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Trends in laboratory utilization in British Columbia hospitals 1966 to 1980 : implications for manpower… Judd, Bryan Douglas 1984

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TRENDS IN LABORATORY UTILIZATION IN BRITISH COLUMBIA HOSPITALS - 1966 TO 1980; IMPLICATIONS FOR MANPOWER PLANNING BY BRYAN DOUGLAS JUDD B.SC., The University of B r i t i s h Columbia, 1975 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology Health Services Planning Programme We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October 1984 © Bryan D. Judd, 1984 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of HEALTH CARE AND EPIDEMIOLOGY The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date 12 OCTOBER 1984 Page i i ABSTRACT One might expect that there are a number of factors that influence the demand for laboratory services including changes i n population, physician supply, the d e l i v e r y system, changing technology, and the a v a i l a b i l i t y of a s k i l l e d workforce. S i m i l a r l y , the supply of laboratory services i s affected by the supply of a v a i l a b l e manpower, p a r t i c u l a r l y physicians, and the amount of c a p i t a l flowing into the health care sector of the economy. Trends i n the u t i l i z a t i o n of laboratory services have a substantial impact on manpower use i n t h i s sector of the health care system. In order to prepare appropriate manpower projections for laboratory personnel, planners must consider the impact of trends i n the above f a c t o r s . This study presents an analysis of data showing trends i n the pattern of laboratory u t i l i z a t i o n i n B r i t i s h Columbia public hospitals from 1966 to 1980 and relates these trends to changes i n the above f a c t o r s . Trends are i d e n t i f i e d by analyzing u t i l i z a t i o n data for each of 1966, 1970, 1974, 1978, and 1980. The primary source of data i s the HS-1 Health and Welfare Canada s t a t i s t i c a l returns prepared annually by a l l h o s p i t a l s . The analysis involves c a l c u l a t i n g percentage changes between each period i n key u t i l i z a t i o n measurement parameters. U t i l i z a t i o n measurement parameters include patient days per acute care admission, acute care admissions per bed, laboratory workload and expenses per patient day Page i i i and per acute care admission, and other parameters related to demographics, bed d i s t r i b u t i o n , physician supply, and laboratory manpower supply. This analysis i s put into the B r i t i s h Columbia context and discussed i n r e l a t i o n to p r o v i n c i a l p o l i c i e s and the development of the p r o v i n c i a l health care d e l i v e r y system. Data are presented showing B.C.'s population to be aging and the impact of t h i s trend on laboratory demand i s discussed. It i s shown that the acute care bed/population r a t i o decreased from 6.1/1,000 i n 1962 to 4.3/1,000 i n 1978 while the r a t i o of extended care beds increased from 0.4/1,000 to 2.2/1,000. It i s also shown that there has been a general decrease i n h o s p i t a l a c t i v i t y related to O b s t e t r i c a l and P e d i a t r i c services i n B.C. hospitals from 1966 to 1980. Physician supply i s reported to have a substantial impact on the use of health care ser v i c e s , including l a b o r a t o r i e s , and B.C. i s shown to have the highest r a t i o of general p r a c t i t i o n e r s i n Canada with one for every 578 people. Automation has permitted more throughput per laboratory worker and helped keep the r i s e i n laboratory operating expenses from increasing proportionately with workload. Laboratory expenses data show an increasing emphasis on supplies and a decreasing emphasis on medical s a l a r i e s . It was found that there were no large changes i n the mix of laboratory personnel employed i n B.C. hospita l s throughout the period 1966 to 1980. Medical Laboratory Technologists generally comprise about 66% of the laboratory workforce. Technical Page i v Assistants account f o r about 7% of the workforce and c l e r i c a l s t a f f comprise approximately 23% of the laboratory workforce. Recommendations for improved data c o l l e c t i o n are made together with some observations related to better development and deployment of laboratory manpower. TABLE OF CONTENTS Page v ABSTRACT i i LIST OF TABLES v i i i ACKNOWLEDGEMENT x I. INTRODUCTION 1 II . METHODOLOGY 4 I I I . BACKGROUND 10 The Cost of Canada's Health Care Services 11 The Health Care Delivery System i n B r i t i s h Columbia 13 The R a t i o n a l i z a t i o n of the Delivery System and F i n a n c i a l Control 19 The Metropolitan Hospital Planning Council 20 Regional Hospital D i s t r i c t s 22 The B r i t i s h Columbia Medical Center 24 The Bed Matrix 25 Fin a n c i a l R a t i o n a l i z a t i o n . . . . 27 The Joint Funding Study 28 The Hospital Role Study 30 IV. IMPLICATIONS FOR LABORATORIES 33 V. GROWTH IN THE DEMAND FOR HEALTH CARE SERVICES 38 Changes i n Demographics - B.C. and Canada 40 Changes i n the Mix of I n s t i t u t i o n a l Beds 43 B r i t i s h Columbia Hospital A c t i v i t y P r o f i l e s 43 Def i n i t i o n s 44 Bed D i s t r i b u t i o n 45 Patient Days 46 Admissions to Acute Care Beds 47 Patient Days Per Acute Care Bed 49 Admissions Per Acute Care Bed 52 Average Length of Stay 53 Physicians and Issues Related to Their Role i n Laboratory U t i l i z a t i o n 55 Page vi The E f f e c t of Technology and Automation i n Laboratories 65 The E f f e c t of Automation on Laboratory Costs 67 Summary 68 Implications for Laboratories 70 VI. ISSUES RELATED TO THE SUPPLY OF HEALTH CARE SERVICES 71 The Supply of Physicians 72 Medical Laboratory Technologists 77 Manpower Planning D e f i n i t i o n s and Objectives 86 H i s t o r i c a l Developments i n Health Manpower Planning i n B r i t i s h Columbia 88 The Health Manpower Planning Organization i n B r i t i s h Columbia 92 Health Manpower Education i n B r i t i s h Columbia 95 Administrative Organization 95 Medical Laboratory Technologist Programs 96 The E f f e c t of Automation on Laboratory Manpower 98 VII. THE ORGANIZATION AND OPERATION OF A HOSPITAL LABORATORY 101 VIII. FINDINGS AND IMPLICATIONS 106 Laboratory Manpower i n B r i t i s h Columbia Hospitals 106 Def i n i t i o n s and Limitations 106 Non-Medical Laboratory Personnel 109 Physicians 118 Laboratory Workloads i n B r i t i s h Columbia Hospitals 119 Laboratory Workload and Hospital A c t i v i t y Comparisons.. 125 Laboratory Workload Per Patient Day 128 Laboratory Workload Per Acute Care Admission 130 Laboratory Operating Costs i n B r i t i s h Columbia Hospitals 132 Non-Medical Salaries 133 Supplies and Expenses 134 Medical Salaries 135 Laboratory Costs Per Hospital A c t i v i t y Indicator 137 Summary 140 Page v i i IX. SUMMARY AND CONCLUSIONS 143 Background 144 Growth i n the Demand for Health Care Services 147 Issues Related to the Supply of Health Care Services 150 Findings and Implications 150 Discussion 153 Recommendations 156 REFERENCES 157 APPENDICES: Appendix 1 Number and Percentage D i s t r i b u t i o n of Hospital Beds by Bed C l a s s i f i c a t i o n by Hospital Size Group 1966 - 1980 165 Appendix 2 Number and Percentage D i s t r i b u t i o n of Laboratory Personnel i n B.C. Public Hospitals Showing Percentage Change from Previous Period and Total Percentage Change from 1970 to 1980; by Type of Personnel and Hospital Size Group 171 Appendix 3 Comparative Use of Laboratory Assistants i n B.C. Public Hospitals; by Size of Hospital: 1970 - 1980 174 Appendix 4 Number and Percentage D i s t r i b u t i o n of Registered Technologists i n B.C. Public Hospitals; by Q u a l i f i c a t i o n and Whether Full-Time of Part-Time and by Hospital Size Group: 1970 - 1980 175 Appendix 5 Number and Percentage D i s t r i b u t i o n of Laboratory Medical Manpower i n B.C. Public Hospitals; by Hospital Size Group and Whether Full-Time or Part-Time: 1970 - 1980 177 Appendix 6 D i s t r i b u t i o n of Laboratory Workload for a l l B.C. Public Hospitals Showing Total Units by Service, Percent of Total Workload, and Percent Change from Previous Period; by Hospital Size Group: 1970 - 1980 178 Appendix 7 Summary of Total Laboratory Workload i n Workload Units and Percentage Change Between Periods for a l l B.C. Public Hospitals Showing Inpatient Workload, Outpatient Workload, and Total Percentage D i s t r i b u t i o n of Workload; by Hospital Size Group: 1970 - 1980 183 Appendix 8 Laboratory Operating Expenses by Category of Expense Showing Percentage Change Between Periods and Percentage D i s t r i b u t i o n for a l l B.C. Public Hospitals; by Hospital Size Group: 1966 - 1980 185 Appendix 9 The Number of Hospitals i n Each Size Group f or Each Period 188 Page v i i i LIST OF TABLES 1. TABLE I 2. TABLE II 3. TABLE III 4. TABLE IV 5. TABLE V Total Patient Days i n Acute Care Beds and Percent Change From Previous Period for a l l B.C. Public Hospitals by Size Group: 1966-1980 47 Total Admissions to Acute Care Beds and Percent Change From Previous Period for a l l B.C. Public Hospitals by Size Group : 1966-1980 48 Patient Days per Acute Care Bed and Percent Change From Previous Period for a l l B.C. Public Hospitals by Size Group : 1966-1980 51 Acute Care Admissions per Acute Care Bed and Percent Change From Previous Period for a l l B.C. Public Hospitals by Size Group: 1966-1980 53 Patient Days per Acute Care Admission and Percent Change From Previous Period for a l l B.C. Public Hospitals by Size Group: 1966-1980 54 6. TABLE VI Number and Percentage D i s t r i b u t i o n of Laboratory Personnel i n B.C. Public Hospitals and Percentage Change From Previous Period, by Type of Personnel: 1970-1980 I l l 7. TABLE VII The Number and Percentage D i s t r i b u t i o n of Registered Technologists i n B.C. Public Hospitals by Q u a l i f i c a t i o n and Whether Full-Time or Part-Time: 1970-1980 115 8. TABLE VIII Laboratory Workload Units per Laboratory Worker f or a l l B.C. Public Hospitals by Size Group: 1970-1980 117 9. TABLE IX Number and Percentage D i s t r i b u t i o n of Laboratory Medical Manpower i n B.C. Public Hospitals: 1970-1980 119 10. TABLE X D i s t r i b u t i o n of Laboratory Workload f o r a l l B.C. Public Hospitals Showing Total Units by Service, Percent of Total Workload, and Percent Change From Previous Period: 1970-1980 122 11. TABLE XI Inpatient Laboratory Workload Units per Patient Day and Percent Change Between Periods, by Size of Hospital: 1970-1980 127 12. TABLE XII Inpatient Laboratory Workload Units per Acute Care Admission and Percentage Change Between Periods, by Hospital Size, a l l B.C. Public Hospitals: 1970-1980 130 Page ix 13. TABLE XIII Laboratory Operating Expenses by Category of Expense Showing Percentage D i s t r i b u t i o n and Percentage Change Between Periods, for a l l B.C. Public Hospitals: 1966-1980 133 14. TABLE XIV Laboratory Costs per Patient Day and Percent Change From Previous Period, for a l l B.C. Public Hospitals by Hospital Size: 1970 - 1980 138 15. TABLE XV Laboratory Costs per Acute Care Admission and Percentage Change From Previous Period, f o r a l l B.C. Public Hospitals by Hospital Size: 1970 - 1980 139 16. TABLE XVI Laboratory Expenses per Laboratory Workload Unit and Percentage Change Between Period, for a l l B.C. Public Hospitals by Hospital Size: 1970 - 1980 140 ACKNOWLEDGEMENTS Page x Several people have contributed to the completion of t h i s p r o j ect. I wish to f i r s t of a l l , extend my gratitude to my committee members, Dr. Anne Crichton, Dr. Lawrie Dunn, and Dr. Annette Stark, a l l of whom gave generously of t h e i r time i n both personal discussions and reviews of the manuscript. Without t h e i r guidance, encouragement, and occassional prodding, t h i s study could not have been completed. I would also l i k e to g r a t e f u l l y acknowledge the generous assistance of the s t a f f of the D i v i s i o n of Health Services Research and Development at U.B.C., p a r t i c u l a r l y that of Susan Chan, who provided much of the data for t h i s study i n usable form. My thanks also the the Minist r y of Health f o r t h e i r permission to access the data and to the University a f f i l i a t e d teaching hospitals of Vancouver who allowed t h e i r data to be used i n t h i s study. Page i x ACKNOWLEDGEMENTS Several people have contributed to the completion of t h i s p r o j ect. I wish to f i r s t of a l l , extend my gratitude to my committee members, Dr. Anne Crichton, Dr. Lawrie Dunn, and Dr. Annette Stark, a l l of whom gave generously of t h e i r time i n both personal discussions and reviews of the manuscript. Without t h e i r guidance, encouragement, and occassional prodding, t h i s study could not have been completed. I would also l i k e to g r a t e f u l l y acknowledge the generous assistance of the s t a f f of the D i v i s i o n of Health Services Research and Development at U.B.C, p a r t i c u l a r l y that of Susan Chan, who provided much of the data for t h i s study i n usable form. My thanks also the the Ministry of Health for t h e i r permission to access the data j -banks—of— t rhe—Heaith—Man-power—Reseafeh—Unit and to the University a f f i l i a t e d teaching hospitals of Vancouver who allowed t h e i r data to be used i n t h i s study. I C H A P T E R 1 I N T R O D U C T I O N There are several factors that influence laboratory u t i l i z a t i o n . Among these factors are: 1. the demand for laboratory services generated by a growing population changing i n demographic composition, 2. the a b i l i t y to supply the appropriate services through an adequate supply of q u a l i f i e d professionals, and 3. s u f f i c i e n t f a c i l i t i e s to provide the se r v i c e s . The purpose of t h i s study i s to review how these, and other f a c t o r s , have contributed to the current pattern of laboratory u t i l i z a t i o n i n B r i t i s h Columbia public hospitals and to speculate how changes i n these areas a f f e c t manpower deployment i n l a b o r a t o r i e s . This study addresses four main questions related to the impact of the above factors on manpower u t i l i z a t i o n i n l a b o r a t o r i e s : Page 2 1. What has been the e f f e c t of changing demographics on the demand for laboratory services? 2. What has been the e f f e c t of changing technology and automation on both the supply of, and demand for laboratory services? « 3. What has been the e f f e c t of the supply of physicians on both the demand for laboratory services and the supply of laboratory services? 4. How has the supply and mix of laboratory manpower changed i n response to changes i n population, physician supply and technology? Issues related to each of the above questions are reviewed, insofar as data were a v a i l a b l e , and analyzed i n terms of t h e i r implications for planning. In the chapters which follow, there i s a discussion of the type of data available for analysis i n t h i s study as well as a b r i e f discussion of data that would have been of i n t e r e s t but was not r e a d i l y a v a i l a b l e f o r review. The study begins with a review of the h i s t o r i c a l development of the B r i t i s h Columbian health care d e l i v e r y system and then moves into a discussion of issues related to the demand for laboratory services followed by issues related to the supply of these s e r v i c e s . Data are presented which represent the development of laboratory u t i l i z a t i o n patterns i n B.C. public h o s p i t a l s from 1966 to 1980 and the patterns of u t i l i z a t i o n are discussed i n terms of t h e i r implications f o r planning. Also included i n these discussions i s the e f f e c t of changes i n laboratory Page 3 technology and the ro l e of physicians i n both the demand and supply of laboratory s e r v i c e s . This i s followed by a discussion of manpower planning i n general and a review of past and present e f f o r t s i n B.C. i n forecasting manpower needs i n the health care sector. There i s then a presentation of data showing the impact of the previously i d e n t i f i e d demand and supply issues on manpower u t i l i z a t i o n i n laboratories and on laboratory operating expenses. The f i n a l chapter presents a summary of the study and draws the reader's attention to conclusions i d e n t i f i e d throughout the text of the study. There i s also a b r i e f discussion of some of the recommendations that could be considered by health care planners i n coming to grips with the issue of c o n t r o l l i n g the use of laboratory s e r v i c e s . Page 4 CHAPTER II METHODOLOGY This study i s mainly d e s c r i p t i v e but i t presents an analysis of ava i l a b l e data showing trends i n the patterns of u t i l i z a t i o n of labor a t o r i e s i n B r i t i s h Columbia public h o s p i t a l s a f t e r describing the evolution of health services and laboratories i n B r i t i s h Columbia. The patterns are i d e n t i f i e d from an analysis of a v a r i e t y of documents l i s t e d below and from discussions with experts i n the f i e l d . U t i l i z a t i o n data were c o l l e c t e d for the period 1966 to 1980 and are discussed i n r e l a t i o n to changes i n medical p r a c t i c e , technological advancements, socio-economic conditions, and government p o l i c i e s e x i s t i n g p r i o r to and during that time period. The impact of such changes on laboratory manpower u t i l i z a t i o n i s discussed i n r e l a t i o n to the v i s i b l e e f f e c t s on s t a f f i n g patterns in v o l v i n g Laboratory Physicians, Laboratory S c i e n t i s t s , Medical Laboratory Technologists, Laboratory Technical Assistants, and Administrative Support Personnel. The "Annual Return on Health Care F a c i l i t i e s - Parts I and I I " (HS-1 and HS-2) i s used as the primary source of data related to laboratory s t a f f i n g patterns, laboratory workload patterns, h o s p i t a l s i z e s and hos p i t a l a c t i v i t y for B r i t i s h Columbia h o s p i t a l s . These Page 5 data are used to c a l c u l a t e several pro d u c t i v i t y and workload i n d i c a t o r s such as laboratory workload units per acute care admission and per patient day, laboratory costs per acute care admission and patient day, laboratory workload units per f u l l time equivalent worker, and laboratory workload units per paid hour. A l l data are grouped and analyzed both i n t o t a l and by h o s p i t a l s i z e groups and h o s p i t a l r o l e . The categories are as follows: 1. Group I: 0-99 acute care beds 2. Group I I : 100-199 acute care beds 3. Group I I I : 200-299 acute care beds 4. Group IV: over 300 acute care beds 5. Group V: University A f f i l i a t e d Teaching Hospitals It was considered that the use of l a b o r a t o r i e s , and hence the s t a f f i n g of l a b o r a t o r i e s , could vary according to h o s p i t a l s i z e and role and therefore data should be analyzed according to these parameters. The si z e groupings were somewhat a r b i t r a r y . Although other studies had found data from hospitals of less than 100 beds of questionable use, i t was decided to include these hopsitals i n a separate group i n order to complete the province-wide picture of laboratory workloads and laboratory s t a f f i n g . The l i m i t a t i o n s of the data re l a t e d to t h i s group are discussed i n the text where appropriate. Teaching hospitals are frequently acknowledged as having service u t i l i z a t i o n patterns d i f f e r e n t from non-teaching h o s p i t a l s . In an attempt to i d e n t i f y differences i n laboratory Page 6 u t i l i z a t i o n and operation between teaching and non-teaching h o s p i t a l s , i t was decided to group the teaching hospitals together i r r e s p e c t i v e of t h e i r i n d i v i d u a l bed s i z e . The other h o s p i t a l s i z e groups were selected by what seemed an appropriate size d i v i s i o n that would group together small community hospita l s i n Group I I , medium sized community hospitals providing some l e v e l of r e f e r r a l services i n Group I I I , and the larger urban center hospi t a l s providing a f u l l range of community and regional r e f e r r a l services i n Group IV. The number of hospit a l s i n each h o s p i t a l size group for each year of t h i s study i s presented i n Appendix 9. The HS-1 and HS-2 data were made ava i l a b l e through the D i v i s i o n of Health Services Research and Development at the University of B r i t i s h Columbia. As i n d i v i d u a l h o s p i t a l data remain the property of the h o s p i t a l s , only aggregated data were released and those with the permission of the B r i t i s h Columbia Mini s t r y of Health, Hospital Programs D i v i s i o n . Because the size of the University A f f i l i a t e d Teaching Hospital group was so small and there was the p o s s i b i l i t y of i d e n t i f y i n g the source of the data, permission to use t h e i r data was obtained from each of Vancouver General Ho s p i t a l , St. Paul's Hos p i t a l , Children's Ho s p i t a l , and Shaughnessy H o s p i t a l . Trends i n laboratory u t i l i z a t i o n i n B.C. hospitals are i d e n t i f i e d by examining data at four year i n t e r v a l s from 1966 to 1980; that i s , data i s presented only for 1966, 1970, 1974, 1978, and 1980. At the outset of t h i s study, i t was hoped to include data for the period 1960 to 1982. Such a time frame would include data p r i o r to the introduction of Medicare which was believed to have had a s i g n i f i c a n t impact on the use of health care f a c i l i t i e s i n B.C. Page 7 It was also expected that data from t h i s time period would c l e a r l y show the impact of automation i n laboratories i n terms of workloads, manpower, and prod u c t i v i t y over the l a s t two decades. However, d i f f i c u l t y i n obtaining data for the period p r i o r to 1966 prevented the i n c l u s i o n of those years i n t h i s study. Because the current method of reporting laboratory workload was not introduced u n t i l 1968, data p r i o r to that year only include f i n a n c i a l and laboratory s t a f f i n g information. It was thought that the present time frame would s t i l l show some degree of impact from the introduction of Medicare when comparisons are made between the 1966 data and that of the subsequent reporting years. There would also be some in d i c a t ion of the impact of technology and automation on laboratories based on the changes i n t h i s regard since 1966. The HS-1 and HS-2 forms are s t a t i s t i c a l reports designed to provide "basic information of value to hospit a l s and p r o v i n c i a l a u t h o r i t i e s " ( l ) . These reports are to be completed by a l l " p u b l i c , proprietary and federal hospitals i n Canada, regardless of the ho s p i t a l ' s status under the f e d e r a l - p r o v i n c i a l h o s p i t a l insurance program" i n accordance with the requirements of the S t a t i s t i c s Act (Section 21) and with Regulation 11 of the Hospital Insurance and Diagnostic Services A c t ( l ) . During the period under review i n t h i s study, the format and i n s t r u c t i o n s for the HS-1 and HS-2 returns underwent three separate r e v i s i o n s . Consequently, i n some cases, f u l l comparative analysis of data for the t o t a l period 1966-1980 was not pos s i b l e . The areas where t h i s occurred are i d e n t i f i e d i n the t e x t . It should also be Page 8 noted that the reporting year changed from the calendar year to the f i s c a l year A p r i l 1 - March 31 i n 1977. Therefore, two reporting years contain data derived from the f i s c a l year A p r i l to March while three reporting years contain data based on the calendar year. As data were not c o l l e c t e d during the t r a n s i t i o n year, there are no cases where a reporting year exceeds 12 months. Other sources of data include published material from a v a r i e t y of researchers, S t a t i s t i c s Canada demographic reports, and personal discussions with a v a r i e t y of professionals i n related f i e l d s . The sources are duly c i t e d i n the text where appropriate and l i s t e d i n the references. It w i l l be noted that t h i s study excludes data related to the private sector la b o r a t o r i e s i n B r i t i s h Columbia. It i s recognized that the absence of such data prevents a complete province-wide picture of laboratory u t i l i z a t i o n being presented; however, as many public hospitals provide laboratory services to ambulatory patients i n competition with the private sector, the trends i n laboratory u t i l i z a t i o n found i n h o s p i t a l laboratories i n terms of workload and costs are l i k e l y very s i m i l a r to those found i n private sector l a b o r a t o r i e s . Other studies have attempted comparisons between public and private sector laboratories and noted d i s s i m i l a r i t i e s i n the type of information c o l l e c t e d by these l a b o r a t o r i e s , making d i r e c t comparisons d i f f i c u l t at best. It was decided at the outset of t h i s study that another attempt at comparisons between the private and public sector laboratories was beyond the scope and time-frame of t h i s study. Page 9 It was considered that data related to changes i n the type of laboratory tests ordered and the frequency with which tests are ordered would be of i n t e r e s t i n such a study as t h i s . Such information could possibly have been made ava i l a b l e through the Medical Services Commission of B r i t i s h Columbia however, the time l i m i t a t i o n s of t h i s study precluded t h i s avenue being explored. Another area of i n t e r e s t that could not be pursued i n t h i s study was related to the introduction of major automated analyzers into B.C. public h o s p i t a l s . It would have been i n t e r e s t i n g to t r y to r e l a t e the introduction of such equipment with changes i n laboratory p r o d u c t i v i t y and the demand for laboratory s e r v i c e s . An important question to consider i s whether the demand for some laboratory services i s increased through the a b i l i t y of laboratories to supply increased s e r v i c e s . A request of the B.C. Ministry of Health for data related to the a c q u i s i t i o n of such equipment found that such information was not r e a d i l y a v a i l a b l e from the Equipment Se c r e t a r i a t . Page 10 CHAPTER III BACKGROUND Over the l a s t f o r t y years, B r i t i s h Columbia has experienced s i g n i f i c a n t changes i n i t s health care system: the introduction of h o s p i t a l insurance and medicare; the expansion of health pr o f e s s i o n a l s ' education encouraged through federal grants; advancements i n medical sciences from new s u r g i c a l procedures to new laboratory and r a d i o l o g i c a l diagnostic and treatment methods; and dramatic changes i n health technology and the philosophy of medical p r a c t i c e . These changes have had varying e f f e c t s on the health care system i n terms of what the system can provide and what the public expects. In order to provide the public with the state-of-the-art health care they expect, i t has become practice to t r a i n and employ highly s k i l l e d health care p r o f e s s i o n a l s . In order to provide the l e v e l of service desired i n the most cost e f f e c t i v e manner possible, there has been a d i v i s i o n of labour i n the health care industry. The d i v i s i o n i s such that there are several l e v e l s of expertise and care f a c i l i t i e s a v a i l a b l e , such that the most highly trained i n d i v i d u a l s are not performing the most elementary of tasks and r e l a t i v e l y well patients are not occupying the most expensive treatment beds. This Page 11 layering of health professionals and health i n s t i t u t i o n s i s evident i n a l l areas of the health sector including medical l a b o r a t o r i e s . In t h i s s e t t i n g , the most highly trained personnel are the Laboratory Physicians while perhaps the le a s t trained personnel are Laboratory Technical A s s i s t a n t s . Each has a s p e c i f i c role to play i n ensuring that high standards i n the practice of laboratory medicine are provided while at the same time, work i s being performed i n the most c o s t - e f f e c t i v e and cost- b e n e f i c i a l manner. With the dramatic developments i n medical technology and medical practice i n the l a s t twenty years, one would expect to see changes i n the number of laboratory personnel as well as i n the type and function of manpower groups. THE COST OF CANADA'S HEALTH CARE SERVICES It i s generally recognized that the cost of health care i n Canada i s increasing at rates exceeding other sectors of the economy. Canada-wide, health expenditures per person increased from $120.34 i n 1960 to $1057.58 i n 1981.(2,3) In terms of i n f l a t i o n adjusted d o l l a r s , the increase was from $171.42 i n 1960 to $478.54 i n 1981 using standard 1971 d o l l a r s . For B r i t i s h Columbia, the projected 1981 figu r e i s $1,310.75, or $524.15 i n 1971 d o l l a r s , making i t t h i r d highest i n the country following the T e r r i t o r i e s and Alberta.(3) The adjustment for i n f l a t i o n was calculated by d i v i d i n g current expenditures by the value of current d o l l a r s indexed to 1971 d o l l a r s . The i n f l a t i o n indices are as reported by S t a t i s t i c s Canada for Health and Personal Care.(4) Page 12 In terms of Gross National Product, health expenditures i n Canada rose from 5.6% i n 1960 to 7.0% i n 1978.(5,6) They have remained r e l a t i v e l y constant throughout the l a s t decade, since the introduction of Medicare, ranging from a low i n 1974 of 6.7% to a high of 7.3% i n 1971.(6) By comparison, national health expenditures i n the U.S. i n 1978 accounted for 8.9% of t h e i r Gross National Product, up from 7.6% i n 1970.(6) A review of t o t a l health care expenditures i n Canada by category of expense, shows that t o t a l expenditures increased from $6.1 b i l l i o n i n 1970 to $16.2 b i l l i o n i n 1978 for a net increase of 166%. Hospital expenditures increased from $2.8 b i l l i o n i n 1970 to $7.3 b i l l i o n i n 1978 representing an increase of 161%. Payments to physicians increased from $1.0 b i l l i o n i n 1970 to $3.7 b i l l i o n i n 1978 representing an increase of 270%. In terms of consumer pr i c e index adjusted 1971 d o l l a r s the t o t a l expenditures increased form $6.22 b i l l i o n to $9.75 b i l l i o n , or 57%, for the same period, h o s p i t a l expenditures increased from $2.86 b i l l i o n to $4.39 b i l l i o n , or 53%, and physician payments increased from $.98 b i l l i o n to $2.23 b i l l i o n , or 128%, for the period 1970 to 1978.(7) It has been suggested that laboratory services account for approximately 10% of the t o t a l h o s p i t a l budget and that t h e i r share of the h o s p i t a l budget has been increasing annually i n some i n s t i t u t i o n s .(8) As laboratories represent an increased proportion of the o v e r a l l h o s p i t a l budget, and the d o l l a r value of laboratory services have become of increasing s i g n i f i c a n c e , they are receiving more attention from governments and h o s p i t a l administrators as areas for p o t e n t i a l improvements i n operating e f f i c i e n c y and u t i l i z a t i o n Page 13 patterns. THE HEALTH CARE DELIVERY SYSTEM IN B.C. The health care d e l i v e r y system i n B r i t i s h Columbia has evolved to i t s present state through a series of incremental moves over the l a s t 60 years. As e a r l y as 1919, a B r i t i s h Columbia Royal Commission reviewed the p o s s i b i l i t y of state health insurance. Its recommendation was for a province-wide pre-paid compulsory program for wage earners below a basic minimum ($3000.00 per annum). Those earning more than the minimum amount would s t i l l have access only to private insurance. The B r i t i s h Columbia government appointed a Royal Commission on Health Insurance and Maternity Benefits i n 1929. The Commission's report resulted i n the enactment of the Health Insurance Act. This l e g i s l a t i o n was passed i n 1936 to provide a form of comprehensive health insurance but i t was never implemented. The halt of t h i s l e g i s l a t i o n was due l a r g e l y to protests expressed by the B.C. Medical Association and protests by a large section of the business community who claimed that the economy could not stand s o c i a l l e g i s l a t i o n at that time.(9) During the 1930's and 1940's, a v a r i e t y of p r i v a t e , pre-paid medical plans were brought into existence i n B.C. These plans had the support of B.C. physicians through the B.C.M.A. which f e l t the plans adequately serviced the target population, ( i e . the employed) and comprehensively covered the great majority of medical services rendered by physicians. These plans were often established i n Page 14 consultation with the B.C.M.A. and, i n some cases, were sponsored by physicians. The problem with these plans was that the premiums were p r o h i b i t i v e l y high for many workers and there was no coverage for the poor and the g e r i a t r i c population.(9) In 1948, the f i r s t steps toward a national health plan were taken by the federal government when i t introduced The National Health Grants Act. This established a federal grant-in-aid program to a s s i s t provinces i n extending and improving public health and ho s p i t a l s e r v i c e s . The federal government l a i d down standards of construction for h o s p i t a l f a c i l i t i e s , and program p r i n c i p l e s and then provided money for s p e c i f i c projects on a matching basis with j o i n t f e d e r a l - p r o v i n c i a l administration.(10) In order to a v a i l themselves of these p a r t i c u l a r grants, the provinces had to develop plans i n which they could forecast h o s p i t a l developments as part of a comprehensive health care d e l i v e r y program. B r i t i s h Columbia engaged the services of a Minnesota-based consulting firm to prepare the p r o v i n c i a l h o s p i t a l construction and manpower plan (Hamilton Report).(11) The objectives of the study were to determine the p r o v i n c i a l bed requirements to 1951 and 1971 and to lay down a plan of how to meet those requirements. The study was also to estimate the number of health care professionals and para-professionals that would be needed and to recommend a plan to t r a i n them. Hamilton found the province's h o s p i t a l s generally i n a poor state of r e p a i r , being poorly designed, aged, f i r e hazards, and often over-crowded. The recommendations were f or the immediate Page 15 addition of 2,864 new beds by 1951 and a further 6,244 beds between 1951 and 1971 of which 4204 would be new beds and 2040 would replace e x i s t i n g beds. The report also recommended the d i v i s i o n of the province into s i x primary health regions and the c l a s s i f i c a t i o n and development of hospitals according to an organized r e f e r r a l pattern. The c l a s s i f i c a t i o n of hospitals was to include: community c l i n i c s and health centres, community h o s p i t a l s , regional h o s p i t a l s , and teaching or base h o s p i t a l s . Each region was to include at least one regional or base h o s p i t a l which would provide r e f e r r a l services not provided elsewhere i n the region.(11) The Hamilton Report recognized the short supply of physicians, nurses, and laboratory technologists, and recommended l e v e l s of enrollment i n the province's t r a i n i n g i n s t i t u t i o n s that would a l l e v i a t e the shortage. The s p e c i f i c recommendations related to manpower are discussed i n more d e t a i l i n Chapter VI. After the h o s p i t a l construction plan was accepted at p r o v i n c i a l and federal l e v e l s , i t became a very loose general guideline for h o s p i t a l development as the plan was subject to p o l i t i c a l pressures for m o d i f i c a t i o n . The National Health Grants Act separated c a p i t a l costs from operating costs. Single or j o i n t m u n i c i p a l i t i e s which could r a i s e 25% of the t o t a l c a p i t a l cost of a h o s p i t a l could then bring pressure to bear on the p r o v i n c i a l government to r a i s e another 25% and then seek the rest of the c a p i t a l funding from Ottawa. There was no i n t e n t i o n that h o s p i t a l s , other than mental or long term care h o s p i t a l s , should be b u i l t or operated by governments. Grants were made available to Societies formed by Page 16 l o c a l i n t e r e s t groups who would take r e s p o n s i b i l i t y for managing the h o s p i t a l s . Building a l o c a l h o s p i t a l became an important community project for many small towns. There was l i t t l e concern regarding the d i f f i c u l t i e s of obtaining operating funds, p a r t i c u l a r l y a f t e r the 1949 introduction of a p r o v i n c i a l h o s p i t a l insurance plan. The introduction of the B.C. Hospital Insurance Act i n 1949 to meet h o s p i t a l operating costs, provided small communities with further impetus to lobby for more h o s p i t a l s . The program was i n i t i a l l y supported by premium payments which proved d i f f i c u l t to c o l l e c t and p u b l i c a l l y unpopular. In 1954, premiums were abolished and the r e t a i l sales tax was raised by 2% to cover h o s p i t a l costs. The mandate of the insurance plan excluded the costs of chronic care hospitals and outpatient s e r v i c e s . This exclusion resulted i n a growing misuse of acute care beds which were i n very short supply. Patients who could not afford chronic care hospitals were often placed i n acute care f a c i l i t i e s . The development of t h i s pattern of use of h o s p i t a l beds seems to p e r s i s t to a large degree today and may have been a contributing factor to the slow development of long term care f a c i l i t i e s . It also served to encourage the use of hospitals for diagnostic services which could be provided i n an ambulatory s e t t i n g i n e i t h e r private or public f a c i l i t i e s . Such services were covered by private insurance, however, as mentioned above, such coverage was frequently beyond the means of a large sector of the population and many people took out h o s p i t a l insurance but not medical insurance. Page 17 The federal Hospital Insurance and Diagnostic Services Act was enacted i n July 1958. It offered the provinces 50 per cent of the funds required to operate t h e i r own h o s p i t a l plans, provided c e r t a i n basic program p r i n c i p l e s were met. In order to p a r t i c i p a t e i n the program, the provinces were required to make insured services uniformly a v a i l a b l e to a l l t h e i r residents. Insured services included h o s p i t a l per diem rates and s p e c i f i c diagnostic services such as laboratory and radiology. The funding formula was such that poor provinces received s l i g h t l y more than 50% of t h e i r funds from Ottawa while r i c h e r provinces received s l i g h t l y l e s s than 50%. Also i n 1958, the B.C. government i n s t i t u t e d the B r i t i s h Columbia Government Employees' Medical Society, a pre-paid medical insurance program a v a i l a b l e to a l l government employees both active and r e t i r e d , with the government paying h a l f the premiums. This was the beginning of a province-wide pre-paid medical insurance program which became a r e a l i t y with the introduction of the B.C. Medical Grant Act i n 1965. The objectives of the Medical Grant Act included the desire to provide a voluntary, non-profit medical insurance plan to any resident of the province who wished to apply. There were no r e s t r i c t i o n s or q u a l i f i c a t i o n s regarding age, state of health, or f i n a n c i a l status and there was a provision for government f i n a n c i a l assistance based on taxable income.(9) The only major r e s t r i c t i o n was that the plan was a v a i l a b l e to i n d i v i d u a l s only, not groups. Page 18 The B.C. Medical Plan was organized to carry out these objectives, c o l l e c t premiums, pay claims and oversee the operation of the plan and was administered by a six-member Board of Directors consisting of three physicians nominated by the B.C.M.A. and three laymen. Under the new plan, physicians were paid on a fee- f o r - s e r v i c e basis according to an agreed fee schedule. A formal process was set up whereby fees were established by the physicians through the B.C.M.A. i n negotiation with the government. The B.C. Medical Plan became the Medical Services Plan of B.C. on July 1, 1968 with the introduction of the federal Medical Care Act. This Act required the federal government to pay one-half the cost of insured services i n p a r t i c i p a t i n g provinces. Insured services included a l l medically required services rendered by a physician or surgeon. The development of the health care d e l i v e r y system i n t h i s manner resulted i n compartmentalization of services rather than a r a t i o n a l approach to d e l i v e r y of adequate health care s e r v i c e s . For example, h o s p i t a l insurance had provided c o s t l y treatment and diagnostic services without d i r e c t charge to the patient i f he was admitted to an acute care h o s p i t a l , but required him to pay for services out of h i s own pocket, or through private insurance premiums, when not a ho s p i t a l i n p a t i e n t . S i m i l a r l y , transfer of a patient to a less expensive extended care f a c i l i t y almost i n v a r i a b l y meant greater d i r e c t costs to the patient because the hos p i t a l plan did not cover extended care s e r v i c e s . This approach to insured health care services l e f t gaps i n some services and promoted o v e r - u t i l i z a t i o n i n others. Page 19 As diagnostic services were included as insured services under the Hospital Insurance and Diagnostic Services Act, h o s p i t a l laboratories experienced an increase i n workload at l e a s t corresponding to the increasing a c t i v i t y of the h o s p i t a l . Also, during the l a s t two decades, the importance of laboratory procedures increased with the a b i l i t y to provide an ever-widening scope of t e s t s , accurate r e s u l t s , shorter response times and decreased costs per t e s t s . These factors led h o s p i t a l laboratories to an expansion phase that saw even small hsopitals having the a b i l i t y and willingness to provide a wide spectrum of t e s t s , many of which could not be j u s t i f i e d i n terms of production costs and user demand. There was, e s s e n t i a l l y , a period of uncoordinated, rapid growth i n laboratory services which, i n a number of areas, p e r s i s t s as a problem today. Although there has been more coordination, there i s s t i l l a need for further coordination and r a t i o n a l i z a t i o n of the laboratory services i n B r i t i s h Columbia. RATIONALIZATION OF THE DELIVERY SYSTEM AND FINANCIAL CONTROL Although the Hamilton Report of 1949 (11) outlined a p r o v i n c i a l h o s p i t a l plan for B r i t i s h Columbia, l o c a l communities were able to bring s i g n i f i c a n t pressure to bear on the p r o v i n c i a l government to fund h o s p i t a l s i n t h e i r areas. As the Social Credit government of the day had strong r u r a l support and commitment, deviations from the o r i g i n a l h o s p i t a l plan were common. Smaller communities struggled to have t h e i r i n d i v i d u a l health care needs met and received the bulk of monies for h o s p i t a l development. Page 20 By the mid-1960's there was a range of hospitals with d i f f e r e n t f a c i l i t i e s spread across the province lacking any degree of technological r a t i o n a l e . As mentioned above, such an arrangement began to present problems i n the coordination of laboratory s e r v i c e s , as well as i n other shared s e r v i c e s . The primary concern was d u p l i c a t i o n of expensive services and the i n a b i l i t y of smaller centres to u t i l i z e t h e i r f a c i l i t i e s e f f i c i e n t l y . Of further concern i n t h i s regard, was the growing prevalence of private laboratory f a c i l i t i e s . ( 1 2 ) There was some question of whether they should be permitted to compete with the h o s p i t a l laboratories since the h o s p i t a l laboratories could provide the same services, a l b e i t , possibly l e s s conveniently, and without a p r o f i t margin. This question i s s t i l l unresolved today. The Metropolitan Hospital Planning Council The B r i t i s h Columbia Hospital Insurance Services (B.C.H.I.S.) recognized a lack of coordination of h o s p i t a l development i n the l a t e 1950's, p a r t i c u l a r l y i n the metropolitan area of the Lower Mainland. During 1959, a large number of development proposals were submitted to the p r o v i n c i a l government by lower mainland h o s p i t a l s . The need for coordination was evidenced by the amount of d u p l i c a t i o n of f a c i l i t i e s and services proposed i n these expansion programs. Using as a foundation for review a report on h o s p i t a l f a c i l i t i e s prepared by the B.C.H.I.S., The B r i t i s h Columbia Hospital Association, a voluntary body, established the Metropolitan Hospital Planning Council which, i n turn, established a professional Page 21 sub-committee. The objectives of the sub-committee were to analyze the e x i s t i n g r e f e r r a l patterns i n the Lower Mainland; to review the e x i s t i n g f a c i l i t i e s ; and to review the long range plans of l o c a l h o s p i t a l s with a view to possible i n t e g r a t i o n and coordination of future developments.(13) The study recommended the construction of 600 a d d i t i o n a l beds i n the metropolitan area, a u n i v e r s i t y located h o s p i t a l , a review of p e d i a t r i c f a c i l i t i e s i n the area, long term care f a c i l i t i e s , r e h a b i l i t a t i v e services, and emergency roon f a c i l i t i e s . It also recommended a review of the trend towards r e g i o n a l i z a t i o n of h o s p i t a l f a c i l i t i e s and c a l l e d for better coordination of diagnostic services such as laboratory services.(13) It was also the recommendation of the sub-committee that B.C.H.I.S. consider implementing a province-wide outpatient diagnostic program. Such were the beginning e f f o r t s to coordinate the planning and development of h o s p i t a l f a c i l i t i e s within geographic regions. The c a l l f o r a province-wide outpatient diagnostic program has never been s a t i s f i e d i n any coordinated sense, however, a c e r t a i n pattern of outpatient s e r v i c e s , including that for l a b o r a t o r i e s , has evoloved i n B.C. h o s p i t a l s since the introduction of the B.C. Medical Plan i n 1965. Page 22 Regional Hospital Districts In an e f f o r t to r a t i o n a l i z e municipal planning and to coordinate development, the p r o v i n c i a l government set up 28 Regional D i s t r i c t s i n 1966 and charged them, among other functions, with the r e s p o n s i b i l i t y of regional planning.(12) The r o l e of the Regional D i s t r i c t s was expanded i n 1967 with the introduction of the Regional Hospital D i s t r i c t s Act delegating authority for h o s p i t a l planning to s p e c i a l committees of the Regional D i s t r i c t s . A l l new c a p i t a l development and equipment proposals submitted by the hospitals then had to be considered by these a u t h o r i t i e s p r i o r to being forwarded to V i c t o r i a for approval and funding. Hospitals were s t i l l required to seek operating grants d i r e c t l y through the Hospital Review Board i n V i c t o r i a which set the per diem rates according to a p r i v a t e l y guarded formula. The functions of the Regional Hospital D i s t r i c t s were to include the d i s t r i b u t i o n of funds for the establishment, construction, operation and maintenance of hos p i t a l s and h o s p i t a l f a c i l i t i e s . However, no c a p i t a l expenditures could be authorized without the approval of the Minister of Health which led to the Regional Hospital D i s t r i c t s being used as somewhat of a buffer organization for the p r o v i n c i a l government when the regional c d i s t r i c t s had to refuse h o s p i t a l requests due to i n s u f f i c i e n t funding from V i c t o r i a . This put the expansion of h o s p i t a l laboratory f a c i l i t i e s under the same constraints as h o s p i t a l construction i n general and e f f e c t i v e l y influenced the expansion of laboratory services by r e s t r i c t i n g the expansion of laboratory f a c i l i t i e s . Page 23 The Regional D i s t r i c t s outside the main urban centres of Vancouver and V i c t o r i a had d i f f i c u l t y getting organized due to a lack of s t a f f or professional input. Major developments i n h o s p i t a l construction and renovations had already taken place i n these areas before the Regional D i s t r i c t s were established so there was l i t t l e a c t i v i t y required by the smaller Regional D i s t r i c t s and there was l i t t l e consequence to t h e i r lack of organization for future developments. In some cases, h o s p i t a l s were modernized or additions were b u i l t on e x i s t i n g structures, but the main planning and construction requirements were i n the Greater Vancouver Regional Hospital D i s t r i c t which had never had the l e v e l of government investment that had gone into r u r a l areas i n the s i x t i e s . In 1969, the Greater Vancouver Regional Hospital D i s t r i c t released i t s regional h o s p i t a l plan that included recommendations for the bui l d i n g and expansion of h o s p i t a l f a c i l i t i e s i n the G.V.R.D. and the p r i o r i t y with which they should be undertaken.(14) The plan had considerable input from the B.C. Medical Association through the Professional Practices Sub- Committee which endorsed the concept of r e g i o n a l i z a t i o n but stressed the importance of maintaining h o s p i t a l operating autonomy. Under such a philosophy, hosp i t a l s were able to exert pressure i n d i v i d u a l l y to have t h e i r own plans included i n the D i s t r i c t s o v e r a l l plans. The fact that the National Health Grants for h o s p i t a l construction expired i n 1971, and that much of the bu i l d i n g a c t i v i t y during the s i x t i e s occurred outside the Vancouver area had l e f t the greater Vancouver hospitals behind i n development. Only the Health Resources Fund remained among federal c a p i t a l cost sharing programs Page 24 and i t was due to expire i n 1980. This fund was established to encourage and a s s i s t i n the construction of teaching hospitals and was eventually used to b u i l d the U.B.C. Acute Care Unit and to upgrade the teaching f a c i l i t i e s i n the other teaching hospitals i n Vancouver. The expiry of the National Health Grants meant the laboratory f a c i l i t i e s of many Vancouver area hospitals would remain over-crowded and make-shift for many years to come, placing constraints on the expansion of the services provided by these l a b o r a t o r i e s . The addition of new f a c i l i t i e s at the University of B.C. Acute Care Unit did l i t t l e to change the s i t u a t i o n as that h o s p i t a l ' s o v e r a l l u t i l i z a t i o n was i n i t i a l l y very sluggish leaving the e x i s t i n g and growing demands for services i n the other teaching h o s p i t a l s . The B r i t i s h Columbia Medical Centre With the 1971 success of the N.D.P. i n forming the p r o v i n c i a l government came a change i n ideology and p o l i c i e s . The new Minister of Health set up a consortium of teaching h o s p i t a l s i n July of 1973 to be known as the B.C. Medical Centre. The objective of the B.C.M.C. was to "provide advice and assistance i n bringing about the orderly development and improvement of f a c i l i t i e s and t r a i n i n g programs i n the health f i e l d " . ( 1 5 ) In his study on the health s e c u r i t y of B r i t i s h Columbians, Foulkes recommended that the member hospitals operate under the d i r e c t i o n of a single board representative of the member hospitals but operating outside the j u r i s d i c t i o n of the G.V.R.H.D.(12) He proposed that G.V.R.H.D. representation would be through board membership only. Page 25 The respective powers of the B.C.M.C. and the G.V.R.H.D. never were c l e a r l y set out or formally established. Whilst the B.C.M.C. did not have any formal or s p e c i f i c authority to plan the development of ho s p i t a l beds for the Regional D i s t r i c t , i t s existence resulted i n power s h i f t s among ho s p i t a l planners at the B.C.M.C, the G.V.R.H.D. and the l o c a l Vancouver h o s p i t a l s . One of the goals of the B.C.M.C. was to construct a new University teaching h o s p i t a l on the Oak Street s i t e of Shaughnessy Hospital and streamline the education of B.C.'s health professionals by c e n t r a l i z i n g t h e i r c l i n i c a l education. Up to that time, the education of health professionals i n B.C. was l a r g e l y based at the Vancouver General Hospital, the University of B.C. and St. Paul's H o s p i t a l . These teaching hospitals obviously f e l t threatened by the new developments and t h i s period of time was characterized by turbulent power struggles. The development of acute care hospitals was slow and incomplete. The B.C.M.C. was abolished when the Socia l Credit Party returned to power i n 1975 before the Shaughnessy s i t e was ever developed. This was also a period that saw the rapid development of extended care hospitals under the G.V.R.H.D., which now took over that r o l e . The Bed Matrix During the p r o v i n c i a l e l e c t i o n campaign of 1975, the Social Credit Party made several promises related to the balancing of the p r o v i n c i a l budget and removing the large d e f i c i t incurred by t h e i r predecessors. Included i n these promises was a plan to abolish the B.C. Medical Centre because i t was becoming too grandiose, too Page 26 expensive and, i n t h e i r view, unnecessary. In place of the B.C.M.C., the Social Credit Party promised to b u i l d a University based teaching h o s p i t a l and to review the present a l l o c a t i o n of ho s p i t a l beds i n the province. Following t h e i r return to power, the Soci a l Credit government quickly abolished the B.C. Medical Centre and the G.V.R.H.D. became the sole c a p i t a l planning authority. Hospital Programs D i v i s i o n and the G.V.R.H.D. then proceeded to develop a bed matrix plan f o r Vancouver i n 1976. The government of the day wanted to reduce the acute care bed r a t i o from 5/1000 to 4.5/1000 across the province and 4.25/1000 f o r urban areas. The government also wanted a f i v e year c a p i t a l expenditure plan. Other concerns at the time included reduction of the massive size of the Vancouver General Hospital for i t had demonstrated i t s i n a b i l i t y to manage i t s e l f e f f i c i e n t l y . The government had also made e l e c t i o n promises to develop new hospitals i n Port Moody, on the University of B.C. campus and to redevelop the Shaughnessy s i t e to include maternity, children's and r e h a b i l i t a t i o n s e r v i c e s . It was perceived that to accomplish these goals beds had to be reduced i n e x i s t i n g h o s p i t a l s . The G.V.R.H.D. was required to develop plans to take into account the above considerations and i t responded by preparing a l i s t i n g of hospitals and ava i l a b l e f a c i l i t i e s which became known as the bed matrix. The evolution of the matrix was an attempt to r a t i o n a l i z e the supply of beds i n Vancouver taking into consideration changes i n demographics and treatment methods such as ambulatory c l i n i c s , and the p o l i t i c a l constraints imposed by the government. The r e s u l t was generally a reduction i n the bed size of Page 27 the larger h o s p i t a l s . F i n a n c i a l R a t i o n a l i z a t i o n Shortly a f t e r the 1968 introduction of the federal Medical Care Act, i t became apparent the government could not afford to continue the e s s e n t i a l l y open-ended payment arrangements negotiated with the provinces.(16) Following much inter-governmental negotiation, the federal government introduced the Established Programs Financing Act (EPF) i n 1977 which moved federal funding of health programs from d o l l a r - f o r - d o l l a r cost sharing to block funding based on a complex formula of per capita funding and changes i n gross national product. This move to block funding was to help control the outflow of federal tax d o l l a r s and to enable the provinces to fund services that were more responsive to regional needs. Under t h i s agreement, the provinces gained means of obtaining more tax money i n addition to a block grant that covered approximately 25% of t o t a l program cost but were also charged with more r e s p o n s i b i l i t y i n containing costs.(17) Concurrently with these f i n a n c i a l negotiations, the Long Range Planning Branch i n Ottawa had been trying to re-think the philosophy of health care. To coincide with the changes i n the funding of health programs came t h i s new philosophy towards health, encouraged by the federal government and outlined i n the Lalonde report.(18) Lalonde urged Canadians to take more r e s p o n s i b i l i t y for t h e i r health by s t r e s s i n g the importance of l i f e s t y l e and environmental factors i n current mortality and morbidity. P r o v i n c i a l governments, f or Page 28 t h e i r part, had to develop and implement r a t i o n a l approaches to the control of r i s i n g health care expenditures. The Joint Funding Study In the 1970's, B r i t i s h Columbia's e f f o r t s towards c o n t r o l l i n g the cost of health care included a plan for working toward a more r a t i o n a l method of determining h o s p i t a l funding procedures. In the early 1970's, the B.C. Ministry of Health budget approached 30% of the t o t a l p r o v i n c i a l budget and hospit a l s accounted for approximately 85% of that budget.(17) The hospital's operating budgets were set by the Health Ministry's Rate Review Board through a formula never disclosed to the h o s p i t a l s . The budget was e s s e n t i a l l y based on h i s t o r i c a l patterns and amounted to l i t t l e more than a simple percentage increase over the previous budget(12). Most hospitals had budget overruns annually and negotiated separately with V i c t o r i a for the necessary a d d i t i o n a l funds. The smaller hospi t a l s u s u a l l y worked through the B.C. Hospital Association to bring a d d i t i o n a l pressure to bear on government to pick up the overruns but often found themselves i n competition with the larger hospitals which always negotiated separately when i t suited t h e i r purposes. With the added pressure from the 1977 EPF Act for p r o v i n c i a l governments to control t h e i r funding p o l i c i e s , the new Bennett government strengthened the r o l e of the Treasury Board, encouraging i t to bring i n better control techniques. Pressures were brought to bear on the Ministry of Health to change the method of funding Page 29 hospitals from a per diem expenditure to a program basis, matching the philosophy of the federal EPF Act, and to end d e f i c i t funding by introducing zero based budgeting. In a F i n a n c i a l Discussion Paper, the government also raised questions of the accountability of ho s p i t a l boards and proposed to designate h o s p i t a l as public bodies i n order to be able to tighten c o n t r o l s . At t h i s point i n time, the hospitals refused to agree with the proposal. In May of 1978, Dr. Chapin Key, then Deputy Minister of Health and former Executive Director of Vancouver General Hospital and President of the B.C. Hospital Association, announced that a Joint Funding Study of B.C. hospitals would be undertaken by a Joi n t Steering Committee composed of representatives from the B.C.H.A., the Min i s t r y of Health, and the Treasury Board.(l7) The actual study involved using the services of the management consultant firm of Ernst and Whinney. The objective of the project was to develop a funding system which would ensure a more equitable d i s t r i b u t i o n of av a i l a b l e funds to public h o s p i t a l s . The tasks included the development of a uniform reporting system, the development of an improved budgeting system and the establishment of a p r o v i n c i a l data base. It was recognized that the e x i s t i n g d e f i c i t budgeting system was retrospective i n that the budget applications and adjustments took place a f t e r the service had been provided. That i s , the system e s s e n t i a l l y permitted, and perhaps encouraged, d e f i c i t budgeting. It was also soon recognized by the Joint Steering Committee that an e f f e c t i v e cost management system required a categorization of hos p i t a l s and the i r s e r v i c e s . Consequently, the Minis t r y of Health Page 30 i n i t i a t e d the Hospital Role Study which was to provide the model f or a r a t i o n a l framework to guide h o s p i t a l development and resource a l l o c a t i o n over the next f i f t e e n years.(17) The Hospital Role Study The Hospital Role Study was a preliminary attempt at defining categories of hospitals according to t h e i r functions. The Role Study recognized that, although a l l ho s p i t a l s share a common goal i n providing health care services, l i m i t e d resources i n health care require that hospitals move towards " r e a l i g n i n g t h e i r objectives i n r e l a t i o n to other hospitals and to other health services i n the community".(19) It was believed that changing the re l a t i o n s h i p s between the various components of the health care system would bring improvements i n e f f i c i e n c y i n the d e l i v e r y system. It was stated that the e x i s t i n g h o s p i t a l system developed out of " s o c i e t a l demands, methods of financing, the organization and d i s t r i b u t i o n of medical p r a c t i c e , and population concentrations".(19) I d e a l l y , , the r o l e of hospitals should be "formulated on the basis of patterns of disease, population and al t e r n a t i v e methods of care".(19) The process of i d e n t i f y i n g h o s p i t a l roles was f e l t to be the f i r s t step i n addressing a number of problems related to the development and operation of an e f f i c i e n t and e f f e c t i v e h o s p i t a l system. There was a recognized need for a plan to guide future developments within the ho s p i t a l system, a more appropriate funding mechanism for hos p i t a l s e r v i c e s , an appropriate d i s t r i b u t i o n of Page 31 h o s p i t a l workloads, the appropriate use and d i s t r i b u t i o n of medical technology and a plan for d e l i v e r i n g l e v e l s of provision for new and expensive health care technologies.(19) The e s s e n t i a l part of the study required that the basis for i d e n t i f y i n g h o s p i t a l roles had to be c l e a r l y understood and accepted by government, h o s p i t a l s , and professional and consumer bodies. A matrix of care functions and service l e v e l s was developed. There were seven care functions including o b s t e t r i c s , p e d i a t r i c s , d e n t i s t r y , medicine, r e h a b i l i t a t i o n , surgery, and psychiatry. There were s i x l e v e l s of care including three l e v e l s of community servi c e s , two l e v e l s of r e f e r r a l s e r v i c e s , and one l e v e l of p r o v i n c i a l r e f e r r a l s e r v i c e . With t h i s matrix, a p r o f i l e of any h o s p i t a l could be i d e n t i f i e d as a combination of various care functions provided at various l e v e l s of s e r v i c e . The obvious implication of such a plan, and the most d i f f i c u l t aspect of i t s implementation, was that each ho s p i t a l would be pigeon-holed into a s p e c i f i c category based on a province-wide assessment of needs. It was apparent that some hospitals would be targeted for expansion or up-grading while others would remain s t a t i c or be down-graded with respect to service a c t i v i t y to f i t t h e i r assigned r o l e . Naturally, a l l hospitals wanted to be up-graded and i t became obvious to the Ministry that such a plan would be, p o l i t i c a l l y , extremely d i f f i c u l t to implement. The plan was, i n f a c t , eventually shelved. Page 32 While the Hospital Role Study focused on long term stategies and r a t i o n a l i z a t i o n , the government of the day was seeking short term cost c o n t r o l . The Socreds renewed t h e i r mandate for f i s c a l r e s p o n s i b i l i t y by winning the e l e c t i o n of 1979, campaigning on a platform of r e s t r a i n t . The pressure for more cost control increased and the health care sector was targeted as being i n need of being brought under c o n t r o l . This objective became clear with the resignation of Chapin Key i n 1981 and the appointment of Peter Bazowski as Deputy Minister of Health under the new Minister of Health, James Neilson. Both Neilson and Bazowski had earned reputations for focusing strongly on f i n a n c i a l control while they were i n the Consumer and Coporate A f f a i r s M i n i s t r y . The Role Study was soon put aside i n favour of more urgently needed cost control mechanisms. The e f f e c t of these e f f o r t s to reorganize and r a t i o n a l i z e the health care d e l i v e r y system i n t h i s province has been to bring attention to areas of d u p l i c a t i o n and oversupply and the corresponding costs associated with these i n e f f i c i e n c i e s . The focus has l a r g e l y been on s p e c i f i c diagnostic and treatment programs such as renal d i a l y s i s , burn treatment, and open heart surgery; however, e f f o r t s at streamlining the d e l i v e r y of such services have a s i m i l a r e f f e c t on the laboratory services that support these programs. Laboratories have received s i g n i f i c a n t a ttention i n t h e i r own r i g h t as the volume of laboratory work per patient i s increasing as are the laboratory costs per patient. The Ministry of Health i s now searching for means to improve the e f f i c i e n c y of the province's laboratory services and to reduce the o v e r a l l cost of t h i s s e r v i c e . Page 33 CHAPTER IV IMPLICATIONS FOR LABORATORIES The focus of medical care towards h o s p i t a l i z a t i o n , encouraged by the fragmented approach to health insurance experienced i n B.C., had s i g n i f i c a n t impact on h o s p i t a l l a b o r a t o r i e s . As h o s p i t a l a c t i v i t y increased, so did laboratory test requests. In addition, as the number of small h o s p i t a l s increased, so did the number of small l a b o r a t o r i e s . Laboratories generally t r i e d to provide as f u l l a range of laboratory procedures as possible, sometimes o f f e r i n g procedures which could not be provided cost e f f e c t i v e l y because they were not frequently used. Such tests would previously have been referred to a larger laboratory. The d u p l i c a t i o n of laboratory procedures became a prime concern of the p r o v i n c i a l government. This development of laboratory services led to the establishment of regional laboratory f a c i l i t i e s during the l a t e 1950's and early 1960's. The Laboratory Advisory Council of the p r o v i n c i a l Health Department emphasized the need for regional laboratory services i n 1955 and by 1960 had guided the establishment of four regional laboratories providing a regional pathologist and a regional technologist i n each of New Westminster, T r a i l , Kamloops, and Kelowna. The objectives of the regional laboratories included Page 34 the provision of technical advice to smaller h o s p i t a l l a b o r a t o r i e s ; the provision of tests not requested every day i n smaller hospitals and that were, hence, uneconomical to provide i n such h o s p i t a l s ; and the provision of tissue pathology and autopsy services.(12) It was hoped that the development of such regional laboratories would encourage the in-migration of more c e r t i f i e d consultants and provide l o c a l physicians with the a b l i t y to investigate a patient completely i n the l o c a l areas and to do i t as c o s t - e f f e c t i v e l y as possible. These i n i t i a l steps towards r e g i o n a l i z a t i o n of laboratory services continued for some years and are s t i l l i n place i n many locations today. Attempts to r a t i o n a l i z e the laboratory services of the province followed the pattern established by s i m i l a r e f f o r t s to r a t i o n a l i z e h o s p i t a l s . Following r e g i o n a l i z a t i o n came the question of laboratory r o l e s . This issue was addressed i n the Hospital Role Study where i t was anticipated that the l e v e l of laboratory services provided i n a h o s p i t a l would only match the l e v e l required by the matrix of care functions provided i n that h o s p i t a l . Since the Hospital Role Study was never implemented, hospitals continued to be i n a p o s i t i o n to define t h e i r own l e v e l of laboratory s e r v i c e s . The government's only c o n t r o l l i n g mechanism was through budget r e s t r i c t i o n s p r o h i b i t i v e to the uncontrolled expansion of laboratory s e r v i c e s . Through t h i s mechanism, the government has forced h o s p i t a l s to develop more e f f i c i e n t and c o s t - e f f e c t i v e methods of operation. One of the outcomes of these e f f o r t s has been the development of i n t e r - h o s p i t a l r e f e r r a l patterns. Many hos p i t a l s have developed t h e i r own r e f e r r a l patterns Page 35 for d i s t r i b u t i n g specimens to laboratories already set up to provide the p a r t i c u l a r test desired. One of the problems with t h i s approach was that the h o s p i t a l budgets were very much the subject of p o l i t i c a l interventions so that the system has not tightened as much as i t might have i n some areas and, perhaps, overtightened i n other areas. Another problem with t h i s approach i s that hospitals began charging each other the outpatient Medical Services Plan rate for inpatient laboratory s e r v i c e s . The hospita l s f e l t the charge was necessary to reimburse t h e i r operating expenses i n providing such service to other h o s p i t a l s , however, the Minis t r y of Health f e l t i t was funding laboratories adequately on the basis of t o t a l workload units regrdless of where that workload came from. This issue remains unresolved today as i n t e r h o s p i t a l b i l l i n g continues and the necessary bureaucracy to manage th i s function continues. Further implications of the r a t i o n a l i z a t i o n of hos p i t a l funding involves bringing a closer focus on the necessity of many laboratory tests i n c e r t a i n c l i n i c a l circumstances. It has long been acknowledged that physicians use laboratory services d i f f e r e n t l y but not a l l general p r a c t i t i o n e r s a c t u a l l y understand the merits and l i m i t a t i o n s of c e r t a i n procedures. The p r o v i n c i a l government i s encouraging B.C. laboratory physicians to a s s i s t t h e i r peers i n proper test s e l e c t i o n . Some laboratory physicians f e e l they should take a very active r o l e i n in t e r p r e t i n g the necessity of c e r t a i n laboratory tests while others f e e l a more passive r o l e i s appropriate.(20,21) Through t h i s mechanism of intervention the Ministry of Health hopes to reduce the volume of laboratory test per Page 36 pa t i e n t . Another area of i n t e r e s t with regard to reducing the cost of laboratory services i n t h i s province i s the role of the private sector i n the provision of laboratory s e r v i c e s . The private sector l a b o r a t o r i e s , controlled l a r g e l y by two major companies, have been p a r t i c u l a r l y successful i n negotiating a fee schedule which permits a s u b s t a n t i a l profit.(12,22) Foulkes showed how the fee schedule, designed around l a r g e l y non-automated methodologies, became unresponsive to improvements i n automation and the corresponding reductions i n the cost of tests.(12) He f e l t the private laboratories were u n f a i r l y taking advantage of an outdated fee structure and recommended a review of the province's c l i n i c a l laboratory test p r i c i n g p o l i c i e s . A t o t a l review of t h i s p o l i cy has never taken place, although recent moves by Medical Services Plan to r e j e c t payment for c e r t a i n test p r o f i l e s under c e r t a i n conditions, suggests that e f f o r t s are continuing to control the cost of laboratory services through f i n a n c i a l r e s t r i c t i o n s . Most hospitals now have active outpatient departments and provide laboratory services for ambulatory patients as evidenced by the growing laboratory workload for outpatients i n B.C. h o s p i t a l l a b o r a t o r i e s as discussed i n Chapter VIII. There are those who believe public sector h o s p i t a l laboratories can assume a more active r o l e i n the provision of laboratory services to outpatients at the expense of the private sector c l i e n t e l e . In f a c t , one of the recommendations of the Foulkes Report (1973) was that the government should move to eliminate private laboratories from the p r o v i n c i a l health care d e l i v e r y system. Such suggestions are s t i l l c i r c u l a t i n g Page 37 today and the government has d i f f i c u l t y r e c o n c i l i n g t h i s c o n f l i c t between i t s support of the free entrepeneurial system and i t s desire to reduce costs i n health care. Page 38 CHAPTER V GROWTH IN THE DEMAND FOR HEALTH CARE SERVICES Vic t o r Fuchs c i t e s several issues related to the demand for health care services and notes that the demand for health care services i s one of those few areas of an economy that i s r e l a t i v e l y i n e l a s t i c with respect to price.(23) That i s , a r i s e i n the price of health care services r e l a t i v e to other prices w i l l not necessarily r e s u l t i n an equal decline i n the quantity of health care services demanded. The r e s u l t w i l l be an increase i n health care expenditures at the expense of some other sector of the economy.(23) Among the factors having the most s i g n i f i c a n t impact on the demand for health care services are r i s i n g incomes along with increased public expectations with respect to a v a i l a b i l i t y of servic e s , changing population demographics, supply of physicians, and the a b i l i t y to provide more. It i s generally recognized that the demand for health care services increases proportionately with income. The average Canadian per capita income increased from $2,303 i n 1966 to $11,520 i n 1981 representing an increase of 400%.(24) In terms of i n f l a t i o n adjusted 1971 d o l l a r s , the increase was 76% from $2,758 i n 1966 to Page 39 $4,863 i n 1981. The average B r i t i s h Columbia per capita income for the same period was $2,570 and $12,538 re s p e c t i v e l y representing an increase of 388%.(24) In i n f l a t i o n adjusted 1971 d o l l a r s , t h i s increase was a c t u a l l y 72% from $3,078 i n 1966 to $5,293 i n 1981. Population changes c l e a r l y have an impact on health care services whether i t be merely from increasing numbers or from changing age d i s t r i b u t i o n s of that population. It i s generally accepted that a small proportion of the e l d e r l y use far more health care services than younger and healthier sectors of the population. In addition to increasing numbers, Canada's population i s also aging. It i s estimated that by 1996 there w i l l be 3.2 m i l l i o n Canadians over the age of 65 compared to about 2 m i l l i o n i n 1976.(25) The percentage of people over 65 during the l a t e 1970's was only 8.6% of the t o t a l population yet t h i s group accounted for more than one-third of the t o t a l annual patient days.(25) The supply of physicians i s considered by some to be the single most important factor governing the demand for health care services .(26) While i t i s generally the consumer who i n i t i a t e s the f i r s t v i s i t for medical treatment, i t i s the physician who suggests h o s p i t a l i z a t i o n , prescribes drugs, orders laboratory tests and x-ray examinations, c a l l s i n consultants and who requests repeat v i s i t s . ( 2 7 ) In addition to being the chief supplier of medical care, the physician also serves as the patient's chief advisor on how much medical care he needs. Figures presented l a t e r i n t h i s study w i l l show that the number of physicians have increased at a f a s t e r rate than the general population. The numbers, lo c a t i o n s , and implications of t h i s trend w i l l be discussed i n more d e t a i l at that Page 40 time. Changing technology and increased automation are also believed to contribute to increased demand for health care s e r v i c e s . These factors are responsible f o r the introduction of new diagnostic techniques and for allowing a fas t e r processing of diagnostic tests making them more desirable to the c l i n i c i a n . As w i l l be discussed l a t e r , j u s t providing the a b i l i t y to do a test quickly and accurately appears to have a s i g n i f i c a n t impact on increasing demand for laboratory services, p a r t i c u l a r l y i n the smaller h o s p i t a l s . Improved access to medical care f o r a l l sectors of the population through h o s p i t a l insurance and medical insurance has contributed to increased demand for health s e r v i c e s . As w i l l be discussed i n d e t a i l l a t e r i n t h i s study, t h i s increased demand and the technological a b i l i t y to provide ever-increasing quantities and improved q u a l i t i e s of diagnostic services has resulted i n a surge i n the volume of laboratory procedures performed i n th i s province i n the l a s t twenty years. This increase i n laboratory a c t i v i t y has helped bring attention to t h i s sector of the health care budget as a possible s i t e for gaining improvements i n e f f i c i e n c y . CHANGES IN DEMOGRAPHICS - B.C. AND CANADA As mentioned previously, one of the most s i g n i f i c a n t factors i n f l u e n c i n g the growing demand f or medical services i s the increasing population. The population of B r i t i s h Columbia increased from 1,874,000 i n 1966 to .2,640,000 i n 1980 which represents a t o t a l increase of 40.9%.(28) Up to 1975, B r i t i s h Columbia experienced a Page 41 much faster rate of growth than any other province. From 1975 onward, the o i l boom i n Alberta attracted most of the moving Canadian population there. B r i t i s h Columbia's growth i n population i s p r i m a r i l y due to migration from other provinces, with t h i s form of population growth outnumbering natural increases i n the order of 2.5 to 1.(29) In addition to the increasing number of people, the age d i s t r i b u t i o n of the population w i l l also influence the demand for medical s e r v i c e s . It i s widely acknowledged that a small proportion of the e l d e r l y use a disproportionately large proportion of health services and i t i s r e a d i l y apparent that Canada's population i s aging. The percentage of the population over the age of 65 has been increasing s t e a d i l y from 5.1% i n 1901 to 7.8% i n 1970.(30) By 1981, the percentage of the Canadian population over the age of 65 was estimated at 9.5%.(31) Population projections place the percentage over 65 by 1996 between 11.0% and 11.8% depending on various scenarios of net migration.(32) For B r i t i s h Columbia, the percentage of population over the age of 65 was 9.8% i n 1976 and 10.9% i n 1981.(33) Major contributing factors to t h i s trend are a slowing i n the rate of immigration, a decline i n the b i r t h rate, and a decline i n the death rate, a l l of which r e s u l t i n a much slower natural rate of increase i n the population. The b i r t h rate has declined from a high of 28.9 l i v e b i r t h s per 1,000 population during the peak of the post war baby boom to a low of 15.1 l i v e b i r t h s per 1,000 population by 1980.(34) During the same period, the death rate per 1,000 population decreased from 9.4 to 7.1.(34) The l i f e expectancy at Page 42 b i r t h i n Canada increased from 60.0 for males and 62.1 for females i n 1931 to 70.2 f o r males and 77.5 f o r females by 1976.(35) This represents increases of 10.2 years and 15.4 years for males and females r e s p e c t i v e l y . During the same period, l i f e expectancy at 60 increased by 0.9 to 17.2 years for males and by 4.8 years to 22.0 years for females. Such trends i n population have had, and w i l l continue to have, a major impact on the demand f o r , and d e l i v e r y of health care. The aging of the Canadian population brings the degenerative diseases of aging into prominance. This requires more emphasis on long term care of the c h r o n i c a l l y i l l and, among other things, pharmaceutical intervention and organ transplants to control the e f f e c t s of organ degeneration. The e f f e c t on laboratories of such changes w i l l l i k e l y be to increase workloads due primarily to increases i n tests of a screening and monitoring nature. Drug monitoring i s already receiving considerable attention i n today's laboratories and i s talked of as the coming trend of the future. The e f f e c t of these changes i n population are r e f l e c t e d i n changes i n the mix of i n s t i t u t i o n a l beds and i n the u t i l i z a t i o n of acute care beds. These subjects w i l l now be discussed i n more d e t a i l . Page 43 CHANGES IN THE MIX OF INSTITUTIONAL BEDS A review of the changing number and mix of i n s t i t u t i o n a l beds coincides with changes i n the Canadian population and the health care demands of that population. The number of acute short-term beds increased from 91,965 i n 1958 to 106,694 i n 1978, representing an increase of 16%.(36) During the same period, extended or chronic care beds increased from 14,337 to 34,211, which represents an increase of 139%.(36) Viewed i n terms of beds per 1,000 population, the number of acute care beds decreased from 5.3 to 4.5 while the number of extended care beds increased from 0.8 to 1.5.(36) S i m i l a r l y , i t was found that the t o t a l number of i n s t i t u t i o n a l beds per 1,000 population i n B r i t i s h Columbia from 1962 to 1978 increased from 15.2 to 17.6.(36) During that same period, the number of acute care beds per 1,000 population decreased from 6.1 to 4.3 and extended or chronic care beds increased from 0.4 per 1,000 population i n 1962 to 2.2 i n 1978.(36) Such figures c l e a r l y show a growing emphasis on f a c i l i t i e s for care of the aged. BRITISH COLUMBIA HOSPITAL ACTIVITY PROFILES In order to i d e n t i f y changes i n the a c t i v i t y of B.C. hospitals over the study period of 1966-1980, several parameters related to ho s p i t a l a c t i v i t y were examined. These parameters include the number and d i s t r i b u t i o n of beds, the number of patient days and the number of acute care admissions. Page 44 In a l l cases, the number of beds includes a l l those staffed and i n operation as reported on the HS-1 return excluding r e h a b i l i t i o n , extended care, other long term care and newborn bassinets. These beds were excluded from review because they t y p i c a l l y have very l i t t l e impact on laboratory a c t i v i t y . The reported categories include medical, s u r g i c a l , undistributed medical and s u r g i c a l , intensive care, o b s t e t r i c a l , p e d i a t r i c , p s y c h i a t r i c and other short term categories not s p e c i f i e d above. A short stay bed i s more commonly referred to as an acute care bed. D e f i n i t i o n s An Acute Care Admission i s defined as the o f f i c i a l acceptance into a h o s p i t a l of a patient requiring medical and hospital services including room and board i n one of the short-stay h o s p i t a l services described above.(l) The count of Acute Care Admissions Per Year includes a l l those acute care patients who were assigned a h o s p i t a l bed commencing from 12:01 A.M. on the f i r s t day of the reporting y e a r . ( l ) A Patient Day i s the period of service to an inpatient between the census-taking hours on two successive days. The day of admission i s counted as a patient day but the day of separation i s not. A l l patient days i n t h i s study are based on stay i n acute care beds only as defined above.(l) Page 45 Bed D i s t r i b u t i o n Appendix 1 shows the d i s t r i b u t i o n of the various bed categories as an absolute number and as a percentage of the t o t a l number of acute care beds for the year of i n t e r e s t . It should be noted that smaller hospitals frequently provide data that has not, or cannot be, r e a d i l y categorized according to the requirements of the HS-1 Return due to the multiple function of beds i n smaller i n s t i t u t i o n s . As Table 1-6 of Appendix 1 i n d i c a t e s , there has been an increase of 1,225 acute care beds i n a l l B.C. hospitals over the study period 1966-1980. This amounts to an increase of 11.6%. The largest increases occurred i n Intensive Care beds and Psy c h i a t r i c beds. Intensive Care beds increased from 26 beds i n 1970 to 415 beds i n 1980 representing an increase of 1496%. Psy c h i a t r i c beds increased from 192 beds i n 1970 to 680 beds i n 1980 f o r a increase of 254%. Steady decreases occurred i n the categories of O b s t e t r i c a l and P e d i a t r i c beds with a drop from 1,190 beds to 998 beds for a 16% decrease i n O b s t r i c a l beds and a drop from 1,600 to 1,252 for a 22% decrease i n Pe d i a t r i c beds. When the data from each size group i s examined i t i s apparent that the only consistent trend i s the ever increasing number of Intensive Care and P s y c h i a t r i c beds i n each siz e group. Contrary to the general trend, Group IV hospitals increased i n O b s t e t r i c a l beds by 54% and i n P e d i a t r i c beds by 40%. This may be a r e f l e c t i o n of the move towards c e n t r a l i z e d services as the Group IV hospitals are mostly regional r e f e r r a l h o s p i t a l s . Page 46 It i s d i f f i c u l t to suggest any consistent differences i n bed d i s t r i b u t i o n between each size group with the possible exception of t o t a l medical and s u r g i c a l beds. This category of bed appears to be c o n s i s t e n t l y more prominent i n the larger hospitals of Group IV and V accounting for an average 72% and 78% of the t o t a l beds i n those groups r e s p e c t i v e l y . In the smaller h o s p i t a l of Groups II and I I I , these categories of beds account for an average 66% and 65% of t o t a l beds r e s p e c t i v e l y . Differences i n the d i s t r i b u t i o n of h o s p i t a l beds may be representative of the changing population demographics i n B.C. as well as changes i n the funding of ho s p i t a l s which now encourage the use of a l t e r n a t i v e treatment methods such as ambulatory care and use of extended care f a c i l i t i e s . Assuming the differences i n the d i s t r i b u t i o n of h o s p i t a l beds i s based l a r g e l y on r a t i o n a l analysis of need, one could conclude that the decrease i n beds i n smaller i n s t i t u t i o n s and the increase i n beds i n the larger ones i s a r e f l e c t i o n of the move towards urbanization i n B.C. and the r e g i o n a l i z a t i o n of medical s e r v i c e s . Patient Days Table I shows the t o t a l number of patient days for each h o s p i t a l size group for the study period from 1966-1980. It also shows the percentage change since the previous reporting period. As i s r e a d i l y evident, there was a net increase of 22.8% i n the t o t a l number of patient days recorded between 1966 and 1980. A l l h o s p i t a l si z e groups exhibit net increases i n patient days for the same Page 47 period ranging from 0.5% for teaching hospitals to 63.7% for hospitals between 200 and 299 beds. There does not appear to be any consistent trend i n the number of patient days for each si z e group with perhaps one possible exception. Following generally large increases i n patient days between 1966 and 1970, a l l size groups experienced decreases, or at least smaller increases, i n the number of patient days i n subsequent years. TABLE I Total Patient Days i n Acute Care Beds and Percent Change from Previous Period for a l l B.C. Public Hospitals by Size Group 1966 - 1980 Hospital Size Group 1966 PD xlOOO 1970 PD % xlOOO C 1974 PD % xlOOO C 1978 PD % xlOOO C 1980 PD % xlOOO C 1966-1980 % Group I 469 729 55.5 624 • -14.5 552 -11.5 559 1.3 +19.2 Group II 635 734 15.6 697 -5.0 724 3.8 801 10.6 +26.1 Group III 219 386 75.8 472 22.5 416 -11.9 359 -13.7 +63.7 Group IV 768 869 13.2 849 -2.3 985 16.0 1008 2.3 +31.2 Group V 706 722 2.3 755 4.6 758 0.4 710 -6.4 +0.5 TOTAL 2797 3440 23.0 3398 -1.2 3435 1.1 3436 0.0 +22.8 PD = Patient Days % = Percent change from previous year. Admissions To Acute Care Beds Table II shows the number of admissions per year to acute care beds for each h o s p i t a l s i z e group throughout the study period. The percentage change between each reporting period i s also presented. O v e r a l l , there was a net increase of 13.5% i n acute care admissions between 1966 and 1980 for a l l B.C. h o s p i t a l s . A l l ho s p i t a l s i z e Page 48 groups show net increases i n acute care admissions with the exception of Group I. The increases range from 16.7% for Group II to 77.6% for Group III h o s p i t a l s . Group I had a 12.1% decrease i n acute care admissions. As for Patient Days, there does not appear to be any consistent trend i n the number of acute care admissions i n each h o s p i t a l size group. TABLE II Total Admissions to Acute Care Beds and Percent Change From Previous Period for a l l B.C. Public Hospitals by Size Group (1) 1966 - 1980 Hospital Size Group 1966 ACA xlOOO 1970 ACA % xlOOO C 1974 ACA % xlOOO C 1978 ACA % xlOOO C 1980 ACA % xlOOO C 1966-1980 % Group I 108 99 -8.4 92 -7.1 88 -3.5 95 7.1 -12.1 Group II 78 87 11.7 92 6.2 91 -1.4 91 -0.2 +16.7 Group III 26 49 88.7 59 20.3 38 -35.1 46 20.6 +77.6 Group IV 66 80 22.7 95 18.4 77 -19.3 794 3.5 +21.3 Group V 60 71 16.8 78 10.6 52 -32.7 72 36.9 +19.0 TOTAL 337 385 14.3 416 7.9 347 -16.6 383 10.4 +13.5 ACA = Acute Care Admissions per acute care bed % = Percentage change from previous period. (1) The count of acute care admissions includes those i n h o s p i t a l at the beginning of each reporting year. It should be noted that the above figures on the number of beds, patient days, and acute care admissions only represent the l e v e l of a c t i v i t y i n each h o s p i t a l size group. Each ho s p i t a l size group changed i n siz e and member hospitals between reporting years as i n d i v i d u a l h o s p i t a l bed complements changed. The number of ho s p i t a l s i n each siz e group for each year i s l i s t e d i n Appendix 9. Page 49 To obtain a more accurate impression of what has been happening i n the various size groups i t i s necessary to r e l a t e h o s p i t a l a c t i v i t y to the a v a i l a b i l i t y of h o s p i t a l f a c i l i t i e s which i s accomplished by c a l c u l a t i n g the number of patient days per bed and the number of acute care admissions per bed. Patient Days Per Acute Care Bed The c a l c u l a t i o n of Patient Days Per Bed i s a common measure of h o s p i t a l a c t i v i t y and i s i n d i c a t i v e of the hospital's occupancy l e v e l or workload. Table III shows the number of patient days per acute care bed for each ho s p i t a l s i z e group and each reporting year. The percentage change between each reporting year i s also i n d i c a t e d . There was an o v e r a l l increase i n patient days per bed of 10.1% for a l l h o s p i t a l s . Three h o s p i t a l size groups demonstrated increases i n occupancy ranging from 4.3% for Group III hosptials to 51% for Group I h o s p i t a l s . The teaching hospitals had a net decrease i n occupancy of approximately 11% and Group II hospitals remained unchanged a f t e r 15 years. The u n c h a r a c t e r i s t i c a l l y large increase i n patient days per acute care bed i n Group I from 1966 to 1970 raises the p o s s i b i l i t y that one of those two figures may be i n error or the r e s u l t of d i f f e r e n t i n t e r p r e t a t i o n s of the d e f i n i t i o n for patient days. The aggregation of the data did not allow for t h i s question to be resolved for the reporting h o s p i t a l s . The increase between 1966 and 1980 for Group I hospi t a l s must therefore be interpreted c a u t i o u s l y . Page 50 As might have been an t i c i p a t e d , occupancy l e v e l s generally increased with the reduction i n available acute care beds. It could be concluded that, o v e r a l l , the reduction i n acute care beds per thousand population has kept pace with decreasing user demand and the increasing a v a i l a b i l i t y of a l t e r n a t i v e care modes. It could a l s o , of course, be argued that the decreasing demand may be the r e s u l t of the decreased a v a i l a b i l i t y . This could e a s i l y be so i f the number of patient days per bed approached the t h e o r e t i c a l maximum of 365. However, the average was 290 patient days per bed i n 1980, down from 300 i n 1970, suggesting that, o v e r a l l , an adequate supply of acute care beds i s a v a i l a b l e . The highest average rate of patient days per bed i s found i n the Group V hospitals with a study period average of 316.5 days per bed. This i s followed by Group III hospita l s at 315.3 patient days per bed and Group IV hospitals at 310 days per bed. Group II had an average of 293.2 days per bed and Group I hospita l s had an average of 241.3 patient days per bed, i f the 1966 entry i s not included. The l a t t e r i s excluded because i t does not r e f l e c t the average pattern seen over the study period and may be a reporting e r r o r . In terms of the actual number of patient days per acute care bed for i n d i v i d u a l h o s p i t a l s i z e groups and trends over the study period, i t w i l l be noted that Group I ho s p i t a l s have c o n s i s t e n t l y reported the lowest use of available beds and that t h i s u t i l i z a t i o n rate has s t e a d i l y decreased from 1966 to 1980. In t e r e s t i n g l y , the teaching hospitals have gone from having the highest bed u t i l i z a t i o n rate i n 1966 to having the second lowest i n 1980. This i s l i k e l y due to the introduction and a p p l i c a t i o n of new treatment methods Page 51 shortening the length of stay and to various r e s t r a i n t measures to promote more e f f i c i e n t use of a v a i l a b l e acute care beds such as through the transfer of many services to ambulatory care and a l t e r n a t i v e i n s t i t u t i o n a l care. The r e s u l t i s that the teaching hospi t a l s have become not only the centres for management of the most d i f f i c u l t and complex acute care cases, but the ones making the greatest use of ambulatory care modes. TABLE III Patient Days per Acute Care Bed and Percent Change from Previous Period for a l l B.C. Public Hospitals by Size Group 1966 - 1980 Hospital Size Group 1966 Pt. Day 1970 Pt.Day % 1974 Pt.Day % 1978 Pt.Day % 1980 Pt.Day % 1966-1980 % Group I 148.4 266.8 79.8 243.2 -8.8 231.1 -5.0 224.1 -3.0 +51.0 Group II 299.9 293.6 -2.1 284.1 -3.2 288.9 1.7 299.9 3.8 0.0 Group III 302.9 305.5 0.9 313.3 2.6 324.0 3.4 331.0 2.2 +9.3 Group IV 305.1 309.4 1.4 304.0 -1.7 313.6 3.2 318.1 1.4 +4.3 Group V 331.5 336.1 1.4 288.9 -14.0 330.7 14.5 295.3 -10.7 -10.9 TOTAL 264.0 300.4 13.8 284.7 -5.2 295.8 3.9 290.7 -1.7 +10.1 Pt. Day = Patient days per acute care bed % = percentage change from previous period. It i s also i n t e r e s t i n g to note that Group III hospitals have the highest bed u t i l i z a t i o n rate and that i t has c o n t i n u a l l y increased from 303 patient days per bed i n 1966 to 331 i n 1980. Hospitals i n t h i s category are between 200 and 299 acute care beds and are t y p i c a l l y located i n the larger centres outside the Vancouver and V i c t o r i a area. Their increased u t i l i z a t i o n may be an i n d i c a t i o n of the increased urbanization of the B.C. population Page 52 and/or r e g i o n a l i z a t i o n of services also r e f l e c t e d i n the drop i n patient days i n hospitals of les s than 100 acute care beds. Admissions Per Acute Care Bed The c a l c u l a t i o n of the number of admissions per bed i s another common ho s p i t a l a c t i v i t y i n d i c a t o r and i s i n d i c a t i v e of the turnover of patients. It may also be considered i n d i c a t i v e of the acuity or sev e r i t y of i l l n e s s of the patient population and/or a r e f l e c t i o n of the standard of practice for a p a r t i c u l a r medical community. It i s not a measure of the length of stay as defined i n the HS-1 returns, but i s i n d i c a t i v e of that measure. Table IV shows the number of acute care admissions per acute care bed and the percent change between reporting periods for each hos p i t a l s i z e group. O v e r a l l , there was only a modest net increase of 1.9% i n the number of acute care admissions per bed. Group III hospitals experienced the largest net increase i n acute care admissions per bed at 18.4% followed by Group I hospitals at 9.5% and Group V hospita l s at 5.3%. Group II and Group IV had modest net decreases of 7.3% and 3.5% r e s p e c t i v e l y . The highest average number of acute care admissions occurred i n Group III hospitals with an average 37.1 acute care admissions per bed. This i s followed by Group I hospitals and Group II h o s p i t a l with 36.3 and 35.9 acute care admissions per bed respectively when averaged over the study period. Teaching hospi t a l s and hospita l s of 300 or more beds had the lowest average acute care admissions per bed with 28.8 and 27.7 r e s p e c t i v e l y . This diff e r e n c e i n acute care Page 53 admissions per bed between ho s p i t a l size groups may be a r e f l e c t i o n of varying patterns of practice and varying acuity of patients seen i n each category of h o s p i t a l with teaching hospitals and regional r e f e r r a l hospitals probably having the most acutely i l l patients requiring the most intensive and lengthy care. When data for i n d i v i d u a l h o s p i t a l size groups are examined from one reporting period to the next, i t i s apparent that once again there are no consistent trends emerging. TABLE IV Acute Care Admissions per Acute Care Bed and Percent Change from Previous Period for a l l B.C. Public Hospitals by Size Group 1966 -1980 Hospital 1966 1970 1974 1978 1980 1966-Size 1980 Group ACA ACA % ACA % ACA % ACA % % Group I 34.6 36.1 4.3 35.7 -1.1 37.0 3.6 37.9 2.4 +9.5 Group II 36.8 34.8 -5.4 37.6 8.0 36.4 -3.2 34.1 -6.3 -7.3 Group III 35.8 38.7 8.1 39.0 0.8 29.7 -23.8 42.4 42.8 +18.4 Group IV 26.0 28.6 10.0 34.1 19.2 24.5 -28.2 25.1 2.4 -3.5 Group V 28.4 32.8 15.5 29.9 -8.8 22.9 -23.4 25.1 30.6 +5.3 TOTAL 31.8 33.7 6.0 34.9 3.6 29.9 -14.3 32.4 8.4 +1.9 ACA = Acute Care Admissions per bed % = percentage change from previous period. Average Length of Stay Data regarding the actual average length of stay were not c o l l e c t e d . This average i s calculated from the number of patient days generated by patients separated i n the reporting year from the date of admission, regardless of when the admission occurred. An approximation of t h i s figure may be calculated' from the number of patient days per acute care admissions although i t w i l l not include the number of patient days p r i o r to the reporting year a t t r i b u t a b l e to patients remaining i n hospitals during the reporting year. Page 54 This c a l c u l a t i o n i s presented i n Table V. It i s r e a d i l y apparent that the average length of stay i s le s s i n the smaller hospitals than the large h o s p i t a l s , ranging from an average of 6.1 days i n Group I hospita l s to an average 11.4 days i n Group IV h o s p i t a l s . It i s d i f f i c u l t to i d e n t i f y any consistent trends between reporting periods throughout the study although i t may be argued that the length of stay i s decreasing i n Group I hospita l s and Group V h o s p i t a l s , increasing i n Group IV h o s p i t a l s , and remaining r e l a t i v e l y constant i n Groups II and I I I . Contrary to what may have been expected based on s i t u a t i o n s reported i n the l i t e r a t u r e , the length of stay i n the teaching hospitals i n B.C. i s not any longer than that of non-teaching hospita l s and, i n f a c t , i n 1980 was considerably l e s s than i n the large hospitals of Group IV. This i s probably a combined r e s u l t of increased medical and s u r g i c a l services offered by the large regional hospitals of Group IV and the r e s u l t of r e s t r a i n t e f f o r t s i n the teaching h o s p i t a l s . TABLE V Patient Days Per Acute Care Admission and Percent Change From Previous Period for a l l B.C. Public Hospitals by Size Group 1966 - 1980 Hospital Size Group 1966 Pt. Day 1970 Pt.Day % 1974 Pt.Day % 1978 Pt.Day % 1980 Pt.Day % 1966-1980 % Group I 4.3 7.4 72.1 6.8 -8.1 6.2 -8.8 5.9 -4.8 +37.2 Group II 8.1 8.4 3.7 7.6 -9.5 7.9 3.9 8.8 11.4 +4.7 Group III 8.5 7.9 -7.1 8.0 1.3 10.9 36.3 7.8 -28.4 -1.2 Group IV 11.7 10.8 -7.6 8.9 -17.9 12.8 43.8 12.7 -0.8 -15.3 Group V 11.7 10.2 -12.8 9.7 -4.9 14.4 48.5 9.9 -31.3 -15.3 TOTAL 8.3 8.9 7.2 8.2 -7.8 9.9 20.7 9.0 -9.1 +8.4 Pt.Day = Patient days per acute care admission % = percentage change from previous period. Page 55 PHYSICIANS AND ISSUES RELATED TO THEIR ROLE IN LABORATORY UTILIZATION As mentioned previously, physicians constitute the single most important element of the supply side of health care s e r v i c e s . However, they also constitute a very important element of the demand side of these s e r v i c e s . This would appear to provide an environment for considerable c o n f l i c t of i n t e r e s t . Nevertheless, as Fuchs points out, a physician's actions are generally not motivated by p r o f i t p o t e n t i a l , but instead by what Fuchs r e f e r s to as a "technologic imperative" .(23) That i s , medical education t r a d i t i o n a l l y emphasizes giving the best care that i s t e c h n i c a l l y po s s i b l e . The only e x p l i c i t l y recognized constraint i n the eyes of the physician i s the state of the a r t . This pattern i s reinforced by the public willingness to support new medical technologies and t h e i r desire that i t be a v a i l a b l e to them. This need for physicians to appear up to date, the innate "need to know", as well as concern over the growing number of malpractice s u i t s , encourages physicians to provide "state of the a r t " medical care. Where there i s a t h i r d party payment system without sanctions, over-servicing may be encouraged. The increasing number of physicians i n Canada and the increasing s p e c i a l i z a t i o n of physicians are often i d e n t i f i e d as being the most important elements i n r i s i n g health care costs .(26,37) While there i s c l e a r l y a d i r e c t r e l a t i o n s h i p between the number of physicians and the cost of health care, t h i s r e l a t i o n s h i p must be viewed i n l i g h t of i t s being demand-induced by a better informed public with more disposable income, and an Page 56 apparent willingness to support the increased a v a i l a b i l i t y of medical services through public channels. (23) The merits of t h i s public desire to spend more on health care, that i s , to make health care services more r e a d i l y a v a i l a b l e , are i d e n t i f i e d i n J.M. Last's " c l i n i c a l iceberg" analogy.(38) The iceberg represents the sum t o t a l of a l l medical needs that can be treated by a physician. The iceberg finds i t s own equilibrium i n water with the bulk of i t s mass being submerged. The proportion of the iceberg which i s above water represents those needs which a c t u a l l y receive the a t t e n t i o n of a physician. Most of the diseases seen by physicians i n the section above water are preceded by s u b - c l i n i c a l manifestations below the water; that i s , manifestations which are not brought to the overt attention of a physician. Last maintains that many acute and chronic diseases may be prevented by e a r l y detection of s u b - c l i n i c a l symptoms, by examination and diagnostic t e s t i n g , followed by an appropriate treatment; that i s , by a planned program of preventive health care. The l e v e l at which the iceberg of disease f l o a t s i n the water i s determined by the a c c e s s i b i l i t y to medical care which i n turn, i s determined by economic b a r r i e r s , the supply of physicians, and the development of diagnostic technology. Improving a c c e s s i b i l i t y to medical care by removal of economic b a r r i e r s and increasing the supply of physicians could possibly lead to a reduction i n chronic i l l n e s s and reduced long term i n t i t u t i o n a l care. The issue then becomes not so much a question of whether increased numbers of physicians w i l l improve the health of the population, but a question of how much health care the public can a f f o r d , e i t h e r through d i r e c t Page 57 payments to care providers or through t h i r d party payers. There are, as yet, s t i l l many questions to be answered with regard to the economic and s o c i a l advantages of increasing physician supply i n the hopes of preventing acute and chronic disease or continuing to concentrate on tre a t i n g such diseases a f t e r they have developed. For now, the r e a l i t y i s that physician supply i s one of the key d r i v i n g forces behind escalating health care costs. The more physicians there are, the more patient v i s i t s there are, and t y p i c a l l y , the more laboratory tests ordered. The r e l a t i o n s h i p between the supply of physicians and the demand for health care services i s p a r t i c u l a r l y evident i n r e l a t i o n to the use of laboratory s e r v i c e s . Several factors are reported to influence the demand for such s e r v i c e s . However, many authors place the supply of physicians as the number one factor i n th i s regard. (39,40,41,42,43) It has been shown that the use of laboratory tests i s increasing at an alarming rate and consuming an increasing proportion of the health care budget.(39) One study has demonstrated that the laboratory's share of the o v e r a l l h o s p i t a l budget increased from 7.14% i n 1971 to 9.0% i n 1976.(40) Health and Welfare Canada reported that during the mid-seventies, laboratory services accounted for over 10% of the t o t a l health care dollar.(44) There are a number of theories put forward to explain why the number of p r a c t i c i n g physicians appears to influence so strongly the use of medical services i n general and laboratory services s p e c i f i c a l l y . Schroeder, a U.S. physician, suggests that a very Page 58 strong association e x i s t s between the use of diagnostic and therapeutic technologies and physician density, saying that they are d i r e c t l y proportional, at least i n a f e e - f o r - s e r v i c e setting.(45) Schroeder f e e l s that the most important factor i n the U.S. contributing to the use of medical technology i s the pro-technology bias of reimbursement for medical care i n hospitals and physicians o f f i c e s . He suggests that many technical procedures carry a higher valuation of physician time than i s necessary, and hence, a higher fee schedule. Assuming t h i s to also be the case i n B r i t i s h Columbia's fee-for service sytem, i t would provide physicians with a f i n a n c i a l incentive to order more procedures i n order to increase t h e i r incomes. One study has shown that a physician i n the U.S. could increase his income by almost three f o l d by performing more i n - o f f i c e procedures and ordering more laboratory tests.(46) This f i n a n c i a l incentive becomes a factor when one considers the probable targeting of physician incomes by physician expectations for a p a r t i c u l a r income l e v e l i r r e s p e c t i v e of physician density.(47) That i s , every physician entering the f i e l d expects to earn a large income to reward his e f f o r t s and the time spent i n t r a i n i n g , and the payment system i s designed to permit t h i s . Schroeder c i t e s estimates suggesting the addition of one physician adds approximately $250,000 to the annual operating cost of the health care systems i n both Canada and the U.S. He a t t r i b u t e s much of t h i s to the use of technologies, including laboratory tests.(48) Page 59 Other factors i n f l u e n c i n g the increased use of laboratory services are u t i l i z a t i o n review and the practice of defensive medicine. It has been suggested that peer review almost i n e v i t a b l y leads to a greater use of services, p a r t i c u l a r l y i n ambulatory care.(49) It has further been suggested that such q u a l i t y assurance programs as the Professional Standards Review Organizations i n the U.S. could perpetuate e x i s t i n g practices rather than examine the necessity of a p a r t i c u l a r service or p r a c t i c e s . Through t h e i r organizational design using current practices as the accepted standard, the contribution of PSRO's to the control of the use of medical services i s l i m i t e d and l i k e l y even increases the use of some services because i t i s deemed "good medicine" by review committees. Similar e f f o r t s i n Canada to standardize the q u a l i t y of care, such as h o s p i t a l q u a l i t y appraisal committees, may also apply upward pressure on the use of diagnostic support services such as l a b o r a t o r i e s . It i s l i k e l y that such committees are able to exert some l e v e l of control on physicians who are c o n s i s t e n t l y using diagnostic services at a higher rate than t h e i r peers. Nevertheless, they may also r a i s e the base u t i l i z a t i o n of such services by below average user physicians by v i r t u e of t h e i r desire to conform to the norm. The development of q u a l i t y appraisal committees i s supported, and indeed required, by the Canadian Council for Hosppital A c c r e d i t a t i o n . Accreditation i s not required for hospitals to maintain t h e i r operation i n B.C. However, since i t i s desirable to prove to the community and p r a c t i c i n g physicians that the f a c i l i t y Page 60 i s a q u a l i t y operation with the mechanisms i n place to provide an acceptable q u a l i t y of care, a l l but the smallest hospitals are accreditated. Accreditation organizations also influence the use of diagnostic services by specifying diagnostic approaches to the treatment of c e r t a i n patients such as pre-surgical laboratory and r a d i o l o g i c a l examinations. One study has shown that when physicians were faced with constraints on t h e i r use of laboratory f a c i l i t e s , among the f i r s t tests given up as non-essential were routine blood counts and u r i n a l y s i s required as part of the admission procedure. Although t h i s study was conducted i n an a r t i f i c i a l environment, i t does provide an i n d i c a t i o n of how the physicians involved viewed the signficance of routine pre-admission tests required by p o l i c y rather than by c l i n i c a l necessity. Physician fear of possible future l i t i g a t i o n must also have a degree of impact on the use of medical technologies although, as yet, there i s l i t t l e evidence to support t h i s view. Comparative evidence of the impact of fear of l i t i g a t i o n i s provided i n a study of the volume of r a d i o l o g i c a l examinations and laboratory tests performed i n Swedish h o s p i t a l s . In t h i s s o c i a l i z e d medical system which has a very structured grievance redress system, the volume of such tests was found to be about half the amount ordered on patients i n American hospitals.(50) There may be some c o n f l i c t i n g impacts of defensive medicine. Some physicians are becoming more cautious i n performing "high r i s k " procedures or i n dealing with patients they regard as being i n c l i n e d to sue. Other physicians are performing more diagnostic tests than would otherwise be necessary.(51) The e f f e c t of defensive medicine Page 61 i s l e s s dramatic i n Canada than i n the United States although with the new Charter of Rights and Freedoms, there i s a growing awareness on the part of the patients of the p o s s i b i l i t y of redress. It i s u n l i k e l y that Canada w i l l ever have a c r i s i s s i m i l a r to that i n the U.S. because the American c u l t u r a l and l e g a l m i l i e u i s d i f f e r e n t and the Canadian health insurance plans discourage suits.(52) Most physicians i n Canada do not carry malpractice insurance but instead, belong to an organization c a l l e d the Canadian Medical Protective Association. The Association i s a mutual non-profit society and there i s no guarantee that a physician w i l l be covered i f he i s sued for malpractice although i t i s v i r t u a l l y assured. Because i t i s a non-profit organization, decisions are not made on the basis of the p r o f i t motive. In some cases, i t may be le s s expensive to pay than f i g h t . However, CM.P.A. w i l l defend the case i f i t believes that i t s member was r i g h t . This a t t r i b u t e of the Association has undoubtedly discouraged many malpractice suits.(53) The number of l e g a l claims against members of the Canadian Medical Protective Association increased 10% from 1980 to 1981 and 31% from 1979 to 1980.(52) These increases may be softened somewhat by noting that the number of members has also increased although the percentage increase i n members i s markedly smaller than the increase i n law s u i t s . The actual number of actions s e t t l e d increased modestly i n 1981 from 121 to 127 and p r e - t r i a l dismissals or discontinuances increased from 156 to 220. Despite t h i s r e l a t i v e l y good record, the number of malpractice s u i t s i n Canada continues to r i s e . Knowledge of t h i s must c e r t a i n l y have an e f f e c t on a Page 62 physician's s t y l e of p r a c t i c e . Other factors that have been i d e n t i f i e d as being associated with how physicians use laboratory services include a physician's personality, the date and place of graduation and the a v a i l a b i l i t y of f a c i l i t i e s and expert medical and technical suppport personnel .(40,42,54) Hardwick has shown that i n an a r t i f i c i a l environment, physicians faced with the constraints of l i m i t e d resources r e l i e d more heavily upon the h i s t o r y and physical examination of the patient than on the technical support of modern medical science.(54) The findings were consistent when f i n a n c i a l constraints l i m i t e d the number of laboratory tests that could be ordered and when p r a c t i c i n g general physicians were faced with not having s u f f i c i e n t expert medical and technical personnel to accurately perform and i n t e r p r e t laboratory r e s u l t s . In B.C.'s health care d e l i v e r y system, the f i n a n c i a l constraints of consumers are not a factor i n determining a physician's use of laboratory s e r v i c e s . The primary f i n a n c i a l constraint i n B.C. i n f l u e n c i n g the use of laboratory services i s the l e v e l of funding granted hospitals to operate t h e i r l a b o r a t o r i e s . By r e s t r i c t i n g the laboratory's a b i l i t y to grow i n terms of s t a f f i n g , equipment, and physical plant, the government can e f f e c t i v e l y l i m i t the growth i n the l e v e l and quantity of laboratory services offered by l a b o r a t o r i e s . U n t i l the present economic down-turn i n the B.C. economy, there has been l i t t l e i n the way of concerted e f f o r t on the part of government to control the use of l a b o r a t o r i e s i n t h i s manner. Wide-spread budget cuts i n the health care sector of the l a s t two years have led to s t a f f i n g reductions i n Page 63 laboratories and l i m i t a t i o n s of the expansion of c a p i t a l equipment. This has forced hospitals to consider the merits of some laboratory procedures and to attempt to control the use of laboratory s e r v i c e s . Schroeder found that, i n the U.S., patients with s i m i l a r ailments paid approximately eleven percent more when admitted to a u n i v e r s i t y associated teaching h o s p i t a l rather than to a general community hospital.(55) Approximately 56% of the difference i n costs was d i r e c t l y a t t r i b u t a b l e to the greater use of diagnostic services i n the teaching h o s p i t a l s . The a v a i l a b i l i t y of the appropriate f a c i l i t i e s and personnel, as well as what Schroeder r e f e r s to as the "don't miss anything" a t t i t u d e of most academic centers, are key contributing f a c t o r s . Freeborn studied changes i n the u t i l i z a t i o n of laboratory services i n the Kaiser-Portland Health Plan.(42) In addition to fi n d i n g that economic b a r r i e r s , as determined by the degree of co-payment, had l e s s impact on laboratory use than was expected, he i d e n t i f i e d several physician c h a r a c t e r i s t i c s related to t h e i r use of laboratory services.(42) Among his findings was the observation that there was a tendency for older physicians to use laboratory services le s s than r e l a t i v e l y new medical school graduates. This was a t t r i b u t e d to what a physician was taught i n medical school on how and when to use diagnostic support s e r v i c e s . However, other factors such as experience, a t t i t u d e , and s k i l l s may play equally important r o l e s . Page 64 Freeborn also found a r e l a t i o n s h i p between the school of graduation and the pattern of laboratory usage. Physicians trained i n medical schools i n the U.S. northeast, i n C a l i f o r n i a and i n the Chicago area were more l i k e l y to be low volume laboratory users than physicians trained i n other areas of the U.S.(42) There was also found to be a r e l a t i o n s h i p between laboratory use and the u t i l i z a t i o n pattern of the chief of service i n that system. In those c l i n i c s where the chief of service had a low laboratory use rate, more than three-fourths of the other physicians were low laboratory users. When the chief of service was a high laboratory user, so were most of the physicians who worked with him.(42) In addition to f i n d i n g considerable v a r i a t i o n i n the use of laboratory services among physicians, Freeborn also found that not only had the t o t a l number of procedures increased annually, but the number of procedures per subscriber and the number of procedures per doctor o f f i c e v i s i t also increased markedly over the study period. Subsequent analysis of t h i s laboratory use over time with respect to c l i e n t morbidity showed that a substantial part of the increased lab u t i l i z a t i o n was i n the category of non-disease or preventative services .(42) Similar findings are reported by Daniels and Schroeder.(56) They examined v a r i a t i o n s i n the use of laboratory services among th i r t e e n s a l a r i e d i n t e r n i s t s t r e a t i n g a group of ambulatory patients for hypertension. The use of laboratory services was correlated with c l i n i c a l p r o d u c t i v i t y and c l i n i c a l outcomes. Their findings of Page 65 considerable v a r i a t i o n i n the use of laboratory tests among t h i s group suggests that those physicians who may be less competent tend to use the laboratory more frequently. In add i t i o n , t h e i r findings did not support a p o s i t i v e a s s o c i a t i o n between the degree of laboratory use and either c l i n i c a l p r o d u c t i v i t y or outcomes of care. From the above evidence, i t i s r e a d i l y apparent that the supply of physicians, t h e i r ages, t h e i r personal backgrounds, t h e i r t r a i n i n g experience, and t h e i r practice environment, including the presence or absence of f i n a n c i a l b a r r i e r s , have a d i r e c t impact on the demand for laboratory t e s t s . This i n turn, has a d i r e c t impact on the demand for medical laboratory manpower. Such a r e l a t i o n s h i p serves to focus attention upon the issue of s p e c i a l i z a t i o n and upon trends developing i n the supply of laboratory physicians. THE EFFECT OF TECHNOLOGY AND AUTOMATION IN LABORATORIES Since the end of the second world war, developments i n technology and automation have been occuring at a rate beyond the c a p a b i l i t y of most people to comprehend and stay abreast. The advent of computer technology and e l e c t r o n i c m i c r o - c i r c u i t r y has led to the creation of more and more automated machines that are "smarter", f a s t e r , more compact, and generally l e s s expensive than t h e i r predecessors. They have also become increasingly simple to operate bringing t h e i r a c c e s s i b i l i t y to a very wide spectrum of po t e n t i a l users. Page 66 This i s p a r t i c u l a r l y true i n laboratory technology. In lab o r a t o r i e s , where i t was once common to have a single machine to perform a few tests i n d i v i d u a l l y under the constant care and handling of a technologist, i t i s now common to have a sing l e machine performing 10 to 20 tests and more on a single machine. The technologist's r o l e has become one of ensuring the equipment i f operating c o r r e c t l y and the correct specimen i s being processed. There i s no need for most technologists to be concerned with the i n t r i c a c i e s of biochemistry i n t h e i r day to day work. Machines have been developed for hematology that go beyond the mere counting of blood c e l l s . C e l l counters now t e l l the technologist how many c e l l s are present, the type of c e l l s present, whether or not the c e l l s are normal, and the r a t i o of one type of c e l l to another. It has only been l a t e l y that automation has made inroads into microbiology. There are now machines that incubate specimens, determine whether or not there i s b a c t e r i a l growth, and through a series of chemical t e s t s , i d e n t i f y the bac t e r i a and print-out the answer for the technologist. With such resources now at hand, one would expect them to have a s i g n i f i c a n t impact on the t r a d i t i o n a l day to day operation of la b o r a t o r i e s . Two expected impact areas are laboratory manpower and laboratory costs. Page 67 As might be expected, such developments have a substantial impact on a laboratory's a b i l i t y to meet increasing demands. However, i t should be noted that an apparent side e f f e c t of increasing automation i s that i t increases the demand for laboratory services by making laboratory tests more r e a d i l y available and more economically f e a s i b l e . THE EFFECT OF AUTOMATION ON LABORATORY COSTS Attempts have been made to quantify the r e l a t i o n s h i p between automation and laboratory operating costs .(57,58,59) Tydeman hypothesized that increased automation would r e s u l t i n increased consumables and reagent costs as measured by Total Cost per FTE.(58) The amount of manpower required to perform a test would decrease and the demand for the test would increase due to a greater v a r i e t y of tests and ease of access to t e s t s . Data derived from Vancouver General Hospital over the study period 1971-1979 demonstrated that while the degree of automation, i n terms of d o l l a r value, increased 3.4 f o l d , the amount of time required to perform tests decreased by an average 2.2% annually.(58) These data also show that while the number of tests per acute care admission increased by 114.4% and the t o t a l laboratory cost per acute care admission increased by 106.9%, the operating costs of the laboratory per FTE increased only 34.1% over the 9 year study period.(58) The authors concluded that technology can reduce the r e a l cost of performing laboratory tests or at l e a s t stem the tide of cost increases. However, the increase i n the a v a i l a b i l i t y of laboratory tests appears to induce a latent demand for tests thereby increasing the o v e r a l l laboratory cost per Page 68 acute care admission. SUMMARY B r i t i s h Columbia's population has increased by approximately 41% between 1966 and 1980. The percentage of B r i t i s h Columbians over the age of 65 increased from 9.8% i n 1976 to 10.9% i n 1981. During the period 1962 to 1978, the r a t i o of acute care beds i n B.C. decreased from 6.1 beds per 1,000 population to 4.3 beds per 1,000 population while the number of extended care beds increased from 0.4 per 1,000 to 2.2 per 1,000 during the same period. Changes i n the d i s t r i b u t i o n of beds i n B r i t i s h Columbia were noted to include o v e r a l l increases i n the number of Intensive Care and P s y c h i a t r i c beds and o v e r a l l decreases i n the number of O b s t e t r i c a l and P e d i a t r i c beds. Trends i n bed d i s t r i b u t i o n were consistent between the various si z e groups with the exception that there were substantial increases i n the number of O b s t e t r i c a l and P e d i a t r i c beds i n the hospitals of Group IV. This was attributed to the c e n t r a l i z a t i o n of these services to regional h o s p i t a l s . Patient days per bed increased by a t o t a l of 10.1% for a l l B.C. h o s p i t a l s , representing a general increase i n h o s p i t a l a c t i v i t y . Hospital a c t i v i t y increased f a i r l y c o n s i s t e n t l y i n h o s p i t a l size groups III and IV and was up and down i n the other si z e groups. Teaching hospitals had the highest a c t i v i t y l e v e l while the hospi t a l s of Group I experienced the lowest a c t i v i t y . Page 69 The number of admissions per bed i s i n d i c a t i v e of the length of stay. The shortest lengths of stay were found i n the smallest hospi t a l s while the Group IV hospitals had the longest lengths of stay. Through the various e f f o r t s to r a t i o n a l i z e and streamline the health care d e l i v e r y system, we have seen a reduction i n the proportion of acute care beds i n B.C. ho s p i t a l s occupied by long term patients. The a v a i l a b i l i t y of a l t e r n a t i v e care modes have been h e l p f u l i n t h i s regard although, as the current waiting l i s t s for entry into an extended care f a c i l i t y i n d i c a t e , there i s s t i l l a shortage of chronic care f a c i l i t i e s and an apparently adequate supply of acute care beds, based on current province-wide occupancy l e v e l s . We have also seen that physicians play a very major r o l e i n determining the demand for laboratory services and, among physicians, i t was noted that t h e i r age, place of t r a i n i n g , personality, and other behavioural factors a l l influence how they use laboratory s e r v i c e s . Such c h a r a c t e r i s t i c s of physicians' use of laboratory services have been the subject of several e f f o r t s to modify or control t h e i r laboratory u t i l i z a t i o n patterns. Another major influence on the demand for laboratory services appears to be the degree of automation. Studies have indicated a r e l a t i o n s h i p between the a v a i l a b i l i t y of tests and the demand for those t e s t s . One of the e f f e c t s of automation i s to improve the a v a i l a b i l i t y of laboratory tests by making them easier to perform, f a s t e r to complete, and makes the technology required to do the test Page 70 widely a v a i l a b l e . Implications f o r Laboratories The r e l o c a t i o n of long term care patients to more appropriate f a c i l i t i e s w i l l have an e f f e c t on the volume of laboratory procedures per bed or acute care admission as acute care hospi t a l s use more of t h e i r beds i n the treatment of the acutely i l l . This w i l l have s i g n i f i c a n t implications for planners of health care f a c i l i t i e s t r y i n g to i d e n t i f y an appropriate sized laboratory for a c e r t a i n sized h o s p i t a l . An addi t i o n a l consideration for health care planners i s the increasing role hospitals play i n providing outpatient s e r v i c e s . Diagnostic support services, including l a b o r a t o r i e s , must be designed, staffed and equipped to meet more than j u s t h o s p i t a l inpatient demand. The degenerative diseases of an aging population may also have a further impact on the u t i l i z a t i o n of h o s p i t a l beds and laboratory f a c i l i t i e s . Drug monitoring, as a means of following the course of pharmaceutical interventions i n moderating the process of aging, i s becoming increasingly common. As the population continues to age, we may see an increase i n the average age of patients i n acute care f a c i l i t i e s and the volume of laboratory workload per patient day w i l l l i k e l y increase due to the monitoring of drug l e v e l s . Page 71 CHAPTER VI ISSUES RELATED TO THE SUPPLY OF HEALTH CARE SERVICES The supply side of health care services i s c h i e f l y c o ntrolled by the supply of labour and c a p i t a l flowing into the industry, e s p e c i a l l y the number of physicians. Retrospectively, the health care industry has, i n the past, usually been able to a t t r a c t an adequate workforce without having to pay inordinately high wages. Only i n recent years have the s a l a r i e s of health care workers approached those of other service i n d u s t r i e s . In an industry where 80% of the t o t a l budget goes to s a l a r i e s , these gains have had an important r o l e i n drawing attention to the high cost of our health care d e l i v e r y system. The flow of c a p i t a l i s a l i t t l e more complicated because i t has been influenced p r i m a r i l y by government decisions and philanthropy and r a t i o n a l thought i s not always the primary concern of government dec i s i o n s . As mentioned previously, p o l i t i c a l patronage played an important r o l e i n the development of B r i t i s h Columbia's h o s p i t a l s . While the government i s s t i l l the major source of c a p i t a l funds for hos p i t a l construction, the private sector (corporations and i n d i v i d u a l s ) i s playing an increasing role i n the funding of health care f a c i l i t i e s and programs as government funding becomes Page 72 incre a s i n g l y t i g h t e r . Technology and automation also play a key role i n the supply of health care s e r v i c e s . New diagnostic and therapeutic techniques can improve the productivity of the physician v i s i t or ho s p i t a l stay by producing more and better r e s u l t s and allowing the throughput of more patients per unit of supply. The Supply of Physicians The number of physicians plays a key r o l e i n the supply of medical care because t h e i r decisions and behaviour a f f e c t almost a l l aspects of the d e l i v e r y of health care s e r v i c e s . S t a t i s t i c s Canada figures show how the number of physicians has increased i n Canada from 1968 to 1978.(60) The number of general and family practioners increased by 52% from 11,778 to 17,913. This represents a change from one general p r a c t i t i o n e r per 1,786 population i n 1968 to one general p r a c t i t i o n e r per 1,316 population i n 1978. During the same period the number of s p e c i a l i s t s increased by 56.5% from 11,191 i n 1968 to 17,519 i n 1978. The r a t i o of s p e c i a l i s t s to population changed from one to 1,852 i n 1968 to one to 1,351 i n 1978. If interns and residents are included, the t o t a l r a t i o of physicians to population changed from one to 741 i n 1968 to one to 559 i n 1978. This represents an increase of 32.6% i n the physician to population r a t i o . Page 73 S t a t i s t i c s Canada also provides figures comparing the number of physicians p r a c t i s i n g i n each province i n 1978.(60) B r i t i s h Columbia had the highest r a t i o of general p r a c t i t i o n e r s to population of a l l provinces with 1,075 people per general p r a c t i t i o n e r . Quebec has the highest number of s p e c i a l i s t s per population followed by B r i t i s h Columbia with 1,266 people per s p e c i a l i s t . Including interns and residents, Ontario and B.C. both report one physician for every 529 people. If interns and residents are not counted, B.C. has far more physicians per population than any other province with one physician for every 578 people. Ontario and Quebec have the next highest r a t i o of physicians to population with one to 645 and one to 649 r e s p e c t i v e l y . Both these figures exclude interns and r e s i d e n t s . It i s c l e a r that interns and residents have a much greater per capita impact on the health care system i n Ontario and Quebec. This i s l i k e l y due p r i m a r i l y to the greater number of funded resident and in t e r n positions i n the long established teaching hospitals of these provinces. It i s generally recognized that interns and residents often order more lab work than a more experienced physician because of the teaching m i l i e u and the fear of missing a diagnosis as well as j u s t being generally more geared towards and dependent on technology.(60) The supply of physicians i s d i r e c t l y related to enrollment p o l i c i e s of medical schools and to immigration p o l i c i e s . Both of these factors are of considerable p o l i t i c a l importance. Most p r o v i n c i a l governments are under strong pressures to provide the opportunity for the sons and daughters of p r o v i n c i a l residents to attend a l o c a l medical school. There are generally s i g n i f i c a n t Page 74 p o l i t i c a l points to be gained by supporting professional opportunities for the electorate on a l o c a l b a s i s . Consequently, most provinces now have at least one medical school providing such opportunities. To reduce medical school enrollments i n these i n s t i t u t i o n s i s p o l i t i c a l l y d i f f i c u l t . Canada i s , therefore, faced with a s i t u a t i o n wherein the long established eastern medical schools continue to turn out increased volumes of graduates while the new " f r o n t i e r " schools have also a c t i v e l y increased t h e i r enrollments. A case i n point i s B r i t i s h Columbia's recent a c t i v i t i e s i n t h i s regard. In f u l f i l l m e n t of a 1975 e l e c t i o n promise of the S o c i a l Credit Party, the Minister of U n i v e r s i t i e s , Science and Technology announced his i n t e n t i o n i n March 1976 to allow the University of B.C. to double the si z e of i t s medical school enrollment from 80 to 160.(61) At that time, B r i t i s h Columbia already had the highest concentration of physicians i n Canada. However, the Minister strongly believed that the opportunity of l o c a l medical education should be provided to the youth of the province. A downturn i n the p r o v i n c i a l economy and the recommendation of the M i n i s t r y of Health's Medical Manpower Advisory Committee to postpone planned expansion of the medical school has delayed f u l l implementation of the increases .(62) Nevertheless, enrollment has increased from 80 to 120. It i s s t i l l too e a r l y to t e l l what impact t h i s move w i l l have on the health care industry i n B.C. but new graduates are already having to search for a v a i l a b l e p o s i t i o n s . Page 75 As already mentioned, Canada's r a t i o of physicians to population reached one to 559 i n 1978; well beyond the goal of one to 600 set by the World Health Organization. However, there are s t i l l gross i n e q u i t i e s between provinces and between regions within provinces i n the d i s t r i b u t i o n of t h i s manpower resource .(60) T y p i c a l l y , urban centres have a much higher concentration of physicians than r u r a l areas, sometimes requiring r u r a l residents to t r a v e l a considerable distance to acquire the l e v e l of medical services r e a d i l y a v a i l a b l e i n urban centers. Recently, there have been attempts to control the d i s t r i b u t i o n of physicians which have met with some degree of success.(63) Ontario has offered grants to a s s i s t physicians i n es t a b l i s h i n g t h e i r practices i n under-serviced areas of the province. Ontario has also experimented with providing guaranteed income l e v e l s during the i n i t i a l years of practice i n such under-serviced regions. B r i t i s h Columbia has also offered subsidized income i n c e r t a i n s i t u a t i o n s . Quebec recently introduced a plan to encouragement better d i s t r i b u t i o n of t h e i r medical manpower by adjusting the fee schedule for i n favour of r u r a l p r a c t i c e s . B r i t i s h Columbia's new Medical Care Act contains proposals designed to control where and how phyicians p r a c t i c e . One proposed method i s to r e s t r i c t the a v a i l a b i l i t y of Medical Services Plan b i l l i n g numbers issued by the government con t r o l l e d Medical Services Commission. Without such a number a physician i s not e l i g i b l e to submit b i l l s to MSP that are normally covered as an insured s e r v i c e . The physician would have to charge the patient d i r e c t l y f o r services provided. By s e t t i n g l i m i t s on the quantity of b i l l i n g numbers Page 76 ava i l a b l e i n each geographic region, the p r o v i n c i a l government w i l l be able to control the flow of physician manpower. As discussed previously, the number of s p e c i a l i s t s per 100,000 population i n Canada increased 56% form 1968 to 1978. During the same period, the number of general and family p r a c t i t i o n e r s increased by 52%. It i s reported that during the 1960's the number of general physicians i n Canada increased by 19% while the number of s p e c i a l i s t s increased by 70%.(63) Some authors have suggested that the output of s p e c i a l i s t s seems to be linked more to the prestige of the s p e c i a l t y and the momentum of the residency t r a i n i n g program than to the need for i t s products.(63) It i s frequently acknowledged that, l i k e the re l a t i o n s h i p between the number of general p r a c t i t i o n e r s and laboratory u t i l i z a t i o n , the more s p e c i a l i s t s there are, the greater the use of laboratory services.(48) Yet, as the volume of laboratory tests has been increasing dramatically i n l a t t e r years, the number of laboratory physicians completing t h e i r Royal College C e r t i f i c a t i o n has been r e l a t i v e l y constant .(64) It would seem that the workload of each i n d i v i d u a l laboratory physician i s increasing given that other factors have remained r e l a t i v e l y unchanged. As i n other s p e c i a l t i e s , the d i s t r i b u t i o n of laboratory physicians indicates a clear concentration of t h i s s p e c i a l t y i n the more densely populated areas of the country. In f a c t , the urban centres of Montreal and Toronto have over half the country's s p e c i a l i s t s i n Microbiology, Hematology and Immunohematology yet a disproportionately small percentage of the country's general Page 77 pathologists.(65) In t o t a l , these two urban centres with approximately o n e - f i f t h of the nation's population have over one-third of the nation's laboratory physicians. The nationwide d i s t r i b u t i o n of laboratory physicians i n 1981 ranged from a low of 2.9 laboratory physicians per 100,000 population i n New Brunswick to a high of 7.1 i n Quebec. B r i t i s h Columbia has a rate of 4.7 laboratory physicians per 100,000 people which i s below the national average of 5.3.(66) With a r e l a t i v e l y low number of s p e c i a l i s t s i n laboratory medicine i n B.C. and the e x t r a o r d i n a r i l y high number of general physicians generating laboratory requests, there appears to be the pot e n t i a l for a shortage of laboratory physicians, with other factors being equal. This apparent need f or laboratory physicians i n B.C. i s o f f s e t somewhat by considerable sharing of manpower. Many laboratory physicians i n B.C. have r e s p o n s i b i l i t y for laboratory medicine i n more than one h o s p i t a l and community. This may be r e f l e c t e d i n the proportion of general pathologists p r a c t i c i n g i n B.C. Approximately 45% of a l l B.C. pathologists are general pathologists compared to 36% i n Ontario and 48% i n Alberta. MEDICAL LABORATORY TECHNOLOGISTS H i s t o r i c a l l y , medical laboratory technologists acquired t h e i r s k i l l s through on-the-job t r a i n i n g i n ho s p i t a l laboratories under the supervision of a pathologist. The f i r s t technologists i n Canada to be c e r t i f i e d had to do so through the American Society of Medical Technologists and th i s avenue only became a v a i l a b l e i n 1930.(67) Page 78 On May 20,1937, the Canadian Society of Laboratory Technologists was incorporated i n Ontario. In 1938, the c e r t i f i c a t i o n examinations were conducted for nine candidates. By 1940, the membership had grown to 200 and i n 1980 there were 15,451 active C.S.L.T. members across Canada.(68) The f i r s t branch of the C.S.L.T. was founded i n Saskatchewan i n 1937. The tenth branch to be formed was i n Newfoundland i n 1962.(67) The Canadian Medical Association formally recognized the C.S.L.T. as the o f f i c i a l r e g i s t r y for medical laboratory technologists i n Canada on January 1,1941. The Canadian Hospital Association f i r s t recognized the C.S.L.T. as an associate member on July 24,1957. In 1958, the Canadian Medical Association o f f i c i a l l y recognized the C.S.L.T. as an a f f i l i a t e society of the CM.A. and i n 1962, the CM.A. introduced the formal a c c r e d i t a t i o n of medical technologist t r a i n i n g programs i n conjunction with the C.S.L.T.(69) The federal education grants of the l a t e 1950's and early 1960"s led to a rapid increase i n the number of community colleges which became involved i n the t r a i n i n g programs. This resulted i n a more formal academic t r a i n i n g of technologists through classroom i n s t r u c t i o n and preserved the h o s p i t a l i n t e r s h i p as the f i n a l requirement for r e g i s t r a t i o n . With the move to the community colleges came a s t r a t i f i c a t i o n of the membership to the point where there are now four l e v e l s of t r a i n i n g and c e r t i f i c a t i o n . The Registered Technologist (RT) q u a l i f i c a t i o n i s the general c e r t i f i c a t i o n for a graduate of one of the approved programs. It i s a v a i l a b l e either as a "subject" RT with c e r t i f i c a t i o n i n only one d i s c i p l i n e or a "general" RT with Page 79 c e r t i f i c a t i o n i n a l l laboratory d i s c i p l i n e s . The RT Subject requires completion of courses equivalent to f i r s t year u n i v e r s i t y plus one year of c l i n i c a l laboratory experience i n a s p e c i f i e d d i s c i p l i n e . The a v a i l a b l e d i s c i p l i n e s include Chemistry, Hematology, Blood Bank, Microbiology, Histology, Cytology, and Virology. Upon completion of the above requirements, the RT Subject candidate must also s u c c e s s f u l l y complete the C.S.L.T. c e r t i f i c a t e examination i n the subject area. The RT General requires completion of an approved laboratory technology program, usually of 18 months to 24 months duration, and one year of c l i n i c a l laboratory experience covering the f i v e subject areas of Chemistry, Hematology, Blood Bank, Microbiology, and Histology. Following the c l i n i c a l t r a i n i n g the candidate must then s u c c e s s f u l l y complete the C.S.L.T. c e r t i f i c a t e examination i n a l l subject areas covered. The Advanced Registered Technologist c e r t i f i c a t i o n (ART) i s av a i l a b l e following a minimum of two years experience as an RT and requires the s a t i s f a c t o r y completion of a l i t e r a t u r e review and technical report or o r a l examination. The advanced r e g i s t r a t i o n i s a v a i l a b l e as either an ART Subject or ART General. The L i c e n t i a t e c e r t i f i c a t i o n i s based on work experience and requires the successful completion of a l i t e r a t u r e review, a thesis i n a p a r t i c u l a r subject area, and an o r a l examination. Page 80 The fourth and highest l e v e l of c e r t i f i c a t i o n i s the Fellowship. It i s reserved for senior members of the profession who have made outstanding contributions i n the f i e l d . It i s awarded following nomination and peer review. Recently, a new l e v e l of q u a l i f i c a t i o n f o r medical laboratory technologists has developed at the u n i v e r s i t y l e v e l . Several u n i v e r s i t i e s are now o f f e r i n g Bachelor degrees i n Medical Laboratory Science. Such programs are generally designed to produce graduates who are t h e o r e t i c a l l y sound, p r a c t i c a l s c i e n t i s t s i n laboratory medicine. It i s considered that graduates of these programs w i l l f i n d roles i n routine medical l a b o r a t o r i e s , i n supervisory p o s i t i o n s , i n research and development, and i n teaching. As most of these programs are quite new, i t i s not yet possible to measure t h e i r success i n placement of t h e i r graduates. Nor i s i t possible to measure the impact on enrollment i n Registered Technologist programs, or on the placement and upward mo b i l i t y of the graduates of such programs. It i s l i k e l y that, to date, the impact of the degree programs on the placement of RT's has been minimal although there may well be increased competition for senior laboratory positions between these graduates and ART's. To coincide with t h i s s t r a t i f i c a t i o n of medical technologists there has been a change i n the mix of medical laboratory technologists now employed i n l a b o r a t o r i e s . This change not only applies to the hierarchy of medical laboratory technologists but also to t h e i r r e l a t i o n s h i p to other laboratory manpower groups. Such changes i n B r i t i s h Columbia h o s p i t a l laboratories have been i d e n t i f i e d previously i n a study by Stark on the l i k e l y demand for Page 81 medical laboratory technologists i n B.C. from 1979 to 1984.(70) That study demonstrated a steady decline i n the number of non-registered technologists employed and a steady increase i n the number of registered technologists. As a percentage of t o t a l laboratory s t a f f , the number of non-registered technologists decreased from 5.1% i n 1970 to 2.7% i n 1976 while the number of registered technologists increased from 61.6% i n 1970 to 64.5% i n 1976. Of p a r t i c u l a r i n t e r e s t i s the f i n d i n g that the proportion of ART's remained r e l a t i v e l y stable throughout the study period within a range of 4.7% to 5.7% of the t o t a l while the number of Licenciates a c t u a l l y showed a s l i g h t decrease from 1.1% i n 1970 to 0.6% i n 1975. Also of i n t e r e s t i s the finding that the number of technical a s s i s t a n t s increased throughout the study period from 5.1% of the t o t a l i n 1970 to 9.3% of the t o t a l i n 1976.(70) It should be pointed out that t h i s included laboratory personnel employed i n both the public and private sector l a b o r a t o r i e s . In theory, c e r t i f i c a t i o n as a Registered Technologist i s voluntary and not required for employment i n a c l i n i c a l laboratory i n B.C. In p r a c t i c e , most c o l l e c t i v e agreements between B.C. hosp i t a l s and laboratory workers require CSLT r e g i s t r a t i o n as a condition of employment. Non-registered technologists may be hired although they are generally paid at a lower rate. In B.C., " q u a l i f i e d - n o t - r e g i s t e r e d " technologists are paid 10% l e s s than registered technologists. It may be t h i s f i n a n c i a l incentive that has led to the decrease i n the number of non-registered technologists. Since the hospitals are generally under pressure to h i r e only CSLT registered candidates, the number and a v a i l a b i l i t y of Page 82 RT's w i l l have a s i g n i f i c a n t impact on the number of positions a v a i l a b l e to non-registered technologists. The change i n the percentage of technical assistants employed i n B.C. hospitals i s of considerable s i g n i f i c a n c e . It s i g n i f i e s a further s t r a t i f i c a t i o n of laboratory workers from a simple grouping of pathologists and technologists. It demonstrates a s p e c i a l i z a t i o n of the technologist's r o l e wherein the more highly trained and s k i l l e d workers do not spend t h e i r time doing less demanding jobs more appropriately performed by l e s s s k i l l e d workers. With the various l e v e l s of s k i l l s and r e s p o n s i b i l i t i e s come various l e v e l s of f i n a n c i a l rewards. It then becomes a management function to ensure the most appropriate workers are used for p a r t i c u l a r tasks. There are many tasks i n the laboratory that do not require the s k i l l of a registered technologist. Hospital laboratories i n B r i t i s h Columbia do not appear to make as much use of the technical a s s i s t a n t as do laboratories i n Ontario. The Canadian Society of Laboratory Technologists approved a Syllabus of Studies for laboratory assistant t r a i n i n g programs i n 1973. P r i o r to that time, laboratory assistants were trained through on-the-job experience which meant that they were only trained i n c e r t a i n tasks, had l i t t l e or no t r a i n i n g i n general science or general laboratory techniques, and therefore did not have the f l e x i b i l i t y to change t h e i r role e a s i l y or to meet the needs of a d i f f e r e n t l a b o r a t o r i e s . Several colleges i n Ontario now o f f e r laboratory assistant t r a i n i n g programs while B.C. s t i l l r e l i e s on on-the-job t r a i n i n g and in-migration of q u a l i f i e d workers from other provinces and countries. Page 83 It has been suggested that the issue of a t r a i n i n g program for laboratory assistants i n B.C. has been d e l i b e r a t e l y avoided i n order to avoid a repeat of the experience with Licensed P r a c t i c a l Nurses (LPN's).(71) As the number of LPN's became more prominant i n the nursing workforce, t h e i r union, the Hospital Employee's Union, was able s u c c e s s f u l l y to negotiate wage increases for t h e i r members that brought the wages of LPN's very close to the s t a r t i n g salary of Registered Nurses (R.N.'s) who had considerably more education and r e s p o n s i b i l i t y . Subsequently the nurses' bargaining agent n a t u r a l l y negotiated a wage scale that would restore an acceptable wage d i f f e r t i a l between the R.N.'s and L.P.N.'s. The e f f e c t of t h i s scenerio was to increase dramatically the cost of health care within the terms of a single contract, as the wage increase offered nurses was approximately 40% over the l i f e of the contract. Hospital administrations are, n a t u r a l l y , very anxious to avoid another s i t u a t i o n that could, have so dramatic an e f f e c t on the operating cost of t h e i r f a c i l i t i e s . This has, however, given r i s e to another problem. Medical Laboratory Technologists have t r a d i t i o n a l l y been paid at a l e v e l comparable to that of Registered Nurses. Following the "catch up" settlement for nurses, the technologists have been t r y i n g , so far unsuccessfully, to restore the h i s t o r i c a l wage p a r i t y with nurses. This i s c e r t a i n l y going to be a key issue to be resolved i n future negotiations between the hospitals and the bargaining agent for the technologists. Page 84 Two manpower surveys i n Ontario for 1974 and 1976 demonstrate the prevalence of laboratory assistants i n that province.(72) The 1974 survey included 71 h o s p i t a l s and found the 200 laboratory a s s i s t a n t s accounted for 12% of the t o t a l technical s t a f f . The study did not include laboratory aides who are generally combined with laboratory a s s i s t a n t s to form the "other technical s t a f f " category i n B.C. h o s p i t a l s t a t i s t i c a l reports. The 1976 Ontario survey included 52 h o s p i t a l s and 62 private l a b o r a t o r i e s . This study found that technical assistants accounted for 12.5% of the t o t a l technical s t a f f and that they were used i n v i r t u a l l y a l l areas of the laboratory except Blood Bank. S i g n i f i c a n t l y , t h i s survey found that private laboratories used a larger proportion of technical assistants than did h o s p i t a l s . This may be l a r g e l y due to the p r o f i t o r i e n t a t i o n of private laboratories although i t may also r e f l e c t the nature of the work private laboratories perform. Because private laboratories deal l a r g e l y with a r e l a t i v e l y healthy c l i e n t e l e , the tests performed for t h i s population may be mostly of a routine nature. Such tests are e a s i l y batched on highly automated equipment. As mentioned previously, the number and a v a i l a b i l i t y of registered technologists w i l l have an e f f e c t on the mix of laboratory personnel. F i n a n c i a l incentives to become reg i s t e r e d , union pressure to h i r e only registered technologists, and the a v a i l a b i l i t y of registered technologists i n B.C. a l l influence the mix of laboratory personnel employed. Page 85 Figures for the period 1970 to 1976 indic a t e there was an average annual increase i n the number of F u l l Time Equivalent (FTE) positions of 5.5% for medical laboratory technologists i n B r i t i s h Columbia(73). This coincides with approximately 54.4 FTE's per year i n new p o s i t i o n s . B.C. colleges and i n s t i t u t e s graduate an average of 80 students per year as general RT's. It i s estimated that roughly 20% of those w i l l f i n d employment i n private laboratories and another 11% i n other l a b o r a t o r i e s . That leaves 56 new graduates every year for the estimated 54.4 FTE p o s i t i o n s . As the vast majority of medical technologists are women, there i s a larger a t t r i t i o n rate due to family r e a r i n g . It would appear that, even with the addition of the subject RTs to the workforce, the supply of registered technologists i s far short of the demand. However, the apparent s h o r t f a l l i s more than made up by the national migration of registered technologists to B r i t i s h Columbia. A recent survey by the CSLT shows B.C. to be a net importer of registered technologists i n increasing numbers.(74) In 1971, B.C. received a net increase of 35 RT's from across Canada while i n 1981 the net increase was 109. Ontario i s the largest loser i n the net migration pattern with a 1981 loss of 140 registered technologists. The reasons for such migration a c t i v i t i e s have not been well documented but could include regional pay d i f f e n t i a l s , movement of spouses, and lack of positions i n provinces where there i s a net loss through migration. Page 86 S t a t i s t i c s Canada figures add an i n t e r e s t i n g perspective to the above surveys. The number of registered technologists and non-registered techologists per capita has almost doubled i n the l a s t decade i n B r i t i s h Columbia and has been well above the national average throughout that period.(75) One could question why the apparent demand for technologists of the l a s t decade did not give r i s e to substantial increases i n B.C.'s own graduates i n medical technology. MANPOWER PLANNING DEFINITIONS AND OBJECTIVES Manpower planning has been defined as having the r i g h t number and the r i g h t kinds of people, at the r i g h t places, and at the r i g h t time, doing things which r e s u l t i n maximum long-term benefits for both the organization and the i n d i v i d u a l s . The goals i n manpower planning might be considered to be: 1. to reduce to a minimum the quantitative and q u a l i t i v e imbalance on the labour market due to the inadequacy and u n s u i t a b i l i t y of both the labour force and employment opportunities; 2. to provide the environment necessary for bringing supply and demand together i n such a way that the objectives of economic growth with s t a b i l i t y i n prices and s e l f r e a l i z a t i o n i n work for the i n d i v i d u a l are promoted i n an optimum way.(76) Page 87 There are e s s e n t i a l l y four d i f f e r e n t approaches to manpower forecasting:(76) 1) The International Comparison approach simply involves comparing the employment patterns of various countries at various stages of economic development. The assumption i s that i f country X has a c e r t a i n employment or occupational structure at a c e r t a i n point i n i t s economic development and country Y i s expected to reach that l e v e l of economic development at some future date, then at that time, country Y should t h e o r e t i c a l l y experience an occupational structure s i m i l a r to that experienced previously by country X. This approach has not proven very successful due to the d i f f i c u l t y i n comparing i n t e r n a t i o n a l data on occupations and education. 2) The S t a t i s t i c a l Trends approach merely extrapolates the past into the future without consideration of technological changes occurring at a more rapid rate and having a greater impact than i n the past. This approach also assumes the appropriate balance between the supply and demand for manpower e x i s t s at the time of the extrapolation. 3) The I n d u s t r i a l Survey approach aims at determining the e x i s t i n g occupational and educational mix of a p a r t i c u l a r industry then combines t h i s information with expert opinions on the rate of technological changes i n progress, the growth expectations of the industry and the possible occupational mixes of the future. A key f a c t o r i n t h i s approach i s the accuracy of the expert opinions. 4) The Econometric model approach involves i d e n t i f y i n g the r e l a t i o n s h i p s between employment and i t s various parameters. This approach uses the incremental study of several such r e l a t i o n s h i p s which may be influenced through various means, such as l e g i s l a t i o n , and thus, may provide an avenue to exert controls i n appropriate places within a model framework and to have Page 88 a more complete picture of the probable outcomes. This approach i s the most complex and d i f f i c u l t to do but also has the po t e n t i a l to provide the most accurate manpower projections .(76) As i s discussed i n subsequent sections of t h i s study, health manpower planning i n B r i t i s h Columbia has involved each of these forecasting methods to a c e r t a i n degree of however, the primary a c t i v i t y i n forecasting manpower needs i n the health care sector i n B.C. has been i n i n t e r n a t i o n a l (and national) comparisons and s t a t i s t i c a l trends. These methods are the easiest to use and require the least information i n terms of a data base. They are also the least accurate and do not take into account on-going changes i n the the p r o v i n c i a l economy, government p o l i c y , and technology. Such factors are taken into consideration i n i n d u s t r i a l surveys and econometric models, however, use of these approaches i n B.C. i s only i n the embryonic stage. HISTORICAL DEVELOPMENTS IN HEALTH MANPOWER PLANNING IN BRITISH COLUMBIA T r a d i t i o n a l l y , B r i t i s h Columbia has been a net importer of health care manpower.(11) The Hamilton Report noted that p r i o r to 1949, B.C. r e l i e d heavily on i t s a b i l i t y to a t t r a c t health care workers from other provinces and countries, generally to the detriment of the supply of q u a l i f i e d health care workers i n t h i s p r o v i n c e . ( l l ) As part of t h e i r mandate, Hamilton and Associates reviewed the supply of health care workers i n 1949 and noted substantial shortages i n personnel, p a r t i c u l a r l y nurses. In Page 89 addition to the short supply of health care workers, including physicians and medical laboratory technologists, Hamilton also noted the poor d i s t r i b u t i o n of physicians and the v a r i a b l e q u a l i t y of t r a i n i n g programs for medical laboratory technologists. Among the recommendations of the Hamilton Report was a c a l l for the immediate enrollment of 50 students per year i n the soon-to-open medical school at U.B.C. It was noted that the d i s t r i b u t i o n of physicians at that time varied from 1:810 people i n metropolitan areas to 1:2500 people i n i s o l a t e d areas. It was hoped that the t r a i n i n g of B.C. residents would improve that d i s t r i b u t i o n as graduates returned to t h e i r home towns to practice medicine. Hamilton also c a l l e d for an increase i n enrollment i n the province's s i x nursing schools, estimating there was a current shortage of 4,412 nurses i n 1949. The Report also recommended the standardization of medical laboratory technologist t r a i n i n g programs and a better d i s t r i b u t i o n of t r a i n i n g f a c i l i t i e s . ( 1 1 ) The next concerted e f f o r t to review the province's p o l i c i e s and d i r e c t i o n s related to health manpower planning came i n 1973 with the Foulkes Report.(12) The Foulkes Report was a plan for the o v e r a l l reorganization and r e o r i e n t a t i o n of the province's health care d e l i v e r y system. Foulkes noted the majority of B.C. physicians were trained outside the province and that of the 60 to 65 graduates from U.B.C. every year, most tended to stay i n the province as family p r a c t i t i o n e r s whilst s p e c i a l i s t s were recruited from outside the province. He recommended that the province accept r e s p o n s i b i l t y for t r a i n i n g i t s own medical manpower provided that the supply of physicians produced could be absorbed by the demand for t h e i r Page 90 s e r v i c e s . He noted that i n order to bring B.C.'s t r a i n i n g of physicians up to the l e v e l of the national average per population, the province would have to graduate 152 new physicians every year. Although there were no s p e c i f i c recommendations directed towards medical laboratory technologists, i t was noted that the P r o v i n c i a l C i v i l Service had no inventory of manpower s k i l l s and recommended the adoption of manpower planning throughout the C i v i l Service Commission.(12) It should not be unexpected that physicians receive the bulk of the attention when i t comes to manpower planning i n health care. It i s physicians who drive the system and each a d d i t i o n a l physician has been estimated to cost the system up to $250,000 per year.(77) Almost i n conjunction with the Foulkes Report came the establishment of the B.C. Medical Centre with i t s mandate to advise and a s s i s t i n the development and improvement of health manpower t r a i n i n g programs and f a c i l i t i e s . The B.C.M.C. Education Sub-Committee reviewed c l i n i c a l t r a i n i n g f a c i l i t i e s for physicians and paraprofessional health care workers such as nurses and physiotherapists.(15) The Sub-Committee made widespread recommendations for the upgrading of e x i s t i n g f a c i l i t i e s for t r a i n i n g c l i n i c a l manpower but made no recommendation regarding s p e c i f i c numbers to t r a i n . A p a r a l l e l e f f o r t i n manpower planning cooperated c l o s e l y with the work at B.C.M.C. and was p r e c i p i t a t e d as a requirement of the f e d e r a l - p r o v i n c i a l health manpower committee. The Health Manpower Working Group was established i n 1973 and i t s research arm, the Page 91 Health Manpower Research Unit, began compiling s t a t i s t i c s on the supply and demand for various health manpower groups.(73) The f i r s t study d i r e c t l y related to forecasting the need for medical laboratory technologists i n B.C. was published by the Health Manpower Research Unit i n March 1979.(70) Its recommendation was e s s e n t i a l l y f or the maintenance of the status quo, as far as student enrollment i n the province's t r a i n i n g f a c i l i t i e s were concerned, for the next f i v e years. Also i n 1979, W.D. Black undertook a study on medical manpower i n the province of B.C.(62) Among his recommendations were that U.B.C.'s medical school should not expand unless supported by needs forecasts considering both p r o v i n c i a l and national needs. It also recognized the poor d i s t r i b u t i o n of B.C.'s physicians and suggested the government help small communities atta c t physicians by b u i l d i n g better f a c i l i t i e s i n such communities and consider r e s t r i c t i o n s on physician b i l l i n g numbers to help temper the supply and m a l d i s t r i b u t i o n of physician manpower.(62) B r i t i s h Columbia has recently part i c i p a t e d i n another e f f o r t to coordinate manpower t r a i n i n g between the western provinces. The Western Canada Health Manpower Training Study was i n i t i a t e d by the Premiers of the western provinces at t h e i r annual conference i n 1980.(78) The objectives were to assess the e x i s t i n g and future needs for health manpower t r a i n i n g programs and f a c i l i t i e s i n western Canada and to make recommendations for the r a t i o n a l i z a t i o n of the l o c a t i o n and funding of health manpower t r a i n i n g programs. Page 92 The study took place over a two year period and consisted of a review of 26 health occupations including physicians and medical laboratory technologists. The study makes projections of manpower needs from 1981 to 2000 based on the most l i k e l y scenario of population growth. The conclusion of t h i s study was that B.C. would need an a d d i t i o n a l 40 medical technologists per year from 1981 to 2000 over and above the current output at the time of the study of about 80 new graduates per year. This projection assumes the ex i s t i n g 1980 migration patterns i n favour of B.C. w i l l remain unchanged and the e x i s t i n g r a t i o of technologists to population w i l l remain appropriate. THE HEALTH MANPOWER PLANNING ORGANIZATION IN BRITISH COLUMBIA B r i t i s h Columbia's current e f f o r t s i n health manpower planning are related to developing a s t a t i s t i c a l data base from current and h i s t o r i c a l manpower l e v e l s by occupation.(78) The Health Manpower Working Group plays the c e n t r a l role i n health manpower planning i n B.C.(78) It i s composed of senior o f f i c i a l s from the Minis t r y of Health, the Minis t r y of Education, the Minis t r y of U n i v e r s i t i e s , Science and Communications, and the Minis t r y of Labour. The Health Manpower Working Group reports to the Deputy Minister of Health and advises the M i n i s t r i e s of Education and U n i v e r s i t i e s , Science and Communications on the needs for health personnel. The Working Group i s responsible for coordinating appropriate health manpower studies, reviewing p o l i c y issues a f f e c t i n g health manpower, assessing the manpower implications of proposed health care programs and reviews Page 93 proposals f o r the establishment of new types of health care workers.(78) The Health Manpower Research Unit of the D i v i s i o n of Health Services Research and Development at the University of B r i t i s h Columbia serves as the primary research resource to the Working Group. It maintains data on 29 health occupation groups.(79) Manpower requirements are estimated using manpower r a t i o s , surveys of s p e c i f i c professions, i n s t i t u t i o n a l vacancy surveys, medical service u t i l i z a t i o n and periodic graduate follow-up surveys. It also conducts s p e c i a l surveys of health agencies to determine current and future manpower requirements for s p e c i f i c occupations. The Health Manpower Research Unit has developed a computer model for projecting health manpower supply known as the General Manpower Stock Simulator Model. It was i n i t i a l l y designed to project the supply of physicians and dentists and to analyze the e f f e c t s of p o l i c y options on supply and d i s t r i b u t i o n of manpower. The model can be used for any occupational group providing there i s a s u f f i c i e n t data base.(78) The o v e r a l l r e s p o n s i b i l i t y f o r coordinating p r o v i n c i a l manpower needs l i e s with the Manpower Needs Committee of the p r o v i n c i a l government. Health Manpower requirements are directed to t h i s Committee through the Minis t r y of Labour which i s advised by the Health Manpower Working Group.(78) Page 94 Two other organizations having input into the health manpower planning process are the B r i t i s h Columbia Health Association and the Education Health Advisory Committee. Both of these organizations l i a i s e with the Health Manpower Working Group through both formal and informal channels.(78) It i s the Minis t r y of Health that i d e n t i f i e s health manpower needs and advises the M i n i s t r i e s of Education and U n i v e r s i t i e s , Science and Communications on the size and number of programs and d i s t r i b u t i o n of graduates. The Ministry of Health also establishes s p e c i a l task forces as required to deal with s p e c i f i c health manpower issues.(78) The Ministry of Education i s represented on the Health Manpower Working Group by the Coordinator of Health and Social Service Programs who i s responsible for reviewing and coordinating health and s o c i a l service programs at the colleges and i n s t i t u t e s . The Coordinator reports to the Director of the Program Services D i v i s i o n , Post-Secondary Education, who i s responsible for curriculum development at colleges and s p e c i a l i z e d i n s t i t u t e s . ( 7 8 ) The Mini s t r y of Labour i s responsible for apprenticeship t r a i n i n g p o l i c i e s , occupational forecasting, l i a i s o n with the fed e r a l government on immigration, and consultation with p r o v i n c i a l m i n i s t r i e s , industries and other agencies on manpower issues.(78) The Education Health Advisory Committee was established by the Academic Council to a s s i s t i n the planning of health education i n the province. The objective of the Committee i s to develop e f f e c t i v e t r a i n i n g programs and f a c i l i t i e s for health manpower. It Page 95 l i a i s e s with the Health Manpower Working Group through the Executive Director of Planning, P o l i c y , and L e g i s l a t i o n of the Ministry of Health who s i t s on the Committee.(78) The above organization does provide an avenue f or appropriate i n t e r a c t i o n between parties involved i n most aspects of manpower planning i n B.C. This system provides the basic foundation of information on which p o l i t i c a l decisions are made with regard to the supply of the various health manpower groups.(78) HEALTH MANPOWER EDUCATION IN BRITISH COLUMBIA Administrative Organization The colleges, i n s t i t u t e s and u n i v e r s i t i e s are managed by autonomous boards and each i s responsible for i t s own educational planning. Each i n s t i t u t i o n cooperates with the Health Manpower Research Unit i n the preparation of a b i e n n i a l status report on the production of health and human service personnel.(79) The Academic Council i s the lay body, established under the Colleges and I n s t i t u t e s Act, charged with r e s p o s i b i l i t y f o r reviewing annual budget submissions from the colleges and i n s t i t u t e s . The Academic Council submits an annual budget request to the Minister of Education and then a l l o c a t e s the approved funds to i n d i v i d u a l i n s t i t u t i o n s . ( 7 8 ) Page 96 The U n i v e r s i t i e s Council i s the lay body established under the U n i v e r s i t i e s Act and serves as an intermediary body between the three u n i v e r s i t i e s and the p r o v i n c i a l government. The Council reports to the Minister of U n i v e r s i t i e s , Science and Communication and i s responsible for funding and approval of programs. E x i s t i n g programs are funded on a formula basis while new programs are funded through a separate mechanism. When new health programs, or changes to e x i s t i n g programs are considered, the Council may seek the advice of the Educational Health Advisory Committee.(78) Medical Laboratory Technologist Programs Medical Laboratory Technology courses are offered by the B.C. I n s t i t u t e of Technology (B.C.I.T.), Camosun College, Cariboo College, College of New Caledonia, Malaspina College, and the University of B r i t i s h Columbia. B.C.I.T. and Cariboo College are the only i n t i t u t i o n s providing a f u l l two year academic program and which coordinate the t h i r d year practicum required before e l i g i b i l i t y to write the c e r t i f i c a t i o n examinations of the Canadian Society of Laboratory Technologists (C.S.L.T.).(79) The other community colleges o f f e r a one year academic program i n medical technology designed to be transferable to one of the i n s t i t u t i o n s o f f e r i n g a complete program. The University of B.C. o f f e r s a bachelor's degree program i n medical laboratory sciences. In 1979, B.C.I.T. and Cariboo College graduated 82 medical laboratory technologists for a r a t i o of 3.20 per 100,000 population. In 1980, there were 78 new graduates i n B.C. for a r a t i o of 2.92 Page 97 new graduates per 100,000 population. On the other hand, the rest of Canada graduated 952 new medical technologists i n 1980 f o r a r a t i o of 4.45 per 100,000. (79) H i s t o r i c a l l y , B.C.'s contribution of new medical technologists has declined s t e a d i l y since the early seventies from 95 i n 1971 to 78 i n 1980.(79) In 1984, B.C.I.T. graduated about 50 medical technologists and Cariboo College graduated about 15.(80) The number of graduates i n B.C. i s c l e a r l y d e c l i n i n g and i s considerably below the national average. B.C. i s a net importer of medical technologists i n growing numbers from other Canadian provinces. This trend i s . i n d i c a t i v e of the general Canadian migration pattern towards B.C. but may also be the r e s u l t of unstated p o l i t i c a l p o l i c y . The t r a i n i n g programs for medical technologists are very expensive and i f B.C. i s able to reap the benefits of other provinces' e f f o r t s there can be substantial f i n a n c i a l savings. There i s a r i s k element associated with such a p o l i c y related to pressure from other provinces not wanting to lose t h e i r graduates to B.C. and from the electorate who may see job opportunities i n t h e i r home province going to outsiders. One of the issues related to the current decline i n numbers of B.C. medical technologist graduates i s the question of who pays for t h e i r t r a i n i n g . At present, the colleges and i n s t i t u t e s of B.C. are funded through the p r o v i n c i a l M i n i s t r y of Education. The t h i r d year practicum for medical technologists which occurs i n ho s p i t a l s or private laboratories i s funded by that p a r t i c u l a r i n s t i t u t i o n and Page 98 hence the Ministry of Health. At a time of wholesale program cuts i n a l l m i n i s t r i e s , there i s considerable concern over which ministry should be responsible for the education and t r a i n i n g of medical technologists. Budgetary constraints i n some hospitals have led to a reduction i n the number of students taken into t h e i r programs i n recent years, as money formerly allocated to student t r a i n i n g i s directed towards the employment of q u a l i f i e d personnel to a s s i s t with the laboratory's workload. This decline i n student positions i s related d i r e c t l y to t h i s c o n f l i c t between the M i n i s t r i e s of Health and Education over who should pay. U n t i l t h i s c o n f l i c t i s resolved i t i s possible that further cuts i n enrollment may occur as t h i r d year placements de c l i n e , thereby increasing B.C.'s dependence on out-of-province manpower resource. THE EFFECT OF AUTOMATION ON LABORATORY MANPOWER The question of whether technological advancements, p a r t i c u l a r l y automation, have an e f f e c t on manpower u t i l i z a t i o n i n laboratories has been discussed by many for some time now but a d e f i n i t i v e answer s t i l l i s not a v a i l a b l e . A review of the l i t e r a t u r e shows a dearth of de t a i l e d studies regarding t h i s subject. Two studies undertaken i n B r i t i s h Columbia suggest there must be some impact on manpower through increased laboratory automation although the degree of impact could not be defined.(70,81) Page 99 The study undertaken on behalf of the Health Manpower Working Group i n 1978 concluded that the considerable increase i n automation over the period 1972-1976 had not led to a reduction i n the number of laboratory s t a f f since there had been a yearly increase of 5% i n the number of Medical Laboratory Technologists for that period.(70) Data for t h i s study were obtained through s t a t i s t i c a l reports and a questionnaire c i r c u l a t e d to a l l Medical Laboratories i n B.C. This study also found only a modest increase i n the proportion of Technical Assistant positions i n r e l a t i o n to the number of Registered Technologists. Admittedly, these data were only a v a i l a b l e from a r e l a t i v e l y small number of hospitals and the o v e r a l l study period covered only f i v e years. This may have been an i n s u f f i c i e n t data base on which to form any d e f i n i t i v e conclusions. The second B.C. study undertaken i n 1981 involved a questionnaire designed to develop a data base by which a number of broad impact questions could be answered regarding technology i n laboratories.(81) Although the study group was r e l a t i v e l y small (30 respondents) the researchers f e l t t h e i r responses were reasonably representative for the province. It was the consensus of the respondents that automation does save time for s t a f f . However, none of the hospitals a c t u a l l y reduced s t a f f due to automation. Any time saved was used to absorb workload increases i n other laboratory functions. In addition, most of the respondents f e l t that, to date, automation had not replaced the technologist or reduced the current demand for s t a f f , although many did suggest that future demand for technologists w i l l be reduced and there w i l l l i k e l y be considerable impact on the technologist's career path. As instrumentation Page 100 becomes simpler to operate, the operators require l e s s sophisticated s k i l l s to perform t h e i r tasks while laboratory supervisors and senior technologists w i l l need more s k i l l i n trouble shooting instruments. This could r e s u l t i n a widening of the gap i n s k i l l s between j u n i o r and senior registered technologists. A subsequent study involving Vancouver General Hospital estimated that without the increase i n automation over the period 1971-1979, the laboratory would have required a 76% increase i n s t a f f i n order to accommodate the 1980/81 laboratory workload.(57) It i s clear from these studies that automation does have a s i g n i f i c a n t impact on laboratory manpower; that being i t s a b i l i t y to increase the number of tests per FTE and thus reduce s t a f f , or at l e a s t slow the rate of increase i n laboratory s t a f f i n g l e v e l s . However, th i s e f f e c t appears to be more than o f f s e t by another apparent aspect of automation; that being i t s a b i l i t y to increase the a v a i l a b i l i t y of tests to physicians, hence increasing the number of tests per acute care admission. How these two aspects of the r e l a t i o n s h i p between automation and manpower i n t e r a c t i s the subject of considerable a t t e n t i o n , p a r t i c u l a r l y with regard to attempts at c o n t r o l l i n g one or both of these parameters. Page 101 CHAPTER VII THE ORGANIZATION AND OPERATION OF A HOSPITAL LABORATORY The role of the c l i n i c a l laboratory i n hospitals may be considered to be one of providing physicians with meaningful information related to the current biochemical and b i o l o g i c a l condition of t h e i r patients. To provide t h i s information i n the most e f f i c i e n t and c o s t - e f f e c t i v e manner requires laboratories to have, among other things, a suitable organizational structure. The organizational structure may vary from the very simple to the very complex depending on the ho s p i t a l s i z e , function and laboratory workload. Laboratories i n hospita l s accreditated by the Canadian Council for Hospital Accreditation are required to e n l i s t the services of a q u a l i f i e d physician as t h e i r director.(82) T y p i c a l l y , the Director i s a s p e c i a l i s t i n Pathology and could report to the hospital's medical d i r e c t o r or administrator. The Director's q u a l i f i c a t i o n s may be as a general pathologist or as a s p e c i a l i s t i n one the d i s c i p l i n e s of laboratory medicine. Page 102 Larger laboratories are generally divided p h y s i c a l l y and administratively into sections based on the category of laboratory t e s t . The laboratory could include sections i n Hematology, Chemistry, Microbiology, Histology, Immunohematology (Blood Banking), and Accessioning (specimen c o l l e c t i o n and handling) among others. There may be more sections or sub-sections depending on the size of the laboratory. For the sake of operational and administrative e f f i c i e n c y , some of the above major sections could be amalgamated or sub-sectioned as required. Each section of the laboratory t y p i c a l l y has a supervisory technologist overseeing the a c t i v i t y of that s e c t i o n . The supervisory technologists are generally responsible for maintaining that sections' operational i n t e g r i t y and for ensuring that laboratory and h o s p i t a l p o l i c y and procedures are adhered to. The supervisory technologist may report to either the laboratory d i r e c t o r or to one of the medical s p e c i a l i s t s i n that p a r t i c u l a r d i s c i p l i n e designated responsible for the se c t i o n . The largest sector of the laboratory's workforce are medical laboratory technologists who perform the bulk of the t e s t i n g procedure. They are often assisted i n t h i s task by laboratory technical assistants who assume r e s p o n s i b i l t y for the less t e c h n i c a l aspects of the testing procedures. They are often involved i n specimen preparation and perhaps some aspects of automated equipment operation. Many laboratories also e n l i s t the services of c l e r i c a l personnel to process the necessary paperwork accompanying each laboratory request. In B.C. public h o s p i t a l s , medical laboratory technologists are members of the Health Sciences Association which Page 103 bargains c o l l e c t i v e l y on t h e i r behalf, while technical assistants and c l e r i c a l s t a f f are members of the Hospital Employees' Union. Technologists may eit h e r rotate through a l l laboratory sections, or d i s c i p l i n e s , and maintain t h e i r f l e x i b i l i t y or, as i s often the case i n larger l a b o r a t o r i e s , they may stay i n a sing l e section becoming expert i n the many aspects of that p a r t i c u l a r d i s c i p l i n e . The laboratory workload i s i n i t i a t e d by a physician making a request for a p a r t i c u l a r laboratory test to be performed on one of his/her patients. Depending on the hospi t a l ' s organization and role i n the community, the patient may be eit h e r an inpatient or an outpatient. The specimen i s c o l l e c t e d by eit h e r the physician, a nurse, or by the laboratory phlebotomists. Again, depending on the size and organization of the laboratory, the specimen w i l l be directed to the section performing the p a r t i c u l a r test ordered. A single specimen may be separated into several aliquots for multiple t e s t s . In addition to the patients' specimens, the laboratory w i l l also process a c e r t a i n number of standards or knowns as a method of measuring the accuracy and r e p r o d u c i b i l i t y of the procedure and equipment. Hospital laboratories generally subscribe to a v a r i e t y of q u a l i t y control programs which d i c t a t e the minimum frequency with which co n t r o l specimens should be tested. Some q u a l i t y control programs also include a number of "unknowns" which are p e r i o d i c a l l y tested i n the subscribing laboratory. The r e s u l t s of these tests are then compared to that reported by a l l the other laboratories Page 104 subscribing to the program. A high l e v e l of q u a l i t y control i s e s s e n t i a l for confidence i n the accuracy of the r e s u l t reported on a c l i n i c a l specimen and i s required by the various accrediting bodies of laboratories.(82) Hospital laboratories i n B.C. are rated and accredited by the B.C. Medical Association i n conjunction with the B.C. Association of Laboratory Physicians.(83) The length of the a c c r e d i t a t i o n varies with the laboratory's compliance with recommended operating standards. Hospital laboratories are also accredited by the Canadian Council On Hospital Accreditation which sets organizational and operational standards for Canadian hospitals.(82) Each laboratory test and control standard i s recorded and given a unit value representative of the t o t a l technical and c l e r i c a l time required to handle and process that specimen from i t s receipt i n the laboratory to the sending out of the f i n a l report. The unit values are usually the ones defined by the Canadian Workload Measurement System for Laboratories and published by S t a t i s t i c s Canada. It i s the t o t a l of these unit values that are used i n management reports related to laboratory p r o d u c t i v i t y . These measurements are also used by governments i n j u s t i f y i n g funding l e v e l s and, hence, s t a f f i n g l e v e l s . Laboratories may be funded i n several d i f f e r e n t ways. U n t i l recently, when the p r o v i n c i a l government adopted a global funding approach to h o s p i t a l budgets, the government provided h o s p i t a l s with what i t f e l t were s u f f i c i e n t funds to operate t h e i r laboratories based on the workload s t a t i s t i c s reported by that laboratory. The Page 105 budget was generally divided into personnel, operating supplies and expenses, and c a p i t a l expenses. The personnel budget was assigned according to a c a l c u l a t i o n of workload units per FTE, with the l e v e l being set somewhat a r b i t r a r i l y by the Mini s t r y , based on h i s t o r i c a l patterns and current expectations. Operating supplies were budgeted l a r g e l y on previous requirements plus new programs, while c a p i t a l equipment was financed on an "as needed" b a s i s . Hospitals now have more f l e x i b i l i t y on how they budget for t h e i r laboratory operation and may use any of a v a r i e t y of budgeting techniques, from a l l o c a t i o n s based on h i s t o r i c a l data, to l i n e or program budgeting such as Zero Base Budgeting. Page 106 CHAPTER VIII FINDINGS AND IMPLICATIONS LABORATORY MANPOWER IN BRITISH COLUMBIA HOSPITALS The impact of the changes i n the demand for laboratory services and i n the system's a b i l i t y to meet that demand are r e f l e c t e d i n laboratory manpower u t i l i z a t i o n data and i n laboratory operating expenses. This chapter presents data related to how the number and mix of laboratory personnel i n B.C. hospit a l s has changed over the study period and how the operating costs for B.C. h o s p i t a l laboratory services have also changed. D e f i n i t i o n s and Limitations Because of changes i n the reporting requirements, data for 1966 are not as d e t a i l e d as those of subsequent reporting years. Reported categories i n 1966 include laboratory technologists, q u a l i f i e d and u n q u a l i f i e d , which i s equivalent to registered and non-registered technologists and q u a l i f i e d and unqualified technicians which were both included i n the category of Technical A s s i s t a n t s . The difference between the sum of these two categories and the reported t o t a l laboratory positions were assumed to be part Page 107 of the administrative support s t a f f and reported under "Other Laboratory S t a f f " . A l l laboratory personnel are reported i n terms of Full-Time Equivalents (FTE). An FTE i s a c a l c u l a t i o n of the number of paid hours equivalent to one f u l l - t i m e worker; f o r example, 7.5 hrs/day x 5 days/wk x 52 wk/yr = 1950 hours per year. The t o t a l recorded accumulated paid hours per year for each personnel group was divided by 1950 hours to obtain the number of FTEs i n each category. Six categories of laboratory personnel have been examined i n t h i s study. Each category i s based on professional and educational q u a l i f i c a t i o n s and functional roles within the laboratory. The s i x categories include: Laboratory Physicians; Laboratory S c i e n t i s t s ; Medical Laboratory Technologists; Non-Registered Technologists; Technical Assistants; and Other Laboratory S t a f f . The categorization and d e f i n i t i o n of each manpower group i s according to the i n s t r u c t i o n s and d e f i n i t i o n s provided for the completion of the HS-1 r e t u r n s . ( l ) The category of Laboratory Physicians includes pathologists and other physicians i n the laboratory. Pathologists are physicians c e r t i f i e d i n the s p e c i a l t y of pathology by the Royal College of Physicians and Surgeons of Canada. Other medical s t a f f r e f e r s to persons with a medical degree who are not c e r t i f i e d pathologists. The category of Laboratory S c i e n t i s t s includes persons q u a l i f i e d to practice as medical laboratory s c i e n t i s t s , by reason of having graduated from a recognized u n i v e r s i t y with a degree, majoring i n an appropriate laboratory d i s c i p l i n e . Recognized Page 108 degrees i n t h i s category include B.Sc, M.Sc. and Ph.D. Persons i n t h i s category could include Biochemists, M i c r o b i o l o g i s t s , Immunologists, P h y s i c i s t s et cetera. The category of Medical Laboratory Technologists ref e r s to persons q u a l i f i e d to practice as medical laboratory technologists by meeting the requirements for c e r t i f i c a t i o n by the Canadian Society of Laboratory Technologists (CSLT) or equivalent standards. This category includes those persons holding any l e v e l of CSLT c e r t i f i c a t i o n (RT,ART,Licentiate) who are currently registered with the CSLT or those who have s u f f i c i e n t q u a l i f i c a t i o n s to assure r e g i s t r a t i o n should a p p l i c a t i o n be made. C e r t i f i c a t i o n and r e g i s t r a t i o n are not e s s e n t i a l f or practice but are normally required by employers. Non-Registered Technologists ref e r s to persons employed as laboratory technologists who are neither registered with the CSLT nor hold equivalent q u a l i f i c a t i o n s or r e g i s t r a t i o n , nor are they e l i g i b l e for such r e g i s t r a t i o n . Technical Assistants ref e r s to those persons q u a l i f i e d through a formal course to function as a laboratory technician but who are not q u a l i f i e d for r e g i s t r a t i o n with the CSLT as a medical laboratory technologist. This category includes combined Laboratory and Radiological Technicians, Laboratory Aides, Laboratory A s s i s t a n t s , and Graduate Nurses working i n l a b o r a t o r i e s . Other Laboratory Staff includes personnel such as clerks and s e c r e t a r i e s . Page 109 administrative support Non-Medical Laboratory Personnel Table VI presents the data c o l l e c t e d f o r a l l laboratory personnel groups, excluding Laboratory Physicians who are dealt with separately. Manpower t o t a l s are presented i n FTE's as calculated from t o t a l paid hours reported i n the HS-1 returns. Data presented i n Table VI are for a l l h o s p i t a l size groups combined. Data rel a t e d to i n d i v i d u a l s i z e groups i s presented i n Appendix 2. Because of differences i n the d e f i n i t i o n s and reporting reguirements of the HS-1 returns, data f o r 1966 were not d i r e c t l y comparable to the subsequent reporting years and were therefore omitted from t h i s a n a l y s i s . Where indicated, the differences between 1970 and 1980 have been tested for s i g n i f i c a n c e at p=0.05 and i n a l l cases, |z| > 1.96 i n d i c a t i n g the proportions tested are indeed s i g n i f i c a n t l y d i f f e r e n t . It i s r e a d i l y apparent (Table VI) that there has been a s i g n i f i c a n t decline i n the number of Laboratory S c i e n t i s t s . In the period from 1970 to 1980, the actual number of Laboratory S c i e n t i s t s has declined by 14.5 FTE from 35.1 to 20.6 FTE and, as a percentage of o v e r a l l laboratory manpower, has ranged from a high of only 2.9% i n 1970 to a low of 0.8% i n 1978. There was a s l i g h t recovery i n numbers i n 1980 to 1.0% of the t o t a l laboratory manpower. This trend i s consistent throughout the various h o s p i t a l s i z e groups but i s p a r t i c u l a r l y so i n the larger hospitals of Groups IV and V (see Page 110 Appendix 2). This change i n the number of Laboratory S c i e n t i s t s i s l i k e l y a r e f l e c t i o n of the changing standards of laboratory d i r e c t o r s and possibly of the supply of laboratory physicians. There has been a s i m i l a r decline i n the number and proportion of Non-Registered Technologists. The aggregated data for a l l hosp i t a l s shows the number of Non-Registered Technologists d e c l i n i n g from 62.6 FTE i n 1970 to 30.8 FTE i n 1980. As a percentage of the t o t a l , the proportion declined from a high of 5.1% i n 1970 to a low of 1.5% i n 1980. This trend i s most consistent and dramatic i n the smaller hospitals of Groups I, II and I I I . The same trend i s evident i n Group IV h o s p i t a l s although there are signs the decrease may be l e v e l i n g o f f . This i s even more evident i n Group V hospitals where i t has remained around 2% of the t o t a l laboratory manpower from 1974 to 1980. The change i n the number of Non-Registered Technologists may be due to members of that category e i t h e r leaving the workforce or taking t h e i r c e r t i f i c a t i o n examinations with the CSLT. Before the CSLT became such a prominent body i n c e r t i f i c a t i o n and i n employment of medical laboratory technologists, many more technical employees were not registered because the accepted a l t e r n a t i v e to CSLT c e r t i f i c a t i o n was on-the-job-training. The Health Sciences Association (HSA) contract, which governs the employment of medical laboratory technologists i n most B.C. h o s p i t a l s , requires non- registered technologists to be paid 10% l e s s than CSLT registered technologists. In addition, the HSA Page 111 encourages the i n c l u s i o n of CSLT r e g i s t r a t i o n i n a l l laboratory job d e s c r i p t i o n s . The number of Medical Laboratory Technologists f o r a l l hospital s has increased from 755.1 FTE i n 1970 to 1366.4 FTE i n 1980 and as a percentage of t o t a l manpower i n l a b o r a t o r i e s , has increased from 61.7% i n 1970 to 67.3% i n 1980. This increase i n registered technologists i s consistent for a l l h o s p i t a l size groups and i t w i l l be noted that, generally, registered technologists make up a larger proportion of the t o t a l laboratory workforce i n the smaller h o s p i t a l s i z e groups. Much of t h i s increase i s due to the reduction i n Non-Registered Technologists through whatever means. TABLE VI The Number and Percentage D i s t r i b u t i o n of Laboratory Personnel i n B.C. Public Hospitals and Total Percentage Change from 1970 - 1980, by Type of Personnel Laboratory Personnel C l a s s i f i c a t i o n 1970 FTE % 1974 FTE % 1978 FTE % 1980 FTE % TOT % Laboratory S c i e n t i s t s 35.1 2.9 18.9 1.3 13.7 0.8 20.6 1.0 -41 Registered Technologists 755.1 61.7 938.7 65.5 1144.4 66.8 1366.4 67.3 +81 Non-Registered Technologists 62.6 5.1 33.4 2.3 36.6 2.1 30.8 1.5 -51 Other S t a f f , Technical 83.9 6.9 106.0 7.4 120.2 7.0 146.7 7.2 +75 Other S t a f f , Laboratory 287.4 23.5 336.7 23.5 399.1 23.3 465.4 22.9 +62 TOTAL 1224.1 100 1433.6 100 1714.0 100 2029.8 100 +66 FTE = F u l l Time Equivalent % = Percentage of t o t a l non-medical laboratory personnel. TOT % = Total percent change from 1970 to 1980 Page 112 The number of Technical Assistants has remained r e l a t i v e l y constant from 1970 to 1980 ranging from a low of 6.9% of t o t a l laboratory manpower i n 1970 to a high of 7.4% i n 1974. This i s somewhat d i f f e r e n t from the e a r l i e r findings by Stark which showed technical a ssistants to comprise 5.19% of the t o t a l laboratory FTE i n 1970 and 9.3% of the t o t a l i n 1976.(70) That study separated graduate nurses from technical a s s i s t a n t s . As there i s no such separation for HS-1 data recorded for 1978 and 1980, 1 have chosen to combine these laboratory workers as technical assistants throughout the study period. Allowing for t h i s combination, the respective figures of both studies are complementary. The trends have been somewhat v a r i a b l e between the various s i z e groups with a generally decreasing trend i n Group One, r e l a t i v e s t a b i l i t y i n Groups Two and Four, and an increasing percentage i n Groups Three and Five. The largest variance between 1970 and 1980 i s i n Group Five with a spread of only 2.5% i n d i c a t i n g that while the increasing trend i s apparent, i t i s of a very modest magnitude. It was anticipated that increased automation would lead to a reduction i n the proportion of Registered Technologists with a corresponding increase i n the proportion of Technical A s s i s t a n t s . The o v e r a l l change i n the proportion of Technical Assistants i s very small and, indeed, there are fewer i n 1980 than i n 1974. It i s unclear why t h i s anticipated e f f e c t of automation on manpower has not been manifested i n t h i s study. It may be that while there are c e r t a i n l y cost advantages to employing l e s s highly trained workers, there are also disadvantages i n that they are l e s s Page 113 f l e x i b l e i n what they are able to do. Given a choice of having eit h e r a technologist or a technical assistant with no consideration of costs, most laboratories would probably choose the f l e x i b i l i t y of the technologist. Previous constraints from government appear to have been directed towards reducing FTE's with no p a r t i c u l a r concern over the cost of those FTE's. With the recent move away from d e f i c i t budgeting for h o s p i t a l s , there w i l l be r e a l incentives to trade i n d o l l a r s saved by employing more Technical Assistants for a d d i t i o n a l workers as funding from the M i n i s t r y of Health becomes inc r e a s i n g l y t i g h t . Union t e r r i t o r i a l protection also plays a s i g n i f i c a n t r o l e , as Technical Assistants usually are members of the Hospital Employees' Union, and the Health Sciences Association representing medical laboratory technolosists would not l i k e to see positions for i t s members l o s t to members of the HEU. Such an event could also lead to a narrowing of wage d i f f e r e n t i a l s between the technologists and a s s i s t a n t s i n much the same way as has happened between registered nurses and p r a c t i c a l nurses. This w i l l u l timately lead to increased o v e r a l l costs i f allowed to occur. F a i l u r e to show t h i s e f f e c t may also be due to the lack of q u a l i f i e d laboratory a s s i s t a n t s i n t h i s province. As there i s no formal t r a i n i n g program for laboratory assistants i n B.C., h o s p i t a l s must r e l y on either on-the-job t r a i n i n g , or on r e c r u i t i n g q u a l i f i e d personnel from other provinces. An e f f o r t was made to i d e n t i f y the s i z e of h o s p i t a l where the employment of laboratory assistants becomes most f e a s i b l e . The data presented i n Appendix 3 shows the use of t h i s manpower resource to be somewhat random, with some small hospitals using proportionately Page 114 more laboratory assistants than large h o s p i t a l s . It i s apparent that there i s no consistent pattern i n the approach to employing t h i s group of laboratory workers i n B.C. h o s p i t a l s . A subset of data related to the composition of the registered technologist category was examined. Data were c o l l e c t e d on the number of f u l l - t i m e and part-time Registered Technologists (RT's), Advanced Registered Technologists (ART's), and l i c e n t i a t e s . Because of differences i n reporting requirements between reporting years, the number of such technologists could not be c o l l e c t e d i n terms of paid hours and FTEs and so i s not d i r e c t l y comparable to data presented above i n Table VI. However, within the l i m i t a t i o n s of the accuracy and completeness of t h i s data, the trends i d e n t i f i e d w i l l be comparable. These data are presented i n Table VII i n aggregated form for a l l B.C. h o s p i t a l s . Data grouped according to h o s p i t a l s i z e are presented i n Appendix 4. With the exception of 1978, the percentage of RT's and ART's has remained r e l a t i v e l y constant throughout the study period when a l l hospitals are considered c o l l e c t i v e l y , with RT's accounting f o r approximately 89% of t o t a l technologists and ART's accounting f o r approximately 10%. The 1978 data i s of questionable r e l i a b i l i t y as the i n o r d i n a t e l y high number of l i c e n t i a t e s were reported l a r g e l y by a single Group IV h o s p i t a l . The same i s true of the seemingly high number of ART's reported i n 1978, where 65 of the 173 were reported by another single Group IV h o s p i t a l . This seems u n l i k e l y when the 1980 values are so s i m i l a r to the 1974 values. It i s often clerks not associated with the laboratory who f i l l out the HS-1 Returns and such a c l e r i c a l error may not have been noticed as being unusual. Page 115 The time frame of t h i s study, as well as the basis on which the data were made a v a i l a b l e , did not provide an opportunity to v e r i f y the data with the p a r t i c u l a r h o s p i t a l i n question. TABLE VII The Number and Percentage D i s t r i b u t i o n of Registered Technologists i n B.C. Public Hospitals by Q u a l i f i c a t i o n and whether Full-Time or Part-Time: 1970-1980 Qual. 1970 FT % |PT % 1974 FT % |PT % 1978 FT % | PT % 1980 FT % | PT % R.T. A.R.T. Lic e n . TOTAL 601 88|54 93 65 10| 3 5 12 2| 1 2 678 100|58 100 773 89|95 98 83 10| 2 2 12 1| 0 0 868 100|97 100 880 81|150 87 173 16] 18 11 38 4| 4 2 1091 100|172 100 1067 90|201 98 118 10| 1 1 2 01 2 1 1187 100J204 100 FT = F u l l Time technologist PT = Part-time technologist % = Percentage change between periods has been rounded to the nearest whole number to conserve space. Qual. = Level of q u a l i f i c a t i o n ; R.T.= Registered Technologist; A.R.T.= Advanced Registered Technologist; Licen.= L i c e n t i a t e When the i n d i v i d u a l h o s p i t a l size groups are examined, some ind i c a t i o n s of change do become apparent (see Appendix 4). In the smaller hospitals of Groups I, II and III there i s a general increase i n the percentage of ARTs with a corresponding decrease i n the percentage of RTs. There i s very l i t t l e a c t i v i t y surrounding L i c e n t i a t e s i n these h o s p i t a l s . In the larger h o s p i t a l s of Groups IV and V t h i s trend i s reversed. There i s a s l i g h t increase i n the percentage of RTs with a corresponding decrease i n the percentage of ARTs. There are no Page 116 consistent trends i n the percentage of l i c e n t i a t e s i n these h o s p i t a l s . One of the expected e f f e c t s of automation that has not yet developed i n B.C. hospitals i s the s t r a t i f i c a t i o n of the technologist workforce. It was anticipated that there would be a move towards more ARTs, however, the o v e r a l l proportion of the technical workforce holding t h e i r ARTs has remained r e l a t i v e l y unchanged over t h i s 15 year study period as was reported i n a previous f i v e year study of the same population.(70) Again s u r p r i s i n g l y , the trends i n the various h o s p i t a l size groups are reversed from what was expected with the number of ARTs increasing i n the small hospitals and decreasing i n the larger h o s p i t a l s . The reasons behind t h i s unexpected set of findings are not c l e a r . Perhaps i t i s a r e f l e c t i o n of the lack of preparedness of ARTs to f i l l the r o l e expected by some h o s p i t a l s . The hospitals may be using other manpower resources instead of ARTs such as professional managers, educators, and e l e c t r o n i c s engineers. To put the growth i n the o v e r a l l number of laboratory personnel i n a d i f f e r e n t perspective, i t can be compared to the growth i n laboratory workload i n terms of workload per FTE. These data are presented i n Table VIII. A l l h o s p i t a l size categories experienced s i g n i f i c a n t increases i n the number of units per FTE from 1970 to 1980. The o v e r a l l changes between 1970 and 1980 were s u b s t a n t i a l l y a larger i n the smaller h o s p i t a l s , ranging from 22% i n Group I hospitals to 9.7% i n Group V h o s p i t a l s . The combined data indicates an increase of 14.7% for the same period. The rate of increase Page 117 between reporting years and s i z e groups varied considerably, with only 1974 reporting s i g n i f i c a n t increases for a l l size groups. In a l l other years there was a mixture of increases and decreases of varying magnitude. It i s c l e a r that automation has led to higher throughput per FTE, however, as workload units are c o n t i n u a l l y adjusted to r e f l e c t automated methodologies, a more accurate representation of the impact of automation would be a measure of the number of reportable r e s u l t s (or tests) produced by each worker. Such information was, however, not a v a i l a b l e from the HS-1 returns but would undoubtedly show very large increases over such a study period. TABLE VIII Laboratory Workload Units per Laboratory Worker for a l l B.C. Public Hospitals by Size Group: 1970 - 1980 (workload units are i n thousands) Hospital Size Group 1970 units (xlOOO) 1974 units % (xlOOO) C 1978 units % (xlOOO) C 1980 units % (xlOOO) C 1970-1980 % Group I 94 108 15.2 107 -0.5 114 6.4 +22.0 Group II 105 122 15.6 121 -0.1 127 4.9 +21.1 Group III 103 136 31.9 120 -11.6 120 -0.3 +16.2 Group IV 97 109 12.3 147 35.3 110 -25.5 +13.2 Group V 105 108 2.8 118 9.2 115 -2.2 +9.7 TOTAL 101 113 12.1 123 8.6 116 -5.7 +14.7 units = workload units per laboratory worker, i n thousands % = Percentage change from previous period. Page 118 Physicians The number of medical s t a f f i s reported i n terms of f u l l - t i m e and part-time positions for pathologists and other paid medical s t a f f . Most of the part-time positions are pathologists providing services to more than one h o s p i t a l so that the t o t a l number of f u l l - t i m e and part-time medical s t a f f i s greater than the t o t a l number of laboratory medical s t a f f working i n B.C. h o s p i t a l s . Table IX presents the number of f u l l - t i m e and part-time medical s t a f f positions i n B.C. h o s p i t a l l a b o r a t o r i e s . It does not include pathologists working on a sessional basis or those providing consultative laboratory services on a contract b a s i s . The aggregated data for a l l hospitals shows the number of f u l l - t i m e pathologists has increased by 65.9% from 41 i n 1966 to 68 i n 1980. At the same time, the number of part-time pathologist positions has increased by 76.3% from 38 i n 1966 to 67 i n 1980. The change i n the number of "other laboratory physicians" has been les s consistent i n terms of f u l l - t i m e and part-time p o s i t i o n s , although the t o t a l number of positions i s inc r e a s i n g . In 1974 there were 15 f u l l - t i m e and 8 part-time positions and i n 1978 there were 4 f u l l - t i m e and 26 part-time p o s i t i o n s . There i s c l e a r l y a trend towards more part-time positions which i s continued i n 1980. This may be a r e f l e c t i o n of the number of pathologists providing services to multiple hospitals or private l a b o r a t o r i e s . On examining the data for i n d i v i d u a l h o s p i t a l size groups, presented i n Appendix 5, the increased presence of part-time pathologists continues to be evident i n the larger hospitals of Page 119 Groups IV and V but the reverse i s so i n size Groups I and I I . It w i l l also be noticed that, with the exception of Group I h o s p i t a l s , non-pathologist physicians are employed most extensively i n the larger h o s p i t a l s . TABLE IX Number and Percentage D i s t r i b u t i o n of Laboratory Medical Manpower i n B.C. Public Hospitals: 1970 - 1980 Medical Manpower Category 1970 FT % | PT % 1974 FT % | PT % 1978 FT % | PT % 1980 FT % | PT % Pathol. Other TOTAL 52 83| 33 89 11 181 4 11 63 100| 37 100 63 811 34 81 15 19| 8 19 78 100| 42 100 64 94| 51 66 4 6| 26 34 68 100j 77 100 68 901 67 78 8 l l | 19 22 76 100| 86 100 FT = Full-time positions PT = Part-time positions % = Percentage of t o t a l FT or PT medical manpower rounded to the nearest whole number to conserve space. Pathol. = Pathologists Other = Other physicians employed i n the laboratory. LABORATORY WORKLOADS IN BRITISH COLUMBIA HOSPITALS Laboratory workload i s measured i n workload u n i t s . Currently one unit i s equivalent to one minute of t e c h n i c a l , c l e r i c a l or lab aide time required to perform a laboratory t e s t . The system of measurement presently i n use i n Canada i s c a l l e d the "Canadian Workload Recording Method", o r i g i n a l l y developed under the d i r e c t i o n of the Dominion Bureau of S t a t i s t i c s i n 1954 by the Canadian Association of Pathologists. Current unit values are now published annually or semi-annually by S t a t i s t i c s Canada as the "Canadian Page 120 Schedule of Unit Values for C l i n i c a l Laboratory Procedures".(84) The i n i t i a l workload unit developed i n 1954 was expressed as 10 minutes of time of which seven minutes were technical and three minutes supportive. This was quickly recognized as a very i n f l e x i b l e unit of measurement and did not adequately r e f l e c t the work r e s u l t i n g from q u a l i t y control and the development of new procedures. Nor could i t adequately r e f l e c t the changes being introduced by increasing automation and new procedures. The Canadian Association of Pathologists, i n conjunction with several other professional groups, undertook a r e v i s i o n of the so-called DBS unit and published, i n 1969, a new schedule of unit values for c l i n i c a l laboratory procedures. This new schedule was based on time/motion studies of laboratory procedures performed i n 49 hospita l s and introduced the unit as being equivalent to one minute of technical and aide time. The new unit and unit schedule were designed to provide a r e a l i s t i c assessment of the t o t a l t e c h n i c a l , c l e r i c a l , and aide time consumed i n the performance of laboratory procedures including q u a l i t y c o n t r o l , research, development, et cetera. Because of t h i s d i f f e r e n c e i n unit values, laboratory workload s t a t i s t i c s from 1966 are not comparable to subsequent years and are, therefore, not included i n the following presentation and analysis of laboratory workloads i n B r i t i s h Columbia h o s p i t a l s . Page 121 Table X presents the d i s t r i b u t i o n of laboratory workload units by laboratory service for a l l h o s p i t a l s . Laboratory workloads i n i n d i v i d u a l hospitals s i z e groups are presented i n Appendix 6. It should be noted that not a l l small ho s p i t a l s categorized t h e i r laboratory workload into the various laboratory services indicated on the HS-1 Returns but merely reported t o t a l workload. For t h i s reason there are several cases i n Group I hospitals where the sum of laboratory workload from the various services does not equal the reported t o t a l workload for that year. In such s i t u a t i o n s , the t o t a l of the categorized workload i s reported i n brackets and the c a l c u l a t i o n of "Percent of T o t a l " i s based on t h i s f i g u r e . It should also be noted that the data i n Table X only represent the t o t a l workload performed by hospitals f a l l i n g within the s p e c i f i e d size categories and do not make any allowance for the changing number of hospitals and beds i n each si z e group between reporting periods. When the data are aggregated for a l l hos p i t a l s i t i s clear that, almost without exception, workload increased s u b s t a n t i a l l y i n a l l laboratory services and a l l reporting years. For the 11 year period from 1970 to 1980, the t o t a l laboratory workload for a l l hosp i t a l s increased by 90%. However, i t does appear as though the rate of increase may be slowing. Table X also displays the proportion of t o t a l laboratory workload subdivided into the i n d i v i d u a l laboratory service categories. Relevant differences i n proportions have been tested for s t a t i s t i c a l s i g n i f i c a n c e at p=0.05. A l l differences were found to be s i g n i f i c a n t with |z| > 1.96, but i t w i l l be noted that, Page 122 o v e r a l l , there has been r e l a t i v e l y l i t t l e change i n these proportions with only a few exceptions. The proportion of workload a t t r i b u t a b l e to Blood Banking increased from 8.2% of t o t a l workload i n 1970 to 11.5% i n 1980 and the proportion of Procurements increased from 7.7% of the t o t a l i n 1970 to 11.6% i n 1980. The proportion of Microbiology decreased s l i g h t l y during the same period from 19.3% of the t o t a l to 16.5%. TABLE X D i s t r i b u t i o n of Laboratory Workload for a l l B.C. Public Hospitals Showing Total Units by Service, Percent of Total Workload, and Percent Change From Previous Period: 1970 - 1980 (workload i n 1,000's) Category 1970 1974 1978 1980 of units % units % % units % % units % % Service (xlOOO) T (xlOOO) T C (xlOOO) T C (xlOOO) T C Chem. 33879 27.4 44956 27.7 32.7 56701 26.9 26.1 62900 26.8 10.9 Hem. 20843 16.9 27435 16.9 31.6 30062 14.3 9.6 33993 14.5 13.1 Blood Bk 10189 8.2 17214 10.6 68.9 25336 12.0 47.2 27043 11.5 6.7 Histo. 10732 8.7 13203 8.1 23.0 14753 7.0 11.7 20385 8.7 38.2 Cytology 4676 3.8 7294 4.5 56.0 9792 4.7 34.2 10935 4.7 11.7 Micro b i . 23795 19.3 21471 13.2 -9.8 32305 15.4 50.5 38657 16.5 19.7 Services 2312 1.9 3539 2.2 53.0 0 0 - 0 0 -Procure. 9495 7.7 15578 9.6 64.1 25444 12.1 63.3 27249 11.6 7.1 Other 6339 5.1 9678 6.0 52.7 12747 6.1 31.7 13729 5.8 7.7 TOTAL 123536 100 162115 100 31.2 210421 100 29.8 234894 100 11.6 units = workload units % T = percent of t o t a l laboratory workload for that period. % C = percent changed from previous period. Chem. = Chemistry, Hem. = Hematology, Blood Bank = Blood Bank, Histo. = Histology, Microbi. = Microbiology, Procure. = Procurement Page 123 On examination of data aggregated by ho s p i t a l s i z e groups, i t i s apparent that there are subtle differences between each siz e group, with some services experiencing varying degrees of change over time (see Appendix 6). Generally, the proportion of workload a t t r i b u t a b l e to a p a r t i c u l a r laboratory service has remained r e l a t i v e l y constant over time with only a few notable exceptions. The proportion of Chemistry workload i n teaching hospitals has decreased s t e a d i l y over time from 32.3% i n 1970 to 26.6% i n 1980 while that of other siz e groups has remained r e l a t i v e l y constant. The general trends mentioned above for Blood Banking and Procurements appear consistent throughout a l l size groups. The modest general decrease i n the proportion of Microbiology mentioned above i s l e s s consistent with the largest decreases occurring i n the teaching hospitals and r e l a t i v e s t a b i l i t y i n the other h o s p i t a l size groups. The increased a c t i v i t y i n Blood Banking i s l i k e l y due to increased s u r g i c a l a c t i v i t y i n some hospital s and changes i n Blood Banking procedures which have not been r e f l e c t e d i n new unit values. Unit values for Blood Banking procedures have remained r e l a t i v e l y unchanged over the years and are only now being reviewed. New Blood Banking unit values to be implemented i n 1985 w i l l r e s u l t i n decreases of more than 50% i n many cases. The recently revised unit values i n Hematology and Chemistry implemented i n 1983 caused reductions i n the order of 20% and 40% re s p e c t i v e l y i n c e r t a i n cases. The small incremental changes made over the years were pr i m a r i l y i n hematology and chemistry and were l a r g e l y i n response to automation. It may be that the apparent increase i n the Page 124 proportion of Blood Banking i s merely the r e s u l t of increasingly d i s t o r t e d values of the measurement units for t h i s d i s c i p l i n e . C e r t a i n l y , increased s u r g i c a l a c t i v i t y as determined by the amount of work flowing through Histology does not appear to have changed s i g n i f i c a n t l y i n r e l a t i o n to o v e r a l l laboratory workload during the study period when a l l hospitals are considered c o l l e c t i v e l y . The increased prominence of Procurements i s l i k e l y due to two f a c t o r s . The number of patient days has increased over the study period and hence, i t should be expected that the number of specimens c o l l e c t e d should also increase. Because the e f f i c i e n c y of specimen c o l l e c t i o n has not yet been dramatically affected by automation, the unit values have remained r e l a t i v e l y unchanged over the years. Over the same time period, unit values for automated tests have decreased so that while the number of tests resulted has increased, the unit value has decreased. It should, therefore, be expected that the proportion of the workload a t t r i b u t a b l e to specimen c o l l e c t i o n w i l l increase under these conditions. This increase i n procurements could also be a r e f l e c t i o n of the increased i n t e n s i t y of laboratory t e s t i n g per patient. The evidence that the proportion of laboratory workload a t t r i b u t a b l e to Chemistry i s decreasing i n teaching hospitals i s l i k e l y i n d i c a t i v e of increased automation i n t h i s service or perhaps, increased use of private l a b o r a t o r i e s . The workload volume i n the large teaching h o s p i t a l s can support large automated equipment which may not be cost j u s t i f i e d i n smaller h o s p i t a l s . Such large volume, multifunction analyzers generally have a lower unit value than smaller, less automated analyzers. This apparent Page 125 trend i n Chemistry may also be a t t r i b u t a b l e to e f f o r t s i n a teaching environment to reduce the volume of unnecessary tests and to demonstrate to medical students the responsible use of laboratory s e r v i c e s . There have been several reports i n the l i t e r a t u r e regarding successful e f f o r t s to control the unnecessary use of laboratory tests.(39) A review of the percentage of t o t a l laboratory workload comprised of inpatient and outpatient workload shows that generally, the proportion of h o s p i t a l laboratory workload a t t r i b u t a b l e to outpatients has been increasing from 1970 to 1980 i n e s s e n t i a l l y a l l h o s p i t a l s i z e groups. The exception was a substantial decline i n outpatient work i n Group I hospitals between 1970 and 1974. It i s i n t e r e s t i n g to note that the volume of outpatient work decreases as h o s p i t a l sizes increase. This may be a r e f l e c t i o n of the lack of private laboratories i n smaller communities providing services to ambulatory patients so the hospitals have assumed t h i s function to a larger degree than they might have had there been competition from the private sector. Laboratory Workload and Hospital A c t i v i t y Comparisons To obtain a more accurate picture of how laboratory workloads have changed i n each si z e group, laboratory units are related to Patient Days and Acute Care Admissions. Both of these c a l c u l a t i o n s provide a measure of the i n t e n s i t y of laboratory testing i n the reporting h o s p i t a l s . Page 126 While the number of patient days and acute care admissions are accurate within the l i m i t a t i o n s of the reporting practices of the h o s p i t a l s , the laboratory workload reported cannot be divided into acute care patient workload and long term patient workload due to the reporting requirements of the HS-1 returns. Such a breakdown i s not requested on these returns. It was assumed for the purposes of t h i s study that the proportion of t o t a l laboratory workload a t t r i b u t a b l e to long term care patients i n predominantly acute care i n s t i t u t i o n s i s miniscule i n r e l a t i o n to t o t a l workload and w i l l not s i g n i f i c a n t l y a f f e c t the above mentioned c a l c u l a t i o n s . Appendix 7 summarizes the t o t a l laboratory workload for a l l h o s p i t a l size groups as well as summarizing the laboratory workload d i r e c t l y a t t r i b u t a b l e to i n p a t i e n t s , outpatients, r e f e r r e d - i n specimens, and q u a l i t y control workload. Table XI presents the number of inpatient laboratory workload units per patient day and Table XII presents the number of laboratory workload units per acute care admission. The measure of inpatient laboratory workload used i n these tables include units from q u a l i t y control work, related to the performance of inpatient t e s t s . The quantity of q u a l i t y control work performed i n a laboratory i s related to the volume of patient workload, however, the format of recording q u a l i t y control precludes i t s d i v i s i o n according to i t s r e l a t i o n to inpatient or outpatient workloads. For the purpose of these tables, q u a l i t y control workload was divided proportionately between inpatient, outpatient, and r e f e r r e d - i n , and then added to that component of workload. The proportions are recorded i n Appendix 7. It should therefore be Page 127 understood that the data presented i n Tables XI and XII do not represent the exact volume of laboratory workload d i r e c t l y a t t r i b u t a b l e to in p a t i e n t s , but does provide a reasonable estimate on which to base comparisons between reporting years and h o s p i t a l si z e groups. TABLE XI Inpatient Laboratory Workload Units per Patient Day and Percentage Change Between Periods, by Hospital Size Group, 1970 - 1980 Hospital Size Group 1970 units 1974 units % 1978 units % 1980 units % 1970-1980 % Group I 14.1 20.9 48.2 28.7 37.3 32.3 12.5 +129.0 Group II 20.0 27.7 38.5 30.7 10.8 31.5 2.6 +57.5 Group III 22.7 30.6 34.8 29.6 -3.3 30.2 2.0 +33.0 Group IV 28.5 34.0 19.3 39.5 16.2 40.9 3.5 +43.5 Group V 43.7 45.8 4.8 63.5 38.6 73.8 16.2 +68.9 TOTAL 25.2 30.8 22.2 38.4 24.6 41.1 7.0 +63.0 units = inpatient laboratory workload units per patient day % = percent change from previous period. As i s r e a d i l y apparent, there have been considerable increases i n both measures between a l l reporting years f or most h o s p i t a l s i z e groups. This finding i s consistent with what was expected based on reports i n the l i t e r a t u r e regarding increased use of laboratory services.(40,41,85) By looking at the rate of increase between reporting years i t i s clear that following very large increases i n the early 1970's the trend i s towards much smaller increases, and i n some cases decreases, by the end of that decade. It w i l l also be noticed that, generally, the smaller hospitals experienced the Page 128 largest increases i n both measures. Laboratory Workload Per Patient Day The net increases i n the laboratory workload per patient day ranged from a high of 129.0% for Group I hospitals from 1970 to 1980, to a low of 33.0% for Group III ho s p i t a l s over the same period. This could be an i n d i c a t i o n that physicians p r a c t i c i n g i n centres with very small hospitals have come to r e l y more heavily on laboratory screening to support t h e i r diagnoses. It could also be an e f f e c t of increased automation allowing, small h o s p i t a l laboratories to perform many tests previously referred to larger laboratories or simply not ordered. Such improvements i n automation may be allowing smaller laboratories to f i l l a latent demand for laboratory t e s t i n g . Present multi-parameter analyzers come i n various s i z e s , at various costs, with almost c e r t a i n l y an appropriate machine to f i t most needs and cost considerations. This trend could also be a r e f l e c t i o n of increased outpatient a c t i v i t y i n the smaller centers. There i s d e f i n i t e l y a move towards more ambulatory services offered out of hospitals including laboratory services and, as w i l l be noted from Appendix 7, the percentage of out-patient workload was co n s i s t e n t l y higher i n the smaller hospitals and generally increased throughout the study period. There i s more competition i n the larger centres between h o s p i t a l and private laboratories so that increased laboratory work i n t o t a l would not a f f e c t such h o s p i t a l s as much as the same trend i n a l o c a t i o n without laboratory Page 129 competition. The trend i s probably due to a combination of a l l three of the above f a c t o r s , and possibly others. It i s of i n t e r e s t to note that the rate of increase i n laboratory workload per patient day appears to be slowing o v e r a l l , but i s p a r t i c u l a r l y noticeable i n the smaller hospitals which experienced very large increases between 1970 and 1974. I n t e r e s t i n g l y , the teaching hospitals of Group V experienced the reverse trend. It should be noted that t h i s time period corresponds to the period when the N.D.P. was i n power i n B r i t i s h Columbia. The N.D.P. campaigned on the issue of the Social Credit ignoring s o c i a l programs including health care arguing that they were i n desparate need of an i n f u s i o n of money. It would be i n t e r e s t i n g to review c a p i t a l equipment expenditures for laboratories for the period 1970 to 1980 to see i f there was more equipment purchased i n the 1970 to 1974 period than during the remainder of the decade. If such were the case, i t would tend to strengthen the l i n k between the capacity to perform a test (supply) and the demand for that t e s t . Unfortunately, such information was not a v a i l a b l e when requested of the M i n i s t r y of Health. The slowing rate of increase i n laboratory workload per patient day may also be i n d i c a t i v e of successful r e s t r a i n t measures to reduce laboratory u t i l i z a t i o n , p a r t i c u l a r l y through physician education. It may also be that the latent demand generated by improved access to laboratory tests has peaked. Page 130 As would be ant i c i p a t e d , based on the l i k e l y acuity of patients seen i n the hospitals of various s i z e groups, the actual volume of laboratory workload per patient day generally increased with h o s p i t a l s i z e . Laboratory Workload Per Acute Care Admission Data related to the volume of laboratory workload per acute care admission shows s i m i l a r i t i e s to that of workload per patient day. Again, the highest volume of laboratory workload per acute care admission, (ACA), occurred i n the teaching hospitals and progressively decreased to the lowest l e v e l i n the hospital s of Group 1. It was also found that the rate of increase i n laboratory workload per admission i s slowing and, i n some cases, even d e c l i n i n g . TABLE XII Inpatient Laboratory Workload Units per Acute Care Admission and Percentage Change Between Periods, by Hospital Size Group, 1970 - 1980 Hospital 1970 1974 1978 1980 1970-Size 1980 Group units units % units % units % % Group I 104.2 142.6 36.9 179.1 25.6 190.9 6.6 +83.2 Group II 169.0 209.1 23.7 243.9 16.6 277.2 13.7 +64.0 Group III 178.7 245.9 37.6 322.6 31.2 236.1 -26.8 +32.1 Group IV 308.4 303.1 -1.7 506.7 67.2 518.2 2.3 +68.0 Group V 447.5 442.8 -1.1 916.3 106.9 729.2 -20.4 +62.9 TOTAL 225.0 251.4 11.7 380.3 51.2 368.7 -3.0 +63.0 units = inpatient laboratory workload units per acute care admission % = percent change from previous period. Page 131 It was i n t e r e s t i n g to note that the t o t a l percentage increase from 1970 to 1980 was very s i m i l a r for a l l h o s p i t a l s i z e groups, with the exception of Groups I and III with Group I experiencing a larger than average increase and Group III experiencing a lower than average increase i n laboratory workload per acute care admission. This would suggest that changes that have led to increased laboratory t e s t i n g i n hospitals have, for the most part, been general changes a f f e c t i n g a l l physicians and hospitals and not something that can be related to a p a r t i c u l a r group of hos p i t a l s or physicians. There has been considerable speculation on which factors contribute to the growing use of laboratory t e s t i n g . Griner suggests that overuse stems from concern over missing unsuspected diagnoses or unexpected changes i n the patient's c l i n i c a l condition, medico-legal considerations, innate c u r i o s i t y and, i n some s i t u a t i o n s , the need to "work up" a patient completely to s a t i s f y one's peers or supervisory physicians.(86) As the primary generators of laboratory demand, physicians have been the subject of e f f o r t s to control the mis-use of laboratory t e s t s . It i s often suggested that the percentage of laboratory studies that d i r e c t l y a f f e c t patient management i s low.(56,87) Most e f f o r t s to c o n t r o l the over-use of laboratory tests have been directed toward educating the physician on appropriate test ordering habits, the costs of t e s t s , and the l i m i t a t i o n s of c e r t a i n laboratory procedures.(39,40,86,87) These e f f o r t s have met with varying degrees of success but e f f o r t s continue to f i n d even more control mechanisms to ensure the most c o s t - e f f e c t i v e and Page 132 c o s t - b e n e f i c i a l use of laboratory s e r v i c e s . LABORATORY OPERATING COSTS IN BRITISH COLUMBIA HOSPITALS Categories of information related to laboratory operating costs include: Medical S a l a r i e s ; Non-Medical S a l a r i e s ; and Supplies and Expenses. Medical Salaries include a l l s a l a r i e s and fees paid to f u l l - t i m e , part-time, s e s s i o n a l , and f e e - f o r - s e r v i c e physicians employed by the h o s p i t a l for the operation of the laboratory. Non-Medical Salaries include a l l s a l a r i e s paid to t e c h n i c a l , c l e r i c a l , and administrative personnel employed i n the laboratory. Supplies and Expenses includes a l l other laboratory operating expenses excluding medical and s u r g i c a l supplies and drugs. This category includes purchased services from outside l a b o r a t o r i e s , radioactive material, and such laboratory supplies as glassware, p l a s t i c s and chemical reagents.(l) These costs are presented i n Appendix 8 for each h o s p i t a l s i z e category. The figures for a l l hospitals combined are presented here i n Table XIII. A l l figures have been adjusted for i n f l a t i o n , except as noted, and are reported i n 1971 d o l l a r s . The schedule of i n f l a t i o n used was as reported by S t a t i s t i c s Canada for a l l of Canada.(4) The year 1971 was chosen as base year as i t i s the year most commonly used i n a l l government reports where there are adjustments for i n f l a t i o n . These Tables also demonstrate how the proportion of each expense category changed over time and between ho s p i t a l s i z e groups. These figures do not consider changes i n the number of beds i n each h o s p i t a l s i z e group between reporting periods. Page 133 TABLE XIII Laboratory Operating Expenses by Category of Expense Showing Percentage D i s t r i b u t i o n and Percentage Change Between Periods, 1966 - 1980 Exp. Cat. * 1966 $ % xlOOO T 1970 $ % xlOOO T % C 1974 $ % xlOOO T % C 1978 $ % xlOOO T % C 1980 $ % xlOOO T % C 1966 1980 % Med. S a l . 1021 16 2262 18 122 3107 16 37 3843 13 23 4669 14 22 +357 Oth. S a l . 3679 56 8045 62 119 12364 62 54 17632 62 43 19759 60 12 +437 S&E 1815 28 2618 20 42 4488 22 71 7164 25 60 8633 26 21 +376 TOT. 6515 100 12925 100 98 19959 100 54 28640 100 44 33061 100 15 +407 % T = Percent of t o t a l expenses for that period rounded to the nearest whole number to conserve space. % C = Percent change from the previous period rounded to the nearest whole number to conserve space. Exp. Cat. = Expense Category Med. Sa l . = Medical Salaries Oth. S a l . = Other Salaries S&E = Supplies and Expenses * A l l cost figures are adjusted f o r i n f l a t i o n by presenting i n 1971 d o l l a r s . Non-Medical Salaries The largest portion of laboratory costs i s a t t r i b u t a b l e to non-medical s a l a r i e s . T y p i c a l l y , t h i s expense accounts for approximately 60% of the t o t a l laboratory budget. This r a t i o has not changed dramatically over the study period for most h o s p i t a l size categories. Group I and Group V hos p i t a l s experienced the most a c t i v i t y i n t h i s regard with Group I non-medical s a l a r i e s ranging from 55.1% to 67.1% of the t o t a l and Group V non-medical s a l a r i e s ranging from 54.9% to 71.0% of the t o t a l operating costs. Page 134 The rate of growth between reporting years for t h i s item i s c l e a r l y slowing for a l l h o s p i t a l s , i n aggregate, and for each i n d i v i d u a l s i z e group. O v e r a l l , the rate of increase has slowed from 118.7% between 1966 and 1970 to 12.1% between 1978 and 1980. Even considering the two year spread between 1978 and 1980, the trend i s s t i l l c l e a r l y towards a much slower rate of growth. This trend i s consistent for a l l h o s p i t a l s i z e groups, but perhaps to a lesser extent i n Group V h o s p i t a l s . A further note regarding non-medical s a l a r i e s i s that t h i s expense item r e a l i z e d the largest increase from 1966 to 1980 at 437%, compared to increases of 357% and 376% for medical s a l a r i e s and supplies and expenses r e s p e c t i v e l y . Supplies and Expenses The second largest portion of the laboratory operating budget i s supplies and expenses. This comprises something of the order of 24% of the o v e r a l l budget and has been increasing slowly but s t e a d i l y since 1970, from 20.3% to 26.1% i n 1980. The percentage increases between each reporting period have been c o n s i s t e n t l y large and do not demonstrate any clear trends towards an increasing or decreasing rate of growth. When data from the i n d i v i d u a l h o s p i t a l si z e groups are examined, there are apparent diffences i n the prominence of t h i s expense item i n r e l a t i o n to the other two expense categories. T y p i c a l l y , supplies and expenses account for a larger portion of the o v e r a l l budget i n smaller h o s p i t a l s . Any trends regarding d i r e c t i o n or rate of growth are le s s c l e a r for each size group. However, i t should be noted that the percentage increases Page 135 between reporting years are much larger for non-medical s a l a r i e s than for supplies and expenses i n the smaller hospitals while the reverse i s true i n the larger h o s p i t a l s . Medical Salaries Medical Salaries t y p i c a l l y comprise the smallest proportion of the o v e r a l l budget, averaging approximately 15% for a l l h o s p i t a l s , and do not demonstrate any cle a r trends with regards to d i r e c t i o n or rate of growth. This i s consistent for each h o s p i t a l s i z e group. It w i l l be noted that there i s a very clear d i f f e r e n c e i n the proportion of medical s a l a r i e s for laboratory work as a component of the o v e r a l l laboratory budget i n hosp i t a l s of the various s i z e groups. Medical s a l a r i e s comprise approximately 6% of the laboratory budget i n hosp i t a l s of l e s s than 100 beds but approximately 20% of the laboratory budget i n hospitals with more than 300 beds, which i s only s l i g h t l y higher than for teaching hospitals at 19%. This i s obviously an i n d i c a t i o n of the l e v e l of laboratory physician coverage i n small r u r a l hospitals where, commonly, a si n g l e general pathologist provides coverage for several h o s p i t a l s . I n t e r e s t i n g l y , i t i s not the teaching hospitals that expend the largest proportion of t h e i r budgets on medical s a l a r i e s , but the l a r g e l y regional r e f e r r a l hospitals of Group IV. Among the factors contributing to t h i s s i t u a t i o n i s the r o l e of the University of B.C. i n p a r t i a l l y supporting the s a l a r i e s of some laboratory physicians i n teaching h o s p i t a l s . Another major factor i s that the s a l a r i e s of Page 136 laboratory physicians i n teaching hospitals i s s u b s t a n t i a l l y below those of non-teaching h o s p i t a l s . This i s i n large part a t t r i b u t a b l e to a d i f f e r e n t set of aims and goals of pathologists and laboratory physicians i n the teaching hospitals as compared to t h e i r collegues i n the non-teaching h o s p i t a l s . One must be cautious when r e l a t i n g medical s a l a r i e s to laboratory workloads or when making comparisons between hospitals i n terms of laboratory medical s a l a r i e s . In addition to the l i m i t a t i o n s i d e n t i f i e d , above, some hospitals have developed unique arrangements for laboratory services and laboratory physician consultation. One large regional h o s p i t a l r e f e r s much of i t s laboratory workload to a private laboratory b u i l t adjacent to the h o s p i t a l . The medical s t a f f of the private laboratory provide a consulting service to the h o s p i t a l . Therefore, fees paid to laboratory medical s t a f f w i l l be recorded on the HS-1 Return, but laboratory workload performed i n the private laboratory w i l l not be recorded i n terms of workload units but l i k e l y as an operating expense. This gives the impression that the hos p i t a l has a much lower rate of laboratory workload per patient day or acute care admission than i t a c t u a l l y has. It would also appear to have an ino r d i n a t e l y large volume of consulting fees i n r e l a t i o n to the volume of laboratory work performed i n the h o s p i t a l . Another large regional h o s p i t a l has i t s laboratory workload performed i n i t s own laboratory but laboratory medical fees are paid to a group of laboratory physicians and pathologists organized to operate the hospital's laboratory on a contractual basis and not as ho s p t i a l employees as i s most common. Page 137 In depth and meaningful comparisons of laboratory services between hospitals would c e r t a i n l y be enhanced by increasing the uniformity of the organization and operation of h o s p i t a l laboratories throughout the province. Laboratory Costs Per Hospital A c t i v i t y Indicator A clearer picture of what i s a c t u a l l y happening to laboratory costs i n each h o s p i t a l size group may be found by standardizing costs to acute care admissions, patient days, and laboratory workloads u n i t s . These parameters are demonstrated i n Tables XIV, XV, and XVI, a l l of which are also presented i n constant 1971 d o l l a r s . The laboratory cost per patient day as presented i n Table XIV has e s s e n t i a l l y increased between a l l reporting periods and for a l l h o s p i t a l size groups. C o l l e c t i v e l y , costs per patient day have increased from $2.72 i n 1966 to $6.02 i n 1980 i n 1971 d o l l a r s . The highest cost per patient day occurs i n the teaching hospitals and generally decreases with h o s p i t a l s i z e . The rate of increase for a l l h o s p i t a l size groups i s c l e a r l y slowing which may be a t t r i b u t a b l e to improved cost e f f i c i e n c i e s through increased automation as well as e f f o r t s to control the volume of laboratory work ordered on each patie n t . Laboratory cost per acute care admission follows a s i m i l a r pattern to that described above. As was expected, the costs per acute care admission were found to increase with h o s p i t a l s i z e . The rate of increase between reporting years i s l e s s consistent than for Page 138 costs per patient day and while no clear trends have emerged, i t would appear that there i s a general slowing i n the rate of increase i n costs per acute care admission. TABLE XIV Laboratory Costs Per Patient Day and Percent Change From Previous Period, by Hospital Size Group, 1970 - 1980 Hospital 1970 1974 1978 1980 1970-Size 1980 Group $ $ % $ % $ % % Group I 1.67 2.47 47.9 3.86 56.2 4.42 14.5 +165.6 Group II 2.21 3.24 46.6 4.09 26.2 4.05 -0.9 +83.2 Group III 2.72 3.57 31.2 4.20 17.6 4.41 5.0 +62.1 Group IV 2.95 4.44 50.5 5.71 28.6 6.06 6.1 +105.4 Group V 4.03 5.76 42.9 8.19 42.1 10.52 28.4 +161.0 TOTAL 2.72 3.96 45.5 5.44 37.3 6.02 10.6 +121.3 $ = Laboratory costs per patient day % = Percentage change from previous period. A l l cost figures adjusted for i n f l a t i o n by reporting i n 1971 d o l l a r s . Laboratory costs per workload unit have increased at a much slower rate than the other two parameters described above. During the study period from 1970 to 1980, Group V ho s p i t a l s experienced the l a r g e s t increase from $0,092 i n 1970 to $0,141 i n 1980 representing an increase of 54.6%. Group I hospita l s reported the lowest net increase at 15.2%; increasing from $0.119/unit i n 1970 to $0.137/unit i n 1980. Page 139 TABLE XV Laboratory Costs Per Ac.ute Care Admission and Percentage Change From Previous Period, by Hospital Size Group, 1970 - 1980 Hospital Size Group 1970 $ 1974 $ % 1978 $ % 1980 $ % 1970-1980 % Group I 12.38 16.87 36.2 24.13 43.0 26.13 8.2 +111.0 Group II 18.64 24.43 31.0 32.50 33.0 37.71 16.0 +102.3 Group III 21.48 28.64 33.3 45.77 59.8 34.44 -24.7 +60.3 Group IV 31.89 39.61 24.2 73.27 84.9 76.84 4.8 +141.0 Group V 41.21 55.76 35.3 118.31 112.1 103.87 -12.2 +152.1 TOTAL 24.31 32.39 33.2 53.83 66.1 54.06 -0.4 +122.4 $ = Laboratory costs per acute care admission. % = Percentage change from previous period. A l l cost figures adjusted for i n f l a t i o n by reporting i n 1971 d o l l a r s . In terms of actual unit cost, the figures are remarkably s i m i l a r , with seldom more than one to two cents per unit d i f f e r e n c e between the highest and the lowest value. Generally Group IV hospitals had the highest cost per unit and Group II the lowest. The r e l a t i o n s h i p between Group I hospitals and Group V hospitals noted above does not appear to apply i n t h i s measurement. The rate of change between reporting years varies considerably between siz e groups and makes i d e n t f i c a t i o n of trends d i f f i c u l t , although i t may be suggested that the rate of increase i s generally slowing. This i s p a r t i c u l a r l y c l e a r for Group IV h o s p i t a l s . As s a l a r i e s have increased s u b s t a n t i a l l y over the study period, t h i s slower rate of increase i n laboratory costs per unit must be a t t r i b u t a b l e to higher p r o d u c t i v i t y l a r g e l y through increased automation. Page 140 TABLE XVI Laboratory Expenses Per Laboratory Workload Unit and Percentage Change Between Periods, by Hospital Size Group, 1970 - 1980 Hospital Size Group 1970 $ 1974 $ % 1978 $ % 1980 $ % 1970-1980 % Group I 0.119 0.118 -0.3 0.135 13.8 0.137 1.6 +15.2 Group II 0.110 0.117 5.9 0.133 14.0 0.129 -3.3 +16.8 Group III 0.120 0.116 -3.0 0.141 21.8 0.146 2.8 +21.5 Group IV 0.103 0.131 26.4 0.145 10.6 0.148 2.6 +43.5 Group V 0.092 0.126 36.7 0.129 2.5 0.142 10.1 +54.6 TOTAL 0.105 0.123 17.7 0.136 10.6 0.141 3.4 +35.5 ,. .„,.,„. _„,.,„ „_ _________— _____________ $ = Cost per workload unit ( i n 1971 d o l l a r s ) . % = Percentage change from previous period. SUMMARY It was expected that the proportion of technical assistants employed i n laboratories would increase with automation and c o s t - e f f i c i e n c y e f f o r t s . Such was not the case i n B.C. h o s p i t a l s . This was at t r i b u t e d l a r g e l y to a lack of q u a l i f i e d technical assistants i n the market-place, union t e r r i t o r i a l protection, and the desire to maintain the f l e x i b i l i t y of using s k i l l e d t echnologists. Another expectation that did not mate r i a l i z e was a more pronounced s t r a t i f i c a t i o n i n the ranks of medical laboratory technologists. Although the r e l i a b i l i t y of some of the data i s i n question, i t would appear that, e s s e n t i a l l y , there has been no change i n t h i s regard throughout t h i s study period. Page 141 The only aspect of the f i n d i n g s , related to laboratory personnel, that approached the expected outcomes was that the growth i n the workforce i s not progressing as quickly as the growth i n laboratory workload. Laboratory workload increased by about 90% from 1970 to 1980 whereas t o t a l laboratory personnel, excluding medical s t a f f , increased by 65.8% over the same period. This i s among the expected r e s u l t s of automation. In terms of workload units per FTE, the amount of work each employee can process per year has c o n t i n u a l l y increased, thanks p r i m a r i l y to increased and improved automation. It has been reported i n the l i t e r a t u r e that automation does have a s i g n i f i c a n t impact on both laboratory p r o d u c t i v i t y and laboratory operating costs. In B r i t i s h Columbia, between 1970 and 1980, workload i n h o s p i t a l laboratories increased by 90%. There was l i t t l e change i n the d i s t r i b u t i o n of the workload between laboratory se r v i c e s , with the exception that Blood Banking and Procurements increased i n proportion to other service areas. This was a t t r i b u t e d to increased s u r g i c a l procedures and increased i n t e n s i t y of laboratory t e s t i n g r e f l e c t e d i n more specimens c o l l e c t e d . Chemistry, i n the teaching h o s p i t a l s , accounted for an increasingly smaller proportion of t o t a l workload u n i t s . This was a t t r i b u t e d to advancements i n automation and to e f f o r t s to control use of laboratory services through education and other means. Laboratory workload per patient day and per acute care admission increased for a l l h o s p i t a l s i z e groups throughout the study period, r e f l e c t i n g increased u t i l i z a t i o n of laboratory s e r v i c e s . Smaller hospi t a l s generally experienced the largest Page 142 increases i n t h i s regard, perhaps r e f l e c t i n g a f u l f i l m e n t of a latent demand for laboratory s e r v i c e s , s a t i s f i e d by improvements i n automated equipment i n regards to size and cost. Generally, increases i n laboratory workload per patient day are slowing; perhaps an i n d i c a t i o n of successful r e s t r a i n t measures or a s a t i s f a c t i o n of latent demands. As was expected, data on laboratory operating costs show those costs to be increasing i n r e a l terms by an average 14% per annum for the period 1970-1980. The most rapid growth appears to have occurred during the early 1970's with subsequent smaller increases up to 1980. Salaries led the increases i n the early part of the study period, p a r t i c u l a r l y from 1966 to 1970 while Supplies and Expenses were increasing at a f a s t e r rate by the end of the study period. This trend i s c l e a r l y what one would expect to see a r i s i n g from improved laboratory e f f i c i e n c y through increased automation; that i s , increased consumables cost and decreased labour cost. As a percentage of o v e r a l l laboratory expenses, both medical and non-medical s a l a r i e s decreased continually throughout the study period while the percentage of t o t a l expenses a t t r i b u t a b l e to supplies s t e a d i l y increased. Page 143 CHAPTER IX SUMMARY AND CONCLUSIONS The objective of t h i s study was to review laboratory u t i l i z a t i o n i n public hospitals i n B r i t i s h Columbia and to analyze trends i n t h e i r u t i l i z a t i o n , i n r e l a t i o n to the future development of laboratories and the impact of these trends on manpower deployment and planning. The study encompassed the period from 1966 to 1980 and trends were i d e n t i f i e d by examining data for each of 1966, 1970, 1974, and 1980. The primary source of laboratory u t i l i z a t i o n data were the HS-1 s t a t i s t i c a l returns prepared annually by a l l h o s p i t a l s . The study addresses four main areas that impact on, or are affected by, the u t i l i z a t i o n of laboratory s e r v i c e s . Data related to these impact areas were analyzed i n terms of t h e i r e f f e c t on e i t h e r the demand for laboratory services or the supply of laboratory services i n B r i t i s h Columbia. Data c o l l e c t e d were related to the e f f e c t of changing demographics, changes i n technology and automation, changes i n the supply of physicians, and changes i n the supply and mix of laboratory manpower. Page 144 There were occasions when data reported i n the HS-1 returns appeared to be inconsistent with other findings and generally improbable. This i s l i k e l y the r e s u l t of c l e r i c a l error or misinterpretation of the i n s t r u c t i o n s and d e f i n i t i o n s for completing these s t a t i s t i c a l returns. In such s i t u a t i o n s , the inconsistencies were pointed out and the item i n question omitted from the a n a l y s i s . It would be b e n e f i c i a l to a l l users of these data i f the in s t r u c t i o n s and d e f i n i t i o n s provided to complete the HS-1 and HS-2 returns were c l a r i f i e d to avoid any confusion and misinterpretation on the part of the people completing the forms. At the outset of t h i s study i t was hoped that data related to c a p i t a l equipment a c q u i s i t i o n would be a v a i l a b l e i n order to r e l a t e changes i n t h i s regard to laboratory workloads, laboratory costs, and laboratory s t a f f i n g . When i t was found that such information was not r e a d i l y a v a i l a b l e from the Minis t r y of Health, these re l a t i o n s h i p s could only be the subject of conjecture. It would be an i n t e r e s t i n g future undertaking to review the a v a i l a b i l i t y of automated equipment and i t s r e l a t i o n to changes i n the demand for laboratory s e r v i c e s . Background From an i n i t i a l review of the development of B r i t i s h Columbia's health care d e l i v e r y system, i t was found that our present province-wide medical and h o s p i t a l insurance system had i t s beginning i n a 1919 B.C. Royal Commission on state health insurance. Following further Royal Commissions, i n i t i a l l e g i s l a t i o n , and growing d i s s a t i s f a c t i o n with the private insurance Page 145 plans, B.C. introduced the Hospital Insurance Act i n 1949. While t h i s h o s p i t a l insurance plan was universal i n a p p l i c a t i o n , i t excluded chronic care and outpatient s e r v i c e s . This approach meant i t was l e s s of a f i n a n c i a l burden to patients to have c e r t a i n health care services provided on a h o s p i t a l inpatient basis and hence, focused B.C.'s u t i l i z a t i o n of health care services around h o s p i t a l care. At approximately the same time, the federal government introduced i t s National Health Grants Act (1948) which provided a source of funds to provinces covering 50% of the c a p i t a l costs of h o s p i t a l construction. Communities then had a source of funds to b u i l d t h e i r own h o s p i t a l s , and through the Hospital Insurance Act, a source of guaranteed payment to operate them, The outcome was a p r o l i f e r a t i o n of new or renovated hospitals throughout the province during the 1950's and 1960's. The consulting firm of James Hamilton and Associates was hired by the B.C. government i n 1949 to prepare a p r o v i n c i a l h o s p i t a l construction and manpower plan. Out of that study came recommendations for more h o s p i t a l beds, enlargement of the province's health manpower t r a i n i n g f a c i l i t i e s , and the adoption of a regional h o s p i t a l plan with an organized r e f e r r a l pattern. It was from t h i s base that the province's e x i s t i n g regional h o s p i t a l system developed. This r e g i o n a l i z a t i o n concept was further developed by the subsequent establishment i n 1967 of Regional Hospital D i s t r i c t s . Page 146 Insured health care services were expanded to include physician services i n 1965 with the introduction of the Medical Grant Act i n B.C. followed by the federal government's Medical Care Act i n 1968. The B.C. Medical Grant Act was based on a fee-for-service payment system and allowed physicians a r o l e i n s e t t i n g the fee schedule. The federal Medical Care Act required the federal government to pay 50% of a l l insured medical s e r v i c e s . The impact of these developments on laboratories was an increase i n laboratory workload because of the increased opportunities presented i n the new f a c i l i t i e s to provide laboratory se r v i c e s , the removal of f i n a n c i a l b a r r i e r s , and the increased importance which laboratory procedures played i n the diagnosis and treatment of patients. There was a period of rapid, uncoordinated laboratory expansion which resulted i n considerable d u p l i c a t i o n of expensive procedures. This drew the attention of the p r o v i n c i a l government which i n i t i a t e d a regional r e f e r r a l system for laboratory services s i m i l a r to that intended for h o s p i t a l services i n general. Later e f f o r t s to coordinate and r a t i o n a l i z e the d e l i v e r y system, as i t r e l a t e s to laboratories and h o s p i t a l s , included the various planning e f f o r t s of the B.C. Medical Center, the Bed Matrix study, the Joint Funding study and the Hospital Role study. A l l of these e f f o r t s have had some degree of impact on the health care d e l i v e r y system i f only to bring attention to the need for more co s t - e f f e c t i v e organization and management of the system. E f f o r t s are continuing today to bring more r a t i o n a l planning and a c c o u n t a b i l i t y into the system. Page 147 Growth i n the Demand for Health Care Services A number of factors have been i d e n t i f i e d as contributing to the growing demand for laboratory services. Among these factors are included an increasing and aging population accustomed to a high l e v e l of q u a l i t y health care services; a growing supply of physicians, each of whom wish to provide t h e i r patients with the best care possible and who also wish to maintain a high standard of l i v i n g ; and the a b i l i t y to meet the demand e a s i l y and in c r e a s i n g l y e f f i c i e n t l y through increased and improved automated equipment. It was found that B.C.'s population increased by approximately^ 41% from 1966 to 1980 and that the increase was predominantly due to in-migration from other provinces. It was also noted that the e l d e r l y tend to use a disproportionately large amount of health care services and the the population of B.C. and the rest of Canada i s aging. The percentage of the population i n Canada over the age of 65 increased from 5.1% i n 1901 to an estimated 9.5% by 1981. The percentage of the population over the age of 65 i n B.C. increased by a f u l l percentage point to 10.9% between 1976 and 1981. The changes i n demographics and funding of health f a c i l i t i e s are r e f l e c t e d i n changes i n the number, mix, and u t i l i z a t i o n of i n s t i t u t i o n a l beds. It was found that, o v e r a l l , the number of ho s p i t a l beds i n B.C. increased i n proportion to the population from 15.2/1000 i n 1962 to 17.6/1000 i n 1978. The d i s t r i b u t i o n of these beds by function also changed, with acute care beds decreasing from 6.1/1000 to 4.3/1000 for the same period and long term care beds increasing from 0.4/1000 to 2.2/1000 also for the same period. Page 148 In addition to the changing number of beds, there were also changes i n the d i s t r i b u t i o n of these beds by h o s p i t a l service. It was found that generally, there were increases i n the proportion of Intensive Care beds and P s y c h i a t r i c beds and decreases i n the proportion of O b s t e t r i c a l and P e d i a t r i c beds. The exception to t h i s general trend was the finding that the proportion of O b s t e t r i c a l and P e d i a t r i c beds i n the r e f e r r a l hospitals of Group IV increased s u b s t a n t i a l l y throughout t h i s study period. It was suggested that t h i s r e f l e c t e d a move towards c e n t r a l i z a t i o n of these rather s p e c i a l i z e d beds As would be expected from the increased population and the growing supply of h o s p i t a l beds i n B.C., i t was found that the use of h o s p i t a l f a c i l i t i e s increased i n terms of Patient Days and Acute Care Admissions. More s i g n i f i c a n t l y , i t was found that the a v a i l a b l e f a c i l i t i e s appear to be used more c l o s e l y to t h e i r capacity with general increases i n the number of patient days per acute care bed for a l l h o s p i t a l s i z e groups except for Group V which experienced a decrease of 11%. In addition, i t was found that there was an o v e r a l l modest increase i n the number of admissions per bed and a more substantial increase i n the average length of stay. It was i n t e r e s t i n g to note that while Group I hospitals had a very large increase i n the average length of stay, the h o s p i t a l s of Groups IV and V had quite substantial decreases i n t h i s measure. This was attributed to r e s t r a i n t e f f o r t s and increased use of ambulatory services i n the larger h o s p i t a l s . Page 149 The increased inpatient a c t i v i t y i n h o s p i t a l s , h o s p i t a l s ' increased role i n the provision of outpatient services, and the increased amount of laboratory work ordered by the physician population, have a l l contributed to the growth i n the demand for laboratory s e r v i c e s . With regard to the impact of the supply of physicians on laboratory u t i l i z a t i o n , i t was found that many researchers i d e n t i f y physicians as having the single most important r o l e i n the d e l i v e r y of health care services because t h e i r decisions and behaviour a f f e c t almost a l l aspects of the d e l i v e r y system. It was noted that several authors have suggested that a physician's place of t r a i n i n g and his or her personality are key factors i n determining how a physician uses laboratory s e r v i c e s . It has been these areas that have recieved considerable attention i n e f f o r t s to control the u t i l i z a t i o n of laboratory services and some successes of varying degree were reported. The implication of these increases i n the demand for laboratory services on laboratory manpower i s to increase the demand for laboratory manpower resources. In addition to merely considering the growth i n the demand for medical technologists i n terms of B.C.'s a b i l i t y to r e c r u i t trained personnel or i t s d e s i r e , or o b l i g a t i o n , to increase the t r a i n i n g f a c i l i t i e s for l o c a l residents, health manpower planners must also consider the appropriateness of the current emphasis on medical laboratory technologists and whether p o l i c y changes may be imminent that would impact the type of personnel laboratories employ. Page 150 Issues Related to the Supply of Health Care Services This study included a review of the current patterns of manpower deployment i n B.C. h o s p i t a l l a b o r a t o r i e s . The development of medical laboratory technologists as an organized group of para-medical professionals was reviewed from t h e i r e arly days of on-the-job t r a i n i n g to become assistants to pathologists, to the current extensive t r a i n i n g programs and multiple l e v e l s of c e r t i f i c a t i o n and r e g i s t r a t i o n . The study goes on to describe issues relevant to manpower planning and the h i s t o r i c a l development and organization of manpower planning i n B.C. from the Hamilton Report of 1949 to the Western Canada Health Manpower Training Study of 1982. It was noted that B.C. has t r a d i t i o n a l l y been, and continues to be, a net importer of trained health care manpower and the possible implications of th i s were discussed. Findings and Implications One of the expectations of t h i s study was the prospect of fi n d i n g evidence of increasing technical s t r a t i f i c a t i o n i n the laboratory workforce due l a r g e l y to the impact of automation on career paths and h o s p i t a l expectations for c o s t - e f f e c t i v e operation. It was believed at the outset of t h i s study that increasing automation would si m p l i f y many aspects of the day-to-day workflow i n la b o r a t o r i e s , leading to a reduction i n the need for such highly trained personnel as medical laboratory technologists and an increasing demand for technical a s s i s t a n t s . It was also expected Page 151 that there would be an increasing proportion of A.R.T.s and L i c e n t i a t e s among Registered Technologists, as technologists use these a d d i t i o n a l q u a l i f i c a t i o n s to advance themselves i n t h e i r professions and careers. If such trends are indeed an e f f e c t of automation as suggested i n the l i t e r a t u r e , t h i s concept could not be supported by evidence presented i n t h i s study. However, rather than r u l i n g out t h i s e f f e c t , i t should be considered that the study period may have been too short for the e f f e c t to be manifested and perhaps a study covering a wider time period should be undertaken. It was found that the percentage d i s t r i b u t i o n of the various laboratory personnel groups changed only s l i g h t l y over the study period with the proportion of Registered Technologists increasing s l i g h t l y , the proportion of Technical Assistants increasing even more modestly,and the proportion of Laboratory S c i e n t i s t s decreasing s l i g h t l y . The proportion of c l e r i c a l s t a f f remained e s s e n t i a l l y unchanged throughout the study period. It was also found that o v e r a l l , there was very l i t t l e change i n the d i s t r i b u t i o n of A.R.T.'s, L i c e n t i a t e s , and R.T.'s although i t was noted that i n h o s p i t a l size Groups I, I I , and I I I , t h e i r numbers were increasing, while the reverse was true for hospitals of Group IV and V. Data related to actual laboratory workload were c o l l e c t e d for each h o s p i t a l size group. As expected, the volume of laboratory work increased throughout the study period for a l l h o s p i t a l size groups and by a l l measures including workload per patient day and workload per acute care admission. It was i n t e r e s t i n g to note that Page 152 the smaller hospitals of Group I experienced the largest increase i n laboratory workload per patient day, possibly r e f l e c t i n g the a p p l i c a b i l i t y of current automated equipment to small l a b o r a t o r i e s allowing them to s a t i s f y a latent demand. It was also i n t e r e s t i n g to note that contrary to what may have been expected, based on reports i n the l i t e r a t u r e , the amount of laboratory work per admission i n teaching h o s p i t a l s i n B.C. i s not increasing at a f a s t e r rate than i n non-teaching h o s p i t a l s . Another expected e f f e c t of automation on laboratories was r e l a t e d to laboratory operating expenses. This study shows that the proportion of the o v e r a l l laboratory operating budget al l o c a t e d to operating supplies i s increasing s t e a d i l y while the proportion a t t r i b u t a b l e to technical s a l a r i e s i s remaining r e l a t i v e l y constant and that of medical s a l a r i e s appears to be decreasing. It was demonstrated that the volume of laboratory work being processed i n B.C. public hospitals has been increasing throughout t h i s study period. This was demonstrated i n terms of t o t a l laboratory workload reported, as well as i n terms of laboratory workload per patient day and per acute care admission. A f a c t o r that could not be analyzed i n t h i s study was the change i n the number of laboratory tests per patient day or acute care admission. The test count i s not reported by hospitals to the Ministry of Health except for tests referred out. The number of tests per patient day or acute care admission would l i k e l y show a greater increase than the laboratory workload units per patient day or acute care admission as the necessary workload units to complete a test are s u b s t a n t i a l l y moderated by increasing automation. Page 153 Discussion A number of paradoxical s i t u a t i o n s have been described that r e l a t e to various aspects of laboratory operation and s t a f f i n g . It was noted that the use of technical assistants i s more prevalent i n some hospita l s then others and that t h e i r use could contribute to a more c o s t - e f f e c t i v e operation, yet B.C. does not have a laboratory assistant t r a i n i n g program and must r e l y on r e c r u i t i n g from out of province or on-the-job t r a i n i n g . Reasons for the absence of such a t r a i n i n g program have been discussed i n t h i s study and include fear of wage d i f f e r e n t i a l struggles between technical assistants and technologists, such as had developed between registered nurses and p r a c t i c a l nurses; union protectionism preserving a share of the marketplace f o r t h e i r members; the question of whether to include a c l i n i c a l t r a i n i n g period and who would pay for i t ; and the unwritten p o l i c y that requires B.C. to import trained personnel as long as i t i s able to do so. If B.C. h o s p i t a l laboratories are to become as c o s t - e f f i c i e n t i n t h e i r operation as possible, i t w i l l be necessary to have a better d i s t r i b u t i o n of highly trained and lesser trained personnel. This w i l l require changes i n the way B.C. currently uses laboratory technical a s s i s t a n t s . Related to the use of laboratory a s s i s t a n t s i s the supply of medical laboratory technologists. It was reported that one study projected a need for an ad d i t i o n a l 40 medical laboratory technologist graduates per year, over and above the current l e v e l of graduates, u n t i l the turn of the century. At the present time, Page 154 B.C.'s technologist t r a i n i n g i n s t i t u t i o n s are having to reduce t h e i r enrollments because, i n part, hospitals are reducing the number of positions a v a i l a b l e for t h i r d year c l i n i c a l practicums. The problem i s l a r g e l y one of financing which has the Minis t r y of Health funding post-secondary education i n that hospitals pay t h e i r student technologists a minimum wage. Because of general f i n a n c i a l constraints some hospital s are trading i n t h e i r student positions for f u l l y q u a l i f i e d bench technologists. If t h i s trend continues, B.C. w i l l f i n d i t s e l f more dependent on out-of-province manpower which could lead to eventual manpower shortages not to mention domestic unrest. A speedy s o l u t i o n should be sought f o r t h i s present s i t u a t i o n before i t becomes a major problem. Another possible c o n f l i c t related to the o v e r a l l laboratory services d e l i v e r y system that should be addressed i s the ro l e of the private laboratories i n providing laboratory s e r v i c e s . Private l a b o r a t o r i e s are o f f e r i n g services that could be provided by public hospitals without the substantial p r o f i t margin b u i l t into the payment system being incurred. At a time when wholesale cuts are being considered i n many s o c i a l programs the government must be considering whether i t can afford to continue to support the private sector i n heatlh care as i t rel a t e s to laboratory s e r v i c e s . This must be an issue of major philosophical c o n f l i c t for the present S o c i a l Credit government that prides i t s e l f on i t s support of the private sector and small businesses. This c o n f l i c t may be such that the question i s temporarily avoided by government p o l i c y makers who may focus t h e i r attention towards other options i n c o n t r o l l i n g the use of laboratory s e r v i c e s . Page 155 There are a number of areas discussed i n t h i s study where government ei t h e r has looked, or could look for ways of c o n t r o l l i n g laboratory u t i l i z a t i o n . Modifying how a physician makes use of laboratory services i s an area receiving considerable attention because i t i s the physician's actions that i n large part drive the demand for such s e r v i c e s . I n i t i a l studies by Hardwick, Freeborn, and Schroeder, among others, suggests there may be some successes i n t h i s regard. A less d i r e c t method of c o n t r o l l i n g the use of laboratory services by physicians i s c o n t r o l l i n g the number of physicians. E f f o r t s are only now being made i n t h i s d i r e c t i o n by l i m i t i n g Medical Services Plan b i l l i n g numbers and by not increasing the enrolment of the U.B.C. medical school. The area i n which government influence i n c o n t r o l l i n g laboratory use i s most apparent i s i n f i n a n c i a l r e s t r i c t i o n s on h o s p i t a l s . Through budgetary constraints on both operating and c a p i t a l budgets, the government i s able to a f f e c t i n d i r e c t l y the a v a i l a b i l i t y of laboratory s e r v i c e s , however, t h i s may a c t u a l l y serve to increase laboratory costs. Hospitals under such constraints may f i n d i t necessary to reduce t h e i r outpatient workload i n favour of inpatient needs and thus force more work towards the private l a b o r a t o r i e s . At best, t h i s approach can only serve as a stop-gap measure as w i l l any approach based on the c y c l i c a l nature of the p r o v i n c i a l economy and one that focuses c o n s t r i c t i o n s on the producers rather than the i n i t i a t o r s of the demand. Page 156 A more r a t i o n a l approach i s where the perceived need for laboratory services i s changed. This i s p r i m a r i l y accomplished through educating the users of laboratory services and through eliminating a l l f i n a n c i a l incentives, both d i r e c t and i n d i r e c t , that promote the use of diagnostic services to ensure that the use of these services i s based s o l e l y on c l i n i c a l merit. The B.C. Association of Laboratory Physicians must take a more active r o l e i n i d e n t i f y i n g the appropriate use of laboratory procedures and a s s i s t i n g t h e i r peers i n proper test s e l e c t i o n . Hospital pathologists and laboratory physicians must also become more involved, with the support of h o s p i t a l administrators, i n assuring appropriate test s e l e c t i o n by h o s p i t a l s t a f f and following up and c o r r e c t i n g apparent abuses. It i s hoped that the information presented i n t h i s study w i l l be of some value to health care planners and p o l i c y makers. It i s recognized that i t i s primarily a compilation of data and thoughts rather than an emperical analysis of a problem and a presentation of fi n d i n g s , however, i t should serve to generate i n t e r e s t and discussion i n some of the areas explored above and may be of some assistance i n the continuing e f f o r t s to operate the province's health care system i n as e f f i c i e n t a manner as possible. Recommendations 1. E f f o r t s should be made to improve the consistency of data reported by h o s p i t a l s . Improving the c l a r i t y of the Instructions and D e f i n i t i o n s for the HS-1 and HS-2 Returns and reviewing the scope of information c o l l e c t e d should be of some Page 157 assistance i n t h i s regard. 2. Private sector laboratories should be required to report t h e i r workload a c t i v i t i e s and s t a f f i n g patterns to government i n the same manner and format as public sector l a b o r a t o r i e s . 3. The government of B.C. should examine i t s p o l i c i e s regarding funding of health manpower t r a i n i n g f a c i l i t i e s and programs to ensure current trends i n manpower production w i l l not increase the province's r e l i a n c e on out-of-province trained personnel. 4. A mechanism should be established to record and monitor the i n s e r t i o n of major c a p i t a l equipment into the health care system so that these data may be used for future impact studies. 5. Hospitals should be encouraged to make use of a l t e r n a t i v e manpower resources, where appropriate, to increase operating e f f i c i e n c y and should not be r e s t r i c t e d i n t h i s regard by organized protectionism. Page 158 REFERENCES 1. 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(1) Sub-Total 1,971 63.5 1,918 70.2 1,728 67.4 1,593 66.7 1,695 68.0 -14.0 Intensive Care 12 0.4 12 0.4 44 1.7 39 1.6 46 1.8 +283.3 Ob s t e t r i c a l 436 14.0 324 11.8 300 11.7 312 13.1 319 12.8 -26.8 P e d i a t r i c 620 20.0 474 17.3 481 18.8 433 18.1 424 17.0 -31.6 P s y c h i a t r i c 5 0.2 4 0.1 12 0.5 10 0.4 10 0.4 +100.0 Other 62 2.0 2 0.0 0 0 1 0.0 0 0 -100.0 TOTAL 3,106 100 2,734 100 2,565 100 2,388 100 2,494 100 -19.7 % T = Percentage of t o t a l beds for that period. 1966-1980 % = Total percentage increase from 1966 to 1980. (1) Undistributed beds are those not o f f i c i a l l y c l a s s i f i e d as medical or surg i c a l but may be used f o r e i t h e r . APPENDIX 1 (CONT'D) TABLE 1 - 2 Number and Percentage D i s t r i b u t i o n of Hospital Beds by Bed C l a s s i f i c a t i o n f o r a l l Public Hospitals; by Hospital Size Group : 1966 - 1980 Group II Hospitals Bed 1966 1970 1974 1978 1980 1966-% % % % % 1980 C l a s s i f i c a t i o n Beds T Beds T Beds T Beds T Beds T % Medical 0 0 639 25.5 539 22.0 506 20.2 479 17.9 -S u r g i c a l 0 0 512 20.4 415 16.9 437 17.4 409 15.3 -Undistributed 1,380 65.1 538 21.5 668 27.2 717 28.6 891 33.3 -35.4 Med/Surg. (1) Sub-Total 1,380 65.1 1,689 67.5 1,622 66.1 1,660 66.2 1,779 66.6 +28.9 Intensive Care 0 0 53 2.1 71 2.9 90 3.6 97 3.6 +83.0* O b s t e t r i c a l 326 15.4 329 13.2 268 10.9 241 9.6 234 8.8 -28.2 P e d i a t r i c 373 17.6 367 14.7 373 15.2 349 13.9 337 12.6 -9.7 P s y c h i a t r i c 18 0.8 63 2.5 121 4.9 132 5.3 184 6.9 +922.2 Other 22 1.0 0 0 0 0 34 1.4 40 1.5 +81.8 Total 2,119 100 2,501 100 2,455 100 2,506 100 2,671 100 +26.1 % T = Percentage of t o t a l beds for that year. 1966-1980 % = Total percentage change i n the number of from 1966 to 1980. (1) Undistributed beds * This percentage change i s from 1970 to 1980. APPENDIX 1 (CONT'D) TABLE 1 - 3 Number and Percentage D i s t r i b u t i o n of Hospital Beds by Bed C l a s s i f i c a t i o n f o r a l l B.C. Public Hospitals; by Hospital Size Group : 1966 - 1980 Group III Hospitals Bed 1966 1970 1974 1978 1980 1966 % % % % % 1980 C l a s s i f i c a t i o n Beds T Beds T Beds T Beds T Beds T % Medical 0 0 346 27 .4 166 11.0 304 23 .7 333 30 .7 -Surgical 0 0 449 35 .6 208 13.8 371 28 .9 362 33 .4 -Undistributed 456 63.0 0 0 690 45.8 153 11 .9 0 0 -100 .0 Med/Surg. (1) Sub-Total 456 63.0 795 63 .0 1,064 70.6 828 64 .5 695 64 .1 +52 .4 Intensive Care 0 0 29 2 .3 36 2.4 48 3 .7 39 3 .6 +34. 5* O b s t e t r i c a l 96 13.3 115 9 .1 125 8.3 90 7 .0 87 8 .0 -9 .4 Pe d i a t r i c 149 20.6 216 17 .1 195 12.9 134 10 .4 100 9 .2 -32 .9 Ps y c h i a t r i c 23 3.2 29 2 .3 87 12.9 87 6 .8 67 6 .2 +191 .3 Other 0 0 78 6 .2 0 0 97 7 .6 97 8 .9 +25. 6 * TOTAL 724 100 1,262 100 1,507 100 1,284 100 1,085 100 +49 .9 APPENDIX 1 (CONT'D) TABLE 1 - 4 Number and Percentage D i s t r i b u t i o n of Hospital Beds by Bed C l a s s i f i c a t i o n f o r a l l B.C. Public Hospitals; by Hospital Size Group : 1966 - 1980 Group IV Hospitals Bed 1966 1970 1974 1978 1980 1966-% % % % % 1980 C l a s s i f i c a t i o n Beds T Beds T Beds T Beds T Beds T % Medical 0 0 920 32 .8 311 11.1 192 6.1 316 10.0 -Surgical 0 0 689 24 .6 372 13.3 236 7.5 386 12.2 -Undistributed 1.927 76. 6 468 16 .7 1,280 45.8 1,789 57.0 1,479 46.7 -23.2 Med/Surg. (1) Sub-Total 1,927 76. 6 2,067 73 .6 1,963 70.3 2,217 70.6 2,181 68.9 + 13.2 Intensive Care 14 0. 6 38 1 .4 54 1.9 97 3.1 131 4.1 +835.7 O b s t e t r i c a l 168 6. 7 212 7 .5 222 7.9 244 7.8 258 8.1 +53.6 P e d i a t r i c 192 7. 6 241 8 .6 311 11.1 281 8.9 269 8.5 +40.1 P s y c h i a t r i c 106 4. 2 211 7 .5 199 7.1 205 6.5 235 7.4 +121.7 Other 109 4. 3 30 1 .1 45 1.6 97 3.1 93 2.9 -14.7 TOTAL 2,516 100 2,809 100 2,794 100 3,141 100 3,167 100 +25.9 APPENDIX 1 (CONT'D) TABLE 1 - 5 Number and Percentage D i s t r i b u t i o n of Hospital Beds by Bed C l a s s i f i c a t i o n for a l l B.C. Public Hospitals; by Hospital Size Category: 1966 - 1980 Group V Hospitals Bed 1966 1970 1974 1978 1980 1966-% % % % % 1980 C l a s s i f i c a t i o n Beds T Beds T Beds T Beds T Beds T % Medical 0 0 597 27.8 929 35.5 648 28.3 719 29.9 -Surgical 0 0 550 25.6 1,142 43.7 997 43.5 1,100 45.8 -Undistributed 1,596 74.9 506 23.6 34 1.3 109 4.8 76 3.2 -95.2 Med/Surg. (1) Sub-Total 1,596 74.9 1,653 77.0 2,105 80.5 1,754 76.5 1,895 78.9 +18.7 Intensive Care 0 0 31 1.4 37 1.4 99 4.3 102 4.2 +229.0* O b s t e t r i c a l 164 7.7 160 7.4 137 5.2 125 5.5 100 4.2 -39.0 P e d i a t r i c 266 12.5 255 11.9 222 8.5 122 5.3 122 5.1 -54.1 P s y c h i a t r i c 40 1.9 49 2.3 106 4.1 184 8.0 184 7.7 +360.0 Other 64 3.0 0 0 7 0.3 8 0.3 0 0 -100.0 TOTAL 2,130 100 2,148 100 2,614 100 2,292 100 2,403 100 +12.8 * Percentage change calculated from 1970 to 1980 APPENDIX 1 (CONT'D) TABLE 1 - 6 Number and Percentage D i s t r i b u t i o n of Hospital Beds by Bed C l a s s i f i c a t i o n f o r a l l B.C. Public Hospitals; by Hosptial Size Group: 1966 - 1980 A l l Hospitals Bed C l a s s i f i c a t i o n 1966 % Beds T 1970 % Beds T 1974 % Beds T 1978 % Beds T 1980 % Beds T 1966-1980 % Medical 0 0 2,775 24.2 2,166 18.1 2,084 17.9 2,351 19.9 -Surgical 0 0 2,442 21.3 2,332 19.5 2,303 19.8 2,580 21.8 -Undistributed 7,330 69.2 2,915 25.4 3,984 33.4 3,665 31.6 3,314 28.0 -54.8 Med/Surg. (1) Sub-Total 7,330 69.2 8,132 71.0 8,482 71.1 8,052 69.3 8,245 69.8 +12.5 Intensive Care 26 0.2 163 1.4 242 2.0 373 3.2 415 3.5 +1496.1 O b s t e t r i c a l 1,190 11.2 1,140 10.0 1.052 8.8 1,012 8.7 998 8.4 -16.1 P e d i a t r i c 1,600 15.1 1,553 13.6 1,582 13.3 1,319 11.4 1,252 10.6 -21.8 P s y c h i a t r i c 192 1.8 356 3.1 525 4.4 618 5.3 680 5.8 +254.2 Other 257 2.4 110 1.0 52 0.4 237 2.0 230 1.9 -10.5 TOTAL 10,595 100 11,454 100 11,935 100 11,611 100 11,820 100 +11.6 Page 171 APPENDIX 2 TABLE 2 - 1 Number and Percentage D i s t r i b u t i o n of Laboratory Personnel i n B.C. Public Hospitals Showing Percentage Change from Previous Period and Total Percentage Change; by Type of Personnel and Hospital Size Group Group I Hospitals : 1970-1980 Laboratory Personnel C l a s s i f i c a t i o n 1970 FTE % 1974 FTE % 1978 FTE % 1980 FTE % 1970-1980 % Laboratory(1) 2.2 1.1 2.9 1.1 1.6 0.4 7.6 1.8 +245.5 S c i e n t i s t Registered (2) 140.4 67.7 177.0 65.6 250.5 62.7 299.6 69.7 +66.4 Technologist Non-Registered 11.8 5.7 11.1 4.1 16.6 4.2 8.6 2.0 -27.1 Technologist (3) Other Staff 5.4 2.6 2.9 1.1 2.5 0.6 6.8 1.6 +1.5 Technical (4) Other Staff 47.6 23.0 75.8 28.1 128.4 32.1 107.3 25.0 +27.0 Laboratory (5) Group I TOTAL 207.4 100 269.7 100 399.6 100 429.8 100 +107.2 (1) Refers to persons holding a recognized degree i n an appropriate laboratory d i s c i p l i n e , (eg. B.Sc.,M.Sc.,Ph.D.) (2) Refers to persons registered as a medical laboratory technologist with the Canadian Society of Laboratory Technologists and those persons who could be registered should a p p l i c a t i o n be made. (3) Refers to persons employed as medical laboratory technologists but who are not e l i g i b l e for r e g i s t r a t i o n with C.S.L.T. (4) Refers to persons q u a l i f i e d through a formal course to function as a laboratory technician but are not q u a l i f i e d for r e g i s t r a t i o n as a technologist with the C.S.L.T. (5) Includes a l l other laboratory s t a f f . ( C l e r i c a l , Administrative, etc.) Page 172 APPENDIX 2 (CONT'D) TABLE 2 - 2 Number and Percentage D i s t r i b u t i o n of Laboratory Personnel i n B.C. Public Hospitals Showing Percentage Change From Previous Period and Total Percentage Change; by type of Personnel and Hospital Size Group Group II and Group III Hospitals : 1970 - 1980 Laboratory Personnel C l a s s i f i c a t i o n 1970 FTE % 1974 FTE % 1978 FTE % 1980 FTE % 1970-1980 % GROUP II Laboratory S c i e n t i s t s 0 0 0.1 0.0 0.8 0.3 0 0 -Registered Technologists 124.6 71.3 170.7 74.3 214.7 76.7 237.0 76.2 +74.6 Non-Registered Technologists 14.0 8.0 5.9 2.6 3.5 1.2 2.6 0.8 -81.4 Other S t a f f , Technical 3.1 1.8 5.1 2.2 3.6 1.3 6.8 2.2 +1.9 Other S t a f f , Laboratory 33.1 18.9 47.8 20.8 57.5 20.5 64.8 20.8 +20.3 Group II TOTAL 174.7 100 229.6 100 280.1 100 311.2 100 +78.1 GROUP III FTE % FTE % FTE % FTE % % Laboratory S c i e n t i s t s 0 0 0 0 0 0 0 0 Registered Technologists 69.7 65.2 98.2 71.1 103.0 72.0 106.5 74.6 +70.7 Non-Registered Technologists 7.3 6.8 4.6 3.4 2.0 1.4 1.5 1.0 -79.4 Other S t a f f , Technical 1.8 1.7 3.1 2.2 6.6 4.6 6.1 4.3 +3.2 Other S t a f f , Laboratory 28.2 26.3 32.3 23.4 31.5 22.0 28.7 20.1 +22.9 Group III TOTAL 107.0 100 138.1 100 143.2 100 142.8 100 +33.4 Page 173 APPENDIX 2 (CONT'D) TABLE 2 - 3 Number and Percentage D i s t r i b u t i o n of Laboratory Personnel i n B.C. Public Hospitals Showing Percentage Change From Previous Period and Total Percentage Change; by Type of Personnel and Hospital Size Group Group IV and Group V Hospitals : 1970 - 1980 Laboratory Personnel C l a s s i f i c a t i o n 1970 FTE % 1974 FTE % 1978 FTE % 1980 FTE % 1970-1980 % GROUP IV Laboratory S c i e n t i s t s 18.9 5.5 9.0 2.4 7.3 1.9 5.5 1.0 -94.7 Registered Technologists 208.8 60.3 247.5 64.8 263.0 68.7 370.9 66.3 +66.0 Non-Registered Technologists 4.9 1.4 3.6 1.0 3.3 0.9 4.7 0.8 -4.0 Other S t a f f , Technical 32.5 9.4 35.5 9.3 45.5 11.8 50.3 9.0 +9.9 Other S t a f f , Laboratory 81.4 23.5 86.2 22.6 63.9 16.7 127.7 22.8 +21.4 Group IV TOTAL 346.5 100 381.9 100 383.0 100 559.1 100 +61.3 GROUP V FTE % FTE % FTE % FTE % % Laboratory S c i e n t i s t s 14.0 3.6 6.9 1.7 4.0 0.8 7.5 1.3 -46.4 Registered Technologists 211.6 54.5 245.3 59.2 313.1 61.6 352.3 60.0 +58.8 Non-Registered Technologists 24.6 6.3 8.0 1.9 11.2 2.2 13.4 2.3 -45.5 Other S t a f f , Technical 41.1 10.6 59.5 14.4 62.1 12.2 76.7 13.4 +12.6 Other S t a f f , Laboratory 97.2 25.0 94.6 22.8 117.8 23.2 136.9 23.3 +23.6 Group V TOTAL 388.5 100 414.3 100 508.1 100 586.9 100 +51.0 APPENDIX 3 Comparative Use of Laboratory Assistants i n B.C. Public Hospitals by Size of Hospital: 1970 -1980 H Beds 1970 Units FTE Beds 1974 Units FTE Beds 1978 Units FTE Beds 1980 Units FTE 1 100 708779 1.0 100 844370 1.5 118 1229397 1.0 118 1465796 0.8 2 128 1046253 1.0 128 1341181 1.0 125 1229397 1.0 160 2488612 2.7 3 151 1610852 1.1 141 2182975 1.0 154 2439784 1.6 144 1708065 0.5 4 151 2254681 1.6 170 2540446 2.8 5 225 2864104 1.0 237 3676735 1.4 225 2394321 1.1 226 2297531 1.7 7 261 2099028 0.8 252 1925550 1.0 274 4223911 1.0 288 5865354 4.5 8 274 3712719 0.7 288 5147662 4.5 9 313 3314174 6.2 418 7076998 8.2 391 5908827 8.9 415 5792513 3.7 10 430 5900682 8.2 766 12799973 27.2 397 4556390 2.7 455 6424631 10.5 11 604 7720264 18.1 413 8501392 10.0 456 5760793 12.0 12 463 10253970 24.0 H = Hospital sequence number. Beds = Number of acute care beds. Units = Number of laboratory workload u n i t s . FTE = Number of s t a f f i n laboratories i n terms of FTE. Page 175 APPENDIX 4 TABLE 4 - 1 Number and Percentage D i s t r i b u t i o n of Registered Technologists i n B.C. Public Hospitals by Q u a l i f i c a t i o n and whether Full-Time of Part-Time and by Hospital Size Group : 1970 - 1980 Qual. 1970 1974 1978 1980 GROUP I FT % | PT % FT % PT % FT % PT % FT % PT % R.T. 111 90 | 23 96 150 92 20 95 197 92 41 93 226 89 48 100 A.R.T. 5 0 0 8 5 1 5 18 8 2 6 26 11 o 0 Licen. 8 1 4 5 3 o 0 0 o 1 2 1 0.4 o 0 TOTAL 124 1001 24 100 163 100 21 100 215 100 44 100 253 100 48 100 GROUP II R.T. 107 96 | 13 100 138 95 29 100 153 87 38 95 181 92 42 100 A.R.T 4 * l 0 0 8 6 0 0 22 13 2 5 15 8 o 0 L i c e n . 1 1| 0 0 0 o o 0 0 o o 0 0 o o 0 TOTAL 112 100| 13 100 146 100 29 100 175 100 40 100 196 100 42 100 GROUP III R.T 54 90 | 6 100 89 95 11 100 77 89 15 100 70 82 18 100 A.R.T. 6 10| 0 0 5 5 0 0 10 11 0 0 12 14 o 0 Licen. 0 0| 0 0 0 o 0 0 0 0 0 0 3 o 0 TOTAL 60 100 | 6 100 94 100 11 100 87 100 15 100 85 100 18 100 FT = F u l l Time Technologist PT = Part Time Technologist % = Percentage d i s t r i b u t i o n of technologsits by q u a l i f i c a t i o n Qual.= Level of q u a l i f i c a t i o n ; R.T.= Registered Technologist; A.R.T.= Advanced Registered Technologist; Licen.= L i c e n t i a t e Page 176 APPENDIX 4 (cont'd) The number and Percentage D i s t r i b u t i o n of Registered Technologists i n B.C. Public Hospitals by Q u a l i f i c a t i o n and Whether Full-Time or Part-Time and by Hospital Size Group: 1970 - 1980 Qual. GROUP IV 1970 FT % |PT % 1974 FT % |PT % 1978 FT % |PT % 1980 FT % |PT % R.T. A.R.T. Licen. TOTAL 153 79[ 3 60 38 20| 2 40 1 l | 0 0 192 100| 5 100 190 81|16 100 45 19| 0 0 0 0| 0 0 235 100|16 100 165 52 j17 50 117 37|14 41 37 11| 3 9 319 100|28 100 260 83|50 96 49 16| 0 0 1 l | 2 4 310 100|52 100 GROUP V R.T. A.R.T. Lic e n . TOTAL 176 93| 9 90 12 6| 1 10 2 l | 0 0 190 100|10 100 206 90|19 95 17 7| 1 5 7 3| 0 0 230 100|20 100 288 98|39 100 6 2| 0 0 1 0| 0 0 295 100|39 100 330 95|43 98 16 5| 1 2 0 0| 0 0 346 100|44 100 FT = Full-Time technologists PT = Part-Time technologists % = Percentage d i s t r i b u t i o n of technologists by q u a l i f i c a t i o n Qual.= Level of q u a l i f i c a t i o n ; R.T.= Registered Technologist; A.R.T.= Advanced Registered Technologist; Licen.= L i c e n t i a t e Page 177 APPENDIX 5 Number and D i s t r i b u t i o n of Laboratory Medical Manpowerin B.C. Public Hospitals by Position Status and Hospital Size Group : 1970 -1980 Medical Manpower Category GROUP I Pathol. Other TOTAL 1970 FT % |PT % 5 100 0 0 5 100 20 100 0 0 20 100 1974 FT % PT % 5 100 0 0 5 100 12 86 2 14 14 100 1978 FT % |PT % 5 100 0 0 5 100 10 63 6 37 16 100 1980 FT % |PT % 7 100 0 0 7 100 10 53 9 47 19 100 GROUP II Pathol. Other TOTAL 2 100 0 0 2 100 7 100 0 0 7 100 3 100 0 0 3 100 11 100 0 0 11 100 4 100 0 0 4 100 1 17 5 83 6 100 2 100 0 0 2 100 1 33 2 67 3 100 GROUP III Pathol. Other TOTAL 6 100 0 0 6 100 0 0 1 100 1 100 7 100 0 0 7 100 0 0 1 100 1 100 7 100 0 0 7 100 0 0 0 8 100 0 0 8 100 1 100 0 0 1 100 GROUP IV Pathol. Other TOTAL 25 89 3 11 28 100 1 50 1 50 2 100 35 95 2 5 37 100 3 50 3 50 6 100 27 90 3 10 30 100 12 52 11 48 23 100 28 88 4 12 32 100 18 82 4 18 22 100 GROUP V Pathol. Other TOTAL 14 64 8 36 22 100 5 71 2 29 7 100 13 50 13 50 26 100 8 80 2 20 10 100 21 96 1 4 22 100 28 88 4 12 32 100 23 85 4 15 27 100 37 90 4 10 41 100 FT = Full-Time positions; PT = Part-Time p o s i t i o n s . % = Percentage d i s t r i b u t i o n of laboratory medical manpower Pathol.= Pathologists; Other = Other laboratory physicians Page 178 APPENDIX 6 TABLE 6 - 1 D i s t r i b u t i o n of Laboratory Workload for A l l B.C. Public Hospitals Showing Total Units by Service, Percent of Total Workload, and Percent Change From Previous Period Group I Hospitals : 1970 - 1980 Category 1970 1974 1978 1980 of units % units % % units % % units % % Service xlOOO T xlOOO T C xlOOO T C xlOOO T C Chem. 3694 20.1 6203 22.7 67.9 10594 24.7 70.8 12323 25.1 16.3 Hematol. 3362 18.3 4627 16.9 37.6 7372 17.2 59.3 8407 17.1 14.0 Blood Bk 556 3.0 1459 5.3 162.0 1634 3.8 12.1 1829 3.7 11.8 H i s t o l . 622 3.4 720 2.6 15.7 1183 2.8 64.4 1638 3.3 38.4 Cytology 4077 22.2 6657 24.4 63.3 8938 20.9 34.3 8620 17.6 -3.6 Microbi. 2567 14.0 2371 8.7 -7.6 4530 10.6 91.0 6226 12.7 37.5 Services 423 2.3 553 2.0 30.7 0 0 - 0 0 -Procure. 2105 11.4 3506 12.8 66.5 5486 12.8 56.5 6226 12.7 13.5 Other 992 5.4 1227 4.5 23.6 3113 7.3 153.7 3793 7.7 21.9 D i s t r i b . 18674 100 27323 100 48.5 42852 100 56.8 49063 100 14.5 TOTAL(1) Actual 19674 29071 47.8 42859 47.4 49063 100 14.5 T0TAL(2) units=Laboratory workload u n i t s . % T = Percent of t o t a l laboratory workload reported i n that period. % C = Percent change from previous period. (1) = Total of laboratory workload reported i n d i s t r i b u t e d form. This i s the t o t a l used to cal c u l a t e % T. (2) = Total of a l l laboratory workload reported i n that period. This i s the t o t a l used to ca l c u l a t e o v e r a l l changes between reporting periods. This d i f f e r e n c e i n t o t a l s only occurred i n the smaller hospitals of Group I which l i k e l y did not process enough laboratory work to make i t worth while reporting i n categories. Page 179 APPENDIX 6 TABLE 6 - 2 D i s t r i b u t i o n of Laboratory Workload for a l l B.C. Public Hospitals Showing Total Units by Service, Percent of Total Workloads, and Percent Change From Previous Period GROUP II Hospital : 1970 - 1980 Category 1970 1974 1978 1980 of units % units % % units % % units % % Service (xlOOO) T (xlOOO) T C (xlOOO) T C (xlOOO) T C Chem. 5639 30.7 8534 30.5 51.2 10805 31.7 26.8 12771 32.2 18.2 Hematol. 3924 21.4 6051 21.7 54.2 5659 16.6 -6.5 5842 14.7 3.2 Blood Bk 1366 7.4 2284 8.2 67.2 3288 9.7 44.0 3712 9.4 12.9 H i s t o l . 397 2.2 1036 3.7 161.1 1323 3.9 27.7 1644 4.2 24.2 Cytology 10 0.1 4 0.0 -64.2 14 0.0 283.8 23 0.0 61.1 Microbi. 3421 18.6 4403 15.8 28.7 6382 18.8 45.0 8023 20.2 25.7 Services 633 3.4 1012 3.6 60.0 0 0 - 0 0 -Procure. 2009 10.9 3423 12.3 70.4 4600 13.5 34.4 5452 13.8 18.5 Other 982 5.3 1181 4.2 20.2 1959 5.8 65.9 2183 5.5 11.4 TOTAL 18380 100 27917 100 51.9 34030 100 21.9 39649 100 16.5 units = Laboratory workload u n i t s . % T = Percent of t o t a l laboratory workload i n that period. % C = Percent change from previous year. Page 180 APPENDIX 6 TABLE 6 - 3 D i s t r i b u t i o n of Laboratory Workload for a l l B.C. Public Hospitals Showing Total Units by Service, Percent of Total Workload, and Percent Change From Previous Period GROUP III Hospitals : 1970 - 1980 Category 1970 1974 1978 1980 of units % units % % units % % units % % Service (xlOOO) T (xlOOO) T C (xlOOO) T C (xlOOO) T C Chem. 2854 25.9 5207 27.7 82.4 4491 26.1 -13.8 4372 25.6 -2.6 Hematol. 1794 16.3 3262 17.4 81.8 2450 14.2 -24.9 2389 14.0 -2.5 Blood Bk 1134 10.3 2429 13.5 123.0 2161 12.6 -14.5 2022 11.8 -6.5 H i s t o l . 1268 11.5 1541 8.2 21.5 1918 11.1 24.5 1849 10.8 -3.6 Cytology 4 0.0 13 0.0 209.1 121 0.7 811.5 139 0.8 15.0 Microbi. 2168 19.7 2262 12.1 4.3 2947 17.1 30.3 3177 18.6 7.8 Services 388 3.5 792 4.2 104.2 0 0 - 0 0 -Procure. 873 7.9 2039 10.9 133.5 2170 12.6 6.4 1855 10.8 -14.5 Other 546 4.9 1133 6.0 107.5 951 5.5 -16.1 1303 7.6 37.0 TOTAL 11031 100 18778 100 70.2 17210 100 -8.4 17106 100 -0.6 units = Laboratory workload u n i t s . % T = Percent of t o t a l laboratory workload for that period. % C = Percent change from previous period. Page 181 APPENDIX 6 TABLE 6 - 4 D i s t r i b u t i o n of Laboratory Workload for a l l B.C. Hospitals Showing Total Units by Service, Percent of Total Worload, and Percent Change From Previous Period GROUP IV Hospitals : 1970 -1980 Category 1970 1974 1978 1980 of units % units % % units % % units % % Service (xlOOO) T (xlOOO) T C (xlOOO) T C (xlOOO) T C Chem. 8467 25.2 11536 27.8 36.2 14184 25.2 23.0 15372 25.1 8.4 Hematol. 5899 17.6 7115 17.1 20.6 7399 13.1 4.0 8448 13.8 14.2 Blood Bk 2545 7.6 3693 8.9 45.1 7282 12.9 97.2 7460 12.2 2.4 H i s t o l . 3923 11.7 5342 12.9 36.2 7362 13.1 37.8 8243 13.4 12.0 Cytology 174 0.5 227 0.5 30.3 401 0.7 76.7 795 1.3 98.1 Microbi. 8920 26.6 8104 19.5 -9.1 11026 19.6 36.1 12022 19.6 99.0 Services 249 0.7 580 1.4 133.5 0 0 - 0 0 -Procure. 1922 5.7 3208 7.7 66.9 6577 11.7 105.0 6577 10.7 0.0 Other 1455 4.3 1718 4.1 18.1 2115 3.7 23.1 2376 3.9 12.3 TOTAL 33555 100 41524 100 23.7 56346 100 35.7 61292 100 8.8 units = Laboratory workload u n i t s . % T = Percent of t o t a l laboratory workload for that period. % C = Percent change from previous reporting period. Page 182 APPENDIX 6 TABLE 6 - 5 D i s t r i b u t i o n of Laboratory Workload for a l l B.C. Public Hospitals Showing Total Units by Service, Percent of Total Workload, and Percent Change From Previous Period GROUP V Hospitals: 1970 - 1980 Category 1970 1974 1978 1980 of units % units % % units % % units % % Service (xlOOO) T (xlOOO) T C (xlOOO) T C (xlOOO) T C Chem. 13225 32.3 13487 30.1 2.0 16628 27.7 23.3 18062 26.6 8.6 Hematol. 5863 14.3 6380 14.2 8.8 7182 12.0 12.6 8906 13.1 24.0 Blood Bk 4587 11.2 7249 16.2 58.0 10969 18.3 51.3 12023 17.7 9.6 H i s t o l . 4522 11.1 4565 10.2 0.9 6240 10.4 63.3 7012 10.3 12.4 Cytology 410 1.0 393 0.9 -4.2 318 0.5 19.1 1358 2.0 327.3 Microbi . 6719 16.4 4331 9.7 -35.5 7420 12.4 71.3 9209 13.6 24.1 Services 620 1.5 601 1.3 -3.1 0 0 - 0 0 -Procure. 2586 6.3 3401 7.6 31.5 6612 11.0 94.4 7140 10.5 8.0 Other 2364 5.8 4419 9.9 87.0 4609 7.7 4.3 4073 6.0 11.6 TOTAL 40896 100 44825 100 9.6 59977 100 33.8 67783 100 13.0 units = Laboratory workload u n i t s . % T = Percent of t o t a l units for that period. % C = Percent change from previous period. Page 183 APPENDIX 7 TABLE 7 - 1 Summary of Total Laboratory Workload i n Workload Units and Percentage Change Between Periods, for a l l B.C. Public Hospitals by Size Group 1970 - 1980 Hospital 1970 1974 1978 1980 1970-Size units units % units % units % 1980 Group (xlOOO) (xlOOO) C (xlOOO) C (xlOOO) C % C Group I 19,674 29,071 47.8 42,859 47.4 49,063 14.5 +149.3 Group II 18,380 27,917 51.9 34,030 21.9 39,649 16.5 +115.7 Group III 11,031 18,778 70.2 17,210 -8.4 17,106 -0.6 +55.0 Group IV 33,555 41,524 23.7 56,346 35.7 61,292 8.8 +82.6 Group V 40,896 44,825 9.6 59,977 33.8 67,783 13.0 +65.7 TOTAL 123,536 162,115 31.2 210,421 29.7 234,894 11.6 +90.1 % C = percent change between periods. 1970-1980 % C = t o t a l percent change between 1970 and 1980 A l l workload expressed i n S t a t i s t i c s Canada workload units APPENDIX 7 (CONT'D) TABLE 7 - 2 Laboratory Workload D i r e c t l y A ttributable to Inpatient Care i n Workload Units for a l l B.C. Public Hospitals by Size (1) 1970 -1980 Hospital 1970 1974 1978 1980 Size Group units units units units Group I 9,086,018 10,956,647 12,935,249 14,561,445 Group II 12,619,950 16,220,690 18,042,735 20,188,132 Group III 7,339,230 11,173,058 9,954,982 8,298,975 Group IV 20,511,369 22,846,378 31,619,960 33,406,225 Group V 23,970,952 25,012,111 38,015,746 .40,790,400 TOTAL 73,527,519 86,208,884 110,568,672 117,245,177 (1) Does not include q u a l i t y control or development work related to i n p a t i e n t s . Page 184 APPENDIX 7 (CONT'D) TABLE 7 - 3 Laboratory Workload D i r e c t l y Attributable to Outpatient Care i n Workload Units for a l l B.C. Public Hospitals by Size 1970 - 1980 Hospital 1970 1974 1978 1980 Size Group units units units units Group I 7,824,036 5,924,122 11,270,001 14,012,501 Group II 2,774,994 5,841,092 8,015,622 9,852,563 Group III 1,262,992 2,297,155 2,812,724 3,399,767 Group IV 3,544,951 5,928,922 8,475,087 10,211,542 Group V 2,996,186 3,196,598 4,828,801 6,182,237 TOTAL 18,403,159 23,187,889 35,402,235 43,658,610 (1) Does not include q u a l i t y control or development work rel a t e d to outpatients. APPENDIX 7 (CONT'D) TABLE 7-4 D i s t r i b u t i o n of Laboratory Workload by Percent of To t a l , i n Workload Units for a l l B.C. Public Hospitals by Size 1970 - 1980 Hospital Size Group % IP 1970 % % OP RI % OTH % IP 1974 % % OP RI % OTH IP 1978 % % OP RI % OTH % IP 1980 % % OP RI % OTH Group I 46 40 2 12 38 20 26 16 30 26 24 19 30 29 23 19 Group II 69 15 2 14 58 21 5 16 53 24 5 19 51 25 5 20 Group III 67 11 6 16 60 12 6 23 58 16 7 19 49 20 8 24 Group IV 61 11 11 17 55 14 10 21 56 15 10 19 55 16 10 19 Group V 69 7 10 24 56 7 10 28 63 8 8 21 60 9 9 22 TOTAL 60 15 8 18 53 14 11 21 53 17 11 20 50 19 21 21 IP = Inpatient workload OP = Outpatient workload RI = Referred-in workload OTH = Other laboratory workload; includes q u a l i t y c o n t r o l , standards, Research and Development, and Routine Health Examines. Percentages have been rounded to the nearest whole number. APPENDIX 8 TABLE 8 - 1 Laboratory Operating Expenses by Category of Expense Showing Percentage Change Between Periods and Percentage D i s t r i b u t i o n , for a l l B.C. Public Hospitals by Hospital Size Groups: 1966 - 1980 (Presented i n 1971 Dollars) Group I and II Hospitals Expense Category GROUP I HOSPITALS Med. S a l . Oth. S a l . Sup.& Exp. TOTAL 1966 $ % (xlOOO) T 1970 $ % % (xlOOO) T C 1974 $ % % (xlOOO) T C 1978 $ % % (xlOOO) T C 1980 $ % % (xlOOO) T C 1966-1980 % 59 5.3 608 55.1 437 39.6 1,105 100 167 7.2 184.3 1,387 59.3 228.4 783 33.5 79.0 2,337 100 111.6 196 5.7 17.4 2,308 67.1 66.4 935 27.2 19.3 3,439 100 47.2 353 6.1 79.6 3,810 66.0 65.1 1,611 27.9 72.3 5,773 100 67.9 446 6.6 26.5 4,269 63.6 12.0 1,999 29.8 24.1 6,714 100 16.3 +658.7 +601.7 +357.1 +507.9 GROUP II HOSPITALS Med. S a l . Oth. S a l . Sup.& Exp. TOTAL 116 10.0 652 56.5 386 33.5 1,153 100 138 6.8 19.1 1,178 58.1 80.8 712 35.1 84.3 2,028 100 75.8 245 7.5 78.1 1,983 60.8 68.3 1,034 31.7 45.2 3,262 100 60.9 224 4.9 -8.6 2,713 59.8 36.8 1,597 35.2 54.5 4,534 100 39.0 203 4.0 -9.5 3,010 58.9 11.0 1,894 37.1 18.6 5,107 100 12.6 +75.5 +361.9 +390.3 +342.7 Med. Sal.= Medical S a l a r i e s , Oth. Sal.= Other Sa l a r i e s , Sup.& Exp.= Supplies and Expenses $ = Laboratory operating costs i n 1971 d o l l a r s . % T = Percent of t o t a l expenses for that period. % C = Percent change between periods. APPENDIX 8 (CONT'D) TABLE 8 - 2 Laboratory Operating Expenses by Category of Expense Showing Percentage Change Between Periods and Percentage D i s t r i b u t i o n for a l l B.C. Public Hospitals by Hospital Size Group: 1966 - 1980 (Presented i n 1971 do l l a r s ) Group III and IV Hospitals Expense Category GROUP III HOSPITALS 1966 $ (xlOOO) % T 1970 $ % (xlOOO) T % C 1974 $ % (xlOOO) T C 1978 $ % (xlOOO) T % C 1980 $ % (xlOOO) T % C 1966-1980 % Med. S a l . 74 17.2 285 21.5 284.7 411 18.8 44.0 445 18.2 8.2 454 18.2 2.1 +512.3 Oth. S a l . 241 56.0 748 56.4 210.2 1,215 55.6 62.5 1,390 56.9 14.4 1,426 57.2 2.5 +491.3 Sup .& Exp. 115 26.7 292 22.0 154.4 560 25.6 91.7 607 24.8 8.3 615 24.6 1.3 +435.3 TOTAL 430 100 1,326 100 208.2 2,187 100 64.9 2,442 100 11.7 2,495 100 2.2 +480.0 GROUP IV HOSPITALS Med. S a l . 276 16.7 836 24.1 203.0 1,249 23.0 49.4 1,495 18.4 19.7 1,861 20.5 24.5 +574.6 Oth. S a l . 991 59.6 2,059 59.4 107.8 3,300 60.8 60.3 5,063 62.2 53.4 5,514 60.7 8.9 +456.4 Sup.& Exp. 396 23.8 574 16.6 44.9 878 16.2 52.9 1,588 19.5 80.9 1,714 18.9 7.9 +332.7 TOTAL 1,663 100 3,469 100 108.6 5,327 100 56.4 8,146 100 50.1 9,190 100 11.6 +446.6 Med. Sal.= Medical S a l a r i e s , Oth. Sal.= Other S a l a r i e s , Sup.S Exp.= Supplies and Expenses $ = Laboratory operating expenses i n 1971 d o l l a r s . % T = Percent of t o t a l expenses for that period. % C = Percent change between periods. APPENDIX 8 (CONT'D) TABLE 8 - 3 Laboratory Operating Expenses by Category of Expense Showing Percentage Change Between Periods and Percentage D i s t r i b u t i o n for a l l B.C. Public Hospitals by Hospital Size Group: 1966 - 1980 (Presented i n 1971 d o l l a r s ) Group V Hospitals and A l l Hospitals Combined Expense Category GROUP V HOSPITALS Medical Oth. S a l . Sup.& Exp. TOTAL 1966 $ % (xlOOO) T 1970 $ % % (xlOOO) T C 1974 $ % % (xlOOO) T C 1978 $ % % (xlOOO) T C 1980 $ % % (xlOOO) T C 1966-1980 % 497 23.0 1,187 54.9 480 22.2 2,164 100 836 22.2 68.2 2,673 71.0 125.2 256 6.8 -46.6 3,766 100 74.0 1,005 17.8 20.3 3,558 63.0 33.1 1,081 19.2 321.9 5,644 100 49.9 1,327 17.1 32.0 4,656 60.1 30.9 1,761 22.7 62.9 7,744 100 37.2 1,704 17.7 28.5 5,540 57.4 19.0 2,411 25.0 36.9 9,655 100 24.7 +243.0 +366.7 +402.0 +346.1 ALL B.C. HOSPITALS Med. S a l . Oth. S a l . Sup.& Exp. TOTAL 1,021 15.7 3,679 56.5 1,815 27.9 6,515 100 2,262 17.5 121.5 8,045 62.2 118.7 2,618 20.3 41.9 12,925 100 98.4 3,107 15.6 37.3 12,364 61.9 53.7 4,488 22.5 71.4 19,959 100 54.4 3,843 13.4 23.7 17,732 61.6 42.6 7,164 25.0 59.6 28,640 100 43.5 4,669 14.1 21.5 19,759 59.8 12.1 8,633 26.1 20.5 33,061 100 15.4 +357.1 +437.0 +375.7 +407.4 Med. Sal.= Medical S a l a r i e s , Oth. Sal.= Other Salaries, Sup.& Exp.= Supplies and Expenses $ = Laboratory operating expenses i n 1971 d o l l a r s . % T = Percent of t o t a l expenses f or that period. % C = Percent change between periods. Page 188 APPENDIX 9 The Number of Hospitals i n Each Size Group for Each Period. 1966 -1980 Hospital Size Group 1966 1970 1974 1978 1980 GROUP I 87 82 85 80 80 GROUP II 18 19 19 19 19 GROUP III 3 5 6 5 4 GROUP IV 6 6 6 7 7 GROUP V 2 2 3 4 4 TOTAL 116 114 119 115 114 GROUP I = Hospitals with le s s than 100 beds. GROUP II = Hospitals with between 100 and 199 beds. GROUP III = Hospitals with between 200 and 299 beds. GROUP IV = Hospitals with over 300 beds excluding teaching h o s p i t a l s . GROUP V = Teaching Hospitals. 

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