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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
11
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
13
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
21
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
23
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)
24
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: [email protected]
See Chapter 12 for pathology data
New report – 19th Nov 2013