D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2017 . No. 5 EFFECT OF A PRICE TRANSPARENCY INTERVENTION IN THE ELECTRONIC HEALTH RECORD ON CLINICIAN ORDERING OF INPATIENT LABORATORY TESTS Mina S. Sedrak, Jennifer S. Myers, Dylan S. Small, Irving Nachamkin, Justin B. Ziembar, Dana Murray, Gregory W. Kurtzman, Jingsan Zhu, Wenli Wang, Deborah Mincarelli, Daniel Danoski, Brian P. Wells, Jeffrey S. Berns, Patrick J. Brennan, C. William Hanson, Jessica Dine, Mitesh S. Patel JAMA Internal Medicine, April 2017 KEYFINDINGS Despite the promise of price transparency, clinicians did not change their ordering of inpatient lab tests when Medicare allowable fees were displayed in the electronic health record at the time of order entry. THE QUESTION The research team conducted subgroup comparisons of differences in ordering behavior for patients with varying comorbidities, for those who With estimates that nearly 30% of laboratory testing in the United States had an intensive care unit (ICU) stay, and for tests from the highest and is wasteful, health systems are considering making clinicians more aware lowest cost brackets. of the costs of the tests they order. Price transparency, at the time of ordering, may encourage clinicians to consider the cost of their decisions. THE FINDINGS This study sought to answer the question: if clinicians knew the cost of the tests they order in the hospital, would they change their ordering behavior? The mean number of tests per patient day did not change significantly in the intervention group compared to the control group over time. As shown, the mean number of tests ordered per patient-day remained THE STUDY virtually unchanged in both the intervention and control group. Even after This year-long randomized clinical trial was conducted at three hospitals within the University of Pennsylvania Health System in Philadelphia. It UNADJUSTED NUMBER OF INPATIENT LABORATORY TESTS analyzed the ordering practices of physicians, nurse practitioners, and ORDERED PER PATIENT-DAY BY GROUP AND MONTH physician assistants, but did not differentiate between these clinicians. The analysis included a one-year pre-intervention period and a one-year intervention period. The authors randomized 60 lab tests to two groups: one that displayed Medicare allowable fees at the time of order and the other that did not. The primary outcome was the number of tests ordered per patient-day, after adjusting for patient characteristics and other variables. The authors also looked at the associated fees per patient-day. Source: Sedrak et al., JAMA Internal Medicine. COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI adjusting for other factors, there was no significant change in the mean This could explain the small but significant decrease in ordering for the number of tests ordered or mean fees attributable to the intervention. most expensive tests and the small but significant increase in ordering for In subanalyses, the authors found a relative decrease in test ordering for the least expensive tests. Other ways to frame price transparency, such as patients with an ICU stay and a relative increase for patients without an comparisons of differences in price between options, using other forms ICU stay, and relative decrease in test ordering of tests in the top-quartile of price, such as charges, or targeting only more expensive tests, may be of fees and a relative increase of tests in the bottom-quartile of fees. needed. THE IMPLICATIONS Sedrak, M.S., Myers, J.S., Small, D.S., Nachamkin, I., Ziemba, J.B., Prior evidence has been inconsistent on the effectiveness of price Murray, D., Kurtzman, G.W., Zhu, J., Wang, W., Mincarelli, D., Danoski, transparency as a way to influence medical decision-making. This study D., Wells, B.P., Berns, J.S., Brennan, P.J., Hanson, C.W., Dine, J., provides further evidence that price transparency, by itself, is not likely to Patel, M.S. (2017), Effect of a Price Transparency Intervention in the reduce ordering of wasteful tests in the hospital. Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests. JAMA Intern Med. doi:10.1001/jamainternmed.2017.1144 A number of explanations may account for these findings and point the way toward more effective interventions. First, the allowable fees in the intervention were 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 might target price ABOUT LDI transparency more selectively. Second, the intervention might have had reduced salience because it did Since 1967, the Leonard Davis Institute of Health Economics (LDI) not consider clinician practice habits. In a qualitative analysis at one of the has been the leading university institute dedicated to data-driven, hospital sites, 91% of resident physicians reported that unnecessary lab policy-focused research that improves our nation’s health and health testing was due to the habit of entering repeating daily lab test orders on care. Originally founded to bridge the gap between scholars in the patient’s first day of admission. If repeating orders were entered at business (Wharton) and medicine at the University of Pennsylvania, admission, the clinician would not need to place another order and thus LDI now connects all of Penn’s schools and the Children’s Hospital of would not be presented with price transparency information when it would Philadelphia through its more than 250 Senior Fellows. be most salient. This might explain the effects of the intervention when patients had an ICU stay. Because health care decisions are changing LDI Research Briefs are produced by LDI’s policy team. For more more rapidly in this setting, clinicians may be less likely to rely on repeating information please contact Janet Weiner at weinerja@mail.med.upenn.edu. orders and therefore may have been exposed to the intervention more often. Pairing price transparency information with interventions reducing the use of repeating test orders could address this problem. Third, clinicians’ prior beliefs about costs of each test might influence the effectiveness of the intervention. Clinicians may have previously believed that the cost of some tests was higher or lower than the displayed price. LEAD AUTHORS DR. MINA SEDRAK Mina S. Sedrak, MD, MS is an Assistant Professor at City of Hope cancer center. He completed a Master of Science degree in Health Policy Research from Perelman School of Medicine at the University of Pennsylvania. His research focuses on studying the mechanisms by which social media and mobile technology can enhance individual and population health behaviors and outcomes in oncology. DR. MITESH PATEL Mitesh S. Patel, MD, MBA, MS is an Assistant Professor of Medicine and Health Care Management at the Perelman School of Medicine and The Wharton School at the University of Pennsylvania. He is a Staff Physician at the Crescenz VA Medical Center in Philadelphia. His research focuses on studying innovative ways to change health behaviors and improve health outcomes by combining digital health approaches that collect data using wireless and wearable devices with engagement strategies that leverage insights from behavioral economics. As Director of the Penn Medicine Nudge Unit, he leads an initiative within the health care system to systematically test ways to apply insights from behavioral science to choice environments to improve health care value and outcomes.