Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests

Abstract

are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration.OBJECTIVE To test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year. DESIGN, SETTING, AND PARTICIPANTSThe Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions.INTERVENTIONS Inpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record. MAIN OUTCOMES AND MEASURESPrimary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees. RESULTSThe sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.

Nudge Units to Improve the Delivery of Health Care

“…Similarly, in a randomized trial of price transparency for inpatient laboratory testing, we found that displaying prices for more expensive tests led to a small though significant decline in test ordering, but it was offset by increases in ordering of less expensive tests. 5 Although displaying prices may intuitively seem like a good idea, many prices may have been lower than clinicians expected (e.g., a basic metabolic panel was $11). Careful evaluation of intended and unintended consequences is essential in optimizing these interventions.…”

Effectiveness of provider price display in computerized physician order entry (CPOE) on healthcare quality: a systematic review

“…Another 6 studies were added from those identified by pearling reference lists for a total of 13 studies [10][11][12][13][14][15][16][17][18][19][20][21]26 for the final analysis. The results constituted 8 randomized controlled trials, 10,12,15,16,18,20,21,26 2 interrupted time series studies, 14,19 2 controlled clinical trials 11,13 and a prospective comparative study. 17 The sequence describing the above process can be found in Figure 2.…”

“…Designs of the studies varied as described above. Randomized studies differed based on level of randomization (Four at the level of test, 15,16,21,26 2 at the level of ordering provider, 18,20 1 at the level of patient 12 and 1 at the level of physician's computer session 10 ) The population and the setting in which the studies were done also varied (Four studies done in a community outpatient setting where providers who completed graduate medical education practiced, 11,14,18,20 9 studies done in hospital and outpatient settings of teaching hospitals 10,12,13,[15][16][17]19,21,26 ) The design of the price display also varied (2 studies displayed cost data, 18,20 2 studies utilized hospital input cost, 17,19 7 studied used charge data 10,12,[14][15][16]21,26 and 2 studies displayed wholesale market price 11,13 )…”

“…11,14,18,20 Similarly, the 6 studies done in inpatient and outpatient settings of teaching hospitals did not find any cost savings with price display. 12,13,16,19,21,26 Two randomized controlled trials, 1 done in an inpatient 15 and 1 in an outpatient setting 10 of teaching hospitals showed cost savings with price display. One prospective non-randomized study restricted to reference laboratory tests (ie tests sent to an outside laboratory) showed significant cost savings.…”

“…Price display on paper in the non-electronic health record era was associated with reduced costs. 8,9 Coinciding with the introduction of electronic health records (years 1990-2000) and the diffusion of EHR adoption (years 2000-2015), various authors [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] studied the impact of price display during computerized physician order entry on domains of healthcare quality such as efficiency, effectiveness, and safety. These studies differed in the setting, and design, as well as their conclusions.…”