1. In this randomized controlled trial, electronic health record display of cost for laboratory studies was not linked to a change in clinician ordering habits.
2. Subgroup analysis demonstrated a small decrease in orders entered for patients in intensive care unit (ICU) and for the most-costly studies, while ordering of the least expensive tests increased.
Evidence Rating Level: 2 (Good)
Study Rundown: Health-care costs continue to increase and many laboratory tests performed in the hospital may ultimately be unnecessary. Efforts to curtail these wasteful expenditures include education and greater transparency to clinicians of costs. This randomized controlled trial investigated the use of electronic health records to display the Medicare allowable fees for common laboratory studies at time of ordering and monitored the effect on physician ordering habits.
Compared to investigations with no displayed costs, the study group did not experience any significant change in ordering habits after the intervention. However, there was a small but statistically significant reduction in ordered tests in the ICU. Costlier studies were also ordered less often, but the least expensive tests were ordered more often. The strengths of the study include the study design, the relatively long study period of one year post intervention, multiple hospital sites, and adjustment for important covariates such as patient demographics and comorbidity. Weaknesses included not having the costs of more expensive tests available, and the intervention group had a higher order rate to begin with, which confounds the results.
In-Depth [randomized controlled trial]: This study included 3 hospital sites in Philadelphia, and monitored clinician ordering behavior for inpatients admitted and discharged within the study period one year prior to and following the intervention. A total of 60 groups of laboratory tests were randomized to either display of Medicare allowable fees or control; with the randomization stratified by volume of test ordering and cost of the tests.
The study included 142,921 hospital admissions. The mean ordering of tests did not change from the pre-intervention to intervention periods for either the study group or control: from 2.31 to 2.34 orders/day in the control group and 3.93 to 4.01 orders/day in the study group (p = 0.35 for difference). For the subgroup of ICU patients there was an observed reduction of ordering (mean -0.16 orders/day, p = 0.04). For tests in the top quartile of costs there was a reduction of -0.01 tests/day (p < 0.001), while for the lowest quartile for cost there was an increase of 0.03 tests/day (p = 0.04).
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