Healthcare non-expenditure statistics - methodology

Latest update of text: August 2023

This background article explains non-expenditure healthcare statistics, a data set concerning healthcare resources (such as personnel, beds and medical equipment) and healthcare activities (such as information on surgical operations and procedures and hospital discharges) in the European Union (EU).

The article provides information on the main features of these data, their historical development and current legal basis, some main methodological features, information concerning data quality and finally an overview of the uses of the data that come from this source.

This article is one of a set of online background articles concerning the methodology for the production of health statistics in the EU and accompanies a number of statistical articles which make up an online publication on health statistics.

Full article

Main features

Statistical objectives

Non-expenditure healthcare statistics provide information on access to health care.

Data on non-expenditure healthcare subjects form a major element of public health information as they describe the capacities available for different types of healthcare provision as well as potential ‘bottlenecks’ that may be observed in healthcare systems.

These data support healthcare policies which place particular emphasis on the access to, and the quality and sustainability of health care. Data on access to health care and the introduction of technological progress complement financial indicators available from healthcare expenditure statistics.

Scope of the data

Information on the non-expenditure component of health care can be divided into two broad groups of data.

Resource-related healthcare data:
- personnel (healthcare staff): physicians, dentists, midwives, nursing and caring professionals, pharmacists, physiotherapists, and healthcare graduates;
- availability of facilities: hospital beds, beds in nursing and residential care facilities, day care places in hospitals, operating theatres and medical technology.
Activity or output-related data (contacts between patients and the healthcare system and the treatment thereby received):
- consultations;
- procedures and treatment;
- cancer screening;
- immunisation against influenza;
- use of medical technology;
- curative care bed occupancy rate;
- length of stay;
- hospital discharges.

Note that data on some aspects of non-expenditure healthcare statistics are also available from the European health interview survey (EHIS) and EU statistics on income and living conditions (EU-SILC).

Coverage

All public and private hospitals should be covered.

Data on healthcare staff, in the form of human resources available for providing healthcare services, are provided irrespective of the sector of employment (in other words, regardless of whether the personnel are independent, employed by a hospital, or any other healthcare provider).

Data on the availability of beds should ideally cover all hospitals (including general hospitals, mental health and substance abuse hospitals, and other specialty hospitals).

Data on the availability of other facilities as well as healthcare activities cover hospital and ambulatory care.

Development and legal basis

Development and history

In order to arrive at common definitions, a first meeting on this area of statistics took place between Eurostat and the Organisation for Economic Co-operation and Development (OECD) in April 2006: the World Health Organisation (WHO) was invited but could not participate. A list of items common to the Eurostat and the OECD annual data request was established, and for each item existing definitions used by Eurostat, the OECD and the WHO were compared. Based on this material and discussions, definitions were compiled and agreed for those items that are routinely collected by Eurostat and the OECD. Further meetings involving also the WHO took place in March 2007 and April 2008 and at the latter it was agreed to create a joint questionnaire on non-expenditure data. Subsequently these three organisations met twice a year to discuss the choice of variables and the questionnaire structure.

Since 2010, Eurostat, the OECD and the WHO have been jointly collecting data on healthcare resources and in addition, Eurostat collected data on healthcare activities. Since 2013, healthcare activities have been incorporated in the joint data collection and Eurostat has introduced a separate module on the number of physicians by speciality, regional data and hospital technical resources.

A Task Force chaired by Eurostat with the participation of nine Member States and DG SANTE was set up in December 2013, and proposed a dataset to meet the main needs on healthcare statistics at EU level.

In 2015, a new module on health workforce migration was added to the JQNMHC responding to the growing need to have data on movement of healthcare personnel.

In 2019, the Task Force on Healthcare non-Expenditure reviewed the minimum dataset foreseen to be mandatory in the future. An ad-hoc pilot data collection on hospital beds was made and a revised minimum dataset was discussed in the Technical Group Healthcare non-Expenditure. The focus is on the most policy-relevant indicators while taking into account data availability.

In 2021, pilot indicators on Intensive Care Units and Teleconsultations were included for the first time, and will continue to be collected on a pilot basis for the foreseeable future.

Data collected in 2023, for reference year 2021, is the first collection where a set of variables are mandatory for Eurostat reporting countries. The variables provided on voluntary basis remain important to collect annually and improve in the future.

Legal basis

Until 2021, data were submitted to Eurostat on the basis of a gentlemen’s agreement, in other words, without a legal obligation.

A Regulation on Community statistics on public health and health and safety at work (EC) No 1338/2008 was adopted by the European Parliament and the Council in December 2008. Within the context of this Regulation, a Commission Regulation 2022/2294 was adopted in November 2022, outlining the mandatory variables, and metadata covering healthcare non-expenditure statistics, the reporting countries are required to deliver. The first data submitted according to the new legal bases were for reference year 2021.

Methodology

Main sources

Non-expenditure healthcare data are mainly based on national administrative sources and reflect the country-specific way of organising health care.

A few countries compile this information from surveys where administrative sources are insufficient.

Statistical units

Non-expenditure data mainly relate to resources and activities within healthcare institutions.

Main concepts and definitions

Reference period: data generally refer to the calendar year, the situation at the end of the year or the annual average. One exception is the influenza vaccination programme data, which can be reported according to the influenza season. In this case, data refer to the season preceeding the reference year, e.g. 2021 data refer to influenza season 2020/2021.

Wherever applicable, the definitions are in line with the system of health accounts (SHA). The SHA is a framework for the systematic description of the financial flows related to health care.

Three main concepts are used for health professionals: practising, professionally active and licensed to practise.

Practising health professionals (e.g. doctor, nurse, or dentist) provide services directly to patients;
Professionally active health professionals include those who practise, as well as those working in administration and research with their medical education being a pre-requisite for the job they carry out;
Health professionals licensed to practise are those entitled to work as physicians plus, for example, those who are retired.

Eurostat gives preference to the concept of ‘practising’ health professionals, as it best describes the availability of healthcare resources.

Hospital bed numbers provide information on healthcare capacities, in other words, on the maximum number of patients who can be treated by hospitals. Hospital beds (occupied or unoccupied) are those which are regularly maintained and staffed and immediately available for the care of admitted patients.

Curative care (or acute care) beds are those that are available for curative care; these form a subgroup of total hospital beds, alongside psychiatric care beds, long-term care beds and other hospital beds.

An in-patient is a patient who is formally admitted (or ‘hospitalised’) to an institution for treatment and / or care and stays for a minimum of one night or more than 24 hours in the hospital or other institution providing in-patient care. ‘Inpatient care’ means the care of an inpatient

An Outpatient is a patient who receives medical and ancillary services in a healthcare facility and who is not formally admitted and does not stay overnight. ‘Outpatient care’ means the care of an outpatient.

Day cases: day care comprises medical and paramedical services (episode of care) delivered to patients who are formally admitted for diagnosis, treatment or other types of healthcare with the intention of discharging the patient on the same day. An episode of care for a patient who is admitted as a day-care patient and subsequently stays overnight is classified as an overnight stay or other in-patient case. Under the definition set in Regulation (EC) 2022/2294 ‘Day case’ as a patient who receives planned care. Some countries may identify/define ‘Day cases’ differently and will outline this in the metadata.

Discharges, rather than admissions, are used because hospital abstracts for in-patient care are based on information gathered at the time of discharge. A (hospital) discharge is the formal release of a patient from a hospital after a procedure or course of treatment (episode of care). A discharge occurs anytime a patient leaves because of finalisation of treatment, signs out against medical advice, transfers to another healthcare institution or because of death. A discharge can refer to in-patients or day cases. Healthy newborns should be excluded. Transfers to another department within the same institution are excluded.

Discharges by diagnosis refer to the principal diagnosis, in other words the main condition diagnosed at the end of the hospitalisation (in-patients) or day treatment (day cases). The main condition is the one primarily responsible for the patient’s need for treatment or investigation (for additional details, see International statistical Classification of Diseases and related health problems — ICD-10 Volume 2).

The average length of stay is calculated by dividing the number of hospital days (or bed-days or in-patient days) from the date of admission in an in-patient institution (date of discharge minus date of admission) by the number of discharges (including deaths) during the year.

Procedures are all types of medical interventions with the intention of achieving a result in the care of persons with health problems. They include diagnostic or therapeutic procedures.

Main classifications

For surgical operations and procedures a shortlist of the International Classification of Diseases — clinical modification (ICD-9-CM) is used.

For hospital discharges, the International Shortlist for Hospital Morbidity Tabulation (ISHMT) is used for data from 2000 onwards. The complete list is also available as part of the joint questionnaire. For data for the period 1989–2002 a Eurostat shortlist of some 60 selective diseases based on the International Classification of Diseases (ICD) was used.

For regional data, the classification of territorial units for statistics (NUTS) is used for EU Member States and the classification of statistical regions outside the EU is used for EFTA and candidate countries.

Further methodological information

The Healthcare non-expenditure statistics manual provides an overview of the classifications, both for mandatory variables and variables provided on voluntary basis.

Common definitions for many non-expenditure healthcare indicators were agreed with the OECD and the WHO in the context of the joint questionnaire on non-monetary healthcare statistics. Following the adoption of Regulation (EC) 2022/2294 countries reporting to Eurostat use the definitions outlined in Annex I of the regulation.

Further definitions (as well as country specific notes) in the form of metadata are available here: Healthcare non-expenditure statistics European metadata report

Data quality

The comparability of data over time is checked before dissemination. Some countries may have a change in their data collection and so a break in series. These breaks in series are flagged and (where available) information is given in the metadata accompanying the data.

The comparability of data across EU Member States is limited by the fact that national data is subject to the way in which information is available.

While data on the number of beds should include public as well as private sector establishments, some EU Member States are only able to provide data only for the public sector.

Data dissemination

Published data

Statistical data are available in various formats. Statistics Explained articles and publications provide data and analysis, while Eurobase provides a set of multi-dimensional databases and information in a simpler format as main tables.

Time coverage

All data are annual.

The length of the time series varies between individual datasets.

Data set	Oldest data
Personnel, physicians, health graduates	1980
Hospital beds	1960
Long-term care beds	1980
Day care places and operating theatres	2000
Availability of medical technology	1980
Procedures and treatment; use of medical technology	1990
End-stage renal failure patients	1980
Curative care bed occupancy rate	1960
Hospital discharges	1970 (detailed data from 2000)
Length of stay / number of days	1960 (detailed data from 1999)
Consultations	1960
Breast cancer and cervical cancer screenings; vaccination against influenza	2000

Geographical coverage

Data are generally available for all EU Member States as well as EFTA and candidate countries.

For all indicators national data are provided. For some indicators (health personnel, hospital beds, long-term care beds, hospital discharges and length of stay) regional data are also available, normally at levels 1 and 2 of the NUTS 2021 classification.

Further analysis / classifications

As well as a geographical analysis (see below for details), depending on the indicator, a variety of other classifications are used to analyse the data. The table below gives a summary — precise details can be found in each dataset.

Data set	Additional analysis
Personnel	Type of personnel
Physicians	Type of specialisation; age and sex
Health graduates	Type of personnel
Hospital beds	Type of care, type of ownership
Long-term care beds	–
Day care places	Type of care
Operating theatres	–
Availability of medical technology	Type of technology, type of provider
Procedures and treatment	Type of medical procedure, type of patient
Use of medical technology	Type of technology, type of provider
End-stage renal failure patients	Type of procedure
Curative care bed occupancy rate	Type of patient
Hospital discharges	Type of patient, age, sex, selected (groups of) diseases; resident status
Length of stay / number of days	Age, sex, selected (groups of) diseases
Consultations	Type of personnel
Breast cancer and cervical cancer screenings	Type of data source (survey or programme data)
Vaccination against influenza	–

Units

Data on the length of stay are presented in terms of the number of days.

For most other indicators data are provided in absolute numbers and per 100 000 inhabitants (population-standardised rates, also referred to as density rates or the frequency of services rendered).

Data on the number of personnel are provided not only as simple head counts (how many doctors, nurses and so on) but also converted into full-time equivalents to improve comparability. As well as being provided in numbers and per 100 000 inhabitants, data on personnel may also be provided as an inverse figure, for example, the number of inhabitants per healthcare worker.

For data on cancer screening and influenza immunisation, percentage (%) of those screened/immunised is used.

Timing of data release

All data and national reference metadata for the reference year T shall be transmitted T+2 years by the dates in the table below for the mandatory variables (Article 6 of Regulation (EU) 2022/2294). For the non-mandatory variables, reporting countries are kindly requested to send all the data by 28 February if possible.

Data section + reference metadata	Deadline
1. Data on Health Employment	28 February (mandatory from reference year 2023)
2. Data on Health Graduates	28 February (mandatory from reference year 2021)
3. Data on Hospital Beds and Beds in Residential Long-Term Care Facilities	28 February (mandatory from reference year 2021)
4. Data on Devices for Medical Imaging	28 February (mandatory from reference year 2021)
5. Data on Ambulatory Care	28 February (mandatory from reference year 2021)
6. Data on Hospital Care	31 August (mandatory from reference year 2023)
7. Data on Surgical Procedures	31 August (mandatory from reference year 2023)