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Technology diffusion : the troll under the bridge : a pilot study of low and highhealth technology in… Kazanjian, Arminée, 1947-; Friesen, K Jun 30, 1990

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Centre for Health Services______and Policy ResearchTECHNOLOGY DIFFUSION:THE TROLL UNDER THE BRIDGEA Pilot Study of Low and HighHealth Technology in British ColumbiaA. KazanjianK. FriesenHPRU 90:9D June 1990Health Policy Research UnitDiscussion Paper Seriesvi. fiw“s •‘THE UNIVERSITY OF BRITISH COLUMBIA..TECHNOLOGY DIFFUSION:TI-IE TROLL UNDER TI-IE BRIDGEA Pilot Study of Low and HighHealth Technology in British ColumbiaA. KazanjianK. FriesenHPRU 90:9D June 1990REALm POLICY RESEARCH UNITDivision of Health Services Research and DevelopmentThe University of British ColumbiaVancouver, B.C.V6T lZ6This research was supported by the National Health Research and DevelopmentProgram (Grant No. 6610-1722-55) . The authors would like to acknowledge theassistance of Dr. D. Schneider, Senior Medical Consultant, Medical ServicesPlan (B.C . Ministry of Health) and Dr. M.D. Low, President, University ofTexas, Health Science Center at Houston, formerly Coordinator of HealthSciences, University of British Columbia.,. ....•...TABLE OF CONTENTSList of FiguresList of TablesI . IntroductionII . Review of the LiteratureIII. Data DevelopmentIV . AnalysisPage1101516l.2.3.Utilization and DiffusionInstitutional ProfileProvider Profile183337V. Summary and Discussion 43Referencesr •...,Figure 1Figure 2Figure 3Figure 4Figure 5FIGURESDeterminants of Diffus ionServices Per 1000 Population , HDL Cholesterol byPatient Age and SexChange in Services Per 1000 Population , HDLCholesterol by Patient Age and SexNumber of Services Per 1000 Population SingleChemical Tests, Male and Female 1979/80, 1982/83and 1987/88Adjusted MSP Payments to Selected SpecialtiesPage426273244,.Table 1Table 2Table 3Table 4Table 5Table 6Table 7Table 8Table 9Table 10Table 11TABLESTechnology Classification Fee Item GroupingsNumber of Services and Rates per 1000 populationFee Item Group by TimeServices Per 1000 Population , Common LaboratoryTests - Individual Fee Items by Year of ServiceTotal MSP Payments, Common Laboratory Tests byYear of Service in Constant 1988 DollarsServices Per 1000, High Technology by Year of ServiceHigh Technology MSP Payments For Individual FeeItems by Year of Service in Constant 1988 DollarsPopulation of Metropolitan and Non-MetropolitanAreas of B.C . by Years Under StudyAnnual Return of B.C . Health Care FacilitiesStandard Total Units Done During Year of Service byPercentage for Metropol itan and Non-Metropolitan AreasGrouped Fee Items by Year of Service, Percentage ofServices by Type of Physician PracticePercentage of Referring Physic ians by Location by Typeof TechnologyTotal and Adjusted MSP Fee-For -Service Payments forSelected Specialties in B.C .Page171923252931343539414 3••,I. INTRODUCTIONThis study set out to compile a classificatory scheme for examiningtechnology in health care, and to generate hypotheses regarding patterns ofdiffusion and utilization in British Columbia. 1 Specifically, the twoobjectives of the pilot study were:i) To develop from the literature on technology assessment a taxonomyfor classifying technology in health care; andii) to examine the empirical evidence on the diffusion and utilizationof two diagnostic technologies - CT scanners and Automated Lab Testsselected specifically for their apparent dissimilitude on a numberof dimensions such as cost, volume, and type of innovation.For the first objective , it was anticipated that a taxonomy with multipleclassification axes would be developed which would supply a comprehensive anddetailed descriptive profile of what characterizes health technology. Aswell, the taxonomy would indicate the relative importance of identifieddimensions of the technology for future policy formulation and implementation .Results of the second objective were to provide information on theprocess and time frame of technology diffusion as well as the generation ofhypotheses for future study.The role governments play in the development and diffusion of technologyis clearly an influential one , especially in health care. While it appears tobe uncoordinated, this role spans a wide range of levels of involvement : fromsupporting the development of technologies (through funding of research inbasic sciences) , to regulating the marketing of certain technologies andlThe pilot study was intentionally limited in scope in order to explorethe potential usefulness of provincial administrative databases for the studyof diffusion of health care technology.2licensing of facilities for the provision of certain technological services,to paying for such services through public funds (medical insurance) . What isalarming, however. is that these types of policy decisions are most often madein the absence of accurate knowledge on the health system impllcations oftechnological change. Ideally, policy decisions regarding health caretechnology should be made based on evidence from comprehensive assessment,i.e. information on the safety. effectiveness, cost and ethical/legalimplications of the technology under consideration .Reality proves otherwise. The large majority of technologicalinnovations in health care (with the possible exception of pharmaceuticals andmedical devices), are in use long before any systematic assessment has takenplace. Sometimes at the second or third generation level, technologies arefound to be ineffective, or even unsafe, after belated assessment.Furthermore, while the Drug and Environmental Health Inspection Division ofthe Health Protection Branch of National Health and Welfare polices the safetytesting of pharmaceutical products and medical devices (acting as theregulator), the studies are carried out by employees of the respectiveindustries. often using .questionable research designs.While the need to know more about the impact of future - as well ascurrent - health care technology on population health is equally important tothe health professional, consumer, and policy maker, in times of acceleratedtechnological change it is unreasonable to expect anyone to fully understandall of its important consequences.r,3Since researchers have neither the comprehensive knowledge base thatwould fully explain the impact of health technology on population health, nora mechanism whereby the available knowledge on this relationship - limited asit may be - is taken into consideration, policy decisions regarding technologyare made in an ad hoc manner. Thus, health care needs do not appear to playalarge part in the diffusion of heaith care technology. Rather, certaincharacteristics of adopters, as delineated in the literature (Coleman et a1,1957; Hillman, 1986), provide some explanation postfacto on patterns ofdiffusion. A number of determinants of diffusion are suggested by theInstitute of Medicine (1985), identifying the relative role that po1icymakersmay have in the process of technology diffusion. The first four sources ofinfluence as seen in Figure 1 are relatively insensitive to change bypo1icymakers. These correlates of diffusion possess characteristics that aremainly descriptive of the development of the technology outside the healthcare system or its introduction into the system through the clinical field.The last six are identified to be subject to influence by po1icymakers invarying degrees . Our analysis concurs with some of these findings .The first four factors which have some influence on the adoption andabandonment of health technology refer to the innovation directly or thepotential users. Prevailing theory refers to accepted beliefs for healthpatterns. Prevailing theories appear to either prejudice the acceptance ofinnovations which turn out to be clinically proven or hasten the acceptance ofunsubstantiated practices which are ultimately proven to be of little value.The attributes of an innovation may influence diffusion by the potential4benefits and costs to physicians and their compatibility with physicianpractice style. The innovation may be more acceptable if it features animportant clinical problem for resolution. Finally, diffusion and abandonmentdepends on whether there is an authoritative advocate for either side andwhether in fact what they say turns out to be true in the final analysis.The setting in which clinical practise takes place is not easily changedin a system which, historically, has grown into a vast network of hospitals,doctors' offices and laboratories. Technological innovations appear to bemore readily adopted in group practise settings, and in teaching hospitals,where peer-group pressures and hospital hierarchies act as strong incentivesfor rapid adoption of technology.Figure 1Determinants of Diffusion*rRole of Po1icymakersRelatively insensitive to changeby po1icymakersSubject over time to somepolicy influenceRelatively susceptible toinfluence by po1icymakersSources of Influence1. Prevailing theory2. Attributes of the innovation,3. Features of the clinical innovation4. Presence of an advocate5. Practice setting '6. Decision-making process7. Characteristics of potential adopters8. Environmental constraints & incentives9. Conduct and methods of evaluation10. Channels of communication*(Adapted from the Institute of Medicine, 1985)5Practice decisions regarding technology range from independent practitionersto groups of peers to the institutional domain. A decision making processthat involves more people may require a longer time frame for resolution . Yeta decision regarding technology is not necessarily limited to its acquisition.Once that has been procured by the institution, the decisions regardingutilization are being made by the individual practitioners on an on-goingbasis .In British Columbia, the very structure of the health care system allowstechnological diffusion without systematic checks as to appropriateness ofutilization rates . For example, common laboratory tests may be ordered by aphysician as a routine protocol for certain medical conditions. There is nosystematic audit of test orders or frequency of testing for individual orcohorts of physicians. Thus, a battery of tests may be repeated on a regularbasis with no evidence of value to the patient's health but at appreciablecost to the system . In contrast, the acquisition and utilization of anembodied technology such as the NMRI is subject to the decision making proces sat a number of different institutional levels . The time frame of its adoptionand diffusion has been much longer than the diffusion of common laboratorytests.Attributes of the potential adopter often explains patterns of practiceand diffusion . Characteristics such as technical skills, demographics,sociometric status and institutional affiliation of physicians will impact ontheir acceptance and utilization of an innovation. In British Columbia , it6was found that physicians in certain types of practice (TOP) tended to adoptthe innovation such as CT scans more quickly than others. These physicianswere relatively young males (40 - 55 years), and usually affiliated with ateaching hospital. However, access to the technology is also usuallyrestricted to one or two specific institutions because of the differentresearch expertise (such as diagnoses of the head and neck) available indifferent hospitals . As the technology is acquired in other areas, access byphysicians other than sub-specialists becomes more widespread.The three sources of influence - practice setting, decision-makingprocess and characteristics of potential adopters are subject over time tosome policy influence. While most hands-on work in clinical practise takesplace in physicians' offices and in the hospital far removed from thepolicymaker, two policy levers can be used to in~luence technology diffusion:financing of medical acts and organizational restructuring. In BritishColumbia, the government as payor of health services can determine which kindsof equipment/devices will be purchased or which programs financed with publicfunds, where these services/equipment will be located and, throughnegotiation, which providers will have access to these technologies . Theproviders ultimately determine which patients will utilize the services. Thedegree of policy influence seems to be a direct function of the materialnature of the technology. For example, it is difficult to influence diffusionof laboratory tests or the use of a new surgical procedure, but relativelyeasy to influence programs of open heart surgery or the acquisition of CTscanners . As well, once approval for a technology goes through and money isdisbursed to an institution, there is little direct control over how thatr7money is spent. The larger the institution the less the likelihood of itscontrol .Environmental constraints and incentives refers to the various regulatorylevers involved in controlling diffusion of medical technology. In Canada,the standards for the approval of new drugs are written into health protectionand drug legislation (and medical devices) and regulated through the HealthProtection Branch of the National Health and Welfare (NHW). Within theprovincial jurisdiction, the Medical Services Plan sets the remunerationlevels for physician services while Hospital Programs determines the approvalprocess for hospital equipment and services which will affect physicianpractices . While these are formal mechanisms of control, there are also moresubtle environmental influences such as conSlmer demand and peer pressure .All of these factors impact on physician behaviour.The role of formal evaluation in shaping physician behaviour is ofprimary importance in technology diffusion . As pointed out in the literature(10M, 1985 : 179), evaluation may act directly on the perceptions of individualphysicians, or it may influence physicians indirectly (through variouschannels of communication) . It may also influence the centralized policydecisions of regulatory bodies (such as NHW) and of payors (such as theEquipment Grants Secretariat of the B.C. Ministry of Health).Of course , different channels of communication serve as conduits ofvarying i nf l uence . The literature indicates that some are more effective i nreaching larger numbers of physicians (such as professional journals), and8others are more effective in how persuasive the communication is (Anderson andLomas, 1985). For example, consensus conferences to establish expert views ondifferent technologies have grown in number in recent years. However, withthis increase in numbers , different panels on the same subject often tend todisagree with each other (Canadian Consensus Conference on Cholesterol, 1988).This leaves the individual physician in a decision vacuum with no clearclinical policy guiding utilization.Our pilot study describes the changing patterns of diffusion and examinesthe major determinants of two selected categories of technologies - imagingdevices and common laboratory tests. In contrast to narrow definitions ofdiffusion that imply the acquisition of technology, we have used a broaderdefinition incorporating the extent of utilization into this definition.Technology diffusion is defined as the process by which a technology entersand becomes part of the health care system, usually depicted as an S-shapedcurve that characterizes the stages of adoption (OTA, 1976). Despite thelimited resources and the narrow focus of the pilot project, the analysisprovides several interesting findings (Section IV).While some mechanisms exist for influencing technological change, such asregulation under special programs for the purchase of expensive technologies(Deber et a1, 1988), or fee-for-service schedules that indicate what servicescan be prOVided and how much the payment will be (Evans, 1982), prOVincial andfederal policy mechanisms are neither coordinated nor applied consistently toassure defined goals . Moreover, it is unlikely that the assessment of the,9consequences of these policy decisions have ever been part of that process.Clearly, a certain quality and quantity of information is needed for decisionmaking purposes, which is presumed to vary by type of technology.The development of the proposed taxonomy to classify emerging andexisting technologies was deemed an important first step in the compilation ofuseful information for policy decisions . While it would be prohibitive toundertake extensive technology assessment work everytime a resource allocationor other policy decision has to be made, it is desirable to make these basedon informed judgements about the clinical, economic, and social impact of thespecific health technology before it is used extensively. A comprehensivetaxonomy would serve two purposes: it would provide a priorization oftechnologies that could serve as guideline for further ev ~ luative research,yet would provide sufficient detail to indicate the regulatory mechanism(s)most appropriate to the specific technology.In the cour s e of this research activity, we reviewed a vast and rapidlyincreasing literature in the area of technology assessment, and in a morelimited fashion the clinical literature pertaining to the two selectedcategories of technologies , and the literature on taxonomy development. Twoimportant points warrant noting . First , as voluminous as the literature onhealth care technology assessment may be. this body of work covers only asmall number of technologies. is most frequently based on the less rigorousmethods, and provides very limited information about the consequences of thesetechnologies . Second, this information as incomplete as it may be in breadth ,is of technical nature, not easily retrievable. and generally concerns a10single technology at a time. The policy maker confronted with an allocationdecision has very little use for highly technical information specific to theattributes of one or another technology. A decision tool that quantifies therelative merits of the technologies under consideration is unarguab1y what isneeded. As mentioned above, a comprehensive taxonomy of health technology wasthought to provide that function .The purpose of taxonomy °i s : identification of the object, recognition ofits specific limits, grouping it into natural groups, and constructingclassifications which as near as possible show the course of evolution withina group (Cain, 1959). Our research indicated clearly that neither theinherent characteristics of health care technologies nor their assumedproperties lend themselves to taxonomic classification. Detailedcharacteristics and/or attributes are so variable in scope that meaningfultaxonomic dimensions could not be easily constructed. Conversely, summarymeasures of these are futile because they lack the breadth of scope expectedof such measures .II. REVIEW OF THE LITERATURETechnological change in the 1970s and 1980s .has accelerated to the pointthat it threatens to outpace society's ability to reflect on the impact ofchoosing to use or not use the results of new information. Nowhere is thismore apparent than in the health care field. Inevitably, the products ofresearch from the basic sciences, the military , engineering and medicine findtheir way into health care applications. Technology, though, is a term insearch of a definition (Banta et aI, 1981). In defining the term, society can11begin to put parameters and meaning into what the choices are that mustultimately be made. The Office of Technology Assessment (1978) has definedmedical technology as:"The drugs, devices, and medical and surgical procedures used in medicalcare, and the organizational and supportive systems within which suchcare is provided."Government, as the representative of public interest and reflectingsocietal values, must necessarily make choices daily as to which technologieswill be chosen for diffusion, adopted by its health care organizations andused by providers and consumers in reducing health deficits. Despite theliterature on policy formulation in health technology (Hannan, 1987; Banta,1982; Feeny et aI, 1986), so far there has emerged no useful framework forpolicy decision makers. Rutten et a1 (1988) distinguished between two policyoptions for diffusion control: 1) regulations by directive and 2) regulationby incentive; it is our contention that both must be attempted to support theoverall goal of cost effective services.In an effort to develop an instrument useful to decision-making andspecifically to assist policy decisions in technology diffusion, it washypothesized at the outset of our study that developing a taxonomy forclassifying technology in health care, by virtue of its descriptive profile,would prOVide a method for priority setting in decisions . The development ofa taxonomy is dependent on the dimensions identified for such classification .These dimensions described by Cain (1959) as: form/features,12function/structure, mode of specialization, degree of differentiation/modification/diversification, sensitivity and simplicity/complexity, are wellsuited to classifying biological processes or species.They do not, however, transfer well to the specifics of diverse materialgoods, organizational processes or new knowledge with application to healthcare. With a broad definition of technology, a classification scheme ratherthan a taxonomy with predictive qualities seemed more appropriate to the taskat hand. Numerical taxonomic development of technology is an option but thisattempt would likely narrow the definition of technology to that of a materialnature.Classification or categorization structures exist for technology in thebasic sciences. In physics, the broad classification of Cross-DisciplinaryPhysics and Related Areas of Science and Technology yields the subsystem,Biophysics, Medical Physics and Biomedical Engineering (Physics Abstracts,1989). This category contains vast areas of research drawn from the fields ofphysics, chemistry and the biological sciences which have been applied tobiomedical devices or techniques. As well , library sciences have referencemanuals such as Excerpta Medica which categorize technology according tospecific fields such as radiology or nuclear medicine, etc. These formats,like physics, reclassify techniques and devices according to science of originor the products for application in health care.Directories such as the Canadian Medical Device Directory (1988) and theU.S. Encyclopedia of Medical Devices and Instrumentation (1988) list health13care equipment and supplies. Both of these formats though, do not contain theessential dimensions of a taxonomy. In effect, technology in health care doesnot, at this point in time, "fit" into the development of a taxonomicalframework.The development of technology and subsequent application in health carewas historically, and continues to be, met with a variety of responses. Themajor stakeholders - the medical community, hospital administrators andconsumers - each approach technology from a different perspective and adopttechnology for individual reasons (Tannon and Rogers, 1975) . Lately,questions of doubt about what the technology actually does or its impact onhealth status has been examined among the three identified stakeholders(Burson, 1984; Cohn, 1988; Davison, 1989; Friedlander, 1986; Kutner, 1987) .Ultimately the issues of ethics, equiuy, utility and economics are central tothe question of "just because we have the technology do we use it" (McMahon,1987; Menkin, 1985; Moore, 1989; Samuel, 1986). Both the arts and scienceliterature has begun to question the diffusion of technology and look totechnology assessment for some answers.Technology assessment in health is a field in early stages ofdevelopment. Most of the literature on technology assessment is specific tothe technical aspects of the particular technology (Lundberg, 1987; Hillman ,1988), focuses on the economics of utilization (Altman and Blendon, 1984;Ball, 1984; Russel, 1984; Lister, 1987) or describes diffusion in differentcountries (Russel, 1988; Stocking, 1988; Rublee, 1989). As well, much of theliterature focuses on how to do technology assessment (Tugwell et aI, 1986;14Chrzanowski, 1988) either from an epidemiological (Weinstein, 1985; Challah,1986) or economic evaluation perspective (Westlake, 1981; Doessel, 1986;Hutton, 1986; Drummond, 1987). Few studies were found which attempt toevaluate the effect of technology on health outcomes (Lohr, 1988; Roberts,1988; Roos, 1988). Technology assessment activity is reported in acomprehensive document published by the Institute of Medicine (1985). A smallnumber of studies attempt to examine ethics (Cohn, 1988; Campbell, 1987)and/or the patient response (AJMCN, 1985; Davison, 1987). In sum, technologyassessment is just emerging as a methodology with which the health care fieldand society can begin to address problems pertaining to rapid technologicalchange.Literature specific to low and high technologies examined in this studywas found to be either of a clinical nature or economic perspective. Theclinical literature on laboratory testing was silent on questions ofeffectiveness and not so silent on comparative reviews of one machine versusanother (Cassaday, 1985; Kambayashi, 1985; Belsey, 1987; Lifshitz, 1989). Aswell, in the u.s. literature, much of the focus tends to be on the economicconsiderations of acquiring new diagnostic equipment for both revenue andcosting purposes (Levitt, 1984; Martin, 1985; McGivney, 1988). In Canada, thedebate tends to center more on control of diffusion (Feeny et aI, 1986) andincentive structures (Evans, 1982) of both categories of technology. Economicevaluation in both countries for laboratory services reveals a vast amount ofutilization unrelated to need and tied more to the incentives inherent in thereimbursement system of physicians (Blendon, 1984; Rosenthal, 1982; Fineberg,1977; OTA, 1981).15The literature on Nuclear Magnetic Resonance l ~l aging equipment is eitherof a clinical nature (Hendrick, 1985; Health Technology, 1986; Winkler, 1988)or entirely economic analysis (Evans, 1984; Atkins, 1985; Elliot, 1986) .Literature pertaining to policy development for both laboratory testing and"high technology" was found to be limited almost entirely to economicconsiderations of technology diffusion (Rutten et ai, 1988) or to questions ofone specific technology, a single patient population or geographic area (Goel,1989; Garber and Gluck , 1989; Ellencweig, 1988). In short, it was found thatthe literature was rapidly accumulating on technology diffusion and beginningto develop · in the area of assessment but that it was limited incomprehensiveness to contribute significantly to the policy decision makingprocess.III. DATA DEVELOPMENTIn order to explore the current state of the selected technologies inB.C . • two administrative data sets were utilized. These data sets included:i) the Medical Services Plan (MSP) Master Tapes for payment information toB.C. physicians for medical services; and ii) Annual Return of Health CareFacilities - Part I (HS1) for statistical data on services provided byhospital laboratories. Examination of these large provincial data setsinvolved significant effort in data extraction and development.The two administrative data sets were analyzed independently forfeasibility of collecting information on the two selected technologies - CTscanners and automated laboratory equipment . Upon examination, we found thatit was more useful to consider t he classification of these and other16technologies into two broad categories of 'low' and 'high' technology (Table1). The 'low' technology group was limited to selected common laboratorytests which are generally used for diagnostic and patient monitoring purposes.Since these tests are performed using automated equipment in mostlaboratories, for the purposes of this study the tests are a proxy for theequipment.The 'high' technology group represents imaging devices also used fordiagnostic and patient monitoring purposes. High technology was furthergrouped into 'new' and 'old' technology. For the purposes of this study 'new'technology included CT scanners and NMRI devices while 'old' technologyincluded those imaging techniques which may be substituted by new technologynow and in the future, specifically for diagnosing neurological disorders.These items were then examined using MSP data for rates of diffusion andvolume of utilization measured by the total number of services and dollars percapita and in some cases disaggregated to illustrate utilization by age andsex. The data represent the years 1979/80, 1982/83 and 1987/88. HS1 datawere examined to develop institutional profiles . The years under study were1979/80, 1982/83 and 1986/87.IV. ANALYSISThe data obtained from the MSP Master Tapes and HS1 tapes were aggregatedinto the groups of low and high technology as illustrated in Table 1. Thisdetailed retrospective analysis provided historical baseline data for threeareas of interest :Table 1TECHNOLOGY CLASSIFICATIONFEE ITEM GROUPINGSTYPE OF TECHNOLOGY MAJOR GROUP FEE ITEM FEE ITEM No.i. Chemistry Profile Chemistry Profile 91392. Single Chemistry Potassium 9209Glucose 9043Blood Urea Nitrogen I 9241LOW (B.U.N.) 9384Creatinine 9163HDL with Cholesterol 9465Total Cholesterol 9158Akaline Phosphatase 9173Uric Acid 9242P04 Phosphate 9204Calcium 9153-Laboratory Total Protein 9210Albumin 9211Total Bilirubin 91463. Haematology Profile Hematology Profile 90054. Single Hematology Red Blood Cells 9002White Blood Cells 9011Hemoglobin 9007Differential 90125. Urine Tests Complete - Urine 9366HIGH - New 6. Computer Tomographic Head Scan - r-Scans - without contrast 8690- with contrast 8691- double scan ortwo planes 8692Body Scan one region- without contrast 8693- with contrast 8694- Imaging - double scan ortwo regions - r- 86957. Nuclear Magnetic Standard 2-sequence or - r-Resonance Imaging 2-plane study T8697Additional sequences orplanes - 1--+ T8698- Old 8 . Invasive and Brain Scan, Static 9867Non-Invasive Imaging Routine Skull X-Ray 8500Encephalogram 8502EEG & Interpretation 0415EEG - Interpretation 0416Electrocorticography 0417Cerebral Angiography- unilateral 8615- bilateral 8616Air Encephalogram 0720Myelogram 0721181. patterns of diffusion and volume of utilization2. institutional profile; and3. provider profile.In order to be useful to policy development, the analysis included, wherepossible. the examination of the determinants of diffusion that were amenableto policy influence (Figure 1).1. Diffusion and UtilizationThe initial examination of MSP data on the larger groupings of theselected technologies illustrates the gross number of services and the ratesper 1,000 population for each of the representative years (Table 2) . As well,the change in the volume and rates of service between the three years isshown. The population in thousands and the percentage changes allows acomparison between the rate of testing and the rate of growth in population.These larger groupings reveal relationships between patterns of servicespecific to the type of technology. Each of these was examined separately.a) Low TechnologyIn general. testing on selected laboratory items has increasedbetween 1979/80 and 1987/88. The magnitude of the increaseillustrates that population increases alone are an insufficientexplanation for these facts. For example. utilization of chemicalprofiles (auto analyzer. six or more channels) between 1979/80,1983/84 and 1987/88 increased 60.92% and 17.12% respectively whilesingle chemistry tests also increased. at a rate similar to19TABLE 2Number of ServicesFee Item Group by TimeTYPE OFTECHNOLOGY MAJOR GROUP 1.W.Q CHANGE 83/84 CHANGE 87/88Chemical Profile 208,463 60.92% 335,466 17.12% 392,904LOW Single Chem 542,534 54.42% 837,768 39.58% 1,169,380- Laboratory Heam. Profile 535,011 40.77% 753,125Single Haem 2,430,188 -8.73% 2,218,110 -45.24% 1,214,599Urine 612,870 39.92% 857,545 7.74% 923,914HIGH New CT Scans 30,217 75.73% 53,101- Imaging MR.I 1,301Old Old Technologies 49,691 -12 . 53% 43,464 -20.63% 34,499Rates Per 1,000 Pop.Fee Group By TimeTYPE OFTECHNOLOGY MAJOR GROUP 1.W.Q CHANGE 83/84 CHANGE 87/88LOW Chemical Profile 80.50 48.05% 119.19 12.67% 134 .29Single Chem 209.51 42 .07% 297.65 34.28% 399.69- Laboratory Hearn. Profile 190.08 35.42% 257.42Single Haem 938.48 -16.03% 788.07 -47.32% 415.15Urine 236.68 28.73% 304.68 3.65% 315.79HIGH New CT Scans 10.74 69.06% 18.15-Imaging MR.I 0.00 0 .44Old Old Techno1o 19.19 -19 . 53% 15.44 -23.64% 11.79POP in 1000's 2589 .5 8.69% 2814.6 3.95% 2925.7Population source: British Columbia Population Forecast 1987-2011, Forecast 2/89. [Table2]20(54.42%) or higher than (39.58%) the respective rates forautoanalyzers. Haematology profiles , conversely, have increasedsince aggregation between 1979/80 and 1983/84 while singlehaematology tests have decreased . It is, therefore, reasonable toassume that chemistry profiles have not replaced single chemistrytests in the same manner and degree that the haemato1ogy profilehas replaced single tests .The last common test examined, urine tests (per capita), show alsoa substantial increase (28.73%) between 1979/80 and 1983/84.However, it is the only test between 1983/84 and 1987/88 where theincrease relative to the population increase is minimal (3 .65%) .b) High TechnologyThe rate of diffusion for high technology is clearly mapped by theintroduction of CT scanners and NMRI's into B.C. during the1980's. The first CT scanner was installed in Vancouver in 1974,the second in 1980 and a third in 1982. The base year of 1979/80reveals that utilization of CT scans was not yet reflected in theMSP fee schedule while the 1983/84 data reveal the diffusion ofthis technology. The province currently has 18 "approved" CTscanners which is reflected in the rapid increase in utilizationstatistics for 1987/88.21The first magnetic resonance imaging equipment was installed in Vancouverin 1985 mainly for research purposes and limited clinical use. Clearly,partial utilization is only beginning to show in 1987/88 but is expectedto increase rapidly with the operation of 2 more NMRIs in 1990.In general, it appears as though there was a small substitution effect ofthe old technologies for the newer diagnostic methods. Evidence of thischange may be seen by the 69.06 percent increase in CT scans per capita,in concert with a -23.64 percent decrease in old technology utilization.The eight major groups (as seen in Table 1) were disaggregated intoindividual fee items in order to determine more specifically where thechanges were taking place. These detailed data were examined for changesin the rate of utilization and are discussed separately for low and hightechnology.a) Low TechnologyThe common laboratory tests subsumed under low technology , listed inTable 3, reveal that utilization on most items increased morerapidly between 1979/80 and 1983/84 than for the time period between1983/84 and 1987/88. However, in many cases the small percentchange in the second period detracts from the fact that a largerabsolute number of tests occurred in that time. The largerdenominator for 1983/84 causes the percent change to appearproportionately smaller compared to those changes between 1979/8022and 1983/84.The trend of increased utilization per capita for both time periodsis interesting to note for all selected fee items . However, largeincr~ases in blood glucose (fee item 9043) and blood urea nitrogen(fee item 9384) may be explained by increases in small numbers ofservices «200). Large increases in cholesterol testing (fee items9158 and 9465) warrant closer examination .In order to illustrate the fiscal implications of utilization ofcommon laboratory tests, Table 4 shows the total MSP payments byyear of service for individual fee items. Five tests from thoseselected for study show the largest increases in both utilizationand payments. These five tests, creatinine (9163), alkalinephosphatase (9173), potassium (9209), blood urea nitrogen (B.D.N.9241) and HDL with cholesterol (9465), account for 78 percent($11,481,446) of the total ($14,786,112) expenditures in 1987/88 forthe selected group. While it is extremely interesting to note theselarge increases in utilization, it is beyond the scope of this studyto explain why this phenomenon is occurring.Closer examination of cholesterol testing is warranted by the largeimpact on both rate of utilization and total payment. As alreadyseen in Table 3, total cholesterol testing (9158) per capita wasdeclining between 1979/80 and 1983/84 by -23.57 percent butincreased again by 1987/88 (35.97%). The total dollar figure forTable 3Services Per 1000 PopulationCommon Laboratory Tests - Individual Fee ItemsBy Year of ServiceServices79180 Change 83/84 Change 87/88--- -- - - -- -- -Chemical Profile9139 80.50 48.05% 119.19 12 .67% 134.29TOTAL 80.50 48.05% 119 .19 12 .67% 134 .29Single Chemistry9043 Glucose 0.04 3.50% 0 .04 135.98% 0.109146 Total Bilirubin 11 .55 41.36% 16.32 5 .25% 17 .189153 Calcium 7.88 56 .45% 12.32 13.54% 13.999158 Total Cholesterol 20.98 -23.57% 16.04 35 .97% 21. 819163 Creatinine 21. 36 74 .07% 37 .19 31.42% 48 .879173 Alkaline Phosphatase 20.77 48 .08% 30.75 16.95% 35.979204 Phosphates, inorganic 4 .51 70 .13% 7 .67 9 .36% 8.389209 Potassium 49.89 59 .56% 79 .60 14.08% 90.809210 Total protein 1. 95 31. 54% 2.57 64.02% 4 .229211 Albumin 5.29 56.81% 8.29 3.88% 8.619241 Urea (B .U.N.) 37 .30 28 .96% 48 .10 11.89% 53 .839242 Uric Acid 20 .37 13.35% 23.09 10 .06% 25 .429384 Urea 0.04 -65 .50% 0.01 60.34% 0.029465 H.D.L w/cho1estero1 7.58 106.33% 15 .64 350 .61% 70 .50TOTAL 209 .51 42.07% 297.65 34.28% 399.69Haem Profile9005 NA 190.08 35.42% 257 .42TOTAL NA 190.08 35.42% 257.42Single Haematology9002 Red blood cells 57.60 79.65% 103.48 -42 .65% 59.359007 Haemogob1in 337.45 - 36 . 43% 214.53 -41 .71% 125 .069011 White blood cell 279.92 -41.80% 162.93 -60 .41% 64 .519012 Differential 263.51 16.55% 307.13 -45. 88% 166 .24TOTAL 938.48 -16.03% 788.07 -47.32% 415 .1524this item is moderately large compared to other testing and doesappear to be on a rising trend (Table 4). Conversely, HDL withcholesterol (9465) showed per capita increases of 106.33 percent and350.61 percent for 1979/80 to 1983/84 and 1983/84 to 1987/88,respectively. In terms of total MSP payments, services for thistest accounted for $278,826 in constant 1988 dollars for 1979/80 androse to $4,662,962 in 1987/88. Clearly, cholesterol testing showsan unequivocal trend of rapidly increasing utilization per capita.Curious as to where utilization was coming from in cholesteroltesting, we disaggregated these data into services per thousandpopulation by age and sex . Figure 2 illustrates the dramaticincreases in number of services per capita while Figure 3illustrates the percentage change in services per capita between theyears of service in the study. Research into the relationshipbetween cholesterol and heart disease was widely disseminated around1983/84 which may partially explain the increases . However, therewas clear evidence to suggest that total cholesterol measurement wasa good routine screening strategy for males between the ages of 35and 59 years. The Canadian Task Force on Periodic HealthExamination concluded that there was poor quality evidence regardingthe benefit of routinely screening for and treating hyper­cholesterolemia in other segments of the population. Anderson et a1(1989) found that of five major Canadian and American expert panelson cholesterol screening conducted between 1985 and 1987, there didnot appear to be clear agreement among the expert panels on theTable 4Total HSP Payments,Common Laboratory Tests by Year of Service79/80 87/88Chemical Profile9139TOTAL$2,709,367 119.77% $5,954,474 17.91% $7,021,176$2,709,367 119.77% $5,954,474 17.91% $7,021,176$4,073$486,011$538,178$697,319$1,382,684$1,150,153$337,695$2,762,855$119,259$402,696$1,522,792$719,119$316$4,662,962$14,786,112148.50%10.16%-14.41%42.13%37 .21%22.26%13.78%19.17%71 .61%8.60%16.98%14.85%69.02%372.40%55 .95%$1,639$441,177$628,804$490,630$1,007,738$940,707$296,788$2,318,478$69,493$370,807$1,301,789$626,125$187$987,070$9,481,432244.33%148.18%157.14%-13.98%138.78%66.46%182.04%201.28%80.30%157.70%195.44%31.49%-43.51%254.01%123.96%$476$177,763$244 ,541$570,348$422 ,039$565,133$105,230$769,547$38,544$143,893$440,625$476,166$331$278,826$4,233,462Single Chemistry9043 Glucose9146 Total Bilirubin9153 Calcium9158 Total Cholesterol9163 Creatinine9173 Alkaline Phosphatase9204 Phosphates, inorganic9209 Potassium9210 Total protein9211 Albumin9241 Urea (B.U.N.)9242 Uric Acid9384 Urea9464 HDL w/cho1estero1TOTALHaem Profile9005TOTAL$0$0NANA$4,922,135 41.52% $6,965,856$4,922,135 41.52% $6,965 ,856Single Haematology9002 Red blood cells9007 Haemogob1in9011 White blood cell9012 DifferentialTOTAL$542,354$1,301,010$2,158,596$3,112,260$7,114,220118.97% $1,187,59911.70% $1,453,2063.30% $2,229,824132.37% $7,231,88970.12% $12,102,518-40.06%-39.07%-58.61%-43.44%-45.38%$711,891$885,422$922,863$4,090,258$6,610,434Urine9366TOTAL$1,825,214 125.79% $4,121,134$1,825 ,214 125.79% $4,121,1348.17% $4,457,8448.17% $4,457,844*The MSP payments to physicians and/or hospitals in this table were adjustedto constant 1988 dollars. The adjustments were made using a fee index basedupon the series of average fee increases during the period. The value used toinflate the 1979/80 payments was 1.69 and for 1983/84 the value was 1 .06 .Figure 2Services Per 1000 Population,HDL CholesterolBy Patient Age and SexServices. 0'-200150100".50o_VI 7)Z m ~ ~0-24 25-34 35-44 45-54 55-64 65+Age GroupPrepared by: Health ManpowerReaearch Unit, U.B.C.87M87F83M83F79M79FFigure 3Change in Services Per 1000 Population,HDL CholesterolBy Patient Age and Sex% Change in Services/1000 Population500,..------------------83-87F400300 -20010079-83M65+55-6435-44 45-54Age Group25-340'------'-------L------l-----1------..J0-24Prepared by: Health ManpowerReaearch Unit, U.S .C .28ideal target population. However, all panels, except one,recommended that total plasma cholesterol be used as the first stagein a two stage process, in which the results of the first test areused to define populations who should receive more complet~diagnostic analysis (including HDL with total cholesterol) andtreatment in the second stage. The preliminary analysis of the B.C.data clearly indicate quite a different phenomenon . It would appearthat HDL with cholesterol (9465) is being used as a primaryscreening test for all age groups and sexes instead of the totalcholesterol (9158) measure. In the 1987 fee-for-service paymentschedule in B.C., total cholesterol (9148) was charged at $10.93,total cholesterol combined with a HDL cholesterol (9465) measurementwas charged at $22.81. At this time, it is unclear why one ischosen over the other as the screening or monitoring test of choicein B.C.b) High TechnologyTable 5 illustrates the high technology category disaggregated toindividual fee items for both new and old technology. It reveals aclear trend of increased utilization (add-on) following thediffusion of new diagnostic imaging technology. The oldtechnologies, chosen for examination due to their substitutiveproperties with the new technology, show a declining utilizationtrend . This trend does not indicate wholesale substitution sinceservices per thousand population show a -23.64 percent decreasewhile the new technologies have increased 69.09 percent. TheseTable 5Services Per 1000 Population, High TechnologyBy Year of Service87/88Services..,..----,----:::--=--79/80 Change 83/84 ChangeCT Scans8690 Head scan w/o contrast NA 2.57 87.32% 4 .828691 Head scan w contrast NA 3.55 -0.05% 3.558692 Head scan doub1e/2 planes NA 0.80 119.03% 1. 758693 Body scan w/o contrast NA 1.47 157.96% 3 .808694 Body scan w contrast NA 1.22 81. 86% 2.238695 Body scan doub1e/2 regions NA 1.11 79 .65% 2.00NEW TOTAL NA 10.74 69.06% 18.15MRl8697 Standard 2-sequence/2-p1ane NA8698 Additional sequences/plane NATOTAL NANANANA0.320.130.44Old Technologies Invasive and Non-invasive imaging0415 EEG & interpretation 1. 64 -2.82% 1. 59 7 .48 % 1.710720 Air encephalogram 0.03 -98.81% 0.00 -100.00% 0.000721 Myelogram 1. 35 4.94% 1.42 -100.00% 0.008500 Routine skull X-ray 9.68 -24.22% 7.33 -21. 97% 5.72OLD 8502 Encephalogram 0.00 124.89% 0.01 9.32% 0 .018615 Cerebral angiography 0.01 89.75% 0.01 139.05% 0.038616 Cerebral angiography 0.01 544 .02% 0.04 -8.65% 0.049402 EEG tracing w/o inte 4 .28 -4.51% 4.09 -8.07% 3 .769867 Brain scan - static 2.20 -56 .77% 0.95 -44.66% 0.53TOTAL 19.19 -19.53% 15.44 -23.64% 11.79POP in 1000 2589.5 8.69% 2814.6 3.95% 2925 .730changes in servicing patterns indicate that the new technologies maybe complementary and are being used in conjunction with otherdiagnostic testing modalities. This is consistent with the findingsof Daly (1989).Table 6 demonstrates the financial impact of these observations in1988 constant dollars. While the amount of MSP payments increasedby 70.31 percent for all types of CT scans, the amount of paymentsonly declined by -20.94 percent for old technologies . The totalamount of high technology in constant 1987/88 dollars for 1983/84($4,493,235) compared to the total amount for 1987/88 ($5,571,942)shows that there is a 24 percent increase in monies spent ondiagnostic imaging of these few fee items.In low and high technology categories, the data were disaggregatedby age and sex to determine if there were any extraordinary patternsof utilization (Figure 4). In both areas of technology, womenshowed a trend of higher utilization rates than men until ages 50 ­65. This age-group seemed to represent a turning point at whichtime men became extremely high users of diagnostic and imagingtechnologies. This pattern generally continues until the oldest agegroup (85+).2. Institutional ProfileThe Annual Return of Health Care Facilities - Part I (HSl) was used asthe source for data on services provided by laboratory, radiology and nuclearTable 6High Technology HSP Payments forIndividual Fee Items By Year of Servicein Constant 1988 Dollars87/88~~:-----::---,Adjusted Payments*_~~~79/80 Change 83/84 ChangeNEW CT Scans8690 Head scan w/o contrast $0 NA $269,839 84.51% $497,8888691 Head scan w contrast $0 NA $525,125 -1. 51% $517,2038692 Head scan doub1e/2 planes $0 NA $152,274 106.80% $314,9068693 Body scan w/o contrast $0 NA $313,414 153.08% $793,1798694 Body scan w contrast $0 NA $285,336 78.45% $509,1918695 Body scan doub1e/2 regions $0 NA $352,781 70.47% $601,390SUB-TOTAL $0 NA $1,898,768 70.31% $3,233,758HR.I8697 Standard 2-sequence/ $0 NA $0 NA $246,634or 2-p1ane study8698 Additional sequences $0 NA $0 NA $40,252or planesSUB-TOTAL $0 NA $0 NA $286,886Old Technologies - Invasive and Non-invasive imaging0415 EEG & interpretation $401,784 3.50% $415,840 6.09% $441,1440720 Air encephalogram $5,383 -98.88% $60 -100.00% $00721 Myelogram $118,944 4.58% $124,388 -100 .00% $08500 Routine skull X-ray $1,018,321 -18.24% $832,587 -22.99% $641,2088502 Encephalogram $882 131. 35% $2,041 9.00% $2,2258615 Cerebral angiography $1,432 181.45% $4,029 100.46% $8,0778616 Cerebral angiography $2,543 724.31% $20,965 -27.06% $15,2929402 EEG tracing w/o iinterpretation $808,872 0.36% $811,792 -9.58% $733,9989867 Brain scan - static $862,021 -55 .60% $382,765 -45.30% $209,355SUB-TOTAL $3,220,181 -19.43% $2,594,467 -20.94%$2,051,298TOTAL $3,220,181 +39.53% $4,493,235 +24.01 $5,571,942*The MSP payments to physicians and/or hospitals in this table were adjustedto constant 1988 dollars. The adjustments were made using a fee index basedupon the series of average fee increases during the period. The value used toinflate the 1979/80 payments was 1.69 and for 1983/84 the value was 1.06.Figure 4Number of Services Per 1,000 PopulationSingle Chemical Tests, Male and Female1979/80, 1982/83 and 1987/88Female 82/83~ .....[tJMale 79/80- Female 79/80.~~-Number per 1,000 populationo0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-79 80-84 85+AgeMale 87/881650i ~Male82/831500 , --.--- - Female 87/88135012001050900750600450300150~ ~ ! I?-_... ~I I I iiiPrepared by: Health ManpowerResearch Unit, U.B.C.33medicine units in hospitals. The information is reported in standard un itsfor the technical and non-professional workload (excluding pathologists orother medical specialists who are counted under MSP fee-for-service data).The unit is defined in the Canadian Workload Measurement System - Laboratoryof the National Hospital Productivity Improvement Program (1986-87 Edition) asthe time spent on activities specifically related to the production of patientanswers - "one minute of the productive time of technical, clerical and labaide staff". The unit values are further classed as permanent, temporary,automated and manual. Tests which are automated exhibit variation in timedependent on the characteristics of the instruments. The instruments arelisted to reflect unit values associated with specific instruments . Chemistryand haematology analysis is usually automated in most laboratories using avariety of analyzer instruments. The total units are the important measure inthis exercise rather than automation or manual values.The results of this investigation are reported by regional hospitaldistrict (RHD). In British Columb ia there are 30 RHDs, with the metropolitanand non-metropolitan areas comprising approximately 52 percent and 47 percentof the population respectively (Table 7). The metropolitan areas areidentified as the Capital Region and Greater Vancouver, while the non­metropolitan include all other regions in the province.Six procedures were examined in this study for general trends ininstitutional utilization of services . These services were selected to beconsistent with the technologies previously identified: clinical chemistry ,haematology, nuclear medicine, EEGs and diagnostic radiology (total, head and34Table 7Population* of Metropolitan and Non-MetropolitanAreas of B.C. by Year (Under Study)1979 1982 1987NUMBER % NUMBER % NUMBER %Non-metropolitan subtotal 1,255.407 47.7 1,350,631 48.4 1,359.791 46.7Metropo1it~n subtotal 1,377,916 52.3 1.437.168 51. 6 1,553.248 53.2TOTAL 2,633.323 100 2,787,799 100 2.918,155 100*Statistics Canada Interpolations Based on Census Data 1976, 1981, 1986.neck and, CT scans). The years 1979/80. 1982/83 and 1986/87 (most recent dataavailable at time of study) are reported in Table 8 by percentage of totalunits for metropolitan and non-metropolitan areas.Laboratory services (clinical chemistry and haemato1ogy) are providedthroughout the province with approximately 60 percent occurring inmetropolitan areas and 40 percent in non-metropolitan areas. This isconsistent with the distribution of the population and given that all teachinghospitals are located in metropolitan areas.Nuclear medicine services show a different pattern of diffusion; almost90 percent occur in metropolitan areas in 1979/80 decreasing to 80 percent by1986/87. Similarly . EEG's occur approximately 73 - 83 percent in metropolitanTable 8Annual Return of B.C. Health Care FacilitiesStandard Total Units Done During Year of Service by PercentageFor Metropolitan* and Non-Metropolitan Areas1979/80 1982/83 1986/87Clinical Chemistry Metro 60.97 57.82 60.18Non-Metro 39.03 42.18 39.82Hematology Metro 59.29 60.15 64.18Non-Metro 40.71 39.85 35.82Nuclear Medicine l Metro 88.22 77.61 80.81Non-Metro 11. 78 22.39 19.19EEG2 Metro 73.41 83.69 77 .81Non-Metro 26.59 16.31 22.19Diagnostic Radiology Metro 44.89 29.67 31.84- Head and Neck Non-Metro 55.51 70.33 68.16Diagnostic Radiology Metro N/A 82.67 75.97- CT Scans Non-Metro N/A 17.33 24.03Diagnostic Radiology Metro N/A 38 .79 44.34- Total Non-Metro N/A 61.21 55.661, 2 Calculations for EEG and nuclear medicine are reported by numbers ofexams. Percentages have been calculated by adding inpatient and outpatientexams in metropolitan areas as a proportion of the total.* Metropolitan includes the Capital Regional District (Victoria) and GreaterVancouver.36areas and 16 - ~3 percent in non-metropolitan areas . The fact that mostneurological centers would be located in metropolitan areas would supportthese figures.Diagnostic radiology services show a pattern of diffusion which would beexpected for access to sophisticated technology. Head and neck radiologyservices in 1979/80 were divided almost equally between metropolitan and non­metropolitan areas. It would appear that as more CT scanners becameoperational in metropolitan areas that this technology displaced head and neckradiology. By 1986/87 the figures reveal that the vast majority of head andneck radiology was done in non-metropolitan areas. While total units inradiology shows a less dramatic pattern of utilization, it is similar to thatof head and neck .Computer tomographic scanning services illustrate that initially thesefacilities were predominantly provided in metropolitan areas (82.67%) in1982/83. By 1986/87, when the technology presumably became more availableoutside metropolitan areas, the data show the proportion changing betweenmetropolitan (75 .97%) and non-metropolitan areas (24.03%).In general, it appears that laboratory services or low technologyservices are widely diffused throughout the province. Conversely, old,technology in the form of radiology services are used more in non-metropolitanareas than newer high technology services (CT scans). Unequal access to theseservices is the most feasible explanation for these facts .373. Provider ProfileThe B.C. Medical Services Plan Master Tapes were used as the source ofdata on physician sociodemographic variables such as age and sex, andspecialty and location. Test ordering behaviour in the years under study byplace of graduation was illustrated by the British Columbia College ofPhysicians and Surgeons database. The information is descriptive in contentand should be used only as observations about physician utilization of thespecific technologies delineated in Table 1. The process by which atechnology enters and becomes part of the health care system is diffusionwhich has two phases: the initial period during which a decision is made toadopt the innovation, and the second phase which encompasses the manydecisions to ~ the innovation (Banta, et aI, 1981). The data re~orted inthis study pertains to adoption (of new technology) and utilization (of alltechnology).3 .1 AgePhysicians ordering common laboratory tests and old diagnostictechnologies in all years were predominantly between the ages of 35 and55 years old. This is consistent with the majority of B.C. physicians(71%) falling within this age group (B.C . Ministry of Health AnnualReport, 1987/88). This same age group also made the majority ofreferrals to new technologies (73%) in both 1983/84 and 1987/88.3 .2 SexTesting ordered in both low and high technology categories were referredpredominantly by male physicians. In all three years studied , male38physicians ordered tests between 87-89 percent of the time while femalephysicians were the source of referrals 11-13 percent of the time. Thisis consistent with the estimated proportion of male to female physiciansreported in the B.C. Ministry of Health Annual Report, 1987/88. In sum,age- or sex-specific test ordering behaviour was not observed for theyears under examination.3.3 Specialty and LocationTable 9 illustrates referring physicians by groups of services for thethree time periods in the study. Laboratory services in B.C. for1979/80, 1983/84 and 1987/88 show a consistent pattern of referrals byphysician specialties. General practitioners referred most frequentlyfor lab tests (approximately 80% of lab tests ordered in all threeperiods) while internal medicine (about 11%), general surgery (2% - 4%)and urology (1% - 2%) ranked consistently behind.Old technology services for all three time periods were most frequentlyreferred by general practitioners (62% - 67%). Neurology, Paediatricsand Internal Medicine followed in the same order for all three years;the percent difference for any ~pecialty between time periods wasgenerally 1 - 2 percent. Neurosurgeons were referring patients to olddiagnostic technologies in 1979/80 but not in the later periods.New technology referrals, first reported in the 1983/84 data, show adifferent referral pattern. CT scans were referred to most frequently byneurologists (27.7%), followed by internists (15.4%), generalTABLE 9Grouped Fee Items by Year of Service andPercentage of Services by Type of Physician Practice1979/80 % 1983/84 % 1987/88 %GPs 76.6 GPs 81.6 GPs 80.7LOW Internal Medicine 11.5 Internal Medicine 10.2 Internal Medicine 10.6- LABORATORY General Surgery 4.3 General Surgery 2.2 General Surgery 1.9Urology 2.0 Urology 1.0 Dermatology 1.3n = 208,300 n = 334,404 n = 392,439GPs 61.6 GPs 64.3 GPs 67.2HIGH Neurology 13.6 Neurology 11.1 Neurology 15.2- OLD IMAGING* Pediatrics 5.5 Pediatrics 7.3 Pediatrics 7.6Internal Medicine 5.0 Internal Medicine 4.0 Internal Medicine 3.4Neurosurgery 3.9 n = 41,407 n = 32,594n = 47,736Neurology 27.7 GPs 28.0Internal Medicine 15.4 Neurology 21.0- NEW IMAGING* N/A GPs 14.7 Internal Medicine 15.5CT Scans Neurosurgery 10.4 Neurosurgery 9.5Orthopedic Surgery 6.2 Orthopedic Surgery 7.9CT n = 30,158 CT n = 52,988Neurology 69.4Neurosurgery 8.7MRI Orthopedic Surgery 7.3GPs 4.5Internal Medicine 4.5MRI n = 1,301n = Total number of services for entire population* See Table 1 for detailed classification40practitioners (14.7%), neurosurgeons (10.4%) and orthopaedic surgeons(6.2%).In 1987/88, new technology referrals included both CT scans and .NMRIs.The referral patterns changed again to reflect diffusion of CT scannersinto a greater number of locations and of limited access to the one NMRIin Vancouver. CT scan referrals for this period were more frequentlymade by general practitioners (28.0%), neurologists (21.0%), internists(15.5%), neurosurgeons (9.5%), and orthopaedic surgeons (7.9%) . The vastmajority of NMRI services (69.4%) were referrals from neurologists,general practitioners comprising only 4 .5 percent of referrals . Thispattern reflects the strict utilization protocol established by thoseresponsible for medical imaging in the institution where the single NMRImachine was available, primarily for research purposes . .For all three time periods (Table 10), the location of physicians followsa similar trend to the institutional profile in that, on average, between72.7 and 74.9 percent of referrals for laboratory services were frommetropolitan areas; between 27.3 and 25.1 percent were from non­metropolitan areas. Old technology referrals in metropolitan areasdecline from 62 percent in 1979/80 to 59.8 percent in 1987/88 . Newtechnology referrals (CT scans) were mostly in metropolitan areas (78%)in 1983/84 and in 1987/88 (68%). In 1987/88, referrals for NMRIs werealmost exclusively from metropolitan areas (90%).TABLE 10Percentage of Referring Physicians by Location by Type of Technology1979/80 1983/84 1987/88LOW Metro 74 .9 72.7 74 .5- LabNon-Metro 25 .1 27 .3 25.5HIGH* Metro 62 .0 59 .3 59.8- Old ImagingNon-Metro 38 .0 40 .7 40 .2Metro N/A 78 .2 68 .4- New - CTNon-Metro N/A 21. 8 31. 6Metro N/A N/A 90 .2- MRINon-Metro N/A N/A 9.8*See Table 1 for detailed class ification42The population ratio of metropolitan to non-metropolitan areas, between1979 and 1987, was consistent at 52 percent to 47 percent respectively.It is difficult to draw any conclusions between access and populationdistribution since these data (Table 10) show only the location ofphysicians referring for the specific service.The data were examined for significant differences between new and oldtechnology services referred by place of graduation. The place ofgraduation was reported as British Columbia, other Canada, UnitedKingdom, and other for 1979/80, 1983/84 and 1987/88.There were no significant differences found by training location inreferring for tests in either the new or old technologies categories forall three time periods.The financial impact of utilization of all pathology, nuclear medicineand radiological services is reflected both in the professional andinstitutional costs to the health care system. The institutional costswere reported earlier for technical and non-professional services. Inthis section, only professional fee-for-service payments made through theMedical Services Plan are reported. In Table 11, there is a dramaticincrease in fee-for-service payments to all specialties for the threetime periods. Pathology and bacteriology show the greatest amount ofdollars ($116,323,221 in 1987/88) while nuclear medicine shows thegreatest rate of increase (106.96%) between 1984 and 1988 (see Figure 5) .43Table 11Total and Adjusted MSP Fee-For-Service PaymentsFor Selected Specialties in B.C. by Year of Service79/80 Changes 83/84 Changes 87/88-----------._.*** Actual Fee for Service ***PE:' :l ogy &terio1ogy $40,749,318 133.28% $95,060,101 22.37% $116,323,221Nu . 'r Medicine $974,611 205.60% $2,978,414 119.48% $6,536,989Rat -:1 gy $27,637,276 107 .72% $57,408,450 23.91% $71,136 I 13046.28% $100,812,164 15.39% $116,323,22191.63% $3,158,637 106.96% $6,536,98930.25% $60,882,221 16.84% $71,136,130$68,916,897$1,648,302$46,741,280*** . 1at ed Fee for Service ***Pathology &BacteriologyNuclear MedicineRadiologyInflation Index$30,7781.69$49,0831.06$52,0531.00Base = 1987/88V. SUMMARY AND DISCUSSIONThe role governments play in the development and diffusion of technologyis c1e~11y an influential one, especially in health care. It spans a wideraT . f levels of involvement: from supporting the development of: l ogi es , to regulating the marketing of certain technological services,iying for such services through public funds (medical insurance) . What isLmi ng, however, is that policy decisions are most often made in the absence_ accurate information on the implications of technological change. Ideally ,policy decisions regarding health care technology should be made based onevidence from comprehensive assessment .Millions120Figure 5Adjusted MSP Paymentsto Selected Specialties1008060 '4020o79/80Prepared by: Health ManpowerResearch Unit, U.S .C.jj1!!!!!::::::::mE::::lillllli83/84nmm11111111Em::::::::::::mm~~mm~~,m~~~~~ill!!!!!!IIIIIIII87/88SpecialtiesHlHlHlH!l Pathologyc:J Nuclear Medicine~ RadiologyBase • 1987/8845Realistically, the large majority of technological innovations are in uselong before any systematic assessment has taken place. Retrospective policymaking , once the technology is widely diffused, is possible but may be seen asdirect interference into clinical practice. Prospective policy developmentanticipates changes to the system in view of the technological horizon andparticipates with the clinical community in rational decision making throughinformation on technology assessment and utilization review procedures .The purpose of this pilot study was twofold:i) to develop from literature on technology assessment a taxonomy forclassifying new technology i n he al t h care; andii) to examine the empirical evidence on the diffusion and utilizationof two diagnostic technologies selected specifically for theirapparent dissimilitude on a number of dimensions - CT scanners andAutomated Lab Tests .The research design included a detailed review of the literature for thepurpose of taxonomic classification of health care technologies, and anempirical analysis of B.C. data on the two selected categories oftechnologies.The method used to explore the current state of selected technologies inB.C . was limited to provincial data from the Ministry of Health . Twoadministrative data sets (MSP payments and Annual Hospital Returns) wereanalyzed independently for the retrospective study of three major areas :46patterns of diffusion, institutional profile, and provider profile. Theseanalyses pertain to imaging technologies and common laboratory testing only.The literature review indicated, with particular clarity, that given thebreadth of definition, health technology does not lend itself to the type ofclassification that would be helpful in decision-making; that is, thefeasibility of a classification which provides priorization schemes wasexamined and considered to be of limited use for policy development. However,we found that a decision framework that reflects notions of equity andutility, and rationalizes choices between technologies in terms of theseattributes, is arguably more useful than a superimposed classification schemethat does not take into consideration health consequences of the technology.It was beyond the scope of this initial study to develop the framework but ithas been proposed for the next phase of research.There are four important points that warrant noting about the literature.First, as voluminous as the literature on health care technology assessmentmay be, this body of work covers only a small number of technologies, is mostfrequently based on the less rigorous methods, and provides very limitedinformation about the consequences of these technologies. Second, thisinformation as incomplete as it may be in scope, is of technical nature, noteasily retrievable, and generally concerns a single technology at a time. Thepolicy maker confronted with an allocation decision has very little use forhighly technical information specific to the attributes of one or anothertechnology. Third, while assessment is specific to a particular technology,it tends to focus on clinical or economic utilization as well as diffusion in47particular countries. Fourth, much of the literature focuses on how to dotechnology assessment e ither from an epidemiological or economic evaluat ionperspective.Few studies were found which attempt to evaluate the effect of technologyon health outcomes. In fact, health care needs do not appear to playa largepart in the diffusion of health care technology . For example, in the U.S.literature, much of the focus tends to be on the economic considerations ofacquiring new diagnostic equipment for revenue and costing purposes. InCanada, the debate tends to center more on control of diffusion and incentivestructures. Economic evaluation in both countries for laboratory servicesreveals a vast amount of utilization unrelated to need and tied more to theincentives inherent in the reimbursement system of physicians . Prospectivepayment systems and utilization review appear to be a positive influence inreversing this kind of trend .A detailed retrospective analysis provided baseline data for three areasof interest: 1) patterns of diffusion and volume of utilization; 2)institutional profile; and 3) provider profile specific to both low and hightechnology categories outlined in Table 1. The analysis included, wherepossible, the examination of the determinants of diffusion that were amendableto policy influence (Figure 1). The results of this analysis are as follows:1. PATTERNS OF DIFFUSION AND UTILIZATIONIn general, the results indicate that testing on selected laboratoryitems (low technology) has accelerated between 1979 and 1988; population48increases alone are an insufficient explanation for this fact (Table 2). Whenthe common laboratory tests were disaggregated into individual fee items(Table 3), it was found that the largest volume of utilization increases wasfor tests such as HDL with cholesterol. Although utilization increasesfollowed diffusion of information regarding the role of cholesterol in heartdisease, the patterns examined were in conflict with the recommendation ofexpert panels regarding the type of screening tests to be used for targetpopulations (Figure 2). This item alone realizes gross payments of 4.6million dollars per year (Table 4) without question as to the value of thetests or contribution to health.The rate of diffusion for high technology is clearly mapped by theintroduction of new imaging equipment into B.C. during the 1980's. The oldtechnologies show a trend of abandonment by declining utilization (Table 5)while the newer diagnostic equipment has been rapidly adopted subject toaccess to equipment. This trend does not indicate wholesale substitutionsince new technologies services have increased three times greater than oldertechnologies have decreased.The data were also examined for any extraordinary patterns of utilization(Figure 4). In both areas of technology, women showed higher utilizationrates than men until ages 50-65. At this age group, men became extremely highusers of diagnostic and imaging technologies which continues until the oldestage group (85+).492. INSTITUTIONAL PROFILEThe institutional profile, derived from data on services provided bylaboratory, radiology and nuclear medicine units in hospitals, showed therewas regional variations. Laboratory services are widely diffused throughoutthe province in approximately 60 percent metropolitan and 40 percent non­metropolitan distributions. Nuclear medicine services occur 90 percent inmetropolitan areas while diagnostic imaging services were almost equallydivided between metro/non-metropolitan areas (1979/80) until CT scannersbecame available (Table 8). It would appear that CT scanning technologydisplaced head and neck radiology in metropolitan areas. By 1986/87 thefigures reveal that the vast majority of head and neck radiology was done innon-metropolitan areas. This pattern of diffusion would be expected forlimited access to sophisticated technology.In general, what the data reveal is the location of service provision.What they do not indicate, is whether or not there are regional variations inservices received. Future study should explore whether equitable access is afactor in diagnostic testing. For example, does patient location affect typeof service received?3. PROVIDER PROFILEThe B.C. Medical Services Plan Master Tapes were used as the source ofdata on physician sociodemographic variables such as age and sex, andspecialty and location. Physicians referring for both low and high technologyservices were predominantly between the ages of 35 and 55 years old which isconsistent with the majority of B.C. physicians within this age group. As50well, age- or sex-specific test ordering behaviour was not observed for theyears under examination.The. provider profile shows that the geographic distribution of physiciansis similar in proportion to those reported in the institutional profile formetropolitan and non-metropolitan areas since all of the imaging services andsome of the laboratory testing is done in hospitals.Patterns of referral by physician specialty are similar for both low andhigh technology (Table 9). For low technology, general practice, internalmedicine and general surgery referred most frequently. Differences inspecialty referrals show up for high technologies such as CT scans and MRI's.When there is limited access for high technology, the specialties appear todominate referral patterns whereas general practice dominates in all otherareas.The financial impact of utilization of all pathology, nuclear medicineand radiological services is partly reflected in the professional fee-for­service payments. There has been a dramatic increase in fee-for-servicepayments to all specialties for the time periods under study (Table 11) whichis consistent with the overall increase in diagnostic testing. It is unclearat this point whether or not the people of British Columbia have experiencedhigher morbidity (become sicker) in the last ten years or whether there areother unexamined factors which may explain more convincingly findings of thisstudy.51In summary, this study has provided a foundation for the development of adecision matrix for po1icymaking and a base for comparison of future diffusionof both low and high technology in British Columbia. 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(1985), "Medicine, technology, and lived relations", Perspectivesin Biology and Medicine, 28(2):314-322.Wood, D.E. (1986), "A laboratory network for the future", ClinicalBiochemistty, 19(5):277-280.Yael, B., Gafni, A. and Maital, S. (1986), "The diffusion of medicaltechnology: a 'prisoner's dilemma' trap?", Socio-economic Planning Sciences,20(2):69-i4.,Yi n , R.K. (1984), Case Study Research. Design and Methods, Beverly Hills: SagePublications .\Zielstorff, R. (1987), "In h1:gh-tech care, the challenge remains: to nurse",Am,rican Nurse, 19(4):4, 18. ~", (HEALTH POLICY RESEARCH UNIT429 - 2194 Health Sciences MallUniversity of British ColumbiaVancouver, B.C. CANADAV6T 1Z6DISCUSSION PAPER SERIESHPRU 88:1D Accommodating Rapid Growth in Physician Supply: Lessons fromIsrael, Warnings for Canada. February 1988. (M. L. Barer, A.Gafni, J. Lomas)BPRU 88:1R Barer , M.L., Gafni, A. and Lomas, J . (1989), "AccommodatingRapid Growth in Physician Supply : Lessons from Israel,Warnings for Canada", International Journal of Health Services19(1):95-115HPRU 88:2D The Long Goodbye: The Great Transformation of the BritishColumbia Hospital System. March 1988. (R.G. Evans, M.L.Barer, C. Hertzman, G.M. Anderson, l.R. Pulcins, J. Lomas)HPRU 88:2R Evans, R.G., Barer, M.L ., Hertzman, C., Anderson, G.M . ,Pulcins, I.R . and Lomas, J . (1989), "The Long Goodbye: TheGreat Transformation of the British Columbia Hospital System" ,Health Services Research 24(4) :435 -459HPRU 88:3D Reading the Menu With Better Glasses: Aging and Health PolicyResearch. April 1988. (R.G. Evans)HPRU 88:3R Evans, R.G. (1989), "Reading the Menu With Better Glasses:Aging and Health Policy Research", in S . J . Lewis (ad .), Agingand Health : Linking Research and Public Policy, LewisPublishers Inc ., Chelsea, 145-167HPRU 88:4R Barer, M.L. (1988), "Regu l at i ng Physician Supply: TheEvolution of British Columbia's Bill 41", Journal of Healthpolitics, Policy and Law 13(1):1 -25HPRU 88:5D Regionalization of Coronary Artery Bypass Surgery: Effects onAccess . May 1988 . (G.M. Anderson, J. Lomas)HPRU 88:5R Anderson, G.M . and Lomas, J . (1989), "Regionalization ofCoronary Artery Bypass Surgery: Effects on Access", MedicalCare 27(3):288-296HPRU 88:6D Diagnosing Senescence: The Medicalization of B.C.'s Elderly .July 1988. (M.L. Barer, I.R. Pulcins, R.G. Evans, C.Hertzman, J. Lomas, G.M. Anderson)HPRU 88:6R Barer, M.L., pulcins, I .R., Evans, R.G., Hertzman, C., Lomas,J . and Anderson, G.M . (1989), "Trends in Use of MedicalServices by the Elderly in British Columbia", Canadian MedicalAssociation Journal 141:39-45HPRU 88:1D The Development of Utilization Analysis: How, Why, and WhereIt's Going. August 1988. (G.M. Anderson, J. Lomas)HPRU 88:8D Squaring the Circle: Reconciling Fee-for-Service with GlobalExpenditure Control. September 1988. (R.G. Evans)D = Discussion Paper R = ReprintHEALTH POLICY RESEARCH UNITDISCUSSION PAPER SERIESHPRU 88:9D Practice Patterns of Physicians with Two Year Residency VersusOne Year Internship Training: Do Both Roads Lead to Rome?September 1988. (M .T. Schechter, S.B. Sheps, P. Grantham, N.Finlayson, R. Sizto)HPRU 88:10R Anderson, G.M. and Lomas, J . (1988), "Monitoring the Diffusionof a Technology: Coronary Artery Bypass Surgery in Ontario",American Journal of Public Health 78(3):251 -254HPRU 88:11R Evans, R.G. (1988),""We'll Take Care of it For You": HealthCare in the Canadian Community", Daedalus 117(4):155-189HPRU 88:12R Barer, M.L., Evans, R.G. and Labelle, R.J. (1988), "FeeControls as Cost Control: Tales From the Frozen North" , TheMilbank Quarterly 66(1):1 -64HPRU 88:13D Tension, Compression and Shear : Directions, Stresses andOutcomes of Health Care Cost Control . December 1988. (R.G.Evans)HPRU 88:13R Evans, R.G. (1990), "Tension, Compression, and Shear:Directions, Stresses and Outcomes of Health Care CostControl", Journal of Health Politics, Policy and Law15(1):101-128HPRU 88:14R Evans, R.G., Robinson, G.C. and Barer, M.L. (1988), "WhereHave All the Children Gone? Accounting for the PediatricHospital Implosion", in R.S. Tonkin and J .R . Wright (eds .) ,Redesigning Relationships in Child Health Care, B.C .Children's Hospital, 63-76HPRU 89:1D Physician Utilization Before and After Entering a Long TermCare Program: An Application of Markov Modelling. January1989. (H. Krueger, A.Y. Ellencweig, D. Uyeno, B. McCashin, N.Pagliccia)HPRU 89:2D Flat on Your Back or Back to Your Flat? Sources of IncreasedHospital Services Utilization Among the Elderly in BritishColumbia. January 1989. (C. Hertzman, I.R. Pulcins, M.L.Barer, R.G . Evans, G.M. Anderson, J. Lomas)HPRU 89:2R Hertzman, C., Pulcins, I.R., Barer, M.L ., Evans, R.G.,Anderson, G.M. and Lomas, J. (1990) "Flat on Your Back or Backto your Flat? Sources of Increased Hospital ServicesUtilization Among the Elderly in British Columbia", SocialScience and Medicine 30(7):819-828HPRU 89:3R Buhler, L., Glick, N. and Sheps, S.B . (1988), "Prenatal Care:A Comparative Evaluation of Nurse-Midwives and FamilyPhysicians", Canadian Medical Association Journal 139: 397-403HPRU 89:40 Recent Trends in Cesarean Section Rates: Ontario Data 1983 to1987. February 1989. (G.M. Anderson, J. Lomas)HPRU 89:4R Anderson, G.M. and Lomas, J. (1989), "Recent Trends inCesarean Section Rates in Ontario", Canadian MedicalAssociation Journal 141:1049-1053HPRU 89:5D The Canadian Health Care System: A King'S Fund Interrogatory.March 1989. (R.G. Evans)D = Discussion Paper R = Reprint..HEALTH POLICY RESEARCH UNITDISCUSSION PAPER SERIESHPRU 89:6D Benefits, Risks and Costs of Prescription Drugs in Ontario: AScientific Basis to Evaluate Policy Options. April 1989.(W.O. Spitzer, G.M. Anderson, U. Bergman, J.L. Blackburn, E.Wang, M.C. Weinstein)HPRU 89:7D The Dog in the Night Time: Medical Practice Variations andHealth Policy. June 1989. (R.G. Evans)HPRU 89:8D Life and Death, Money and Power: The Politics of Health CareFinance. June 1989. (R.G. Evans)HPRU 89:9D From Medibank to Medicare: Trends in Australian Medical CareCosts and Use, 1976-1986. August 1989. (M. Barer, M. Nicoll,M. Diesendorf, R. Harvey)HPRU 89:10D Cholesterol Screening: Evaluating Alternative Strategies.August 1989. (G. Anderson, S. Brinkworth, T. Ng)HPRU 89:11R Evans, R.G., Lomas, J., Barer, M.L., Labelle, R.J ., Fooks, C.,Stoddart, G.L., Anderson, G.M., Feeny, D., Gafni, A.,Torrance, G.W. and Tholl, W.G. (1989), "Controlling HealthExpenditures - The Canadian Reality", New England Journal ofMedicine 320(9):571 -577HPRU 89: 120 The Effect of Admission to Long Term Care Program onUtilization of Health Services by the Elderly in BritishColumbia. November 1989. (A.Y. Ellencweig, A.J. Stark, N.Pagliccia, B. McCashin, A. Tourigny)HPRU 89:130 Utilization Patterns of Clients Admitted or Assessed but notAdmitted to a Long Term Care Program - Characteristics andDifferences. November 1989. (A.Y. Ellencweig, N. Pagliccia,B. McCashin, A. Tourigny, A.J. Stark)HPRU 89:140 Acute Care Hospital Utilization Under Canadian National HealthInsurance: The British Columbia Experience from 1969 to 1988.December 1989. (G.M. Anderson, I.R. Pulcins, M.L. Barer, R.G .Evans, C. Hertzman)HPRU 90:1R Anderson, G.M., Newhouse, J.P. and Roos, L.L. (1989),"Hospital Care for Elderly Patients with Diseases of theCirculatory System. A Comparison of Hospital Use in theUnited States and Canada", New England Journal of Medicine321:1443-1448HPRU 90:2D Poland: Health and Environment in the Context of SocioeconomicDecline. January 1990. (C. Hertzman)HPRU 90:3D The Appropriate Use of Intrapartum Electronic Fetal Heart RateMonitoring. January 1990. (G.M. Anderson, D.J. Allison)HPRU 90: 4D A Comparison of Cost Sharing Versus Free Care in Children:Effects on the Demand for Office-based Medical Care. January1990. (G.M. Anderson)HPRU 90:5D Does Family Practice Certification Affect Practice Style? AnAnalysis of Office-based Care. February 1990. (G.M.Anderson)HPRU 90:6D An Assessment of the Value of Routine Prenatal UltrasoundScreening. February 1990. (G.M. Anderson, D. Allison)D = Discussion Paper R = ReprintHEALTH POLICY RESEARCH UNITDISCUSSION PAPER SERIESHPRU 90:7R Nemetz, P .N., Ballard, D.J . , Beard, C.M., Ludwig , J.,Tangalos, E.G., Kokmen, E., Weigel, K.M ., Belau, P .G., Bourne,W.M . and Kurland, L.T. (1989) "An Anatomy of the Autopsy,Olmsted County , 1935 through 1985", Mayo Clini c Proceedings64:1055-1064HPRU 90:8R Nemetz, P .N., Beard, C.M., Ballard, D.J., Ludwig, J .,Tangalos, E.G., Kokmen , E., Weigel, K.M., Belau, P.G ., Bourne ,W.M . and Kurland, L.T . (1989) "Resurrecting the Autopsy:Benefits and Recommendations", Mayo Clini c Proceedings64:1065-1076D Discussion Paper R = Reprint'. .,....•......


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