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Designation, diligence and drift: understanding laboratory expenditure increases in British Columbia,… Sivananthan, Saskia N; Peterson, Sandra; Lavergne, Ruth; Barer, Morris L; McGrail, Kimberlyn M Dec 21, 2012

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RESEARCH ARTICLE Open AccessDesignation, diligence and drift: understandinglaboratory expenditure increases in BritishColumbia, 1996/97 to 2005/06Saskia N Sivananthan*, Sandra Peterson, Ruth Lavergne, Morris L Barer and Kimberlyn M McGrailAbstractBackground: Laboratory testing is one of the fastest growing areas of health services spending in Canada. Weexamine the extent to which increases in laboratory expenditures might be explained by testing that is consistentwith guidelines for the management of chronic conditions, by analyzing fee-for-service physician payment data inBritish Columbia from 1996/97 and 2005/06.Method: We used direct standardization to quantify the effect on laboratory expenditures from changes in: feelevels; population growth; population aging; treatment prevalence; expenditure on recommended tests for thoseconditions; and expenditure on other tests. The chronic conditions selected were those with guidelines containinglaboratory recommendations developed by the BC Guidelines and Protocol Advisory Committee: diabetes,hypertension, congestive heart failure, renal failure, liver disease, rheumatoid arthritis, osteoarthritis and dementia.Result: Laboratory service expenditures increased by $98 million in 2005/06 compared to 1996/97, or 3.6% per yearafter controlling for population growth and aging. Testing consistent with guideline-recommended care for chronicconditions explained one-third (1.2% per year) of this growth. Changes in treatment prevalence were just asimportant, contributing 1.5% per year. Hypertension was the most common condition, but renal failure anddementia showed the largest changes in prevalence over time. Changes in other laboratory expenditure includingfor those without chronic conditions accounted for the remaining 0.9% growth per year.Conclusion: Increases in treatment prevalence were the largest driver of laboratory cost increases between 1996/97and 2005/06. There are several possible contributors to increasing treatment prevalence, all of which can beexpected to continue to put pressure on health care expenditures.Keywords: Clinical Laboratory Techniques/utilization, Clinical Laboratory Techniques/statistics & numerical data,Guideline care, Diagnostic Techniques and Procedures/economics, Diagnostic Techniques and Procedures/trends,Fee-for-Service Plans/trends, Health Expenditures/trends, Physician's Practice Patterns/trends, Chronic Disease/Condition, British Columbia, CanadaBackgroundCanadians are concerned about the rising cost of healthcare and particularly about whether the public model is“sustainable” in the face of these cost pressures [1].Health care was identified as the topic of highest priorityfor Canadian voters during the 2011 Federal election, asit has been in previous elections [2]. Within the overalllandscape of increasing health care costs, expendituresfor physician/specialists services in Canada have risensharply over the past five years, regaining a position asthe second largest cost component (exceeded only byacute hospital costs) [3]. Payments for laboratory ser-vices, especially for services provided to seniors, haveseen particularly rapid increases in British Columbia [4].The question this raises is what the causes are of la-boratory spending increases. Administrative data cannoteasily answer the question of health impact associatedwith this increase in laboratory spending, but it can beused to help diagnose the sources of cost pressure. Re-peat testing and technological innovations are likely* Correspondence: ssivananthan@chspr.ubc.caUBC Centre for Health Services and Policy Research, 201-2206 East Mall,Vancouver, BC V6T 1Z3, Canada© 2012 Sivananthan et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited.Sivananthan et al. BMC Health Services Research 2012, 12:472http://www.biomedcentral.com/1472-6963/12/472contributors but are unlikely to explain all of theincreases [5-7]. Spending of health care dollars onchronic conditions and the tests associated both withdiagnosing and managing those conditions may, on theother hand, help explain the upward trend.More than half of the Canadian population has at leastone chronic condition, and this rises to 81% ofcommunity-dwelling seniors [8]. Previous studies havedemonstrated that high users of health care servicestend to be individuals with (often multiple) chronic con-ditions [9]. In British Columbia, as in many other pro-vinces, there are guidelines associated with themanagement of chronic conditions designed to assistphysicians in providing consistent, evidence-based care[10]. This includes recommendations for specific labora-tory tests to diagnose and/or manage such conditions. Itshould be noted, the study intent is not an evaluation ofadherence to guidelines. Instead, the guidelines are usedsimply to indicate the consensus on recommended la-boratory testing for different chronic conditions. Thispaper addresses the question: to what extent canincreases in laboratory expenditures be explained bytesting that is consistent with guidelines for the manage-ment of chronic conditions?Building on previous research, our analyses focus onBritish Columbia, as no national database exists to allowa more wide-ranging analysis. Our period of analysis is1996/97 to 2005/06. We describe the extent to whichpopulation growth and aging, changes in chronic diseaseprevalence, and guideline-consistent ordering may ex-plain increased expenditures for laboratory services.MethodsStudy population and data sourcesOur analyses are of the entire population of BritishColumbia. The data were accessed through PopulationData BC. Data were analyzed at the individual patientlevel using unique but study-specific codes that do notpermit personal identification of either patients or physi-cians. Permission for data access was provided by theBC Ministry of Health. Ethics approval for this researchwas granted by the University of British Columbia Be-havioural Research Ethics Board.We accessed the following files: 1) a central demo-graphics file for 1996/97 and 2005/06 providing informa-tion on age and sex of individuals and denominatorinformation for the analyses; and 2) the fee-for-servicepayment files for 1995/96-1996/97 and 2004/05-2005/06as a two year period is required to confirm a diagnosis.The fee-for-service data include the date of each visit,total amount paid, a unique study-specific physicianidentification number as well as a study-specific patientidentification number, the physician specialty code, thediagnostic (ICD9) code most responsible for the visit, afee item code which is a code used to identify each ser-vice provided by a practitioner, and a service code, whichis a grouping of the fee items that indicates the type ofservices rendered by a practitioner. We removed theeffects of fee changes over this period by valuing servicesprovided in all years at the fee levels in effect on April 1,2005/06, yielding fee-adjusted expenditures [4].Classifying chronic conditionsThe chronic conditions selected for this study werethose for which specific guidelines developed by the BCGuidelines and Protocol Advisory Committee for theMedical Services Commission containing laboratoryrecommendations which came into place before 2006[10]. These were diabetes, hypertension, congestive heartfailure, renal failure, liver disease, rheumatoid arthritis,osteoarthritis and dementia. Cancer was excluded be-cause the spectrum of diseases encompassed by the termresulted in patient profiles with more widely varying pat-terns of use than those with the other chronic condi-tions. There are other chronic conditions not includedin this analysis that will have associated laboratory tests.Increases in testing for those conditions will be capturedas general increases, since our research question is fo-cused on testing related to guidelines.Chronic conditions were identified using the first 3digits only of the International Classification of Disease(ICD-9) diagnosis codes from records of fee-for-servicepayments to general physicians, medical specialists andsurgical specialists. Individuals were counted as having achronic condition if they had at least two records show-ing a diagnosis for the same condition over a two-yearperiod. This approach to determining treatment preva-lence is consistent with prior research using administra-tive data to identify individuals with chronic conditions[8,11,12]. Treatment prevalence is used here to acknow-ledge the limitations of administrative data in identifyingthe prevalence of disease. While administrative data havebeen shown to be quite valid in for this purpose [12], weare only counting people as having disease if theyreceived services from a physician who recorded relevantdiagnoses on a billing record. Individuals with one rec-ord showing a diagnosis of a chronic condition werecounted in a ‘potential’ category, as the diagnosis mayhave been recorded as something to be ruled out ratherthan being definitive. Payments from 1995/96 – 1996/97were used to identify chronic conditions for the 1996/97study population, and 2004/05-2005/06 paymentswere used to identify chronic conditions for the 2005/06study population.We summarized the information on chronic condi-tions and created five mutually exclusive groups to re-flect an overall chronic disease profile for eachindividual: ‘No Guideline-Related Chronic Condition’,Sivananthan et al. BMC Health Services Research 2012, 12:472 Page 2 of 8http://www.biomedcentral.com/1472-6963/12/472‘Potential Chronic Condition’, ‘One’, ‘Two’ or ‘Three plusChronic Conditions’. Individuals who had no record of achronic condition diagnosis during the two-year periodwere classified in the first category. Those who receivedonly one record showing a diagnosis for one or moreconditions were classified into the “Potential ChronicCondition” group. Those with two or more recordsshowing diagnoses for one condition (irrespective of“potential” conditions) were counted in the “oneChronic Condition” group, and so on. Individuals inthese profile groups reflect categorization based on thechronic diseases with guidelines identified earlier, as perour research question, but may still have other chronicconditions outside of the scope of the study.Laboratory testingMedical laboratory testing in British Columbia is pro-vided by community-based and hospital-based laborator-ies. This study included all laboratory tests paid forthrough the Medical Services Plan (MSP) of BC., i.e. notthrough hospital global budgets. The latter generally in-clude only inpatient laboratory services, so this was nota major limitation.Payments for laboratory testing were identified in theMSP data using service codes, regardless of the type ofpractitioner that billed for the item. A cluster of labora-tory tests was created for each of the eight chronic con-ditions examined, based on the test recommendationsmade by the BC Guidelines and Protocol AdvisoryCommittee (see Additional file 1 for details). All othertests were classified as not attributable to the chronicconditions we were examining. The primary base fee isan administrative cost (similar to a pharmacy dispensingfee) that is applicable under specified criteria to certainpanel tests performed within the same facility. It couldnot be allocated to specific laboratory tests but con-sisted of a large portion of expenditure and thereforewas treated separately. Total payments and paymentsfor test subsets by chronic condition were then summedfor each person in the study population. Some tests areassociated with more than one chronic condition. Allo-cating individuals to the mutually exclusive chronic dis-ease profile groups and summing separately avoideddouble-counting.AnalysisWe approached the analysis using the followingexpression:Total Lab Exp ¼ Nc$TestsrNcþ $TestsoNcþ Nnc$TestsoNcWhere Total Lab Exp is the total expenditure on la-boratory testing in a given year, Nc is the number ofpeople with chronic conditions, Nnc is the number ofpeople without guideline-related chronic conditions,$Testsr is the expenditure on recommended laboratorytests for chronic conditions and $Testso is the expend-iture on other laboratory tests. Using this expression wecan see that after controlling for changes in fees, overallpopulation growth and population aging, changes in la-boratory expenditures will come from changes in thenumber of people with chronic conditions (the treat-ment prevalence), changes in the expenditure on recom-mended tests for each person, or changes in per personexpenditure on other tests. We isolate these three com-ponents in our analyses using direct standardization.ResultsThe cost of utilizationBetween 1996/97 and 2005/06, real (constant dollar)health care services expenditures rose by 25.4% (Table 1).Laboratory service expenditures rose much faster –$98.0 million, or 58.7%, an average of 5.3% per year.Accounting for the growth of the BC population duringthe study period, per capita laboratory costs increasedfrom $41.80 in 1996/97 to $60.40 in 2005/06, still anextraordinary 44.7% growth over the nine years. Agingof the population contributed 5.3% (about 0.6% peryear), leaving 37.4% of the per capita growth attributableto changes in prevalence and changes in laboratory test-ing intensity.Demography, treatment prevalence and co-morbiditiesIn examining chronic condition guideline-consistent la-boratory test expenditures, one factor that may contrib-ute to overall expenditure growth is any population-levelchanges in the treatment prevalence of the identifiedconditions. If age-specific prevalence is increasing, then,laboratory-related expenditures would increase fasterthan what we would expect as a result of populationaging alone.The treatment prevalence increased for seven out ofeight of the chronic diseases examined in this study.Hypertension was the most common condition, affecting6.0% of the population in 1996/97 and 9.9% in 2005/06.However, the most rapid increases in treatment preva-lence were found for renal failure and dementia –227.0% and 145.6% increases respectively (Figure 1A) –albeit on a much smaller starting population than forhypertension.Figure 1B then illustrates the rapid change in the pro-portion of individuals in the different chronic diseasecategories between 1996/97 and 2005/06. An increasingnumber of individuals were classified as having one ormore chronic conditions in 2005/06. The largestSivananthan et al. BMC Health Services Research 2012, 12:472 Page 3 of 8http://www.biomedcentral.com/1472-6963/12/472percentage increase, which reached triple digits in allage categories except for the youngest age group of 0–24 years, was seen for individuals classified as havingthree or more chronic conditions.Intensity of service useTotal expenditures and expenditures per capitaincreased over time for all chronic condition groups(Figure 2A). At both time points, the highest total ex-penditure was on those without chronic conditions,while the lowest total expenditure was on individualswith three or more co-morbidities. In fact, the groupwith the biggest percent increase in expenditure between1996/97 and 2005/06 was also the no guideline-relatedchronic condition category.The intensity of service use, as demonstrated by percapita costs, tells a more nuanced story. As expected, in-tensity of service use was higher among those withchronic conditions, and increased both with the numberof co-morbidities and over time (Figure 2B). The patternof care for individuals classified as having three or morechronic conditions is of particular note because this cat-egory had the most rapid change in expenditure over theperiod.Chronic condition guideline-consistent laboratoryexpendituresTotal expenditures for chronic condition guideline-consistent laboratory tests increased from $9.9 millionto $28.6 million, a 188.2% change (Table 2). Total expen-ditures for all other laboratory tests increased from$138.0 million to $207.5 million, a still substantial butmuch smaller 50.3% increase. So while guideline-consistent laboratory tests showed a much steeper in-crease over time, the other laboratory tests continued torepresent the more significant share of total expenditure,even at the end of the period. The 75–84 age group hadthe highest per capita expenditure for guideline-consistent laboratory tests as well as per capita expendi-tures for other laboratory tests.Summing up the effectsAs shown in Table 1, 37.4% (3.6% average annual in-crease) of growth in laboratory expenditures between1996/9/7 and 2005/06 was attributable to changes otherthan aging and population growth. Of this, 13.9% (1.5%per year) was due to changes in treatment prevalence.Disaggregating the remaining 20.7% (2.1%) further,chronic condition guideline-consistent laboratory testsaccounted for 11.3% (1.2%) of the growth and changesin other laboratory tests 8.5% (0.9%).DiscussionSpending on laboratory testing in BC increased 58.7%between 1996/97 and 2005/06. Many factors, includingchanges in technology, repeat testing and inappropriateutilization have been proposed as potential factors con-tributing to the increase in laboratory utilization [7].One additional explanation for expenditure increases isincreased testing consistent with medical practice guide-lines for diagnosing and monitoring patients withchronic conditions. We find that there was, indeed suchan increase between 1996/97 and 2005/06, but that thisexplains only about one-third of the total increase, netof population growth and aging. Changes in treatmentprevalence were equally important, and unexplainedincreases in other laboratory tests for people with andwithout the specific chronic conditions of interest werea large contributing factor.Several changes in the clinical definition and screeningof chronic conditions occurred between 1996/97 and2005/06. For example, the clinical definition of diabetesshifted from a fasting plasma glucose level of greaterthan or equal to 7.8 to 7.0 mmol/L [13,14]. For renalTable 1 Dynamics of laboratory expenditures in British Columbia, 1996/97 and 2005/06% Change1996/97 2005/06 Overall Average annualTotal health care services expenditures (constant $) 1,594,591,397 1,998,842,372 25.4% 2.5%Per capita health care services expenditures 399 455 14.3% 1.5%Total lab expenditures (constant $) 166,914,987 264,904,987 58.7% 5.3%BC Population 3,999,520 4,383,445 9.7% 1.0%Per capita lab expenditures 41.8 60.4 44.7% 4.2%% Growth attributableGrowth attributable to change in age structure 5.3% 0.6%Growth attributable to other changes 37.4% 3.6%Note: All numbers reflect age-standardization within broad age bands. We used a direct standardization approach, standardizing 1996/97 utilization rates to the2005/06 population.Notes for reading Tables 1 & 2: Rows are only additive for "expenditures per capita". For the other terms of the equation, the denominators differ by columnand so it is impossible to add the values.Sivananthan et al. BMC Health Services Research 2012, 12:472 Page 4 of 8http://www.biomedcentral.com/1472-6963/12/47261 79 1137HypertensionRate per 100 population0102030400−2425-4445-5455-6465-7475-8485+0−2425-4445-5455-6465-7475-8485+486278 875853445527050-102417171730−2425-4445-5455-6465-7475-8485+0−2425-4445-5455-6465-7475-8485+0−2425-4445-5455-6465-7475-8485+0−2425-4445-5455-6465-7475-8485+0−2425-4445-5455-6465-7475-8485+0−2425-4445-5455-6465-7475-8485+Diabetes Congestiveheart failureRenal failure Liver diseaseRheumatoidarthritisOsteoarthritis Dementia-12 17 -1-29957 28215690 1181228073 40 97 145 231 36743867 11 105 69 38 34 2249-11-4 -6-3 0-6-10Reduction in prevalence by 2005/06Additional prevalence by 2005/06% change in prevalence between 1996/97 and 2005/06Prevalence in 1996/9717Reduction in proportion by 2005/06Additional proportion by 2005/06% change in proportion between 1996/97 and 2005/06Proportion in 1996/9717Rate per 100 population0604020801003 or morechronic conditions0−2425-4445-5455-6465-7475-8485+1000 100 100 120165 1862 chronic conditions0−2425-4445-5455-6465-7475-8485+78078667985 8324 191 chronic condition0−2425-4445-5455-6465-7475-8485+3618322421Maybe 1 (or more) chronic condition(s)0−2425-4445-5455-6465-7475-8485+160177 -4-14 -170No guideline-relatedchronic conditions0−2425-4445-5455-6465-7475-8485+-2-7-13-25-27-34abFigure 1 a: Change in treatment prevalence of selected chronic conditions between 1996/97 and 2005/06, by age group. b: Change inproportion of individuals in different chronic disease categories between 1996/97 and 2005/06.Sivananthan et al. BMC Health Services Research 2012, 12:472 Page 5 of 8http://www.biomedcentral.com/1472-6963/12/472disease, serum creatinine levels of 176.8 μmol/L in men(eGFR of ~40 mL/min/1.73 m2 for a 40 year old man)resulting in referral to a renal team for dialysis assess-ment, changed to every patient with urine abnormalitiesand an eGFR <90 mL/min/1.73 m2 receiving immediatefurther assessment and management [15,16]. Similarly,the recommended screening guidelines for Type 2 dia-betes shifted to begin at age 41 instead of age 46 [13,14].There were no major changes in clinical definitions orscreening guidelines for osteoarthritis or rheumatoidNumber of chronic condition(s)a bNumber of chronic condition(s)0 (1) 1 2 3+0 (1) 1 2 3+Constant 2005/06 dollars per capita$0$30m$60m$90m$120m$150mConstant 2005/06 dollars per capita$0$100$200$300$4002005/061996/972005/061996/97Figure 2 a: Total laboratory expenditure on individuals in different chronic disease categories, age standardized, between 1996/97 and2005/06. The total laboratory expenditure on individuals with no guideline-related chronic disease, maybe one chronic disease, one, two andthree or more chronic diseases in 1996/97 and 2005/06. b: Per capita laboratory expenditures on individuals in different chronic diseasecategories, age standardized, between 1996/97 and 2005/06. The per capita laboratory expenditures on individuals with no guideline-relatedchronic disease, maybe one chronic disease, one, two and three or more chronic diseases in 1996/97 and 2005/06.Table 2 Disaggregation of laboratory expenditures in British Columbia, 1996/07 and 2005/06% Change1996/97 2005/06 Overall Average annualTotal expenditure for guideline-consistent laboratory tests 9,929,315 28,615,178 188.2% 12.5%Total expenditure for other laboratory tests 138,034,815 207,496,629 50.3% 4.6%Guideline-consistentlab expenditures byage groupPer capitaguideline consistentlaboratory tests$change%changePer capita otherlaboratory tests$change%changePer capitabase fee$change%change1996/97 2005/06 1996/97 2005/06 1996/97 2005/060 to 24 0.1 0.2 0.1 64.0% 17.3 19.2 1.9 10.9% 1.1 1.3 0.2 16.5%25 to 44 0.7 1.5 0.8 106.3% 36.3 45.0 8.7 24.0% 3.2 3.8 0.6 20.1%45 to 54 2.8 5.8 3.0 109.7% 38.8 52.4 13.5 34.9% 5.9 7.6 1.6 27.7%55 to 64 6.5 13.6 7.1 108.8% 46.1 65.7 19.5 42.3% 9.3 11.8 2.4 26.3%65 to 74 9.9 24.0 14.0 141.0% 58.5 84.1 25.6 43.7% 12.9 16.7 3.8 29.5%75 to 84 10.3 27.8 17.5 170.0% 65.8 99.2 33.5 50.9% 14.5 19.4 4.9 33.8%85 plus 8.2 20.0 11.9 145.4% 55.0 82.5 27.5 49.9% 12.7 16.3 3.5 27.8%% Growth attributableOverall Average annualGrowth attributable to other changes (from Table 1) 37.4% 3.6%Growth attributable to changes in prevalence 13.9% 1.5%Growth attributable to changes in utilization 20.7% 2.1%Growth attributable to changes in guideline-consistent laboratory testing 11.3% 1.2%Growth attributable to changes in other laboratory testing 8.5% 0.9%Sivananthan et al. BMC Health Services Research 2012, 12:472 Page 6 of 8http://www.biomedcentral.com/1472-6963/12/472arthritis and for those conditions we see relatively stableprevalence across age groups over time11. These changesare only two factors that may be driving the increase intreatment prevalence for these chronic conditions, butthey are surely significant ones. Once people are diag-nosed with a condition, it should be no surprise thatassociated health care, and particularly guideline-consistent expenditures will follow.There has also been a trend during this period towarddiagnosing “pre-disease” states as part of screeningguidelines, and a growing demand from patients for testsof their choosing even if the physician may not considerthem beneficial. As previously mentioned, the firstscreen for diabetes is now recommended at earlier agesregardless of risk factors with a diagnosis of “impairedfasting glucose” as a “pre-diabetic” state at fastingplasma glucose levels of 6.1 mmol/L. These individualsbeing flagged as “at risk” subsequently require follow uptests until the disease manifests itself [14]. So recom-mendations for increased population screening at everearlier ages and the lower threshold for these pre-disease"conditions" that then leads to increased monitoring ofindividuals with no disease with testing could be anotherdriver of the increase in other laboratory tests [14,17,18].Much has been made of the aging population and itsimpact on the healthcare system. However, only 5.3% ofthe growth in laboratory expenditure over this periodwas actually attributable to a change in the age structure.More is spent on the elderly and this trend has contin-ued between 1996/97 to 2005/06. However, the impactof an increasing treatment prevalence of age-specificchronic conditions, and particularly of an increasingage-specific prevalence of patients with multiple co-morbidities, is far more important.There are some limitations to this study. The fee-for-service physician data do not include information onservices paid for through alternative payment arrange-ments such as salaries, sessional payments, or contrac-tual arrangements. This does not affect the laboratorypayments, which are all by fee-for-service for patientsoutside of acute care, but may affect our classificationof these individuals into the chronic disease categories.In addition, our analysis of chronic conditions was notexhaustive, but rather focused only on those conditionsthat became the subject of incentive programs for pri-mary care in BC. The “other” laboratory tests, whilenot guideline-recommended for these specific chronicconditions, may still be appropriate for other condi-tions. Therefore individuals with other potentiallyprevalent chronic conditions that were outside thescope of the conditions selected for this study wouldbe classified as ‘no guideline-related chronic condition’,which limits our interpretation of people in thiscategory.ConclusionLaboratory testing is one of the fastest growing areas ofphysician service provision. In British Columbia, therewas just under $100 million in “new” laboratory expen-ditures in 2005/06 compared to a 1996/97 base of $167million. This amounts to a 5.3% average annual increasein expenditure, or 3.6% per year after removing theeffects of population growth and aging. Our primary re-search question was the extent to which diligence – test-ing consistent with guideline-indicated care – couldexplain this increase. The answer is that about one-thirdof the increase, or about 1.2% per year, can be attributedto changes in guideline-consistent test ordering. Surpris-ingly important are designation – the increased likeli-hood of being diagnosed with a chronic condition – at1.5% per year, and drift – the general increase in labora-tory expenditures, including expenditures for peoplewithout these guideline-related chronic conditions - at0.9% per year. This suggests that future research mightproductively focus on the last of these contributing com-ponents, with an emphasis on the extent to which theincrease in designation and the general increase in test-ing affects diagnosis or subsequent treatment.Additional fileAdditional file 1: BC Guidelines and Protocol Advisory Committeerecommended laboratory tests attributed to each of the eightchronic conditions examined.AbbreviationsBC: British Columbia; MSP: Medical Service Plan; ICD: InternationalClassification of Diseases; eGFR: Estimated glomerular filtration rate.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAll authors contributed to the interpretation of the data. KM and MBconceived and developed the initial design of the study and acquired thedata. SS managed the study, further developing the design, conducted theanalysis and interpretation of the data. SP and RL contributed significantly tothe analysis and interpretation. SS wrote the first draft and managedsubsequent drafts with revisions from all other authors. All authors read andapproved the final manuscript.AcknowledgementsWe acknowledge Dawn Mooney for her work on the development anddesign of the study figures and Margaret McGregor for her thoughtful andcritical review of the manuscript. The research reported here and all itsauthors were supported by a Canadian Institutes of Health ResearchOperating Grant.Received: 3 May 2012 Accepted: 10 December 2012Published: 21 December 2012References1. Boileau L: Canadians Fear Rising Health Care Costs Unsustainable. Canada:News Wire; 2010.2. Mayeda A, De Souza M, Cohen T: Conservatives and Liberals each say theycare more about health care. Toronto, Canada: The National Post; 2011.Sivananthan et al. BMC Health Services Research 2012, 12:472 Page 7 of 8http://www.biomedcentral.com/1472-6963/12/4723. Canadian Institute for Health Information: National Health ExpenditureTrends, 1975 to 2010. Ottawa: CIHI; 2010.4. McGrail KM, Evans RG, Barer ML, Kerluke KJ, McKendry R: Diagnosingsenescence: Contributions to physician expenditure increases in BritishColumbia, 1996/97 to 2005/06. Healthcare Policy 2011, 7(1):41–54.5. Van Walraven C, Cernat G, Austin PC: Effect of provider continuity on testrepetition. Clin Chem 2006, 52(12):2219–2228.6. Schwartz WB: The inevitable failure of current cost containmentstrategies. Why they can provide only temporary relief. JAMA 1987,257:220–228.7. Robinson A: Rationale for cost-effective laboratory medicine. Clinc MicroRev 1994, 7(2):185–199.8. Broemeling AM, Watson D, Black C: Chronic conditions and co-morbidityamong residents of British Columbia, Centre for Health Services and PolicyResearch.; 2005. Report No: chspr05-08. Sponsored by The BC Ministry ofHealth.9. Broemeling AM, Watson D, Prebtani F: Population patterns of chronichealth conditions, co-morbidity and healthcare use in Canada:implications for policy and practice. Healthc Q 2008, 11(3):70–76.10. BC Ministry of Health Chronic Disease Guidelines. Available from:http://www.bcguidelines.ca/submenu_chronic_disease.html.11. Kopec J, Rahman M, Sayre E, Cibere J, Flanagan W, Aghajanian J, et al:Trends in physician diagnosed osteoarthritis incidence in anadministrative database in British Columbia, Canada, 1996–1997 through2003–04. Am College Rheum 2008, 59(7):929–934.12. Lix L, Yogendran M, Mann J: Defining and Validating Chronic Diseases: AnAdministrative Data Approach. An Update with ICD-10-CA. Winnipeg, MB:Manitoba Centre for Health Policy, University of Manitoba; 2008.13. Meltzer S, Leiter L, Daneman D, Gerstein H, Lau D, Ludwig S, et al: Clinicalpractice guidelines for the management of diabetes in Canada.Canadian Med Assoc J 1998, 159(8):1–29.14. Canadian Diabetes Association Clinical Practice Guidelines ExpertCommittee: Canadian diabetes association 2003 clinical practiceguidelines for the prevention and management of diabetes in Canada.Can J Diabetes 2003, 27(2):1–163.15. Obrador G, Peirera B: Early referral to the nephrologist and timelyinitiation of renal replacement therapy: a paradigm shift in themanagement of patients with chronic renal failure. Am J Kidney Dis 1998,31(3):398–417.16. Craven N: Management of chronic kidney disease in the primary caresetting. BC Med J 2005, 47(6):296–299.17. Carlsen B, Norheim OF: "Saying no is no easy matter" a qualitative studyof competing concerns in rationing decisions in general practice.BMC Health Serv Res 2005, 5:70.18. Brett AS, McCullough LB: Addressing requests by patients fornonbeneficial interventions. JAMA 2012, 307(2):149–150.doi:10.1186/1472-6963-12-472Cite this article as: Sivananthan et al.: Designation, diligence and drift:understanding laboratory expenditure increases in British Columbia,1996/97 to 2005/06. BMC Health Services Research 2012 12:472.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitSivananthan et al. BMC Health Services Research 2012, 12:472 Page 8 of 8http://www.biomedcentral.com/1472-6963/12/472

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