneously stated this as being 2.8%).
When the deliveries were according to the age of the mother, a normal breakdown was seen, with an average of 30.7 years.
When analyzing deliveries by length of pregnancy, it was found that 84.1% took place at between 38 and 41 weeks. 13.5% occurred prior to the 38-week mark and 2.4%, following week 41. Weight at birth was directly related to the length of pregnancy (FIGURE 7). 6.7% of newborns weighed less than 2,500 grams, while 5.0% weighed more than 4,000 grams. As for the rest of newborn babies (88.3%), the majority weighed between 3,000 and 3,500 grams (44.9%).
Of all newborns, 51.7 % were boys and 48.3% were girls (sex ratio: 1.07).
FIGURE 7. Distribution of deliveries by
weeks of pregnancy and weight of newborn. 2000 DAY
HOSPITAL (HDD)
Day hospitalization
is regarded as planned care by medical or nursing staff for treated people
who require the application of certain treatments or diagnostic techniques
in one day, or who need other support services which would otherwise require
conventional hospitalization.
Day hospital activity is part of the increasingly more ambulatory approach taken by certain healthcare processes that have gradually been included in routine hospital activity. The CMBDAH began receiving day hospital (HdD) information in 1996. Since then, the comprehensive quality and validity of the data have improved.
The total number of HdD sessions reported to the CMBDAH in 2000 was 127,422, meaning a 14.5% increase over 1999. Despite this rise, the HdD activity recorded in the Register only represented around 30% of the total sessions carried out.
The average number of sessions per treated person (2.75) was notably higher than that of conventional activity and CMA (1.22), since day hospitals deal for the most part with treated people receiving continued treatment.
46.6% of the sessions corresponded to women, and the average age was 52.1 years (53.2 years for men and 50.9 years for women).
The main diagnosis and first procedure were analyzed using the diagnostic and procedural categories of the Clinical Classifications for Healthcare Policy Research (CCHPR) proposed by the Agency for Healthcare Policy and Research (AHCPR) of the Department of Health and Human Services of the United States.
Given the predominantly medical nature of this type of activity, the majority of the most frequent procedural categories have been grouped under "Other" categories, and thus do not provide any relevant information. This explains the ranking of the following as the 12 most frequent diagnostic categories for 2000.
They accounted for 52.1% of all HdD activity.
MENTAL
HEALTH
The
CMBDAH compiles the data for psychiatric hospitalization
carried out at both specialized psychiatric hospitals and
general hospitals.
The data for specialized psychiatric hospitals are analyzed separately, since they perform a type of activity that differs significantly from both the overall activity of the CMBDAH, and the psychiatric activity of general hospitals.
Nonetheless, patients in psychiatric hospitals are treated in acute or sub-acute care units, depending on their clinical characteristics. For the most part, acute-care units admit patients with non-developed processes that are often first episodes of the disease. Sub-acute care units, on the other hand, tend to admit patients with severe mental disorders, with serious developments and frequent relapses. They are patients, who thus need a longer, more complex hospital intervention, which includes biological, psychological and social procedures.
TABLE 18 shows some of the indicators by hospital type. It presents the indicators of psychiatric hospitals, differentiating discharges by healthcare unit typology. In general hospitals, the indicators are broken down into hospitals that have psychiatric service and those that do not.
In 2000, the number of discharges prompted by the two types of resources was practically the same. In psychiatric hospitals, the majority of discharges were produced in acute units; in general hospitals they took place in those with psychiatric services.
The characteristics of the patients treated in one type of hospital or another showed differences.
The proportion of men was greater to women in all of the resources analyzed. The average age of patients treated in psychiatric hospitals was lower than those treated in general hospitals.
The average length of stay showed very significant differences, depending on the type of hospital and unit. The latter indicator in particular revealed that these differences were directly related to the clinical characteristics of the patients. This would explain the difference between the 6.4-day average length of stay for general hospitals without psychiatric service and the 91.4 days for sub-acute units.
TABLE 18 shows the most frequent diagnoses of psychiatric hospitals, comparing them with the distribution of the same diagnoses at general hospitals.
Patients with schizophrenia or personality disorders were treated for the most part in psychiatric hospitals, while those suffering from alcohol dependence are treated in general hospitals. As for patients with affective psychoses, the percentage was slightly higher in general hospitals with psychiatric service. It should be stressed that discharges from general hospitals lacking a psychiatric service of their own differ radically from the profile of other hospitals, given that the incidence of the four main diagnoses is very low.
TABLE 18. Global parameters
of discharges from psychiatric hospitals and of discharges
from general hospitals. 2000 THE
CMBDSS REGISTER
Organization
and operation
The
CMBDSS Register presents the data concerning the
healthcare activity of the social healthcare resources
hired by CatSalut.
In this report the term "resources" is applied to all those units or healthcare outfits that carry out activity considered to be social healthcare. The resources are broken down into the following groups:
Hospitalization
resources. The patients treated in this type
of resource receive healthcare while hospitalized.
Depending on the clinical characteristics of the
patients, this care is given in the following
units:
•
Extended care units
These
provide continued care to people with diseases