Health Atlas Medical Biochemistry

This atlas describes publicly funded laboratory tests in the field of medical biochemistry. Examples of such tests are blood tests where the level of iron, vitamin D or folate is measured, and the test can be taken at the GP's office or at a hospital outpatient clinic. Laboratory analyses that are funded through activity-based funding (ISF) are not included in the atlas. This means that laboratory tests performed on patients who are hospitalized, as well as certain types of laboratory tests taken during outpatient appointments at hospitals (so-called starred tests) are not included in our analyses. Read more about this in the section "About the atlas".

Overall analysis for medical biochemistry

Main findings

• NOK 1.5 billion was paid out annually from Helfo in reimbursement for biochemical laboratory tests.
• Annual reimbursement was highest for residents in the South-Eastern Regional Health Authority at NOK 314 per inhabitant per year and lowest in the Northern Norway Regional Health Authority at NOK 247. This means that the reimbursement paid was 27% higher for the population in South-Eastern Norway than for the population in Northern Norway.
• At the hospital referral area level, the difference in reimbursement paid was 40%. The population in Vestfold and Vestre Viken referral areas had the highest reimbursement per inhabitant per year at NOK 339 and the population in Nordland had the lowest at NOK 241.
• If all hospital referral areas had the same level of activity as Nordland, the annual reimbursement would have been reduced by NOK 270 million. The average number of analyses per test varied from 5.9 for residents in Finnmark to over 11 for residents in Vestfold, Diakonhjemmet and OUS hospital referral areas.
• 76% more analyses were performed on residents in Vestfold hospital referral area compared with Finnmark hospital referral area.

Tumor Markers

Main findings

• There was great geographical variation for the four tumor markers we have chosen to include for this atlas.
• Residents in the South-Eastern Norway Regional Health Authority had the highest rate for all tumor markers while residents in the Northern Norway Regional Health Authority had the lowest.
• Twice as many PSA samples per 1000 men were taken in the referral area with the highest rate compared to the referral area with the lowest rate. For the CEA and CA125 samples, the highest rate was three times as high as the lowest rate.
• The greatest variation was for protein electrophoresis, where the highest rate was five times as high as the lowest rate.

Prenatal diagnostics

Main findings

• Nationally, 75% of pregnant women aged 35 years and older had NIPT. For all but one hospital referral area, the proportion of pregnant women aged 35 and older who had NIPT was between 60 and 80%.
• The reason why NIPT is not performed may be that the health service does not offer it or that the pregnant woman declines the test.

Thyroid

Main findings

• Most TSH samples were taken in South-Eastern Norway, where the rate was 40% higher than in Northern Norway, which had the lowest rate. In most cases, TSH and free T4 were taken at the same time, even though TSH alone would have been sufficient in most cases.

Vitamins

Main findings

• There was great variation between hospital referral areas for all the vitamin samples shown, and most samples are taken per capita in South-Eastern Norway and Western Norway. *There are probably far more samples taken than necessary

Heart/vascular

Main findings

• There was great variation between hospital referral areas in the number of samples taken per 1000 inhabitants for total cholesterol, HDL, LDL and NT-proBNP.

Iron status

Main findings

• Annually, ⅓ of the population had at least one ferritin test performed.
• There was great geographical variation in the use of ferritin, both between the hospital referral areas and the regional health authorities. 50% more ferritin tests were taken annually in the South-Eastern Norway Regional Health Authority compared with the Northern Norway Regional Health Authority.

Tests in General Practice

The samples presented in this section are mainly taken in general practice. The same tests are also taken in the specialist health service, but such simple laboratory analyses performed as part of consultations in the specialist health service do not provide a basis for reimbursement from Helfo and are therefore not included in our data material. The results in this section therefore show the extent and variation in the use of these tests only in general practice. A small proportion of the tests may have been ordered by private specialists under the public reimbursement scheme, but the proportion is expected to be small and would not affect the results. Read more about this in the section reimbursement scheme.

Main findings

• For 9 out of 13 of the selected tests in general practice, the South-Eastern Norway Regional Health Authority had the highest number of tests per 1,000 inhabitants.
• There was significant or large geographical variation in the use of all tests presented in this kapittel.

C-reactive protein (CRP)

Main findings

• Approximately 40% of the population had at least one CRP test annually
• A greater proportion of women than men had a CRP test

HbA1c

Main findings

• Approximately 30% of the population had at least one HbA1c test taken annually.
• Most tests were taken in the South-Eastern Norway Regional Health Authority, where the rate was 30% higher than in the Northern Norway Regional Health Authority.

Lactate dehydrogenerase (LD)

Main findings

• Most LD samples were taken in the Western Norway Regional Health Authority, where the rate was 30% higher than in the Central Norway Regional Health Authority.

Lactose intolerance (lactase genotyping)

Main findings

• Most samples were taken in South-Eastern Norway, where the rate was almost twice as high as in the other regions
• Lactose intolerance is examined by a gene analysis and should therefore not be repeated. 15% of the lactose intolerance samples taken in 2018 were repeated in the following years.

Who ordered the blood test?

In 2023, Helfo received almost 9 million reimbursement claims for laboratory examinations. 22 percent of these came from private laboratories, and the rest from laboratories in hospitals.

Population-level knowledge about the reasons why a test is ordered is important to assess geographical variation in the use of laboratory services. However, such information , for example in the form of diagnosis codes (ICD-10 or ICPC-2), is not included in the reporting to Helfo.

In order to implement targeted and effective measures to reduce geographical variation, it is very useful to know what proportion of tests are ordered by hospital doctors, GPs or other groups of healthcare professionals. This information is voluntary to provide when submitting reimbursement claims.

We have investigated the information the laboratories have reported on the referrals and found great variation in reporting practices, both between private laboratories and hospital laboratories , but also between the various public hospital laboratories.

Due to the large variation in reporting practices, information about the referrals is not used in the atlas.

Private laboratories

For analyses from private laboratories, the information about the referrals is complete. The figure below shows that it is mainly general practitioners or out-of-hours doctors who request the tests, and that these account for 95.6 percent of the tests from private laboratories in 2023.

Distributed by the hospital referral areas, the proportion of tests requested by GPs/out-of-hours doctors in 2023 varied from 99.7% (Nord-Trøndelag) to 78.3% (Bergen).

Laboratories in the hospitals

When it comes to tests from the laboratories in the hospitals, there are major gaps in the information about who requested the tests. Half of the submitted reimbursement claims from hospitals lacked information about the referrer. Approximately 30% of the reimbursement claims were requested by a GP/emergency doctor or the specialist health service. The remaining 20% were distributed among various other categories.

The variation in the registration of the referrals by hospital referral area is large. For all hospital referral areas, the proportion of samples requested by GPs/out-of-hours doctors is greater than the proportion from the specialist health service. For the hospital referral areas in the Northern Norway Regional Health Authority, there is a low proportion of samples that lack information about the referrer. The vast majority of samples for residents in the Northern Norway Regional Health Authority are requested by GPs/out-of-hours doctors or the specialist health service and a small proportion fall into the category "other services". In the hospital referral areas of Bergen and Østfold, the majority of tests fall into the “other services” category, which suggests that variation in registration practice. In some hospital referral areas, a significant proportion of tests are also reported to have been requested by the patient themselves. This is probably a result of incorrect registrations.

Data and methods

Data

This atlas studies publicly funded laboratory examinations in the field of medical biochemistry.

Data on publicly funded outpatient laboratory examinations has been provided by the Norwegian Control and Payment of Health Reimbursements database (KUHR). KUHR handles reimbursement claims from therapists and health institutions submitted to the state by Helfo. Only reimbursement claims in the medical biochemistry category are included.

Laboratory analyses that are taken and analyzed at the office of GPs or out-of-hours services, i.e. not submitted to a laboratory, are taken from the Norwegian Registry for Primary Health Care (NRPHC),. The innhold of the NRPHC for GPs and out-of-hours services is based on reimbursement claims from KUHR.

The number of births at different ages is taken from the Norwegian Patient Register (NPR).

Population figures are taken from Statistics Norway.

The reimbursement scheme

The reimbursement of outpatient laboratory examinations is from the Norwegian Laboratory Coding System (NLK), which is managed by the Directorate for eHealth.

Laboratory tests are registered with their own NLK code, and the main rule is that every test performed with an NLK code belongs to a specific reimbursement category. For medical biochemistry, there are 16 reimbursement categories, MB0-MB15. Each reimbursement category is associated with one reimbursement rate. The laboratory has the opportunity to assess whether the requested analyses respond to the clinical problem in the referral, and can therefore answer more or fewer analyses than specifically requested. The reimbursement claim is sent to Helfo.

Reimbursement to public laboratories is paid to the regional health authority that owns the institution. If the health institution is not owned by a regional health authority, or if it is a private laboratory, it is paid directly to the institution in question.

Laboratory analyses that are funded through performance-based funding (ISF) are not included in this scheme. This means that they will not be found in the KUHR database with submitted reimbursement claims. This applies to:

1. patients who are hospitalized, and
2. a selection of analyses carried out for patients who receive outpatient care in hospitals.

The selected analyses are marked with an asterisk in the NLK coding system, which means that the stated reimbursement category and reimbursement amount do not apply when the analysis is performed in connection with outpatient health care.

The laboratory tests that are taken and analyzed at the offices of GPs and emergency services are financed through the normal tariff. In the normal tariff, separate tariffs are stated for the laboratory analyses that are most often taken and analyzed in the office. Claims for reimbursement are submitted to the Norwegian government through Helfo.

According to the ISF regulations, health services performed within the framework of operating agreements between the Regional Health Authorities and private specialists under the public funded contracts are not included in the calculation basis for the ISF scheme. This means that if the private specialist requests or takes blood samples that are submitted for analysis, the laboratory will be reimbursed in the usual way. This means that samples taken in connection with an appointment with a specialist are included in our data material and are included in the results.

Definitions

The terms "sample" and "examination" are defined as a sample taken from a patient. A sample can consist of several analyses. This means that for example, vitamin D, ferritin and TSH (the analyses) can be measured in the same sample.

We define the words "analysis" and "test" to mean that the sample has been analyzed with regard to a specific issue, e.g. Vitamin D or TSH. An analysis or test can be defined with several different NLK codes depending on how it is performed, e.g. analysis of plasma, serum or blood.

By NLK code we mean the individual NLK code from the codebook.

Division into referral areas

The regional health authorities have a responsibility to ensure good and equal specialist health services to everyone who needs them when they need them, regardless of, among other things, place of residence, cf. section 1 of the Health Authorities Act. In practice, it is the individual health authorities and private actors who have an agreement with a regional health authority that offer and perform the health services. Each health trust has a referral area that includes specific municipalities and districts. Different disciplines may have different referral areas, and some services are functionally divided between different health trusts and/or private operators. In SKDE's healthcare atlases, the specialist health service's referral areas for emergency medical care are used.

The sizes of these areas vary considerably, as shown in the figure.

There are also differences in the composition of the population , particularly in terms of the age of the population. The median age varies from 44 years for residents of Innlandet and Helgeland hospital referral areas to 32 years for residents of Lovisenberg hospital referral area. All rates and proportions calculated in the atlas have therefore been gender- and age-adjusted to make them comparable (standardized against Norway's population in 2019).

The list below shows which hospital trusts or hospitals have defined hospital referral areas and the short names of these used in the atlas.

Professional foundation for the work

SKDE participates in the interregional project on variation in the use of laboratory services, and has used some members of this group as reference persons.

In addition, members of the Norwegian Association for Medical Biochemistry, the Norwegian Association for General Practice and the Choosing Wisely campaign have helped us in our work.