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Price transparency for inpatient labratory tests has little effect on clinician ordering behavior, JAMA says

It's been estimated that nearly 30 percent of laboratory testing in the United States may be wasteful.

Jeff Lagasse, Associate Editor

Health systems are increasingly considering a boost to their price transparency efforts when it comes to order entry, but evidence for the effectiveness of this strategy has been spotty. New research published in the Journal of the American Medical Association Internal Medicine finds that displaying Medicare allowable fees for inpatient laboratory tests did not significantly change clinician ordering behavior, or the associated fees.

The findings are significant because it's been estimated that nearly 30 percent of laboratory testing in the United States may be wasteful. Unnecessary blood draws can cause patient discomfort, not to mention harm in the form of hospital-acquired anemia. It may also be associated with increased rates of false-positive results, in turn leading to increased costs and potentially adverse outcomes from unwarranted interventions.

Aiming for a more comprehensive scope than past studies, the JAMA authors collected data from a longer duration and numerous hospital sites, also adjusting for patient demographics, insurance, disposition and comorbidity severity.

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The absence of an overall effect on test ordering behavior may be due to several factors, the authors said, and they may have important implications for hospitals considering the approach. First, the price transparency intervention in the study was always displayed regardless of the clinical scenario. The presence of this information for appropriate tests may have diminished its impact when tests were inappropriate; future efforts may consider more selective targeting.

Clinician practice habit may have played a part as well. In a qualitative analysis at one of the hospital sites, 91 percent of resident physicians said unnecessary laboratory testing was due to the habit of entering repeating daily test orders on the patient's first day of admission. The test may become more unnecessary later in the hospitalization, but if repeat orders were entered at the time of admission, the clinician wouldn't need to place another order for them and so wouldn't be presented with price transparency information when it mattered most.

One indication of this may have been demonstrated when comparing changes for patients with and without a stay in an intensive care unit, the authors said. Because healthcare decisions are changing more rapidly in this setting, clinicians may be less likely to rely on repeating orders, so they may have been exposed to the intervention more often. Future efforts might also consider pairing price transparency information with changing the default setting in the electronic health record so clinicians can't order repeating laboratory testing for an extended time.

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Further, the framing of information in price transparency interventions may influence its effectiveness due to what the authors call "anchoring bias." Clinicians may have previously believed that the cost of some tests was higher than the price displayed. As evidence of this, the research found a small but significant decrease in test ordering for the most expensive quartile of fees, and a small but significant increase in test ordering for the least expensive quartile of Medicare fees. Future efforts may consider other ways to frame price transparency, such as comparisons of differences in price between options, using other forms of price (such as charges), or targeting only the more expensive tests.

The findings suggest that price transparency alone may not lead to significant changes in clinician behavior, and future price transparency interventions may need to be better targeted, framed or combined with other approaches.

Twitter: @JELagasse

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