2.1 - 2.3 1.6 1.6 - 1.7 1.1 - 0.9 0.8 - 0.9

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CHAPTER 9: INVESTIGATIONS

Investigations are important tools to screen for, diagnose, assess severity, monitor and determine treatment options. Medical investigations are essential to the processes of medical care but having more investigations done do not necessarily result in better health outcomes and may increase healthcare expenditure. The rate at which investigations are ordered per condition or per patient affects the overall cost-effectiveness of healthcare delivery. This chapter reports the investigations, including all pathology, imaging or other diagnostic tests which were undertaken for the patients at the point of encounter. The primary care doctors were requested to document all medical investigations ordered and indicate for which diagnoses were the investigations ordered for. More than one investigation may be ordered for each diagnosis and one investigation may be VSHFLÀHGIRUPXOWLSOHGLDJQRVHVRFWRUVPD\DOVRRUGHUWKHLQYHVWLJDWLRQVDVDVLQJOHWHVWRUDVHWRIWHVWV 7KHVHWRIWHVWVZHUHFRGHGDVRQHLQYHVWLJDWLRQDVSHUUHFRUGHGDQGIROORZLQJ,3SOXVFODVVLÀFDWLRQ

9.1 NUMBERS OF INVESTIGATIONS PER ENCOUNTER

From the total encounters, only 19.6 of the patients had investigations ordered or provided as part of management process during visit to primary care clinics. Figure 9.1 displays the number of investigations ordered per encounter in public and private clinics. Among those with investigations, majority had only one investigation ordered or provided per encounter. The maximum number of investigations ordered per encounter was nine public clinic and eight private clinic. Figure 9.1 Number of investigations ordered per encounter in primary care clinics in 2012 Number of investigations ordered per encounter 20 40 60 80 100 Nil One Two Three Four Public 59.8 21.9 7.1 4.5 6.8 Private 89.2 7.0 1.8 1.0 1.0 P e rc e nt a g e o f e nc o unt e rs ✁ ✂ ✄ ☎ ✁ ✆ ✝ ✞ ✟ ✄ ✠ ✁ ✆ ✠ ✁ ✡ ✞ ☛ ✂ ✁ ✂ ✄ ☛ ✂ ✄ ✠ ☛ ☞ ✌ ✍ ☞ ✤ ✣

9.2 TYPES OF INVESTIGATIONS

A total of 53,028 investigations were ordered, at a rate of 37.5 per 100 encounters and 28.1 per 100 diagnoses. Table 9.1 shows the distribution of investigations by ICPC-2 chapters and most common test within each chapter in an order of decreasing frequency. Each ICPC-2 chapter represents a group of investigations and only top 20 ICPC-2 chapters were reported in Table 9.1. ‡ 7KHWRSJURXSVRILQYHVWLJDWLRQVRUGHUHGFRQVWLWXWHGDOPRVWRIDOOLQYHVWLJDWLRQV ‡ 0DMRULW\RIWKHLQYHVWLJDWLRQVUHFRUGHGZHUHODERUDWRU\WHVWV7KLVLVIROORZHGE\GLDJQRVWLF radiologyimaging tests. ‡ QGRFULQH DQG PHWDEROLF EORRG WHVWV ZHUH WKH PRVW IUHTXHQWO\ RUGHUHG LQYHVWLJDWLRQV Within this group, approximately two-third of the investigations involved tests for diabetes mellitus glucose, glucose tolerance, HbA1c, fasting, and random glucose tests. ‡ 8ULQHWHVWVDQGJHQHUDOEORRGWHVWVZHUHWKHVHFRQGDQGWKLUGPRVWFRPPRQO\UHFRUGHGLQYHVWLJDWLRQV in primary care clinics. Table 9.1: Types of investigations by ICPC-2 chapters and common individual test within chapter in primary care clinics in 2012 Investigation Number Percentage of all investigations n = 53,028 Rate per 100 encounters 95 CI n = 141,593 Rate per 100 diagnoses 95 CI n = 188,944 Blood test; endocrine metabolic 14,771 27.86

10.43 10.27 - 10.59 7.82 7.70 - 7.94

Test;glucose glucose tolerance 7,755 14.62 5.48 5.36 - 5.60 4.11 4.02 - 4.19 7HVWOLSLGVSURÀOH 3,896 7.35 2.75 2.67 - 2.84 2.06 2.00 - 2.13 Test;HbA1c 2,473 4.66 1.75 1.68 - 1.82 1.31 1.26 - 1.36 Test;thyroid function 510 0.96 0.36 0.33 - 0.39 0.27 0.25 - 0.29 Test;cholesterol 128 0.24 0.09 0.08 - 0.11 0.07 0.06 - 0.08 Test;cholesterol triglycerides 8 0.02 0.01 0.00 - 0.01 0.01 0.00 - 0.01 Urine test 7,150

13.48 5.05 4.94 - 5.17

3.79 3.70 - 3.87

Test;urine 5,260 9.92 3.72 3.62 - 3.81 2.78 2.71 - 2.86 Test;urine;albumin 1,696 3.20 1.20 1.14 - 1.26 0.90 0.86 - 0.94 Urine drug screen 193 0.36 0.14 0.12 - 0.16 0.10 0.09 - 0.12 Test;albumin creatine ratio 2 0.00 0.00 0.00 - 0.01 0.00 0.00 - 0.00 Blood test 5,535

10.44 3.91 3.81 - 4.01

2.93 2.85 - 3.01

Test;full blood count 2,857 5.39 2.02 1.95 - 2.09 1.51 1.46 - 1.57 Test;blood 2,151 4.06 1.52 1.46 - 1.58 1.14 1.09 - 1.19 7HVWEORRGÀOP 178 0.33 0.13 0.11 - 0.15 0.10 0.08 - 0.11 7HVWEORRGWKLFNÀOP 132 0.25 0.09 0.08 - 0.11 0.07 0.06 - 0.08 Test;ESR 113 0.21 0.08 0.07 - 0.10 0.06 0.05 - 0.07 Blood screen 53 0.10 0.04 0.03 - 0.05 0.03 0.02 - 0.04 continued Note: ESR - erythrocyte sedimentation rate ✁ ✂ ✄ ☎ ✁ ✆ ✝ ✞ ✟ ✄ ✠ ✁ ✆ ✠ ✁ ✡ ✞ ☛ ✂ ✁ ✂ ✄ ☛ ✂ ✄ ✠ ☛ ☞ ✌ ✍ ☞ ✤ ★ Investigation Number Percentage of all investigations n = 53,028 Rate per 100 encounters 95 CI n = 141,593 Rate per 100 diagnoses 95 CI n = 188,944 Test;prolactin 40 0.08 0.03 0.02 - 0.04 0.02 0.02 - 0.03 Test;albumin 6 0.01 0.01 0.00 - 0.01 0.00 0.00 - 0.01 Test;electrolytes 5 0.01 0.00 0.00 - 0.01 0.00 0.00 - 0.01 Test;calciummagnesium phosphate 2 0.00 0.00 0.00 - 0.0.1 0.00 0.00 - 0.00 Diagnostic radiology imaging; pregnancy 4,831 9.11

3.41 3.32 - 3.51 2.56 2.49 - 2.63

Ultrasound;obstetric 4,831 9.11 3.41 3.32 - 3.51 2.56 2.49 - 2.63 Other laboratory test NEC; urinary 4,020 7.58

2.84 2.75 - 2.93 2.13 2.06 - 2.19

Test;renal function 4,020 7.58 2.84 2.75 - 2.93 2.13 2.06 - 2.19 Diagnostic radiology imaging 3,543 6.68 2.50 2.42 - 2.58 1.88 1.81 - 1.94 X-ray;chest 2,920 5.51 2.06 1.99 - 2.14 1.55 1.49 - 1.60 Ultrasound 378 0.71 0.27 0.24 - 0.30 0.20 0.18 - 0.22 Ultrasound;abdomen 104 0.20 0.07 0.06 - 0.09 0.06 0.05 - 0.07 Ultrasound;pelvis 93 0.18 0.07 0.05 - 0.08 0.05 0.04 - 0.06 X-ray;abdomen 47 0.09 0.03 0.03 - 0.04 0.03 0.02 - 0.03 Blood test digestive 3,002

5.66 2.12 2.05 - 2.20

1.59 1.53 - 1.65

Test;liver function 2,485 4.69 1.76 1.69 - 1.82 1.32 1.26 - 1.37 Test;bilirubin 516 0.97 0.37 0.33 - 0.40 0.27 0.25 - 0.30 Test;gGT 2 0.00 0.00 0.00 - 0.01 0.00 0.00 - 0.00 Electrical tracing; cardiovascular 1,268 2.39

0.90 0.85 - 0.95 0.67 0.64 - 0.71

Electrocardiogram 1,260 2.38 0.89 0.84 - 0.94 0.67 0.63 - 0.70 Electrocardiogram; stress test 6 0.01 0.01 0.00 - 0.01 0.00 0.00 - 0.01 Holter monitor 1 0.00 0.00 0.00 - 0.00 0.00 0.00 - 0.00 Blood test; bloodlymph 943

1.78 0.67 0.62 - 0.71

0.50 0.47 - 0.53

Test;haemoglobin 689 1.30 0.49 0.45 - 0.52 0.37 0.34 - 0.39 Test;iron studies 69 0.13 0.05 0.04 - 0.06 0.04 0.03 - 0.05 Test;INR 52 0.10 0.04 0.03 - 0.05 0.03 0.02 - 0.04 Test;ferritin 49 0.09 0.04 0.03 - 0.05 0.03 0.02 - 0.03 Test;haemoglobin epg 44 0.08 0.03 0.02 - 0.04 0.02 0.02 - 0.03 Test;prothrombin time 21 0.04 0.02 0.01 - 0.02 0.01 0.01 - 0.02 Table 9.1 continued: Types of investigations by ICPC-2 chapters and common individual test within chapter in primary care clinics in 2012 continued 1RWH1QRWHOVHZKHUHFODVVLÀHGJ7JDPPDJOXWDP\OWUDQVSHSWLGDVH,15LQWHUQDWLRQDOQRUPDOL]HGUDWLR Haemoglobin EPG = haemoglobin electrophoresis