Istituto Nazionale di Statistica (Istat)

Department for Statistical Production

Directorate for Social and Welfare Statistics (DCSW)

Division “Integrated Statistics on Health care and welfare”

Viale Liegi 13, 00198 Rome, Italy

Statistics on healthcare non-expenditure provide information on healthcare human resources, healthcare facilities, and healthcare utilisation.

- The people active in the healthcare sector (doctors, dentists, nurses, etc.) and their status (graduates, practising, migration of doctors and nurses, etc.);

- The available healthcare technical resources and facilities (hospital beds, beds in residential care facilities, medical technology, etc.);

- The health activities or patient contacts undertaken (hospital discharges, surgical procedures, ambulatory care data, etc.).

Annual national and regional data are provided in absolute numbers or as a rate of a relevant population.

Data are based mainly on administrative records (see section 18.1 ‘Source data’ for more information).

For the collection data on healthcare non- expenditure, the classifications used in the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (https://www.oecd.org/health/health-systems/1841456.pdf ) are applied.

For hospital discharges, the International Shortlist for Hospital Morbidity Tabulation (ISHMT) is used. (https://circabc.europa.eu/ui/group/c1b49c83-24a7-4ff2-951c-621ac0a89fd8/library/6ff71dd5-8200-4fe4-a610-a7707cd47c4d )

For hospital discharges the classification system used by Italy for diagnoses and medical/surgical procedures is the International Classification of Disease, IX revision, Clinical Modification (ICD-9-CM). The Italian Ministry of Health adopted different versions of ICD-9-CM. Since 2001 until 2005 the 1997 version was used; since 2006 until 2008 the 2002 version was used; since 2009 onwards, the 2007 version was used.

For Health Employment, the Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the recognition of professional qualifications apply (https://eur-lex.europa.eu/eli/dir/2005/36/2020-04-24 ).

Definitions of mandatory variables are laid down in Commission Regulation (EU) 2022/2294.

Where possible, the statistics are separated by sex (male/female), age group and NUTS2 region.

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

Public health.

The healthcare non-expenditure statistics describe the public health sector from a non-monetary perspective. The statistics explain the number or rate of different healthcare resources, facilities and utilisations. A wide range of indicators are collected from a multitude of sources and therefore, details pertaining to individual variables are given in the Annex.

Definitions of mandatory variables are laid down in Commission Regulation (EU) 2022/2294.

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

National changes of statistical concepts and national definitions deviating from Regulation (EU) 2022/2294: see Annex at the bottom of the page.

National definition deviating from Regulation (EU) 2022/2294: Cervical cancer screening. % of female aged 20-69 screened. Italian data refer to women aged 25-64 because in the national screening programme this is the target population for Pap smear test to be performed every 3 years. Most Italian Regions are nowadays moving to HPV test for women aged 30/35-64 years old.

Registered health professionals or health care facility categories.

(1) all health care staff

(2) all available beds or equipment in hospitals or in nursing and residential care facilities

(3) all discharges or procedures performed in all hospitals

Complete national territory

Employment: Physicians 2000 onwards (entitled to practice 1985; by age and gender 2005); Dentists and Pharmacists 2013 (entitled to practice 1986); Midwives 2013 onwards (entitled to practice 2000); Nurses 2003 onwards (entitled to practice 2000); Caring personnel and Physiotherapists 2011 onwards; Hospital employment 2003 onwards; Graduates 2001-2002 onwards.

Physical resources: Hospitals beds 2000 onwards; Residential health care beds 2000 onwards; Medical technology 1997 onwards.

Activities: Consultations 1991, 1994, 1999, 2000, 2005, 2013, since 2014 yearly; Immunisation 2000 onwards; Screening breast and cervical cancer 2004 onwards, colorectal cancer 2014 onwards; Hospital aggregates 1996 onwards; Diagnostic exams 2013 onwards; Procedures 2001 onwards.

Workforce migration: 2000 onwards.

Eurostat module: Staff regional 2000 onwards; Hospital beds 1993 onwards; Hospital technical resources 2000 onwards; Non-resident discharges 2011 onwards.

Hospital Discharge Data (HDD) file: 2012 onwards.

Not applicable

Data are provided in absolute numbers except consultations (number per capita), immunisation against influenza and screening (percentage of target population), average length of stay (average number of days), hospital bed occupancy rate (percentage).

For most variables calendar year. For Health Employment: 31^st December

Regulation on Community statistics on public health and health and safety at work (EC) No 1338/2008 

Commission Regulation (EU) 2022/2294 on statistics on healthcare facilities, healthcare human resources and healthcare utilisation 

Gentlemen’s agreement

Joint Questionnaire on Non-Monetary Health Care Statistics, which is carried by Eurostat, OECD and WHO-Europe.

Several national legal acts guarantee the confidentiality of data requested for statistical purposes. In Italy, according to art. 9, paragraph 1 of the Legislative Decree n. 322 of 1989 (concerning the statistical system), statistical data cannot be disseminated but in aggregated form, in order to make it impossible to identify the person to whom the information relates. The data collected can only be used for statistical purposes.

Official statistics must also safeguard the rights, basic freedoms, and dignity of respondents, in particular with regard to the right of confidentiality and personal identity.

Istat assures the protection of personal data according to the General Data Protection Regulation (Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, repealing Directive 95/46/EC) and, as national legislation, Italian Data Protection Code (Legislative Decree no. 196/2003) and Code of conduct and professional practice applying to the processing of personal data for statistical and scientific research purposes within the framework of the national statistical system.

In order to make statistical secrecy and protection of personal data effective, Istat is currently taking appropriate organizational, logistical, methodological and statistical measures in accordance with internationally established standards.

Moreover, Legislative Decree n. 322 of 1989, art. 6 and 6 bis provides that the exchange of microdata and personal data within the National Statistical System (Sistan) is possible if it is necessary to fulfil requirements provided by the National Statistical Programme.

Finally, in implementation of art. 5-ter of the legislative decree 14 March 2013, no. 33, the new "Guidelines for the access for scientific purposes to the elementary data of the National Statistical System" establish the conditions under which the bodies and offices of the National Statistical System can allow researchers to access their own elementary data for scientific purposes.

Protection of confidentiality

Data on physical resources (hospital, hospital beds, medical technology, residential health care beds) are not personal data.

Data on health personnel and activities (consultations, screening, hospital discharges, diagnostic exams, immunisation) are personal data.

The processing of personal data and sensitive data in administrative sources and surveys is carried out in compliance with current legislation on the data protection.

Data transmitted to Eurostat are aggregated, therefore without any risk for disclosure.

Istat press releases are issued according to a fixed press release calendar, however, statistics on healthcare non-expenditure are not disseminated through press releases and are not reported in the calendar.

Istat press release calendar is available on the website: https://www.istat.it/en/information-and-services/journalists/press-releases-/press-calendar

According to its mission, Istat disseminates statistical information in order to make it accessible and usable to everyone and to remove any barriers to the use of data. All data releases are posted on Istat website on the basis, as regards press releases with short-term data and annual data of strong interest for the country, of an annual release calendar set and published in the December preceding the reference year. Time series are available on I.Stat data warehouse and users can choose information according to their needs, building customised tables or downloading prepackaged datasets. Data are always accompanied by meta-information - methodologies, classifications, definitions. Microdata files are released free of charge and in compliance with the principle of statistical secrecy and data protection. Books, press releases, datasets and infographics are also available on Istat web site; moreover main contents are disseminated through Istat Official Twitter account and other social networks. All Istat information are available free of charge and data are reusable providing the source.

Annual

Not Applicable

- ISTAT. Rapporto annuale 2020 sulla situazione del paese. Capitolo 2 “Sanità e salute di fronte all’emergenza COVID-19”. Roma, 3 July 2020. https://www.istat.it/it/archivio/244848

- Sanità: Le risorse umane nel sistema sanitario. Audizione del Presidente dell’Istituto nazionale di statistica Prof. Gian Carlo Blangiardo. Discussione sulla Nota di aggiornamento del Documento di economia e finanza 2022. Roma, 5 December 2022. https://www.istat.it/it/archivio/278536

- Ministero della Salute. Relazione sullo Stato Sanitario del Paese 2017-2021, 19 October 2022. https://www.salute.gov.it/imgs/C_17_pubblicazioni_3270_allegato.pdf

- Ministero della Salute. Annuario Statistico del Servizio Sanitario Nazionale – 2021, 23 March 2023. https://www.salute.gov.it/imgs/C_17_pubblicazioni_3299_allegato.pdf (salute.gov.it)

- Ministero della Salute. Personale delle ASL e degli Istituti di ricovero pubblici ed equiparati – 2021, 28 August 2023. https://www.salute.gov.it/imgs/C_17_pubblicazioni_3348_allegato.pdf (salute.gov.it)

- Ministero della Salute. Personale delle ASL e degli Istituti di ricovero pubblici ed equiparati – 2021, 28 August 2023. https://www.salute.gov.it/imgs/C_17_pubblicazioni_3348_allegato.pdf (salute.gov.it)

- Ministero della Salute. Il personale del sistema sanitario italiano - 2021, 30 January 2024 https://www.salute.gov.it/portale/documentazone/p6_2_2_1.jsp?lingua=italiano&id=3404

ISTAT:

-          I.Stat http://dati.istat.it/

-          Statbase https://www.istat.it/it/dati-analisi-e-prodotti/banche-dati/statbase

-          IstatData https://esploradati.istat.it/databrowser/#/

Ministero della Salute:

Open Data https://www.dati.salute.gov.it/dati/homeDataset.jsp

Not Applicable

Not Applicable

See in Annex: MH Sources and Methods Word file

See in Annex: MH Sources and Methods Word file

Since the 90s Istat has adopted a systematic approach to ensure the quality of statistical information and of its services to the community.

With the aim of strengthening the commitment to quality, in 2020 Istat set up the Quality Committee, for overseeing all quality initiatives in the Statistical Institute. In addition the role of Quality Manager was formally established.

In 2021 a new quality policy for statistical production was adopted. It is consistent with the European quality framework developed by Eurostat, and transposes its main principles and definitions.

For details: https://www.istat.it/en/organisation-and-activity/institutional-activities/quality-commitment

The overall quality assessment for most variables (both those in the Regulation and those provided on voluntary basis) is positive.

Employment: Italy has made a major investment in statistical data on the health system workforce with the aim of having statistics compliant with international definitions and covering all health sectors (public and private). New data sources have been identified, in addition to those already used for statistical purposes. Currently, Italy provides all variables according to the definitions of the methodological manual Healthcare non-expenditure statistics of Eurostat. There is still some difficulty in calculating the availability of staff in hospitals in full-time equivalents (FTE).

Physical resources: Data on hospitals, hospital beds, medical technology (in hospitals and ambulatory sector) and beds in residential long-term care facilities are of high quality.

Activities: Good quality for data on Immunisation against influenza, Screening of cancer, Hospital aggregates and Procedures.

Quality of data on consultations, estimated by different data sources, could be improved. The estimation of “out of pocket” consultations is difficult because of missing administrative data.

Quality of data on diagnostic exams could be improved too: actual data sources do not allow the distinction between exams in hospitals and exams in ambulatories; out-of-pocket exams performed in ambulatories are missing.

Workforce migration: Data on workforce migration are still of poor quality, both because they refer to doctors and nurse entitled to practice and not to practicing, and because the share of professionals whose country of graduation is unknown is high.

Hospital Discharge Data (HDD) file: Very high quality for hospital discharge data.

Non-monetary health care statistics, together with SHA data, allow to monitor health system, provide key information for public health policies and decision makers, for planning future needs. These statistics are relevant also for researchers and for the general public (directly or indirectly via news, publications, online data).

These data, together with mortality and expenditure data, were of great interest in 2020, when the Covid-19 pandemic broke out and all countries faced health emergency. Since then, intensive use was made of these data and, at the same time, information gaps were identified. This led to adding new variables in the data collection, some of which are still pilot variables due to the difficulties of having good quality and comparable data.

Istat is constantly interested in understanding who the users of the statistics it produces are, what the information needs are, whether they match production and if the statistics produced satisfy users. To this aim, together with the analysis of user requests received through the Web Contact Center service, tools for direct consultation were developed, such as the annual online survey of customer satisfaction and indirect tools such as analysis of accesses and of users' browsing paths on the web site.

The data for Italy have a high degree of completeness. The only variables not yet released are: Hospital employment by FTE; Colorectal cancer screening based on survey data by sex; diagnostic exams by type of provider (hospital or ambulatory).

The overall accuracy for variables under Regulation (EU) 2022/2294 is high.

Data on practicing dentists, pharmacists, nurses and midwives are currently estimated, but they will be improved in the near future. Italy is carrying out a project, which aims to measure the supply of health professionals by means of record linkage of individual data from different sources.

Accuracy of data on medical technology and beds in residential long-term care facilities has to be improved concerning private facilities not accredited with the National Health System (NHS).

Accuracy is more limited for some variables provided on voluntary basis because appropriate data sources are still missing. This is the case for professionally active personnel (based on labor force survey), diagnostic exams performed in private ambulatories non accredited with NHS, consultations with doctors or dentists paid by patients (out of pocket), workforce migration (referred to entitle to practice professionals).

Not applicable.

Not applicable.

The whole variables are updated to year T-2.

Data on licensed to practice health personnel and migration of physicians and nurses are updated to year T-1.

Concerning variables under Regulation (EU) 2022/2294, Italy is compliant with the transmission deadlines (14 months after the end of the reference year): data and reference metadata for the reference year 2021 are transmitted to Eurostat by 28 February 2023.

Most variables on voluntary basis are transmitted to Eurostat by 28 February 2023, only the 2 HDD files are transmitted next month.

Most of the variables of the Joint Questionnaire on Non Monetary Health Care (JQNMHC) are the result of many years of collaboration between Eurostat and the Member States. Italy participated to the Task Force (TF) that defined the variables to be included in the current Regulation. For each variable the TF assessed the level of comparability between countries. Therefore, the variables of the Regulation have a high degree of comparability. The remaining variables of the JQ on a voluntary basis in some cases still present problems of comparability, such as the number of hospitals, because they depend strongly on the organisation of health services in each country. The pilot collection variables (teleconsultations and intensive care hospital beds) also still need to be harmonised to ensure geographical comparability.

The comparability of data over time is very high. Breaks in time series occur mainly for variables with long time series.

Breaks in time series occur:

-          For professionally active physicians, nurses, caring personnel, physiotherapists because of changes in the national and European regulations: since 2021 a new definition of “employed” in Labour Force Survey was adopted.

-          Data on physicians entitled to practice previous 2000 included dentists too.

-          Data on physicians by age and gender previous 2012 were referred to entitled to practice.

-          For the availability of new data sources: for health professionals new data sources on practicing and professionally active are available since 2013; for beds in residential health care facilities the linkage between two data sources allows to have data compliant with the definition since 2018; for doctor and dentist consultations the integration of different data sources allows to have annual data since 2014.

-          For the inclusion of data on private hospitals not-accredited with NHS in physical hospital resources.

For revisions of classifications: the revision of ICD-9-CM changed data for some surgical procedures.

Definitions of variables of the JQNMHC are based, when applicable, on the System of Health Accounts - SHA 2011 methodology and classifications. This ensure a high level of coherence cross monetary and non-monetary statistics.

The internal coherence among variables of the Joint Questionnaire is checked and assured before the transmission to Eurostat.

Coherence is verified for time series calculating annual variation ratios.

Coherence between variables is verified for some domains: among practicing, professionally active and licensed to practice data for health professionals; number of hospital beds and discharges provided in different tables has to be coherent.

The data revision regards provisional figures referred to year T-1; they are revised next year to provide final data.

When a break in time series occurs, the entire time series is checked backwards to the first available year.

Data are revised once a year.

Provisional data are replaced with final data and, occasionally, small changes are made to the data for the last two or three years.

Source data for the different variables are given in the Annex at the bottom of the page.

Annual.

Data are collected through the Joint Questionnaire on Non Monetary Health Care (JHNMHC) that every year countries send to Eurostat. Starting from 2023 countries submit data to Eurostat also on the basis of Commission Regulation (EU) 2022/2294 implementing Regulation (EC) No 1338/2008 of the European Parliament and of the Council as regards statistics on healthcare facilities, healthcare human resources and healthcare utilisation.

The sources used by Italy to provide data are mainly administrative data, but, in case administrative data are missing, survey data are used.

A large part of these data are already collected for other statistical purposes, but in some case data sources are required specifically for the compilation of the JQ. This is the case for entitled to practice and practicing health personnel, for migration of doctors and nurses, doctor and dentist consultations.

Main sources of administrative data are provided by the Ministry of Health. Other data sources are provided by the Federations of health professional associations, the Ministry of Education, private companies.

Concerning sample surveys, the National Institute of Statistics (ISTAT) uses the Labour Force survey data for professionally active personnel; the Household Budget survey and the Monthly Survey of Consumer Prices data to estimate out of pocket doctor and dentist consultations.

Variables on cancer screening based on survey data are calculated by the National Board of Health using PASSI surveillance Survey.

The JQNMHC includes a number of formula which allow national data correspondents to perform consistency checks within tables before submitting the data.
Italy carries out several in depth controls of data before the transmission of JQNMHC. Data are compared with information from other independent sources. The consistency between the data, of the year and of previous editions is checked and evaluated. Time series are analysed and double-checked, looking for trends and anomalies; the adequacy of the estimates is assessed.

Any detected inconsistencies is solved before sending data.

Atypical entries are checked. If atypical entries are identified, compilers verify the figures and, if they are correct, a description of the reasons are included in the Sources and Methods Metadata file.
The magnitude of revisions as compared to previously submitted data is checked too.

The variables compiled by Ministry of Health data sources are updated directly by the Ministry, while ISTAT compiles remaining variables (health employment except hospital employment, workforce migration, regional data for physicians, beds in residential long-term care facilities only for private facilities not accredited with NHS, doctor and dentist consultations). The two bodies work together to cooperate in case of coverage or definition problems, in order to find the most appropriate solution. Thanks to this close cooperation, it has been possible to estimate some variables that were not available before. The estimation methodology is agreed in order to have data as close as possible to the definition provided in the Eurostat Methodological manual.

ISTAT and the Ministry of Health request also data to other institutions by means of official letters.

No adjustments are performed.

There are no additional comments.