demand for pathology testing (drivers of demand) 2) The benefits to patients and the health system generally that flow from the early detection of disease 3) The role of pathology in preventive health and chronic disease management 4) Primary care strategies, access, affordability, quality and safety. Appendix A: Methodology of data collection from University Sydney, BEACH AIHW and explanation for EXCEL File.<br><br> Appendix B: EXCEL File (emailed only) 3 . Pathology in Australia (AAPP authorship)* with appendices: Appendix A: Quality of pathology services (The Royal College of Pathologists of Australasia authorship)* Appendix B: History and purpose of the Licensed Collection Centre Scheme and the Approved Collection Centre Scheme (AAPP authorship)* Appendix C: The Pathology Request-Test-Report Cycle ( How pathology services are requested and delivered) (AAPP authorship)* Appendix D: The Role of Small-Medium Private Pathology Practices in Australia (AAPP authorship)* 4. Profitability and returns in the non-government pathology sector (PricewaterhouseCoopers authorship)# 5.<br><br> Review of costs and cost drivers for the non 3government pathology sector (PricewaterhouseCoopers authorship)# Items marked * are included in hardcopy and are also attached to an email. The items marked # are only available in hard copy and will be hand delivered. AAPP assumes that paper 4 ( Profitability and returns in the non-government pathology sector ) and paper 5 ( Review of cost and cost drivers for the non 3 government pathology sector ) will be deemed confidential to be used only by the IDC in the Strategic Review process.<br><br> We draw your specific attention to the following crucial matters in the review: " Fee for Service (FFS) - we seek the maintenance of FFS with the same increments as are applied to other medical practitioners within the MBS; " Removal of the cone that applies to rebates paid for services requested by general practitioners; " The continuance of important governmental and professional forums such as the Pathology Services Table Committee, the Quality Use of Pathology Committee, the Pathology Consultative Committee, and the National Pathology Accreditation and Advisory Committee; and " As part of an emphasis on quality, we support the exploration of improving pathology ordering through the development of intelligent ordering systems to ensure appropriate investigations are ordered for our patients. AAPP would welcome the opportunity to discuss our Submission in person with the IDC. Our consultants, PricewaterhouseCoopers, are also available for independent discussions with the IDC if you so wish.<br><br> Yours sincerely Dr Ian Clark President AAPP 14 th November 2008 Contents of AAPP response to The Strategic Review of Future Funding Arrangements for DI and Pathology 31 st October 2008 Covering letter to Mr John Ignatius, Chair Strategic Review IDC with: 1. Response to the Strategic Review of Future Funding Arrangements for DI & Pathology (AAPP authorship) 2. An Analysis of Pathology Test Use in Australia (AAPP authorship utilising BEACH data): Sections include: A.<br><br> Those influences on the demand for pathology testing (drivers of demand) B. The benefits to patients and the health system generally that flow from the early detection of disease C. The role of pathology in preventive health and chronic disease management D.<br><br> Primary care strategies, access, affordability, quality and safety. Appendix A: Methodology of data collection from University Sydney, BEACH AIHW and explanation for EXCEL File. Appendix B: EXCEL File ( emailed only) 3.<br><br> Pathology in Australia (AAPP authorship) with appendices: Appendix A: Quality of pathology services (The Royal College of Pathologists of Australasia authorship) Appendix B: History and purpose of Licensed Collection Centres and Approved Pathology Collection Centres (AAPP authorship) Appendix C: The Pathology Request-Test-Report Cycle (How pathology services are requested and delivered) (AAPP authorship) Appendix D: The Role of Small-Medium Private Pathology Practices in Australia (AAPP authorship); 4. Profitability and returns in the non-government pathology sector (PricewaterhouseCoopers authorship) with a copy of Confidentiality Undertaking between Department of Health and Ageing and AAPP 5. Review of costs and cost drivers for the non 3government pathology sector (PricewaterhouseCoopers authorship).<br><br> Australian Association of Pathology  Practices Inc.    Response to the  Strategic Review of  Future Funding  Arrangements for DI  & Pathology  Terms   of    Reference:     31 st   October   2008     2 TOR Strategic Review of Future Funding Arrangements for DI & Pathology 1. Appropriateness The review will examine the rationale for current Government expenditure on diagnostic imaging and pathology services and consider future arrangements and funding levels, within a context of fiscal sustainability. Pathology testing underpins virtually all modern heath care and plays a vital role in the prevention, diagnosis and treatment of both acute and chronic illness.<br><br> The current fees and the level of remuneration for pathology services have been reached after a 22 year period of absolute fee restraint. Pathology is the only area of health and medical care, including general practice, diagnostic imaging and other specialist services, which is operating with a lower unit fee level than it had 20 years ago. While government funding of pathology services has increased over this time, this increase is due entirely to increased testing activity resulting from factors outside of the control of the pathology sector, including higher rates of arm 9s length referral and changes in disease frequency, medical practice and management.<br><br> Data from the Bettering the Evaluation and Care of Health (BEACH) program provides useful information which can inform our understanding of the drivers of growth in the pathology sector. The BEACH program is a national study of GP activity. It provides information which can link specific problems that patients present with to GPs' responses to managing these problems, such as writing prescriptions, referrals to specialists and recommendations for further investigations.<br><br> BEACH annually surveys 1000 GPs and its results can be validly extrapolated to all GPs. Over the period 2004/05 to 2007/08 (the current MoU between the pathology sector and the Federal Government), the BEACH data set links the growth in pathology services with the specific presenting problem of patients during this time. This provides a picture of where the growth in pathology services occurs and gives an indication of its role in the overall health care of patients.<br><br> The table below illustrates the association between the percentage growth in pathology services and the specific problems being managed. For example, 11.1% of the growth in pathology services initiated by GPs during this period was associated with the management of diabetes. The 21 problems/conditions included in the Table 1 comprise 19.3% of all problems managed by GPs in 2004/05 and 21.6% in 2007/08.<br><br> This represents a 12% increase in the problems most likely to require further pathology testing during this period. This is then compounded by the growth in total GP activity, i.e. there was both an overall increase in the number of GP services being provided and in the proportion of these services requiring pathology referrals.<br><br> Adding both of these factors together results in a 42% increase in the number of these problems managed over these four years. 3 The growth in the number of pathology tests requested associated with these problems accounted for 75% of the total increase in pathology tests requested by GPs over that period. An extrapolation to the whole of Medicare means that these 21 problems being managed by GPs accounted for 55% of the total increase in Medicare pathology services between 2004/05 and 2007/08.<br><br> As the data in the table below makes clear, a high proportion of the problems/conditions generating the greatest growth in pathology testing are preventive health interventions. These include the problems ranked Numbers 1, 4, 6, 8, 9, 14, and 20 in the table below. Together, these conditions accounted for 31.7% of the total growth of pathology tests requested by GPs during this time.<br><br> * This is the proportion of pathology test growth attributed to this problem as a percentage of the total pathology test order growth ** NOS = Not otherwise specified This outcome is in line with government policy aims to increase activity in the area of disease prevention and also in response to changing patterns of disease within the community, such as the increase in the numbers of Australians with diabetes. In particular, the review will examine issues of access for the public, including affordability of clinically appropriate services, geographic location of services and workforce issues. Pathology has a higher bulk billing rate than other medical services, including general practice, despite having received no fee increases in recent years.<br><br> This is demonstrated in Graph 1 below. Problem managed Per cent of total pathology growth 1. General check-up 12.9 2.<br><br> Diabetes 10.5 3. Hypertension 10.4 4. Blood test NOS** 5.5 5.<br><br> Lipid disorders 4.9 6. Pregnancy 4.0 7. Abnormal test results 3.7 8.<br><br> Female genital check-up 2.9 9. Microbiology/immunology test NOS 2.5 10. Weakness/tiredness general 2.2 11.<br><br> Vitamin/nutritional deficiency 1.8 12. Urinary disease, other 1.6 13. Skin symptom/complaint, other 1.4 14.<br><br> Cardiac check-up 1.4 15. Hypothyroidism/myxoedema 1.3 16. Pain, chest NOS** 1.3 17.<br><br> Abdominal pain 1.3 18. Anaemia 1.3 19. Menopausal symptom/complaint 1.2 20.<br><br> Overweight (BMI < 30) 1.2 21. Endocrine/metabolic/nutritional disease, other 1.1 Total Pathology test growth as % of all GP Path growth 74.4% 4 Percentage of Services Bulk Billed from July 1996 to June 2008 quarterly data published by DoHA 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Sep-96 Mar-97 Se p - 9 7 Mar- 9 8 Sep-98 Mar-99 Se p - 9 9 Mar-00 Sep-00 Mar- 0 1 Sep-01 Ma r - 02 Se p - 0 2 Mar-03 Sep-03 Ma r - 0 4 Sep-04 M a r-05 Se p - 0 5 Mar-06 Sep-06 Ma r - 07 Sep - 07 M a r-08 A ll Medicare Pathology General Practice Diagnostic Imaging Operations Specialist attendances Obstetrics Anaesthetics Pathology also has higher schedule fee compliance compared with other areas of medical practice, as illustrated in Graph 2 below. Schedule Fee Observance by quarter from July 1996 to June 2008 percentage of services charged at schedule fee or less data published by DoHA 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Sep-96 M ar -97 Sep- 9 7 M ar -98 S e p - 9 8 M ar -99 Sep-99 Mar-00 S e p - 0 0 M ar -01 Sep-01 M ar -02 Sep-02 Mar-03 Sep- 0 3 M ar -04 Sep-0 4 Mar-05 Sep- 0 5 Mar-06 Sep- 0 6 M ar -07 S e p - 0 7 Mar-08 All Medicare Pathology General Practice Diagnostic Imaging Operations Specialist attendances Obstetrics Anaesthetics 5 The high overall rate of bulk billing and schedule fee observance is disproportionately due to Pathology and General Practice as their schedules contain many items of low rebate value and apparent high volumes.<br><br> Pathology requests most frequently lead to the generation of a P10 item (episode initiation items) and an average of two P1-P8 items (test items). Consequently, an episode of referral for testing leads to a claim for multiple Medicare cservices d. The aggregation of pathology practices over the past decade and competition between providers has led to a very high level of bulk billing.<br><br> Geographical access The pathology sector is committed to ensuring that all Australians have access to affordable and accessible services and has worked hard to ensure nationwide coverage. As a result of these efforts, Australians in rural and remote areas have better access to pathology services than they do to any other referred health or medical service. Where there appears to be under-servicing by pathology, this is due to under-servicing by GPs in rural areas, rather than a lack of access to pathology services.<br><br> The Approved Collection Centre (ACC) scheme has been extremely effective in ensuring the viability of pathology collection centres in rural and remote locations. A current list of ACCs can be found at https://www.medicareaustralia.gov.au/apps/notesweb/acc.nsf/ACCPDFAttach/PDF/$File/ACCList.pdf?Open Element The Directions for Pathology (Macklin) Review showed that there is in fact a higher use of pathology by regional GPs compared with those in urban areas. Graph 3 below, illustrates the relatively equitable provision of pathology services across states and territories .<br><br> 0 100000 200000 300000 400000 500000 600000 NSW Vic Qld NT SA Tas ACT Pathology services Number of pathology services per 100 000 population by State/ Territory July 2007 to June 2008 3 Medicare Australia data Workforce Pathology has coped with an increasing shortage of pathologists and scientists by developing flexible and innovative work practices. In fact, pathology leads other medical specialties in the increasingly important area of task substitution. The sector has also had a major involvement in 8on the job 9 training and developed the only significant training scheme for specialists in the private pathology sector.<br><br> Currently there are an estimated 36 000 people employed in the pathology sector in Australia. 6 The appropriateness of options for future arrangements and funding should also be considered against the government 9s approach to social inclusion and social equity, and the need to address any market failure. AAPP members are committed to the Government's policy of social inclusion and strongly support the values of equity and accessibility to our work.<br><br> Given the vital role that pathology plays in the prevention, diagnosis and treatment of chronic diseases which occur at higher rates within disadvantaged groups, pathology is an essential part of efforts to reduce the current health gap within our community. As outlined elsewhere in this paper, pathology has the highest rate of bulk billing of all medical services, ensuring that financial barriers to accessing services are minimized. As part of the pathology sector's MoU with Government, pathology providers also charge patients requiring multiple tests for only the three most expensive tests (known as 8coning 9).<br><br> This reduces the cost burden (to both patients and government) of pathology testing on people with serious and complex health problems, but is now estimated to represent a cost to pathology providers of more than 10% of income. While many other parts of the medical profession have moved away from providing mobile and flexible services, AAPP members continue to provide collection services to patients in a variety of locations, including their own homes, nursing homes, hospitals and hostels. Information materials and instructions are provided in language appropriate for patients, including in community languages where required.<br><br> Patients are never discriminated against on ability to pay or gender or racial basis. AAPP is committed to continue working with government and other stakeholders to increase equity and social inclusion within the health sector, including identifying and addressing incidences of market failure. We believe that a strong and diverse private pathology sector provides the greatest opportunity to address market failures without resulting in adverse effects on consumers.<br><br> 2. Effectiveness The review will consider how well current arrangements have met the health needs of the community and look at better ways to do so in future. One of the greatest challenges facing Australia's health system is the increasing rate of chronic diseases in the community.<br><br> Like most other developed countries, over the past 20-30 years Australia has experienced a reduction in the levels of acute illnesses and an increase in the level of longer term chronic conditions. Currently, according to the Australian Institute of Health and Welfare the top 10 causes of disease burden in Australia are chronic diseases. These diseases alone account for nearly 43% of the total disease burden in Australia.<br><br> This trend is likely to continue into the future: in fact the World Health Organisation has predicted that by 2020 three quarters of all deaths will be due to chronic diseases. This change in the health care needs of the Australian community is placing increased pressure on our health system. Other factors which are adding to this pressure include the ageing of our population (which also results in higher chronic disease levels) and global workforce shortages which mean that we need to increase the efficiency of our health workforce.<br><br> It is imperative that we continue to focus our health care efforts on reducing the chronic disease burden and keeping people healthier for longer. The pathology sector has a vital role to play in re-orienting our health system towards illness prevention and chronic disease management. Pathology underpins almost all preventive health care and is vital to the effective management of chronic disease.<br><br> 7 Examples of the role pathology testing plays in preventing, diagnosing and treating some of the most serious diseases affecting the health of our community include: o Preventive health measures 3 diagnosing the presence and severity of conditions such as obesity, diabetes, high cholesterol, cervical cancer, STDs, osteoporosis, bowel cancer and breast cancer; and o Treatment of chronic disease 3 guiding and assessing the efficacy of treatment for conditions such as diabetes, hypertension, breast cancer and high cholesterol. The main unmet needs for pathology testing are for important but uncommon tests and new tests that are not currently included on the Pathology Services Table. This includes genetic tests which for example can be used to diagnose genetic conditions, including in embryos conceived via IVF before implantation.<br><br> In particular, it will examine the impact of current government expenditure on improving health outcomes for individuals, the sustainability of the diagnostic imaging and pathology industries and the long term funding implications for the Commonwealth. Australians currently enjoy one of the highest life expectancies in the world (ranked 4 th at 80.9 years). The recent increases in life expectancy are in part due to improvements in medical practice, leading to the earlier detection of cancer, improved outcomes (decreased mortality) for cancer patients and improved treatment of vascular (heart) disease.<br><br> The two diseases which cause the highest burden of disease (cancer and heart disease) together result in as many life years lost as all other conditions combined. Both of these diseases have a major pathology component in prevention and treatment activities. Over the past 8 years, the percentage of all Medicare services provided by the pathology profession has increased from 28.4% to 34.3%.<br><br> Over the same period, the percentage of Medicare rebates associated with these services has fallen from 15.7% to 14.5% of all Medicare rebates, a reduction of 7.6%. Pathologists are performing more tests for less of the Medicare spend, a trend suggesting sustainability of funding into the future. There is no crisis in pathology funding from the funder 9s perspective, but the ability of pathologists to absorb further relative rebate reductions through continued fee attrition is most definitely under question.<br><br> 3. Efficiency The review will examine whether the current resources for delivering diagnostic imaging and pathology services are used in the most economic or streamlined manner to achieve high quality services, and whether there are better ways to do so. Pathology is a high volume medical service with the majority of Australians receiving at least one pathology service every year.<br><br> Currently, 30 million pathology episodes of care annually are provided through Medicare-funded mechanisms to 11 million Australians. (with an estimated 15 million additional episodes provided through the public hospital system). Pathology services in Australia are of an extremely high standard.<br><br> The level of service is high and the short turnaround time for tests supports the efficient use of other health care resources. Errors in pathology are uncommon 3 although errors in pathology use are more common. The 1995 Quality in Australian Healthcare Study found that 13.6% of adverse events were due to an adverse event arising from delayed or wrong diagnosis but pathology was not specifically attributed to a percentage of these adverse events.<br><br> All pathology laboratories in Australia are accredited to an 8 international standard. No other area of health and medical care is subject to this requirement. While efficiency has been historically a concern in pathology, as in all other areas of health care, internationally the focus is now shifting to a focus on quality improvement rather than cost containment.<br><br> Medicare rebates for pathology testing have not changed since 1985. This fee constraint of the past 23 years (see graphs 6 and 7) has been a driving force of change to the pathology profession, with necessary cost containment coming from automation, practice aggregation, task substitution, and instigation of sophisticated business management. Australian private pathology is now extremely efficient, but opportunities for further efficiency dividends are now at an end (see AAPP paper on Profitability and returns in the non-government pathology sector ) In particular the review will examine the current drivers of growth for DI and pathology services, the use and availability of current and new technologies, the provision of services in public and private settings, the impact of corporatisation and whether alternative arrangements would result in more efficient service provision providing better value for money.<br><br> The recent growth in demand for pathology testing can be linked to a number of factors outside of the control of the pathology sector. These include increasing rates of preventable disease and chronic illness within the community and the Government's response to this and to patient access problems experienced within the general practice sector. For example, measures introduced by the Government to increase access to GP services (from 2003 onwards) included: o increasing bulk billed GP attendance fees by 15%; o the introduction of a practice nurse item number; o the introduction of 'health check' item numbers for specific population groups; o the introduction of chronic disease item numbers; and o an increased emphasis on chronic disease management in GP continuing professional education.<br><br> Collectively these measures resulted in both an increase in the numbers of GPs and an increase in their level of activity. Medicare Australia data show that in the five years to 2007/08 the number of GPs increased by 10.6% and their clinical activity (services) increased by 16.7%. The Medicare payments for their services during this time increased by 70.2% overall (benefits per GP service increased by 45.8%).<br><br> Increases in GP services overall lead to an increase in pathology services as the more patients a doctor sees, the more opportunities there are to identify the need for pathology testing. The types of GP services provided and the types of problems/conditions patients present with also influence the referring patterns of GPs for pathology testing. There is a strong relationship between certain presentations, longer consultations and pathology use.<br><br> This relationship also exists for other referred services, such as diagnostic imaging, specialist medical care and prescribing of pharmaceuticals. During this time the Government introduced a number of new health policies and strategies which also increased the demand for pathology services. These included a Childhood Obesity Strategy, a COAG Diabetes initiative and the Medicare Safety Net.<br><br> The range of policies, programs and initiatives implemented by the Government have been working to address the increased burden of chronic illness within our society. The growth in demand for pathology testing resulting from these Government actions and the changing health care needs of the community have played a crucial role in contributing to the successful implementation of Government policies and programs in this area and helped to achieve a healthier and more productive society. 9 In relation to possible alternative arrangements, it is impossible to compare the relative efficiency of the public and private pathology sectors given that both the quantum of money spent on public pathology and the cost of performing pathology in the public system are unknown.<br><br> The profitability of corporatised private pathology is public knowledge, albeit the data provided needs to be carefully analysed to understand its meaning (see AAPP paper on Profitability and returns in the non- government pathology sector ). High levels of competition between providers have led to high service levels and high quality. Any alternative arrangements which affect competition must pose a serious risk to quality and service.<br><br> Graphs 4 and 5 demonstrate how growth in benefits per service and pathology rebates have lagged behind that of other areas of health care and common cost indices. Medicare Payments - An Index of Benefits per Service rom January 2000 to June 2008 & percentage growth over this period All benefits include EMSN payments, GP benefits also include bulk billing incentive payments 0.90 1.00 1.10 1.20 1.30 1.40 1.50 1.60 1.70 1.80 1.90 Jan-00 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 GPs AWE All others CPI DI Path Shows the remarkable increase in incentive payments and increased rebates for GPs and the fluctuating contribution to average rebates by the Extended Medicare Safety Net and the containment of rebates by capped funding agreements. 6% 18% 32% 48% 48% 75% 10 Movement in Average Pathology Rebates and Cost Indices from January 2000 to June 2008 & percentage growth over this period 0.90 1.00 1.10 1.20 1.30 1.40 1.50 1.60 Jan-00 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 AWE Path Cost Index CPI Path Ed Wilson EW Consultin g P / L The Pathology Cost Index shown is as referred to in the current MoU.<br><br> It is half of CPI plus half of AWE. If Medicare rebates for Pathology had increased by this amount Pathology outlays would have been $2.7 billion more than actual to the end of June 2008. An efficiency dividend of 21.7% 6% 32% 40% 48% 2004/05 Eff.<br><br> Dividend $346.7 million 2005/06 Eff. Dividend $455.8 million 2006/07 Eff. Dividend $555.6 million 2007/08 Eff.<br><br> Dividend $697.8 million 4. Performance assessment The review will consider the development of measurable and effective performance indicators for the programs in contributing to improved health outcomes and more cost-effective health interventions. Medicare counts and records most pathology activity (apart from coned out work).<br><br> Therefore, we know exactly how many tests of each type are performed each year and we know the number of people they have been performed on. This is a much richer source of data than that available for other areas of clinical activity, as the majority of GP and specialist services are recorded simply as a 8non specific professional attendance item 9. This also means that there is ample data available to provide performance indicators for private pathology (as opposed to publicly-funded pathology).<br><br> Given that pathology fees have remained static for more than 20 years, while access to testing and quality of results have improved, there is good evidence that pathology is extremely cost-effective compared with any other area of health and medical care. Graphs 6 and 7 illustrate the lack of growth in pathology schedule fees, relative to CPI and AWE. 11 Pathology Schedule Fee Movement, CPI and AWE from January 1985 to June 2008 22 years of funding attrition 0.8 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 3.2 Jan- 8 5 J an-86 Ja n -8 7 J an-88 J an-89 J a n- 9 0 Jan-91 Jan-92 J a n-93 J a n- 94 J a n- 95 Jan- 96 Ja n- 9 7 Jan-98 Jan-99 J a n -0 0 Jan-01 Jan-02 Jan - 03 J a n- 0 4 J a n- 05 Jan-0 6 Jan-07 Jan-08 AWE CPI Rebate s Ed Wilson EW Consulting 1st August 1986 Pathology schedule reduced by 13.2% The Federal Court challenge which overturned a further arbitrary fee reduction.<br><br> A.W.E. up by 202% C.P.I. up by 146% Pathology Rebates down by 2.8% Pathology Fees vs CPI & AWE The Third Millenium - Funding Attrition Continued 0.9000 1.0000 1.1000 1.2000 1.3000 1.4000 1.5000 Jan-00 Ja n- 0 1 Jan-02 Ja n- 0 3 Ja n- 04 Jan-05 Ja n- 06 J an-07 Ja n- 08 A.W.E.<br><br> C.P.I. Path Rebates 0.2% 32.2% 47.5% Ed Wilson EW Consulting 12 5. Integration/ Strategic Policy Alignment The review will examine how well diagnostic imaging and pathology services integrate with the broader health system and align with current health policy.<br><br> Pathology underpins virtually all other areas of health care and integrates with community health, the hospital sector and all the steps in between, e.g. hospital in the home, step down facilities, home visits to recently discharged patients. For example, many hospital patients (both private and public) could not be discharged when they are without pathology support (e.g.<br><br> Warfarin patients requiring home visits from pathology services). In particular, the review will examine how well diagnostic imaging and pathology service integrate with the broader health system and align with current health policy settings. Pathology is well aligned with primary care and referral to secondary care (specialist and hospitals).<br><br> Due to the high level of information management systems used throughout the sector, dissemination of reports is seamless, which increases efficiency and reduces retesting. Pathology laboratories hold the bulk of patients' critical medical record and this is easily accessed by credentialed providers. Pathology testing plays a vital role in the National Primary Care Strategy in the areas of disease prevention, management of chronic disease, supporting patients with chronic diseases to manage their conditions, and in supporting GPs by providing advice on test selection, result interpretation and follow-up of abnormalities.<br><br> The review will also consider options for future arrangements, taking into account broader health reforms initiated by the government. Current areas of interest for reforms (National Health and Hospitals Reform Commission, NHHRC) are:- (i) Closing the gap in i ndigenous health status In remote areas in particular, Indigenous Australians are grossly 8under-serviced 9 by health and medical services. Pathology can play a greater role in improving Indigenous health status in a number of areas including: monitoring nutritional deficiencies, alcohol abuse, the impact of obesity and STDs as well as for the management of chronic disease, in particular Diabetes mellitus and chronic renal disease.<br><br> (ii) Investing in prevention Pathology underpins almost all preventive health care and is vital to the effective management of chronic disease. Pathology contributes to the overall effectiveness of health care provided to patients through a number of different means, including: o assisting in the diagnosis of a disease (e.g. diagnosing HIV/AIDS); o determining the type of disease present (e.g.<br><br> the specific type of breast cancer); o assessing the level of progression of disease (e.g. the severity of heart disease); o preventing the transmission of disease to others (e.g. testing pregnant women for syphilis to prevent exposure of their baby during the birth); o preventing the development of more serious conditions (e.g.<br><br> testing sexually active women for Chlamydia to prevent infertility); and 13 o ensuring the treatment is targeted to the individual patient's needs (e.g. adjusting insulin levels for people with diabetes). These services all provide long-term health benefits to individuals, as well as the community as a whole, through enabling the early identification of problems and thus providing the best opportunity for early intervention and treatment.<br><br> For example, by testing people with early signs of Osteoporosis for Vitamin D deficiency, one of the main causes of this debilitating condition can be identified and addressed. This reduces the rate of progression of the disease and the risk of serious complications, such as hip fractures, which are complicated and expensive to treat and which result in significant reductions in quality of life for patients. In some cases, such as through testing pregnant women for rubella, potentially serious and disabling consequences of rubella infection for babies in utero can be avoided, thus resulting in life-long benefits.<br><br> With an increasing focus on disease prevention within our health system, pathology testing will continue to support doctors and other health professionals to deliver optimum health outcomes to patients and to contribute to maximizing the efficient use of scarce health resources. (iii) Ensuring a healthy start . Pathology has a major role in fertility, pregnancy management and early childhood assessment, including antenatal testing and neonatal screening programs.<br><br> (iv) Redesigning care for those with chronic and complex conditions. Pathology also plays a vital role in the diagnosis and management of chronic disease. Every case of cancer, diabetes, renal failure, liver disease, endocrine disease and hyperlipidaemia is identified and monitored through pathology tests.<br><br> Other conditions, such as pregnancy, also involve a range of pathology tests for best practice management. Through supporting best practice management of chronic disease, pathology testing provides doctors with the information they need to prevent, as far as possible, further progression of the disease and ensure patients with chronic conditions remain as healthy as possible. (v) Recognizing the health needs of the whole person .<br><br> Pathology is the common link between primary care and specialist care, community based care and inpatient care, acute condition care and chronic condition care. It has a role in managing health at every stage of a person 9s life. (from pre-conception to post mortem).<br><br> Pathology services are often the only constant providers of care as patients move from one care setting to another and make an essential contribution to the continuity of care. (vi) Ensuring timely hospital access. By the appropriate use of pathology testing, patients are often fully diagnosed and assessed prior to hospital admission 3 reducing average inpatient length of stay.<br><br> (vii) Caring for and respecting the needs of people at the end of life. Accurate diagnosis and monitoring using pathology tests enables the best decisions to be made at this time. (viii) Promoting improved safety and quality of health care.<br><br> 14 Pathology has a major role here. See answer provided under 2. Efficiency.<br><br> (ix) Improving distribution and equitable access to services. Discussed under 1. Appropriateness.<br><br> (x) Ensuring access on the basis of need, not ability to pay. Discussed under 1. Appropriateness.<br><br> (xi) Improving and connecting information to support high quality care. As discussed above, the pathology sector leads the health and medical field in its use of information technology. The sector is committed to working with government and other stakeholders to build on the existing IM/IT infrastructure and practices to incorporate system-wide developments including: o unique patient and health care provider identifiers; o individual electronic health record; o electronic discharge summaries; o referrals; o requesting and reporting; o disease registries; and o issues relating to notifiable diseases and biosecurity.<br><br> The AAPP believes that efficient use of the healthcare dollar will be maximized by maintaining fee for service with the same annual increments that apply to other medical practitioners within the Medicare Benefits Schedule, reflecting the ongoing rising costs of testing (see AAPP paper on Costs in pathology ). We also recommend the continuation of the partnership between government and the profession at the PCC, PSTC, NPAAC and QUPC to ensure that the expertise pathology can bring to each of these committees will not be lost. As part of the emphasis on quality, we support the exploration of improving pathology ordering through the development of intelligent ordering systems to ensure appropriate investigations are ordered for our patients.<br><br> Dr Ian Clark President AAPP An Analysis of Pathology Test Use in Australia A paper by the Australian Association of Pathology Practices Inc, utilising data from the BEACH program, Family Medicine research Centre, University of Sydney September 2008 2 The University of Sydney Family Medicine Research Centre School of Public Health A Collaborating Centre of the World Organization of Family Doctors Data source: BEACH program This analysis of BEACH data was undertaken as a consultancy to the Australian Association of Pathology Practices Inc. Dr Helena Britt A/Professor and Director Family Medicine research Centre & Australian GP Statistics and Classification Centre School of Public Health University of Sydney Attached at Appendix A is the methodology used by A/Professor Britt to capture the data reproduced in the main document and presented in its original format in the accompanying Appendix B is the Excel File. 3 Table of Contents: Executive Summary 4 Key Points 6 Sections: 1.<br><br> Those influences on the demand for pathology testing (drivers of demand). 7 -23 2. The benefits to patients and the health system generally that flow from the early detection of disease.<br><br> 24-27 3. The role of pathology in preventive health and chronic disease management. 28-32 4.<br><br> Primary care strategies, access, affordability, quality and safety. 33-34 Appendix A: Methodology of data collection from University Sydney, BEACH AIHW and explanation for EXCEL File. Appendix B: Excel file.<br><br> 4 Executive Summary 1. Pathology underpins most Australians 9 health care. It is the way 70% of diagnoses are reached and plays a critical role in the safe management of most diseases.<br><br> 2. About 85% of the Australian population visits a doctor at least once every year. Clearly some patients have multiple visits.<br><br> In 2007 there were 117 million attendances to GPs and 22 million to specialists. 3. In comparison 50% of Australians have at least one episode of pathology testing each year, with a total of approximately 30 million episodes in 2007.<br><br> Medicare counts services claimed through and paid by Medicare 3 for pathology this is a single test or group of tests, for GPs and specialists this is a single consultation or procedure. In 2007 Pathology accounted for 34.3% of all Medicare services and 14.5% of all Medicare benefits. 4.<br><br> Pathology has been subject to marked fee restraint. The schedule fee for an average pathology item of service is 4% lower in 2008 than it was in 1988 3 during this time CPI and AWE have increased by over 180%. 5.<br><br> Pathology use has grown much faster than GP or specialist activity. The long term trend has been more than 5% per annum. In the last 4 years this growth has been higher (approximately 7% per annum).<br><br> Despite this, in these 4 years, pathology 9s share of Medicare outlays has fallen 7.6% per annum (as a result of declining fees in real terms). 6. GPs directly request 70% of all pathology tests and, through their critical gate keeper role in Australian health care, control referral to specialists and admissions to hospitals, responsible for the other 30% of pathology test ordering.<br><br> 7. Ongoing studies have been made of GPs 9 activity and the pathology they request (BEACH 3 University of Sydney and Australian Institute of Health and Welfare). These show that primary care is changing: GPs are seeing more older and sicker patients, with more time spent on chronic disease management; fewer younger patients with minor acute illness are being seen.<br><br> The pattern of pathology use is also changing 3 more testing is being done for chronic disease management and preventive health strategies. 8. Detailed study of pathology requesting by GPs consistently demonstrates appropriate use 3 for example over 60% of growth in GP pathology requesting is clearly linked to preventive health and chronic disease management.<br><br> Definite over-utilization has been demonstrated only in the circumstance of unnecessary repeat testing in public hospitals by inexperienced doctors. The main cause for concern is variation in requesting rates 3 this is being addressed by the development of guidelines for requesters and electronic decision support. 9.<br><br> Pathology testing plays a vital role in illness prevention and chronic disease management. Pathology testing requested by GPs is the mainstay of preventive health and the early detection of disease in the Australian health system. There is a strong body of scientific evidence supporting this activity and this has become a major mechanism in reducing morbidity and mortality and increasing life expectancy in Australia.<br><br> 5 10. Pathology is the most accessible and affordable medical service. Both in terms of how patients access pathology and how any patient can have any test virtually at any place and any time, pathology has few barriers.<br><br> Pathology has the highest bulk billing rate of any medical service. 11. Pathology leads in the area of quality and patient safety.<br><br> Pathology has an established quality framework which underpins patient safety. Pathology fulfils the main audit process for health care generally. 12.<br><br> Pathology supports the top four of the five priorities of the National Primary Health Care Strategy. 6 Section 1: Those Influences on the Demand for Pathology Testing (Drivers of Demand) Key Points Pathology investigations are a referred service: general practitioners (GPs) and specialists request pathology tests and pathologists respond to these requests. GPs initiate most medical activity, requesting 70% of Medicare pathology, and their referrals to clinical specialists result in much of the remainder of pathology test use.<br><br> Growth in pathology testing is due to increases in a referrer 9s own activity, in the rate that a referrer initiates pathology investigations and in the number of tests requested on each occasion. In the 4 years from 2002/3 to 2005/06: the number of GPs increased by 5.6%, GP services increased by 6.8%, pathology tests requested by GPs increased by 18.6%, and the volume of pathology requested per GP service increased by 11%. Why did GP activity change and how was this managed?<br><br> In the six years from 1997/98 to 2003/04 the average clinical activity per GP fell by 8%. This led to a crisis of reduced patient access and a subsequent political response. The series of measures thus introduced (from 2003 onwards) dramatically increased GP activity, which led to increased pathology use (both GP requested and specialist requested).<br><br> Some measures were 8across the board 9 but many were targeted. Health Check items were introduced and other preventive health activities were encouraged. How did GP activity change and how did this specifically affect Pathology use?<br><br> The BEACH data set (University of Sydney) is derived from an annual survey of GP activity. Examination of this data for the period between 2004/05 and 2007/08 (the current MoU) shows significant changes in GP activity and GP use of pathology. This data shows that there were 20 patient problems that accounted for less than 20% of all problems managed by GPs but were responsible for 73% of pathology growth.<br><br> In these 20 problems preventive health interventions accounted for 32% of pathology test growth by GPs while management of three chronic diseases - diabetes, hypertension and lipid disorders - accounted for a further 27% of pathology test growth. Thus most of the increase in pathology use is due to increased GP activity in two areas 3 preventive health and the management of chronic disease. Both these areas have been the target of government policy, and these data clearly demonstrate the success of those interventions.<br><br> The recent growth in demand for pathology testing is clearly linked to a number of factors outside of the control of the pathology sector. These include increasing rates of preventable disease and chronic illness within the community, and the government's response to these and to the access problems experienced within the general practice sector. The range of policies, programs and initiatives implemented by the government have been working to address the increased burden of chronic illness within our society.<br><br> The growth in demand for pathology testing resulting from these government actions and the changing health care needs of the community has played a crucial role in contributing to the successful implementation of government policies and programs, and has helped to achieve a healthier and more productive society. 7 Introduction Pathology testing differs from many other health and medical services in that it is a referred service. This means that GPs and medical specialists request pathology tests on behalf of their patients and pathologists respond to these requests.<br><br> This differs from many other health and medical services 3 such as GP visits 3 which are generally directly initiated by patients themselves. This is fundamental to the understanding of changes in demand for pathology testing. It means that demand for pathology services is driven primarily by referring doctors (GPs and specialists), rather than by either pathologists or patients.<br><br> GPs, as a group, are responsible for initiating most pathology testing, including requesting about 70% of Medicare funded pathology. GPs are also responsible for referring patients to specialists, who then also may request pathology testing. Due to this, any changes to the ways in which GPs practice and the general practice environment can have a significant impact on the pathology sector.<br><br> There are a range of mechanisms through which referring doctors' patterns of requesting pathology testing can change. These can be broadly grouped into three categories: 1. Increases in referring doctors' own activity (i.e.<br><br> referring doctors seeing more patients); 2. Increases in the rate that referring doctors initiate pathology investigations (i.e. referring doctors ordering tests for a higher proportion of patients); and 3.<br><br> Increases in the number of tests requested on each occasion (i.e. referring doctors ordering more tests per patient). These three mechanisms can operate separately, but more often occur simultaneously to result in a combined effect on demand for pathology testing.<br><br> These mechanisms are themselves influenced by a number of factors, both internal and external to the health and medical sector. Some of these are as follows: o changes in population demographics (for example, the ageing of the population resulting in an increase in chronic disease; an increasing birthrate resulting in a need for more pregnancy care); o the emergence of new diseases or conditions (for example, HIV, Avian flu); o the development of new treatments for existing conditions (for example, more sophisticated treatments for breast cancer which require targeting of drugs to specific types of tumours); o increased community awareness of specific conditions (for example, as a result of a government information campaign or a high profile celebrity contracting a disease); o changes in the GP workforce (for example, workforce shortages which reduce access to GP services); o changes in funding arrangements for GP services (for example, the introduction of new item numbers for chronic disease management); o the implementation of new government health policies (for example, support for the introduction of practice nurses into general practices); o the introduction of new government general practice programs (for example, wellness checks for specific age groups); o changes in the education and training of GPs (for example, an increased emphasis on prevention in medical school curricula); 8 o changes in the affordability of GP services, resulting in increased or decreased access for some groups in the community; o changes in the location where specific conditions are managed (for example, the shift out of hospitals for pregnancy care to 'shared care' between GPs and hospitals); o the introduction of screening programs for specific diseases (for example, the faecal occult blood testing program for colorectal cancer); o changes in guidelines for the management of specific conditions (for example, new and lower targets for cholesterol in certain patients). The specific factors that have influenced changes in demand for pathology testing in recent years and the mechanisms through which these changes have taken effect are discussed in more detail below.<br><br> Increases in overall GP services There is evidence that during the four years from 2002/3 to 2005/06 the number of GP services being provided increased significantly. This followed a six year period in which the total number of GP services being provided declined. Figure A shows the change in general practice activity over the past eight years: Figure A The reasons for the decline in GP activity over the period to 2004 include: a reduction in the overall number of full-time GPs (and an increase in part-time GPs); a decline in the real value of the Medicare rebate; and a reduction in bulk billing levels.<br><br> Together, these factors acted to reduce access to GP services, both through creating cost barriers and reducing the supply of services. 9 The government responded to this through a number of different measures to increase access to GP services (from 2003 onwards). These measures included: o increasing bulk billed GP attendance fees by 15%; o the introduction of a practice nurse item number; o the introduction of 'health check' item numbers for specific population groups; o the introduction of chronic disease item numbers; and o an increased emphasis on chronic disease management in GP continuing professional education.<br><br> Collectively these measures resulted in both an increase in the numbers of GPs and an increase in their level of activity. Medicare Australia data show that in the five years to 2007/08 the number of GPs increased by 10.6% and their clinical activity (services) increased by 16.7%. The Medicare payments for their services during this time increased by 70.2% overall (benefits per GP service increased by 45.8%).<br><br> Figure B illustrates the growth in average GP benefits per service to January 2008, compared with other benefits, CPI and average weekly earnings: Figure B Note: CPI = Consumer Price Index, AWE = Average Weekly Earnings, DI = Diagnostic Imaging, All Others = Other Divisions of Medicare Table. 10 Figure C illustrates the bulk billing rate for general practice, pathology and other medical services from 2000 to 2008: Figure C Note: DI = Diagnostic Imaging. During this whole period specialist activity continued to grow.<br><br> Specialist activity is dependent on three factors: 1. The rate of referral by GPs to specialists 3 this depends on most of the same things that influence GP pathology requesting rates. In particular patients who have longer consultations and have pathology requested are likely to be referred to specialists; 2.<br><br> Once a patient is under specialist care repeat visits are determined mostly by the specialist 9s management plan. Referrals from GPs are current for 12 months, from specialists for 3 months. This is to reinforce the primacy of the GP 9s role in patient care; 3.<br><br> Access to specialists is often restricted by workforce issues and also to some extent by patient co-payment levels. This was the factor that dampened the increase in specialist activity that followed the dramatic increase in GP activity. Increases in GP services overall lead to an increase in pathology services as the more patients a doctor sees, the more opportunities there are to identify the need for pathology testing.<br><br> The types of GP services provided and the types of problems/conditions patients present with also influence the referring patterns of GPs for pathology testing. There is a strong relationship between certain presentations, longer consultations and pathology use. This relationship also 11 exists for other referred services, such as diagnostic imaging, specialist medical care and prescribing of pharmaceuticals.<br><br> This is discussed in more detail in the following section. Increases in pathology services In the 4 years from 2002/3 to 2005/06 the number of pathology tests requested by GPs increased by 18.6%. The Medicare payments for these increased by 26% and benefits per pathology service increased by 6.2%.<br><br> The rate that pathology was requested per 100 GP services increased by 11%. Although pathology use has been growing for over 20 years, this recent increase is greater than that over the previous 16 years. The BEACH data set (discussed in more detail below) helps explain the reasons behind this changed pattern of pathology use.<br><br> BEACH data Data taken from the Bettering the Evaluation and Care of Health (BEACH) program provides useful information which can inform our understanding of the drivers of growth during this period. The BEACH program is a national study of GP activity. It provides information which can link specific problems that patients present with to GPs' responses to managing these problems, such as writing prescriptions, referrals to specialists and recommendations for further investigations.<br><br> BEACH annually surveys 1000 GPs and its results can be validly extrapolated to all GPs. BEACH data and Medicare data are combined by the Australian Institute of Health Welfare in their annual reports on Australia 9s Health Services. Over the period 2004/05 to 2007/08 (the period of the current MoU between the pathology sector and the federal government), analysis of the BEACH data set shows the links between the growth in pathology services with the specific presenting problem of patients during this time.<br><br> This provides a picture of where the growth in pathology services occurs and gives an indication of its role in the overall health care of patients. The table below illustrates the association between the percentage growth in pathology services and the specific problems being managed. For example, at least 11.1% of the growth in pathology services initiated by GPs during this period was associated with the management of diabetes.<br><br> 12 Table 1: Problems in General Practice Associated With Growth In Pathology Services * This is the proportion of pathology test growth attributed to this problem as a percentage of the total pathology test order growth ** NOS = Not otherwise specified The 21 problems/conditions included in Table 1 comprise 19.3% of all problems managed by GPs in 2004/05 and 21.6% in 2007/08. This represents a 12% increase in the management rate of problems most likely to require further pathology testing during this period. This is then compounded by the growth in total GP activity, i.e.<br><br> there was both an overall increase in the number of GP services being provided and in the proportion of these services requiring pathology referrals. Adding both of these factors together results in a 42% increase in the number of these problems managed over these four years. The growth in the number of pathology tests requested associated with these problems accounted for 75% of the total increase in pathology tests requested by GPs over that period.<br><br> An extrapolation to the whole of Medicare means that these 21 problems being managed by GPs accounted for 55% of the total increase in Medicare pathology services between 2004/05 and 2007/08. Problem managed Per cent of total pathology growth 1. General check-up 12.9 2.<br><br> Diabetes 10.5 3. Hypertension 10.4 4. Blood test NOS** 5.5 5.<br><br> Lipid disorders 4.9 6. Pregnancy 4.0 7. Abnormal test results 3.7 8.<br><br> Female genital check-up 2.9 9. Microbiology/immunology test NOS ** 2.5 10. Weakness/tiredness general 2.2 11.<br><br> Vitamin/nutritional deficiency 1.8 12. Urinary disease, other 1.6 13. Skin symptom/complaint, other 1.4 14.<br><br> Cardiac check-up 1.4 15. Hypothyroidism/myxoedema 1.3 16. Pain, chest NOS ** 1.3 17.<br><br> Abdominal pain 1.3 18. Anaemia 1.3 19. Menopausal symptom/complaint 1.2 20.<br><br> Overweight (BMI < 30) 1.2 21. Endocrine/metabolic/nutritional disease, other 1.1 Total Pathology test growth as % of all GP Path growth 74.4% 13 Preventive health As the data in Table 1 makes clear, a high proportion of the problems/conditions generating the greatest growth in pathology testing are preventative health interventions. These include the problems ranked Numbers 1, 4, 6, 8, 9, 14, and 20 in the table above.<br><br> Together, these conditions accounted for 31.7% of the total growth of pathology tests requested by GPs during this time. This outcome is in line with government policy which aims to increase activity in the area of disease prevention and also reflects changing patterns of disease within the community, such as the increase in the number of Australians with diabetes. The BEACH data also provide an outline of the specific tests requested by GPs in response to each managed problem/condition.<br><br> These are detailed in the tables below. Table 2: General Check-up Tests requested for g eneral chec k - up % of all tests ordered for this problem Lipids 17.41 Full blood count 15.06 Glucose tolerance 10.44 Liver function 8.47 Multiple biochemical analysis 6.60 Electrolytes Urea Creatinine 6.42 Prostate specific antigen 6.18 Thyroid function 5.15 Pap (cervical) smear 3.94 These 9 tests or test groups 79.67 A similar pattern of test use is associated with a number of other managed problems/conditions, specifically Number 4, Blood test NOS; Number 14, Cardiac check up; Number 20, Obesity; and Number 21, Endocrine blood test. This indicates that treatment in response to these problems can also be seen as part of a 8check up 9 activity.<br><br> The pattern of test use for Number 8, Female genital check-up, is quite different with the focus clearly on cervical cancer prevention. Table 3: Female Genital Check-up Tests with female genital check-up % of tests for this problem Pap smear 91.34 Chlamydia 1.78 Vaginal swab and C&S 1.24 Lipids 1.15 Full blood count 0.78 Microbiology; other 0.78 These 6 tests or test groups 97.1 14 The pattern of test use for Number 9, Microbiology/Immunology test NOS, indicates this is the presenting problem used for screening for sexually transmitted diseases. Table 4: Microbiology/Immunology Test, NOS Tests with Micro/Imm test % of tests for this problem Venereal disease 18.33 Hepatitis serology 18.05 Microbiology, other 15.56 Chlamydia 15.32 HIV 14.63 Vaginal swab and C&S 2.94 Urine test 2.79 Throat swab C&S 2.59 Cervical swab 1.89 These 9 tests or test groups 92.1 The pattern of test use for Number 6, Pregnancy, is predictably different.<br><br> The increase in pathology test use here results from three things 3 the rising birth rate, the 8shared care 9 initiative whereby GPs have taken over some of the responsibility for antenatal care (from public hospital antenatal clinics) and changes in guidelines for antenatal screening (addition of HIV, HCV and other tests). Table 5: Pregnancy Tests with Pregnancy % of tests for this problem Full blood count 13.26 Hormone assay 11.55 Infertility/pregnancy 11.26 Microbiology; other 10.1 Blood grouping & typing 8.6 Glucose tolerance 6.15 Rubella 4.87 Urine MC&S 4.52 Hepatitis serology 4.02 Ferritin 2.88 Venereal disease 2.85 HIV 2.34 These 12 tests or test groups 82.4 15 Chronic disease management Table 1 also demonstrates that the management of chronic disease is responsible for a significant percentage of the growth in pathology use. The problems/conditions ranked Numbers 2, 3 and 5 (diabetes, hypertension and lipid disorders) together account for 27% of the increase in pathology requested by GPs during this time.<br><br> The increased management of these diseases and the greater use of pathology with these conditions are in line with government policy and published guidelines. Table 6: Diabetes Management Tests for D iabetes % of tests with this problem HbA1c 28.53 Lipids 14.62 Glucose tolerance 11.18 Chemistry, other 8.88 Electrolytes Urea Creatinine 8.04 Full blood count 7.93 Liver function 6.42 Multiple biochemical analysis 5.21 These 8 tests or test groups 90.81 Table 7: Hyperlipidaemia Management T ests for l ipid problem s % of tests with this problem Lipids 47.27 Liver function 10.29 Glucose tolerance 8.18 Full blood count 7.33 Electrolytes Urea Creatinine 6.09 Cardiac enzymes 5.48 Multiple biochemical analysis 5.08 Thyroid function 2.3 These 8 tests or test groups 92.02 16 Table 8: Hypertension Management Tests for h ypertension % of tests with this problem Lipids 20.37 Electrolytes Urea Creatinine 18.98 Full blood count 13.82 Glucose tolerance 10.31 Liver function 9.1 Multiple biochemical analysis 7.15 Chemistry; other 3.77 Thyroid function 3.66 Prostate specific antigen 2.09 These 8 tests or test groups 89.25 Therefore, taken together, tests requested by GPs and performed in association with preventive health and chronic disease management accounted for 42% of all pathology growth during this period. The remaining nine problems from the top 21 listing in Table 1 account for another 13% of overall growth.<br><br> There is some overlap within this group with problems i

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