Clare Bayram & Helena Britt - University of Sydney - GP PATHOLOGY TEST ORDERING —RESULTS FROM...

BEACH

SYDNEY MEDICAL SCHOOL

GPs’ pathology ordering – an update

from BEACH

Helena Britt | Clare Bayram

Family Medicine Research Centre

Sydney School of Public Health

University of Sydney

BEACH

Family Medicine Research Centre

BEACH method

BEACH – Bettering the Evaluation And Care of

Health

Paper based, cross-sectional data collection

1,000 randomly sampled GPs per year (drawn by DoHA)

20 per week x 50 weeks a year

100 consecutive encounters per GP

All types of encounters included

National data for 100,000 encounter records p.a.

2

BEACH

Family Medicine Research Centre

BEACH study

Nationally representative sample

Purpose of BEACH is to describe clinical activity

provided in general practice across Australia

- pathology data is part of this clinical activity

- tests are linked by the GP to the problem/s for which

they were ordered

- Maximum of 5 tests/batteries of tests per encounter

3

BEACH

Family Medicine Research Centre

CSL March 2013 BEACH 2012-13

BEACH

Family Medicine Research Centre

CSL March 2013

BEACH 2012-13

and endorsed by

Thank you to

the GPs

BEACH

Family Medicine Research Centre

Pathology ordering

Current pathology ordering 2012-13

- 47.1 tests/batteries of tests are ordered per

100 encounters

- 18.1% of encounters involved pathology testing

- 2.6 number of tests per tested encounter

6

BEACH

Family Medicine Research Centre

Change in rate of testing

0

5

10

15

20

25

30

35

40

45

50

Rate of pathology per 100 encounters 2003-04 to 2012-13

7

BEACH

Family Medicine Research Centre

Change in the likelihood of testing

14

15

16

17

18

19

Proportion of encounters with at least one test 2003-04 to 2012-13

8

BEACH

Family Medicine Research Centre

Change in the number of tests ordered

2.1

2.2

2.3

2.4

2.5

2.6

2.7

Number of test per pathology order 2003-04 to 2012-13

9

BEACH

Family Medicine Research Centre

Top 10 tests (2012-13)

10

Top 10 tests

accounted for

63% of total

tests Over the past

decade

increases in the

rate of test

Likelihood that

management of

a problem will

involve

pathology varies

Tests % total

tests

Rate per 100

encounters

Full blood count 14.0 6.6

Lipids 8.9 4.2

Electrolyte, urea & creatinine 6.4 3.0

Multibiochemical analysis 6.1 2.9

Thyroid function 6.0 2.8

Liver function 5.4 2.6

Glucose/glucose tolerance 5.3 2.5

Urine MC&S 4.2 2.0

Pap smear 3.2 1.5

Ferritin 3.1 1.5

BEACH

Family Medicine Research Centre

Change in common tests

0

1

2

3

4

5

6

7FBC

Lipids

EUC

MBA

Thyroid

LFT

Ferritin

Rate per 100 encounters

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BEACH

Family Medicine Research Centre

Change in rate of testing

0

5

10

15

20

25

30

35

40

45

50

Rate of pathology per 100 encounters 2003-04 to 2012-13

12

BEACH

Family Medicine Research Centre

Contributors to volume of testing

GP ordering behaviour

- Likelihood that pathology will be ordered

- Number of tests ordered once the decision to order has

been made

GP workload at encounters

- Number of problems managed at encounter

National GP workload – total volume of

encounters

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BEACH

Family Medicine Research Centre

National number of GP encounters

0

20

40

60

80

100

120

140

14

Number (million) of MBS GP services 2003-04 to 2012-13

Financial years

96 million

129 million

BEACH

Family Medicine Research Centre

Number of consultations by age

0

2

4

6

8

10

12

14

16

18

15

Average number of consultations per person (2011-12)

Age (years)

BEACH

Family Medicine Research Centre

Change in number of problems

100

110

120

130

140

150

160

170

180

190

Rate of problems managed per 100 encounters 2003-04 to 2012-13

16

BEACH

Family Medicine Research Centre

Number of problems managed by age

100

110

120

130

140

150

160

170

180

190

<14 15–24 25–44 45–64 65–74 75+

17

Age-specific rate of problems managed (2012-13)

Age (years)

BEACH

Family Medicine Research Centre

Top 10 problems (2012-13)

18

Top 10 problems

account for 39%

of tests ordered

by GPs

Extent to which

management of

a problem will

involve

pathology varies

Likelihood that

management of

a problem will

involve

pathology varies

Problem % total

tests

% contacts

with pathology

No. tests

per order

Diabetes 7.5 29.4 3.0

Hypertension 6.0 12.0 2.9

Check-up 5.8 27.3 3.6

Lipid disorders 4.3 26.9 2.4

Weakness/tiredness 3.6 66.2 4.0

Female genital check-up 3.0 78.2 1.2

Blood test NOS 2.4 81.3 3.7

Abnormal test results 2.3 49.6 1.7

Urinary tract infection 2.2 53.1 1.2

Pregnancy 2.0 37.0 2.0

BEACH

Family Medicine Research Centre

Changes in top problems 2000-02 to 2006-08 to 2011-13

19

Top 10 problems

account for 39%

of tests ordered

by GPs

Extent to which

management of

a problem will

involve

pathology varies

Likelihood that

management of

a problem will

involve

pathology varies Problem

Management

rate

% contacts

with pathology

No. tests per

order

Type 2 diabetes —

Hypertension — —

Health check (15+yrs) — — —

Lipid disorders — — —

Weakness/tiredness — — — — —

Female genital check-up — —

Blood test NOS — —

Abnormal test results — — —

Urinary tract infection — — — — —

Pregnancy — — — — —

BEACH

Family Medicine Research Centre

No. of GP contacts involving testing per

person

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Average age-sex-specific number of contacts involving testing

20

BEACH

Family Medicine Research Centre

Expected future growth

Applying projected population growth and ageing

and

Assuming static (2009-10 levels) of GP

attendance and ordering behaviours

Expect a baseline 2.1-2.5% p.a. increase in the

number of testing episodes in the population

from 2009-10 to 2020

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BEACH

Family Medicine Research Centre

In summary

Types of tests and problems for which GPs order

testing have remained constant

Ordering behaviour has stabilised over the

past 5 years 2008-09 to 2012-13

- Number of tests per episode of testing is increasing

GPs’ workload continues to increase

Baseline 2.1-2.5% p.a. increase in episodes of

ordering to 2020 due to population changes

22

BEACH

Family Medicine Research Centre

Implications

GP perspective - management of the patient’s

clinical problem is the driver for GPs’ ordering

behaviour

Assessment of interventions that aim to support

quality ordering behaviour need to measure

ordering behaviour as distinct from workload

Specialist ordering – 30% of MBS services, GP-

specialist cross-over

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BEACH

Family Medicine Research Centre

Implications

Patient age has a considerable impact on GP

workload, and demand for pathology services

Older patients increased chronic disease,

multimorbidity = monitoring pathology

Monitoring guidance

- Interval between repeated tests

- Not just the primary monitoring tests (e.g. for lipid

disorders – need to monitor LFT, FBC, glucose, TFT)

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BEACH

Family Medicine Research Centre

Prevalence in patients aged 45+years

Hypertension (44.1%)

Lipid disorder (29.8%)

Diabetes (15.1%)

Sample of n=3,160

2012-13

25

20.1%

7.8%

10.3%

6.3%

26

Free PDF versions of the BEACH reports can be downloaded from

http://sydney.edu.au/medicine/fmrc

(go to ‘Publications’ and select ‘Books -

General Practice series’)

Hard copies cost $15-35 for each book

Follow us on twitter @Sydney_BEACH

Contact us

Website: sydney.edu.au/medicine/fmrc

Phone: +61 2 9845 8151

Email: clare.bayram@sydney.edu.au

See Chapter 12 for pathology data

New report – 19th Nov 2013