1. Hospital Episode Statistics (HES) Roy Maxwell (Senior Analyst) roy.maxwell@phe.gov.uk Tel: 0117-970-6474 extn 307 roy.maxwell@phe.gov.uk

2. Learning Objectives What is HES? Where do the data come from? What data are available? How are the data used? Examples of HES use Advanced HES issues

3. What is HES? A data warehouse covering hospital activity relating to NHS Contains 3 ‘universes’: In-patients, Out-patients & Accident and Emergency (Casualty) HES service run ‘owned’ by the Health & Social Care Information Centre (HSCIC)

4. Creation of HES Data Copyright © 2013, Health and Social Care Information Centre. http://www.hscic.gov.uk/media/1366/The-HES-processing-cycle-and-HES-data-quality/pdf/The_HES_Processing_Cycle_and_HES_Data_Quality.pdf

5. What Data are Available? Inpatients Data from 1989/90* 16 Million + records annually Annually / Monthly update Outpatients Data from 2003/04* 90 Million records annually Annually A & E Data from 2007/08* (experimental) 18 Million records annually (set to increase to 19m) Annually

6. HES DATA Discharge Info (dates, destination) Admission Info (dates, source, type) Patient Demo- graphics Diagnosis (ICD10) Procedures (OPCS-4) Bed Days / Waiting times, etc... Organisation / Geography (Treatment and Residence) Patient Identifiers (No Names)

7. Key Terms and Definitions Episodes Vs Spells: The Definitions Episode: a continuous period of care under the same consultant. If the patient is transferred to another consultant or to a different provider this would end the current episode and a new one would begin Spell: a patient’s entire stay with a hospital provider (from admission to discharge). If the patient dies, is discharged or transferred, this would end the current episode and spell

8. Key Terms and Definitions Episodes v Spells: the Definitions 1 Spell Episode 2 Episode 3 ONE SPELL CAN CONTAIN MULTIPLE EPISODES Episode 1 (admission) Episode 4 (discharge)

9. Structure of HES Data: Admitted Patient Care - 1 All Activity vs Admissions vs Discharges (1 patient, 1 spell, 3 episodes) Each episode is a separate HES record Hence the above spell is contained in 3 different years, leading to possible double counting of patients and spells when comparing years When comparing years be careful what you count! AdmissionDischarge

10. Spells vs Episodes vs Patients A patient’s entire stay in hospital (admission to discharge) counts as a ‘spell’. Within a spell, each period of care under a consultant is an ‘episode’ Within a given year one patient may have multiple spells, each of which may have multiple episodes Structure of HES Data: Admitted Patient Care - 2

11. How are the data used? Support analysis of NHS activity, including benchmarking, monitoring and clinical audit Inform public health policies and initiatives Detailed spatial and temporal picture of the health of England Support operational decision-making such as commissioning and performance management Linkage to other data sources (e.g. mortality, crime, NHS costs) Feeds into NHS performance indicators Others?

12. How are the data accessed? Method one: freely available data online Main source: http://www.hscic.gov.uk/heshttp://www.hscic.gov.uk/hes But please read the footnotes as what is published might not be what is most meaningful to you as a user! o

13. How are the data accessed? Method two : Direct access or via Public Health England (PHE) either using HDIS or an extract PHE provides an ad-hoc service for other staff in PHE, LAs, academics and the research community

14. Are you interested in hospital activity, incidence or prevalence, admissions, spells or patients treated?

15. Examples of HES use Trends (temporal comparisons)

16. Seasonal variation

17. Examples of HES use comparisons (spatial and inequalities)

18. Comparative Directly age standardised hospital admission rates for accidents by local authority of residence in the East Midlands aged <15 2001/02 to 2005/06

19. Main causes of accidental injury admissions (ages 0 to 14) 0.5% 0.8% 2.2% 0.4% 1.2% 4.5% 6.1% 8.4% 12.4% 18.7% 44.8% Accidents caused by fire Not elsewhere classified Contact with heat and hot substances Overexertion, travel, privation Other transport accidents Exposure to animate mechanical forces Accidental poisoning Other and Unspecified Road Traffic accidents Exposure to inanimate mechanical forces Accidental falls Main causes

20. Geography – a picture tells a thousand words. Who is your audience?

21. Associations – e.g. deprivation Avoidable injury hospital admissions for children under 15 (2001/02 to 2005/06) and child poverty Index, local authorities

22. 2007/08

23. Equity

24. Linkage: Re-admissions

25. Female breast cancer – Emergency admissions Source: Cancer Inequalities in South Central Strategic Health Authority, OCIU (pending) South Central Direct standardised rates All Hospital admissions 2002/03 - 2006/07 breast cancer

26. South Central SHA Male hospital admissions for lung cancer Percentage which were emergencies by quintile of deprivation 2002/03 - 2006/07 Male lung cancer emergency admissions Source: Cancer Inequalities in South Central Strategic Health Authority, OCIU (pending)

27. Rectal cancer – surgical procedures 2007/2008 APE = abdominoperineal excision AR = Anterior Resection Source: Clinical Standards Indicators in South Central, SEPHO 2009

28. Advanced HES issues Linkage Confidentiality Strengths of HES Limitations of HES

29. Linkage. Linking HES to other databases makes it even more useful and powerful Internal linking of data allows new analysis; e.g. re- admissions, time-series (longitudinal) Links can be performed using PSEUDO_HESID Patient names are not on HES DoB, Postcode, NI Number collected but not routinely availableI number

30. Confidentiality Refer to HES Protocol for (disclosure control) Low numbers (1-5) Sensitive fields Postcode, DOB, NHS Number, Consultant Restricted conditions HIV / AIDS, abortions, neurosurgery Deaths Personally & legally responsible for disclosure control

31. Strengths of HES Almost complete coverage of NHS activity relating to Outpatient and Inpatient care Spatially and temporally referenced in great detail (down to postcodes and days) Standard codes for diagnoses (ICD10) & procedures (OPCS4) Freely available data

32. Limitations of HES Specific data-quality issues: Boundary and organisational changes over time Poor data: Maternity, Critical Care, earlier years Only covers hospital-based activity... No mortality: “Cause of death data cannot be obtained from HES” (HES protocol) Not everything results in hospital activity, e.g: Alcohol, Drugs, Cancer, Mental Health, Obesity...But we can link to external databases

33. Considerations Appropriateness – is HES the right tool? Is the event likely to turn up in HES? Looking at emergency events requiring hospital stay, is the condition clearly recorded? Are all hospitals likely to have similar treatment regimes? Medical Assessment Units? Consultants with an interest? Missing events - will all those who die be included? Could always check public health mortality files Private provision? Emergencies usually NHS, electives might be private depending on procedure

34. Hospital Episode Statistics (HES) Roy Maxwell (Senior HES Analyst) roy.maxwell@phe.gov.uk Tel: 0117-970-6474 extn 307 roy.maxwell@phe.gov.uk