No Change in Ordering Despite Cost Information

Everyone hates the nanny state. When the electronic health record alerts and interrupts clinicians incessantly with decision-“support”, it results in all manner of deleterious unintended consequences. Passive, contextual decision-support has the advantage of avoiding this intrusiveness – but is it effective?

It probably depends on the application, but in this trial, it was not. This is the PRICE (Pragmatic Randomized Introduction of Cost data through the Electronic health record) trial, in which 75 inpatient laboratory tests were randomized to display of usual ordering, or ordering with contextual Medicare cost information. The hope and study hypothesis was the availability of this financial interest would exert a cultural pressure of sorts on clinicians to order fewer tests, particularly those with high costs.

Across three Philadelphia-area hospitals comprising 142,921 hospital admissions in a two-year study period, there were no meaningful differences in lab tests ordered per patient day in the intervention or the control. Looking at various subgroups of patients, it is also unlikely there were particularly advantageous effects in any specific population.

Interestingly, one piece of feedback the authors report is the residents suggest most of their routine lab test ordering resulted from admission order sets. “Routine” daily labs are set in motion at the time of admission, not part of a daily assessment of need, and thus a natural impediment to improving low-value testing. However, the authors also note – and this is probably most accurate – because the cost information was displayed ubiquitously, physicians likely became numb to the intervention. It is reasonable to expect substantially more selective cost information could have focused effects on an adea of particularly high cost or low-value.

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