Original article 247
Does offering pricing information to resident physicians in the emergency department potentially reduce laboratory and radiology costs? Gervais Nougona, Xavier Muscharta, Véronique Gérarda, Caroline Boulouffea, Jacques Jamartb, Dominique Van Peea and Louis De Cannièrea Objectives The aim of this study was to establish whether price list information could reduce laboratory and radiological examination costs in emergency departments (EDs). Materials and methods A prospective survey of adult (>16 years old) admissions was conducted at the ED of a university hospital in Belgium. Nine resident emergency physicians were followed for a span of 6 months, which was divided into 2-month periods: control (October and November 2011), intervention (December 2011 to January 2012), and washout (February and March 2012). Laboratory and radiological costs for each of the daily admissions were calculated during the respective periods and compared.
In addition, we found that laboratory examination costs increased slightly between periods 2 and 3 (+ 6.4%), whereas costs related to radiologic examinations continued to decrease (− 10.16%); however, these differences were not statistically significant. Conclusion We conclude that the distribution of price lists at EDs promotes cost awareness, which can result in significant decreases in examination costs. European Journal of Emergency Medicine 22:247–252 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:247–252 Keywords: Belgium, emergency physicians, examination costs a
Results A total of 3758 patients were registered: 1093 in period 1 (control), 1329 in period 2 (intervention), and 1336 in period 3 (washout). We observed significant reductions in examination costs: 10.73% (P = 0.015) for laboratory and 33.66% (P < 0.001) for radiological costs in period 2 versus period 1; 5.02% (P = 0.014) for laboratory and 40.00% (P < 0.001) for radiological costs in period 3 versus period 1.
Introduction Belgium is one of the top European countries in terms of healthcare expenditures, spending 10.2% of its gross national product on healthcare in 2010 [1]. There are many papers evaluating a reduction in overhead costs through awareness: there is little issue that its works in general and there may be ethical arguments against this idea [2]. Our paper deals with an explicit setting and population: residents at emergency department (ED). What are the effects on the prescription behavior of residents' emergency physicians (EPs) when the price lists of common radiologic and laboratory tests are known? [3]. The aim of this study was to establish whether price list information could reduce laboratory and radiological examination costs in EDs.
Materials and methods Study design and setting
All adult patients (>16 years old) admitted to the ED during normal daytime hours (8 a.m. to 8 p.m., excluding weekends) were eligible for the study. 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Emergency Department and bScientific Support Unit, University Hospital of Mont-Godinne, Catholic University of Louvain, Yvoir, Belgium Correspondence to Gervais Nougon, MD, Emergency Department, University Hospital of Mont-Godinne, Catholic University of Louvain, 5530 Yvoir, Belgium Tel: + 32 81 42 31 30; fax: + 32 81 42 31 15; e-mail: [email protected] Received 14 October 2013 Accepted 14 April 2014
The definition of the pediatric age is not very clear in the literature. In the study of Sills et al. [4], the pediatric patient could reach the age of 17 when he was 19 years in the study of Achuitar et al. [5]. We chose to consider emergency pediatric patients below 16 years to maintain compliance with the legislation in force in Belgium (http://www.zorg-en-gezondheid.be) [6]. There is a change in pricing of medical procedures after 9 p.m. [1]. To not make the calculation of investigation costs unusable, the study was limited to daytime hours. It is not certain that the exclusion of patients attending the ED at night-time hours would have led to a significant change in the goal of the study. The patients were assessed by nine resident EPs at the ED of the University Hospital of Mont-Godinne in Belgium, which is a tertiary hospital with an ED (pediatric and adult). The resident decided on his/her own to order all radiological [including computed tomography (CT) and MRI] and laboratory tests according to standard available protocols. When necessary, the resident EP should provide the reasons of the requested radiological examinations. The residents and the staff DOI: 10.1097/MEJ.0000000000000171
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
248 European Journal of Emergency Medicine 2015, Vol 22 No 4
were informed of the study and explanations were provided by the corresponding author before the start of the study. All excluded patients were examined during daytime hours by nonresident EPs and during night-time hours and weekends by one of the nine resident EPs or by nonresidents. During the study, admissions procedures at the ED were not changed. All critically ill or serious trauma patients where announced as usual. These patients were first examined by one of the two senior EPs at the ED to exclude possible lethal lesions. Dynamic bias because of the number of critically ill or trauma cases was not excluded completely. As this study did not involve any human experimentation, it was exempt from review by the ethical committee. Moreover, confidentiality was ensured completely. Survey instruments
In this study, we used a ‘control–intervention–washout’ design to assess a group of resident EPs during a 6-month academic interval, which was divided into 2-month periods: period 1 was the control period (October and November 2011), period 2 was the intervention period (December 2011 to January 2012), and period 3 was the washout period (February and March 2012). During the control and washout periods, physicians ordered tests from a list of common ED laboratory and radiological examinations, which was available on each patient’s electronic administration form. However, during the intervention period, physicians ordered these same tests from a list that included prices for each examination. Also, the price list was displayed continuously above all medical workstations, in patient rooms, and examination rooms [3,7]. No clinical or admission procedure was changed for this study. In addition, there was always a senior EP at the ED.
ED, the subdivision of medical and surgical departments at our hospital, and according to Belgian legislation (http:// www.zorg-en-gezondheid.be). All patients were seen and tests were ordered by the resident EP. When necessary, explanations were provided by one of the two senior EPs. All inpatient and outpatient analyses were recorded, including standard admission laboratory tests (i.e. hematology, hemostasis, D-dimers, renal function, electrolytes, transaminases) and diagnostic imaging techniques (i.e. electrocardiogram, all standard radiography, ultrasounds, CT, scintigraphy, MRI). MRI is not a typical ED procedure but can be obtained as a normal radiologic examination according to the local protocol. There are no differences in terms of the cost between a cerebral or a spine CT versus MRI. Because of the presence of a relatively important neurologic unit at our hospital, cerebral or spine MRI can be performed any time. After admission, patients were divided into four groups according to the definitive diagnosis at the end of their stay at the ED. The final admissions costs were determined by the financial department of our hospital. One month later, the collected admissions costs with admission numbers were given to the two independent senior EPs. They have no other access to the collected information by the financial department. The records for each admission number were reviewed to accurately determine the cost of radiological and laboratory analyses for each admission number. We hypothesized that providing price list information related to radiological and laboratory tests would result in a considerable reduction in the number of tests prescribed by resident EPs during the intervention period at the ED. Although we anticipated that test ordering would increase again by the end of the washout period, we expected fewer examinations to be requested compared with the control period. Actual costs
The purpose of the washout period, which we believe was the most important, was to see whether the experience gained by the resident EP in previous periods was maintained during the latter period, during which the prices of complementary examinations were no longer displayed at the ED. Patients were divided into four major groups according to their diagnosis (by specialty) after admission at the ED: group A for internal medicine (i.e. pulmonology, cardiology, oncology, endocrinology, general internal medicine, rheumatology, dermatology), group B for orthopedic and traumatologic surgery, group C for general surgery (i.e. abdominal, vascular, thoracic, gynecologic, urologic, plastic), and group D for head and neck pathologies (i.e. neurology, neurosurgery, ophthalmology, otorhinolaryngology, psychiatry). The division was performed according to the prevalence of admitted patients at the
The financial department at the University Hospital of Mont-Godinne provided the costs for all laboratory and radiological examinations. The actual reference costs were officially decided by the National Institute for Health Insurance and Invalidity (INAMI) [1] (Table 1) and are identical for all Belgian hospitals. Costs are reported in Euros. No cost differences were associated with the selected items during daytime hours (8 a.m. to 8 p.m.). Also, investigation costs did not vary in relation to urgency. All imaging and laboratory examinations were available at all times. Data analysis
During each period, mean SDs and ranges for the different ED admissions were determined for the laboratory and radiologic examination costs. Estimated costs were expressed in Euros and were compared between the
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Offering pricing information Nougon et al. 249
Cost of laboratory and radiologic examinations
Examinations
Price (€)
Laboratory examinations Standard laboratory examinations Hematology, hemostasis, renal function, electrolytes, transaminases ECG D-dimers Arterial blood gases BNP Stress test Standard radiographs Finger, hand, wrist, forearm, elbow, clavicle, toe, foot, leg Arm, shoulder, pelvis, hip Knee, femur, hip Cervical spine Lumbar spine Spine Rib cage Thorax Abdomen Computer tomography Spine, head Abdomen, thorax Ultrasounds Abdomen Scrotum Doppler (one leg) Doppler (two legs) Cardiac MRI Neck, thorax, abdomen Spine, head Scintigraphy V/P scintigraphy
53.20 16.00 3.11 5.78 30.00 34.48 13.89 17.89 19.84 39.68 44.64 34.72 23.31 12.40 22.32 89.28 128.95 55.40 19.55 39.11 52.14 69.24 161.19 89.28 205.94
BNP, brain natriuretic peptide; ECG, electrocardiogram; V/P, ventilation/ perfusion.
periods using the Wilcoxon rank sum test. All statistical tests were two-tailed, unpaired, and were carried out using SPSS 15.0 (SPSS Inc., Chicago, Illinois, USA). The Kruskal–Wallis test was used.
(1) 60.37% in period 2 versus period 1 (P = 0.034) for radiologic examination costs in group A (internal medicine). (2) 47.04% in period 3 versus period 1 (P = 0.030) for laboratory examination costs in group B (orthopedic and traumatologic surgery). (3) 17.96% in period 3 versus period 1 (P = 0.011) for radiologic examination costs in group C (general surgery). (4) 14.75% in period 3 versus period 1 (P = 0.012) for radiologic examination costs in group D (head and neck pathologies). Figure 1 shows the number of patients included in the study per month, whereas Fig. 2 shows the proportion of patients within each diagnosis group (by specialty) and Fig. 3 shows the distribution of laboratory and radiologic examination costs per period for all of the groups included. Table 1 shows the prices associated with each of the different laboratory and radiologic examinations costs. Tables 2 and 3 show the mean, median, and SDs for laboratory and radiological examination costs for periods 1, 2, and 3. In all, 142 patients were excluded from the study (incomplete records, dressing control, discharge against medical advice, inadequate internal guidance, etc.). Fig. 1
800 700
In addition, we found that laboratory examination costs increased slightly between period 2 and 3 (+ 6.4%), whereas the costs related to radiologic examinations continued to decrease (− 10.16%); however, these differences were not statistically significant. Furthermore, we observed a significant reduction in the examination costs between the different diagnosis groups:
Patient admission
300 200 100 0 March 2012
40.00% 3 versus
400
February 2012
33.66% 2 versus
500
January 2012
(1) 10.73% (P = 0.015) for laboratory and (P < 0.001) for radiological costs in period period 1. (2) 5.02% (P = 0.014) for laboratory and (P < 0.001) for radiological costs in period period 1.
600
December 2011
A total of 3900 patients were registered, and 3758 were included in the study: 1093 in period 1, 1329 in period 2, and 1336 in period 3. We observed the following significant reductions in examination costs:
November 2011
Results
October 2011
Table 1
Number of patients per month.
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250 European Journal of Emergency Medicine 2015, Vol 22 No 4
Table 2 Mean and SDs for laboratory and radiological examinations from cost periods 1, 2, and 3
Fig. 2
50 45 40 35 30 25 20 15 10 5 0
Period 1 Period 2 Period 3
Orthotrauma
Head and neck
Int. med
Gen. surgery
Proportion of patients according to specialty. Ortho-trauma, orthopedic and traumatologic surgery; Head and neck, head and neck pathology; Int. med, internal medicine; Gen. surgery, general surgery; period 1, October to November 2011; period 2, December to January 2012; period 3, February to March 2012.
Period 1 Laboratory Radiologic Period 2 Laboratory Radiologic Period 3 Laboratory Radiologic
Mean 25 20 15 10 5 0 Laboratory
Radiology Period 1 Period 2 Period 3
Type of examinations
Laboratory and radiologic examinations for all periods. Period 1, October to November 2011; period 2, December to January 2012; period 3, February to March 2012.
Discussion For many years, reduction of healthcare costs has been the subject of various studies. In fact, research carried out in the 1980s by Cohen et al. [8] and Cummings et al. [9] showed that there was a significant reduction in the number of diagnostic tests ordered when physicians were provided price information compared with control groups, with an average cumulative cost reduction of 31% per patient observed in the study of Cummings and colleagues. Between periods 1 and 3, we observed a reduction of more than 60% of demand for radiographic examinations
Mean (€)
SD
Median (€)
examinations examinations
1093 1093
7.1 21.8
10.2 61.5
0.0 0.0
examinations examinations
1329 1329
6.4 14.4
10.0 32.1
0.0 0.0
examinations examinations
1336 1336
6.8 12.9
11.5 31.4
0.0 0.0
Period 1, October to November 2011; period 2, December to January 2012; period 3, February to March 2012. P = 0.015 between periods 1 and 2, is insignificant between periods 2 and 3, and 0.014 between periods 1 and 3 for laboratory examinations. P < 0.001 between periods 1 and 2, is insignificant between periods 2 and 3, and is < 0.001 between periods 1 and 3 for laboratory examinations.
Table 3
Fig. 3
N
Comparative examination costs (€) between the groups
Group A Period 1 Laboratory Radiology Period 2 Laboratory Radiology Period 3 Laboratory Radiology Group B Period 1 Laboratory Radiology Period 2 Laboratory Radiology Period 3 Laboratory Radiology Group C Period 1 Laboratory Radiology Period 2 Laboratory Radiology Period 3 Laboratory Radiology Group D Period 1 Laboratory Radiology Period 2 Laboratory Radiology Period 3 Laboratory Radiology
N
Mean (€)
SD
Median (€)
494 494
10.8 20.8
12.2 79.1
10.2 0.0
594 594
8.8 12.9
11.7 31.3
0.2 0.0
636 636
8.9 11.3
13.1 30.1
0.0 0.0
266 266
1.9 23.7
4.9 40.9
0.0 14.0
269 269
2.7 17.5
5.9 27.5
0.0 0.0
301 301
3.7 17.4
9.4 28.8
0.0 13.6
144 144
7.1 25.0
7.9 48.6
4.1 0.0
186 186
6.4 12.0
8.9 31.1
0.0 0.0
151 151
7.6 12.9
10.4 39.9
0.0 0.0
189 189
4.8 19.1
7.5 36.9
0.0 0.0
280 280
4.6 16.2
8.4 37.7
0.0 0.0
247 247
4.6 11.8
8.3 31.4
0.0 0.0
Group A, internal medicine; group B, orthopedic and traumatologic surgery; group C, general surgery; group D, head and neck pathologies. Group A: P < 0.001 between periods 1 and 3 for laboratory examination costs and P = 0.002 for radiologic examination costs. Group B: P = 0.03 between periods 1 and 3 for laboratory examination costs and P = 0.003 for radiologic examination costs. Group C: P is insignificant between periods 1 and 3 for laboratory examination costs and P = 0.01 for radiologic examination costs. Group D: P is insignificant between periods 1 and 3 for laboratory examination costs and P = 0.012 for radiologic examination costs.
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Offering pricing information Nougon et al. 251
in the group of internal medicine. This decrease relates more to the number of radiological examinations requested and not the choice of the least expensive tests. Allan and Innes [10] found that physicians believed that better knowledge of costs would change their prescription behavior. In addition, a Swedish study using anonymous questionnaires showed that medical doctors involved in emergency patient care considered price lists as a potentially useful tool in their daily work [11]. In our study, we observed a significant reduction in the number of laboratory tests ordered between periods 1 and 2, whereas the amount requested between periods 2 and 3 remained stable. It is difficult to find very clear information. Probably, the residents consider the critical condition of the patient as paramount. Reduction in the number of tests has been observed in less sick patients. We did not notice any significant difference between the three periods in the internal medicine group for laboratory examination costs. Several explanations are possible: the limited number of laboratory tests that may require residents at the ED, and probably the most important the budgeting of laboratory investigations, where there is a hospital charge for a number of laboratory tests, which, in the ED, enables us to identify the great majority of internal medicine pathologies. These observations on the limited number of tests at the ED were already reported by Miyakis et al. [12]. The trend in the reduction of the number of additional examinations found in the interventional period was maintained in the washout period; our main aim was to observe whether the observations of period 2 were still maintained or improved in period 3. These results are not in contrast with the results of Schilling [3], which found decreases of 9% in laboratory costs for orthopedic patients (n = 1442) and 21.4% for medical patients (n = 1885). Cumulatively, we identified a reduction in laboratory examination costs of 10.73% for all diagnoses between periods 1 and 2, and a decrease of 5.02% between the intervention and washout periods. However, this observed cost reduction was more significant for radiologic examinations: 33.66% between the control and intervention periods and 10.16% between the control and washout periods. The majority of our emergency admissions are of group A (internal medicine). Our hospital is not recognized as a trauma center and we do not receive heavy trauma patients; the implementation of ‘evidence-based’ medicine and the introduction of guidelines may have contributed toward the decrease in the number of radiological tests in periods 2 and 3. There was no significant statistical difference between periods 2 and 3 for all disciplines. Eisenberg [13] reported the same conclusions. Continuous efforts must be maintained to
obtain long-term results, especially in training centers where the rotation of residents is common. Taken together, we agree with Schilling [11] that distributing and promoting price lists in EDs can heighten cost awareness among physicians, resulting in significant decreases in examination costs. This study once again shows that medical education teams need to considerably improve training related to healthcare costs, particularly considering the current financial pressures associated with healthcare. The lack of a control EP group was partially resolved by the fact that the same EPs were involved in the ‘control–intervention–washout’ periods. Furthermore, the patient population in our department was homogeneous over the 6-month period of the study; thus, patients’ characteristics were comparable during the three periods. We conclude that the distribution of price lists at the EDs may contribute toward potentially large decreases in costs for examination during workup performed by residents in our ED. The rotation of resident EP in teaching hospitals makes it difficult to maintain the results observed in the intervention period if they are not repeated at regular intervals and combined with continuous education on the reasons for and consequences of inappropriate ordering of laboratory and radiologic tests.
Limitations of the study
This study had some limitations. It is possible that the cost reductions observed by the end of the study may be because of the experience gained by the resident EPs as they trained. To exclude this possibility, future studies examining this topic should include an additional 6-month control period. Furthermore, we could not determine the impact of senior physicians on tests ordering by ED residents during the different periods, and neither the impact of the improvement in clinical evaluation by the residents on the basis of a learning curve. Despite the increasing experience of the residents after their initial 2 months of training in the ED, we do not know what influence the senior EP might have had on the ordering of individual tests when they were consulted by the residents. It is interesting that the reduction in the ordering of blood tests was far less when compared with the reduction in radiology tests ordered. A factor here could probably be that residents who first come to work in an ED have a relatively poor knowledge of the appropriateness of ordering orthopedic radiographs, in particular, and their greater experience after 2 months of orthopedic assessment analysis may have led to a reduction in the number of unnecessary radiographs. The other limitation of the study is that we did not compare the clinical cases involved in the three study periods,
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252 European Journal of Emergency Medicine 2015, Vol 22 No 4
other than classifying them according to the specialty involved.
5
Acknowledgements
6
assess disease progression. J Inherit Metab Dis 2011; 34:923–927. Arrêté Royal du 29 avril 1999. Available at: http://www.etaamb.be/fr/arrete-
7
royal-du-29-avril-1999_n1999022605.html [Accessed 6 October 1999]. Snyder-Ramos SA, Bauer M, Martin E, Motsch J, Böttiger BW. Accessible
The authors gratefully acknowledge all of the resident EPs from the ED at the Université Catholique de Louvain (Mont-Godinne) who participated in this study. Also, the authors are grateful to Mr Jerôme Massart for data collection. Conflicts of interest
Ensenauer R, et al. Nijmegen paediatric CDG rating scale: a novel tool to
price lists at the anaesthesiologist’s workplace enhance cost consciousness as a part of process and cost optimization. Anaesthesist 8
1
2 3
4
Gervais N, Véronique G, Jacques J, Dominique V. How aware are Belgian permanent and resident emergency physicians of common medical care costs and radiation doses? Eur J Emerg Med 2011; 18:344–350. Pellegrino ED. Interest, obligations, and justice: some notes toward an ethics of managed care. J Clin Ethics 1995; 6:312–317. Schilling UM. The acceptance of price lists at the emergency department: how do doctors think about it? Scand J Trauma Resusc Emerg Med 2010; 18:P32. Sills MR, Ginde AA, Clark S, Camargo CA Jr. Multianalysis of quality indicators for children treated in the emergency department for asthma. Pediatrics 2012; 129:e325–e332.
2003; 52:154–161. Cohen DI, Jones P, Littenberg B, Neuhauser D. Does cost information availability reduce physician test usage? A randomized clinical trial
9
There are no conflicts of interest.
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unexpected findings. Med Care 1982; 20:286–292. Cummings KM, Frisof KB, Long MJ, Hrynkiewich G. The effects of price information on physicians’ test-ordering behavior. Ordering of
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diagnostic tests. Med Care 1982; 20:293–301. Allan GM, Innes GD. Do family physicians know the costs of medical
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care? Survey in British Columbia. Can Fam Physician 2004; 50:263–270. Schilling UM. Cutting costs: the impact of price lists on the cost development at the emergency department. Eur J Emerg Med 2010;
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17:337–339. Miyakis S, Karamanof G, Liontos M, Mountoskalakis TD. Factors contributing to inappropriate ordering of test in an academic medical department and the effect of an educational feedback strategy. Postgrad
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Med J 2006; 82:823–829. Eisenberg JM. An educational program to modify laboratory use by house staff. J Med Educ 1977; 52:578–581.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Does offering pricing information to resident physicians in the emergency department potentially reduce laboratory and radiology costs? Gervais Nougona, Xavier Muscharta, Véronique Gérarda, Caroline Boulouffea, Jacques Jamartb, Dominique Van Peea and Louis De Cannièrea Objectives The aim of this study was to establish whether price list information could reduce laboratory and radiological examination costs in emergency departments (EDs). Materials and methods A prospective survey of adult (>16 years old) admissions was conducted at the ED of a university hospital in Belgium. Nine resident emergency physicians were followed for a span of 6 months, which was divided into 2-month periods: control (October and November 2011), intervention (December 2011 to January 2012), and washout (February and March 2012). Laboratory and radiological costs for each of the daily admissions were calculated during the respective periods and compared.
In addition, we found that laboratory examination costs increased slightly between periods 2 and 3 (+ 6.4%), whereas costs related to radiologic examinations continued to decrease (− 10.16%); however, these differences were not statistically significant. Conclusion We conclude that the distribution of price lists at EDs promotes cost awareness, which can result in significant decreases in examination costs. European Journal of Emergency Medicine 22:247–252 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. European Journal of Emergency Medicine 2015, 22:247–252 Keywords: Belgium, emergency physicians, examination costs a
Results A total of 3758 patients were registered: 1093 in period 1 (control), 1329 in period 2 (intervention), and 1336 in period 3 (washout). We observed significant reductions in examination costs: 10.73% (P = 0.015) for laboratory and 33.66% (P < 0.001) for radiological costs in period 2 versus period 1; 5.02% (P = 0.014) for laboratory and 40.00% (P < 0.001) for radiological costs in period 3 versus period 1.
Introduction Belgium is one of the top European countries in terms of healthcare expenditures, spending 10.2% of its gross national product on healthcare in 2010 [1]. There are many papers evaluating a reduction in overhead costs through awareness: there is little issue that its works in general and there may be ethical arguments against this idea [2]. Our paper deals with an explicit setting and population: residents at emergency department (ED). What are the effects on the prescription behavior of residents' emergency physicians (EPs) when the price lists of common radiologic and laboratory tests are known? [3]. The aim of this study was to establish whether price list information could reduce laboratory and radiological examination costs in EDs.
Materials and methods Study design and setting
All adult patients (>16 years old) admitted to the ED during normal daytime hours (8 a.m. to 8 p.m., excluding weekends) were eligible for the study. 0969-9546 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Emergency Department and bScientific Support Unit, University Hospital of Mont-Godinne, Catholic University of Louvain, Yvoir, Belgium Correspondence to Gervais Nougon, MD, Emergency Department, University Hospital of Mont-Godinne, Catholic University of Louvain, 5530 Yvoir, Belgium Tel: + 32 81 42 31 30; fax: + 32 81 42 31 15; e-mail: [email protected] Received 14 October 2013 Accepted 14 April 2014
The definition of the pediatric age is not very clear in the literature. In the study of Sills et al. [4], the pediatric patient could reach the age of 17 when he was 19 years in the study of Achuitar et al. [5]. We chose to consider emergency pediatric patients below 16 years to maintain compliance with the legislation in force in Belgium (http://www.zorg-en-gezondheid.be) [6]. There is a change in pricing of medical procedures after 9 p.m. [1]. To not make the calculation of investigation costs unusable, the study was limited to daytime hours. It is not certain that the exclusion of patients attending the ED at night-time hours would have led to a significant change in the goal of the study. The patients were assessed by nine resident EPs at the ED of the University Hospital of Mont-Godinne in Belgium, which is a tertiary hospital with an ED (pediatric and adult). The resident decided on his/her own to order all radiological [including computed tomography (CT) and MRI] and laboratory tests according to standard available protocols. When necessary, the resident EP should provide the reasons of the requested radiological examinations. The residents and the staff DOI: 10.1097/MEJ.0000000000000171
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
248 European Journal of Emergency Medicine 2015, Vol 22 No 4
were informed of the study and explanations were provided by the corresponding author before the start of the study. All excluded patients were examined during daytime hours by nonresident EPs and during night-time hours and weekends by one of the nine resident EPs or by nonresidents. During the study, admissions procedures at the ED were not changed. All critically ill or serious trauma patients where announced as usual. These patients were first examined by one of the two senior EPs at the ED to exclude possible lethal lesions. Dynamic bias because of the number of critically ill or trauma cases was not excluded completely. As this study did not involve any human experimentation, it was exempt from review by the ethical committee. Moreover, confidentiality was ensured completely. Survey instruments
In this study, we used a ‘control–intervention–washout’ design to assess a group of resident EPs during a 6-month academic interval, which was divided into 2-month periods: period 1 was the control period (October and November 2011), period 2 was the intervention period (December 2011 to January 2012), and period 3 was the washout period (February and March 2012). During the control and washout periods, physicians ordered tests from a list of common ED laboratory and radiological examinations, which was available on each patient’s electronic administration form. However, during the intervention period, physicians ordered these same tests from a list that included prices for each examination. Also, the price list was displayed continuously above all medical workstations, in patient rooms, and examination rooms [3,7]. No clinical or admission procedure was changed for this study. In addition, there was always a senior EP at the ED.
ED, the subdivision of medical and surgical departments at our hospital, and according to Belgian legislation (http:// www.zorg-en-gezondheid.be). All patients were seen and tests were ordered by the resident EP. When necessary, explanations were provided by one of the two senior EPs. All inpatient and outpatient analyses were recorded, including standard admission laboratory tests (i.e. hematology, hemostasis, D-dimers, renal function, electrolytes, transaminases) and diagnostic imaging techniques (i.e. electrocardiogram, all standard radiography, ultrasounds, CT, scintigraphy, MRI). MRI is not a typical ED procedure but can be obtained as a normal radiologic examination according to the local protocol. There are no differences in terms of the cost between a cerebral or a spine CT versus MRI. Because of the presence of a relatively important neurologic unit at our hospital, cerebral or spine MRI can be performed any time. After admission, patients were divided into four groups according to the definitive diagnosis at the end of their stay at the ED. The final admissions costs were determined by the financial department of our hospital. One month later, the collected admissions costs with admission numbers were given to the two independent senior EPs. They have no other access to the collected information by the financial department. The records for each admission number were reviewed to accurately determine the cost of radiological and laboratory analyses for each admission number. We hypothesized that providing price list information related to radiological and laboratory tests would result in a considerable reduction in the number of tests prescribed by resident EPs during the intervention period at the ED. Although we anticipated that test ordering would increase again by the end of the washout period, we expected fewer examinations to be requested compared with the control period. Actual costs
The purpose of the washout period, which we believe was the most important, was to see whether the experience gained by the resident EP in previous periods was maintained during the latter period, during which the prices of complementary examinations were no longer displayed at the ED. Patients were divided into four major groups according to their diagnosis (by specialty) after admission at the ED: group A for internal medicine (i.e. pulmonology, cardiology, oncology, endocrinology, general internal medicine, rheumatology, dermatology), group B for orthopedic and traumatologic surgery, group C for general surgery (i.e. abdominal, vascular, thoracic, gynecologic, urologic, plastic), and group D for head and neck pathologies (i.e. neurology, neurosurgery, ophthalmology, otorhinolaryngology, psychiatry). The division was performed according to the prevalence of admitted patients at the
The financial department at the University Hospital of Mont-Godinne provided the costs for all laboratory and radiological examinations. The actual reference costs were officially decided by the National Institute for Health Insurance and Invalidity (INAMI) [1] (Table 1) and are identical for all Belgian hospitals. Costs are reported in Euros. No cost differences were associated with the selected items during daytime hours (8 a.m. to 8 p.m.). Also, investigation costs did not vary in relation to urgency. All imaging and laboratory examinations were available at all times. Data analysis
During each period, mean SDs and ranges for the different ED admissions were determined for the laboratory and radiologic examination costs. Estimated costs were expressed in Euros and were compared between the
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Offering pricing information Nougon et al. 249
Cost of laboratory and radiologic examinations
Examinations
Price (€)
Laboratory examinations Standard laboratory examinations Hematology, hemostasis, renal function, electrolytes, transaminases ECG D-dimers Arterial blood gases BNP Stress test Standard radiographs Finger, hand, wrist, forearm, elbow, clavicle, toe, foot, leg Arm, shoulder, pelvis, hip Knee, femur, hip Cervical spine Lumbar spine Spine Rib cage Thorax Abdomen Computer tomography Spine, head Abdomen, thorax Ultrasounds Abdomen Scrotum Doppler (one leg) Doppler (two legs) Cardiac MRI Neck, thorax, abdomen Spine, head Scintigraphy V/P scintigraphy
53.20 16.00 3.11 5.78 30.00 34.48 13.89 17.89 19.84 39.68 44.64 34.72 23.31 12.40 22.32 89.28 128.95 55.40 19.55 39.11 52.14 69.24 161.19 89.28 205.94
BNP, brain natriuretic peptide; ECG, electrocardiogram; V/P, ventilation/ perfusion.
periods using the Wilcoxon rank sum test. All statistical tests were two-tailed, unpaired, and were carried out using SPSS 15.0 (SPSS Inc., Chicago, Illinois, USA). The Kruskal–Wallis test was used.
(1) 60.37% in period 2 versus period 1 (P = 0.034) for radiologic examination costs in group A (internal medicine). (2) 47.04% in period 3 versus period 1 (P = 0.030) for laboratory examination costs in group B (orthopedic and traumatologic surgery). (3) 17.96% in period 3 versus period 1 (P = 0.011) for radiologic examination costs in group C (general surgery). (4) 14.75% in period 3 versus period 1 (P = 0.012) for radiologic examination costs in group D (head and neck pathologies). Figure 1 shows the number of patients included in the study per month, whereas Fig. 2 shows the proportion of patients within each diagnosis group (by specialty) and Fig. 3 shows the distribution of laboratory and radiologic examination costs per period for all of the groups included. Table 1 shows the prices associated with each of the different laboratory and radiologic examinations costs. Tables 2 and 3 show the mean, median, and SDs for laboratory and radiological examination costs for periods 1, 2, and 3. In all, 142 patients were excluded from the study (incomplete records, dressing control, discharge against medical advice, inadequate internal guidance, etc.). Fig. 1
800 700
In addition, we found that laboratory examination costs increased slightly between period 2 and 3 (+ 6.4%), whereas the costs related to radiologic examinations continued to decrease (− 10.16%); however, these differences were not statistically significant. Furthermore, we observed a significant reduction in the examination costs between the different diagnosis groups:
Patient admission
300 200 100 0 March 2012
40.00% 3 versus
400
February 2012
33.66% 2 versus
500
January 2012
(1) 10.73% (P = 0.015) for laboratory and (P < 0.001) for radiological costs in period period 1. (2) 5.02% (P = 0.014) for laboratory and (P < 0.001) for radiological costs in period period 1.
600
December 2011
A total of 3900 patients were registered, and 3758 were included in the study: 1093 in period 1, 1329 in period 2, and 1336 in period 3. We observed the following significant reductions in examination costs:
November 2011
Results
October 2011
Table 1
Number of patients per month.
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250 European Journal of Emergency Medicine 2015, Vol 22 No 4
Table 2 Mean and SDs for laboratory and radiological examinations from cost periods 1, 2, and 3
Fig. 2
50 45 40 35 30 25 20 15 10 5 0
Period 1 Period 2 Period 3
Orthotrauma
Head and neck
Int. med
Gen. surgery
Proportion of patients according to specialty. Ortho-trauma, orthopedic and traumatologic surgery; Head and neck, head and neck pathology; Int. med, internal medicine; Gen. surgery, general surgery; period 1, October to November 2011; period 2, December to January 2012; period 3, February to March 2012.
Period 1 Laboratory Radiologic Period 2 Laboratory Radiologic Period 3 Laboratory Radiologic
Mean 25 20 15 10 5 0 Laboratory
Radiology Period 1 Period 2 Period 3
Type of examinations
Laboratory and radiologic examinations for all periods. Period 1, October to November 2011; period 2, December to January 2012; period 3, February to March 2012.
Discussion For many years, reduction of healthcare costs has been the subject of various studies. In fact, research carried out in the 1980s by Cohen et al. [8] and Cummings et al. [9] showed that there was a significant reduction in the number of diagnostic tests ordered when physicians were provided price information compared with control groups, with an average cumulative cost reduction of 31% per patient observed in the study of Cummings and colleagues. Between periods 1 and 3, we observed a reduction of more than 60% of demand for radiographic examinations
Mean (€)
SD
Median (€)
examinations examinations
1093 1093
7.1 21.8
10.2 61.5
0.0 0.0
examinations examinations
1329 1329
6.4 14.4
10.0 32.1
0.0 0.0
examinations examinations
1336 1336
6.8 12.9
11.5 31.4
0.0 0.0
Period 1, October to November 2011; period 2, December to January 2012; period 3, February to March 2012. P = 0.015 between periods 1 and 2, is insignificant between periods 2 and 3, and 0.014 between periods 1 and 3 for laboratory examinations. P < 0.001 between periods 1 and 2, is insignificant between periods 2 and 3, and is < 0.001 between periods 1 and 3 for laboratory examinations.
Table 3
Fig. 3
N
Comparative examination costs (€) between the groups
Group A Period 1 Laboratory Radiology Period 2 Laboratory Radiology Period 3 Laboratory Radiology Group B Period 1 Laboratory Radiology Period 2 Laboratory Radiology Period 3 Laboratory Radiology Group C Period 1 Laboratory Radiology Period 2 Laboratory Radiology Period 3 Laboratory Radiology Group D Period 1 Laboratory Radiology Period 2 Laboratory Radiology Period 3 Laboratory Radiology
N
Mean (€)
SD
Median (€)
494 494
10.8 20.8
12.2 79.1
10.2 0.0
594 594
8.8 12.9
11.7 31.3
0.2 0.0
636 636
8.9 11.3
13.1 30.1
0.0 0.0
266 266
1.9 23.7
4.9 40.9
0.0 14.0
269 269
2.7 17.5
5.9 27.5
0.0 0.0
301 301
3.7 17.4
9.4 28.8
0.0 13.6
144 144
7.1 25.0
7.9 48.6
4.1 0.0
186 186
6.4 12.0
8.9 31.1
0.0 0.0
151 151
7.6 12.9
10.4 39.9
0.0 0.0
189 189
4.8 19.1
7.5 36.9
0.0 0.0
280 280
4.6 16.2
8.4 37.7
0.0 0.0
247 247
4.6 11.8
8.3 31.4
0.0 0.0
Group A, internal medicine; group B, orthopedic and traumatologic surgery; group C, general surgery; group D, head and neck pathologies. Group A: P < 0.001 between periods 1 and 3 for laboratory examination costs and P = 0.002 for radiologic examination costs. Group B: P = 0.03 between periods 1 and 3 for laboratory examination costs and P = 0.003 for radiologic examination costs. Group C: P is insignificant between periods 1 and 3 for laboratory examination costs and P = 0.01 for radiologic examination costs. Group D: P is insignificant between periods 1 and 3 for laboratory examination costs and P = 0.012 for radiologic examination costs.
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Offering pricing information Nougon et al. 251
in the group of internal medicine. This decrease relates more to the number of radiological examinations requested and not the choice of the least expensive tests. Allan and Innes [10] found that physicians believed that better knowledge of costs would change their prescription behavior. In addition, a Swedish study using anonymous questionnaires showed that medical doctors involved in emergency patient care considered price lists as a potentially useful tool in their daily work [11]. In our study, we observed a significant reduction in the number of laboratory tests ordered between periods 1 and 2, whereas the amount requested between periods 2 and 3 remained stable. It is difficult to find very clear information. Probably, the residents consider the critical condition of the patient as paramount. Reduction in the number of tests has been observed in less sick patients. We did not notice any significant difference between the three periods in the internal medicine group for laboratory examination costs. Several explanations are possible: the limited number of laboratory tests that may require residents at the ED, and probably the most important the budgeting of laboratory investigations, where there is a hospital charge for a number of laboratory tests, which, in the ED, enables us to identify the great majority of internal medicine pathologies. These observations on the limited number of tests at the ED were already reported by Miyakis et al. [12]. The trend in the reduction of the number of additional examinations found in the interventional period was maintained in the washout period; our main aim was to observe whether the observations of period 2 were still maintained or improved in period 3. These results are not in contrast with the results of Schilling [3], which found decreases of 9% in laboratory costs for orthopedic patients (n = 1442) and 21.4% for medical patients (n = 1885). Cumulatively, we identified a reduction in laboratory examination costs of 10.73% for all diagnoses between periods 1 and 2, and a decrease of 5.02% between the intervention and washout periods. However, this observed cost reduction was more significant for radiologic examinations: 33.66% between the control and intervention periods and 10.16% between the control and washout periods. The majority of our emergency admissions are of group A (internal medicine). Our hospital is not recognized as a trauma center and we do not receive heavy trauma patients; the implementation of ‘evidence-based’ medicine and the introduction of guidelines may have contributed toward the decrease in the number of radiological tests in periods 2 and 3. There was no significant statistical difference between periods 2 and 3 for all disciplines. Eisenberg [13] reported the same conclusions. Continuous efforts must be maintained to
obtain long-term results, especially in training centers where the rotation of residents is common. Taken together, we agree with Schilling [11] that distributing and promoting price lists in EDs can heighten cost awareness among physicians, resulting in significant decreases in examination costs. This study once again shows that medical education teams need to considerably improve training related to healthcare costs, particularly considering the current financial pressures associated with healthcare. The lack of a control EP group was partially resolved by the fact that the same EPs were involved in the ‘control–intervention–washout’ periods. Furthermore, the patient population in our department was homogeneous over the 6-month period of the study; thus, patients’ characteristics were comparable during the three periods. We conclude that the distribution of price lists at the EDs may contribute toward potentially large decreases in costs for examination during workup performed by residents in our ED. The rotation of resident EP in teaching hospitals makes it difficult to maintain the results observed in the intervention period if they are not repeated at regular intervals and combined with continuous education on the reasons for and consequences of inappropriate ordering of laboratory and radiologic tests.
Limitations of the study
This study had some limitations. It is possible that the cost reductions observed by the end of the study may be because of the experience gained by the resident EPs as they trained. To exclude this possibility, future studies examining this topic should include an additional 6-month control period. Furthermore, we could not determine the impact of senior physicians on tests ordering by ED residents during the different periods, and neither the impact of the improvement in clinical evaluation by the residents on the basis of a learning curve. Despite the increasing experience of the residents after their initial 2 months of training in the ED, we do not know what influence the senior EP might have had on the ordering of individual tests when they were consulted by the residents. It is interesting that the reduction in the ordering of blood tests was far less when compared with the reduction in radiology tests ordered. A factor here could probably be that residents who first come to work in an ED have a relatively poor knowledge of the appropriateness of ordering orthopedic radiographs, in particular, and their greater experience after 2 months of orthopedic assessment analysis may have led to a reduction in the number of unnecessary radiographs. The other limitation of the study is that we did not compare the clinical cases involved in the three study periods,
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252 European Journal of Emergency Medicine 2015, Vol 22 No 4
other than classifying them according to the specialty involved.
5
Acknowledgements
6
assess disease progression. J Inherit Metab Dis 2011; 34:923–927. Arrêté Royal du 29 avril 1999. Available at: http://www.etaamb.be/fr/arrete-
7
royal-du-29-avril-1999_n1999022605.html [Accessed 6 October 1999]. Snyder-Ramos SA, Bauer M, Martin E, Motsch J, Böttiger BW. Accessible
The authors gratefully acknowledge all of the resident EPs from the ED at the Université Catholique de Louvain (Mont-Godinne) who participated in this study. Also, the authors are grateful to Mr Jerôme Massart for data collection. Conflicts of interest
Ensenauer R, et al. Nijmegen paediatric CDG rating scale: a novel tool to
price lists at the anaesthesiologist’s workplace enhance cost consciousness as a part of process and cost optimization. Anaesthesist 8
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2 3
4
Gervais N, Véronique G, Jacques J, Dominique V. How aware are Belgian permanent and resident emergency physicians of common medical care costs and radiation doses? Eur J Emerg Med 2011; 18:344–350. Pellegrino ED. Interest, obligations, and justice: some notes toward an ethics of managed care. J Clin Ethics 1995; 6:312–317. Schilling UM. The acceptance of price lists at the emergency department: how do doctors think about it? Scand J Trauma Resusc Emerg Med 2010; 18:P32. Sills MR, Ginde AA, Clark S, Camargo CA Jr. Multianalysis of quality indicators for children treated in the emergency department for asthma. Pediatrics 2012; 129:e325–e332.
2003; 52:154–161. Cohen DI, Jones P, Littenberg B, Neuhauser D. Does cost information availability reduce physician test usage? A randomized clinical trial
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There are no conflicts of interest.
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