Cost-consciousness among Swiss doctors: a cross-sectional survey

Healthcare cost consciousness among physicians and their attitudes towards controlling costs in Jordan: a cross sectional study

BACKGROUND

One of the most significant factors influencing medication adherence and, ultimately, therapeutic outcomes for patients is the cost. The aim of this study was to examine the cost-containment strategies used by physicians in Jordan while focusing on the importance of cost consciousness in addressing healthcare costs and its consequences.

METHOD

A quantitative study was conducted between June 19 and November 15, 2021, through a cross-sectional survey using a self-administered questionnaire.

RESULTS

A total of 389 physicians participated in this study. Governments (65.6%), health insurance companies (60.2%), and pharmaceutical and device manufacturers (57.9%) were the most frequently mentioned entities as being primarily responsible for reducing healthcare costs. Participating physicians showed a high level of enthusiasm towards all domains of reducing healthcare costs with a mean percentage of 88.3% (standard deviation (SD): 0.04). When discussing physicians' roles in containing healthcare costs and the effects of cost-conscious practice, most respondents agreed that there is currently too much emphasis on test and procedure costs (83.0%), that decision support tools that show costs would be helpful in their practice (84.5%), and that physicians need to take a more prominent role in limiting the use of unnecessary tests (86.0%). Around 70.0% of physicians agreed that they requested more tests when they did not know the patient well, and 80.0% of them stated that they considered the uncertainty involved in patient care to be disconcerting.

CONCLUSION

Participating physicians showed a moderate level of cost consciousness in Jordan. However, this must be higher because it will eventually lead to cost-related nonadherence, which will have a negative impact on the patient's health.

Information Asymmetry in Hospitals: Evidence of the Lack of Cost Awareness in Clinicians

BACKGROUND

Information asymmetries and the agency relationship are two defining features of the healthcare system. These market failures are often used as a rationale for government intervention. Many countries have government financing and provision of healthcare in order to correct for this, while health technology agencies also exist to improve efficiency. However, informational asymmetries and the resulting principal-agent problem still persist, and one example is the lack of cost awareness amongst clinicians. This study explores the cost awareness of clinicians across different settings.

METHODS

We targeted four clinical cohorts: medical students, Senior House Officers/Interns, Mid-grade Senior Registrar/Residents, and Consultant/Attending Physicians, in six hospitals in the United Kingdom, the United States, Australia, New Zealand and Spain. The survey asked respondents to report the cost (as they recalled) of different types of scans, visits, medications and tests. Our analysis focused on the differential between the perceived/recalled cost and the actual cost. We explored variation across speciality, country and other potential confounders. Cost-awareness levels were estimated based on the cost estimates within 25% of the actual cost.

RESULTS

We received 705 complete responses from six sites across five countries. Our analysis found that respondents often overestimated the cost of common tests while underestimating high-cost tests. The mean cost-awareness levels varied between 4 and 23% for different items. Respondents acknowledged that they did not feel they had received adequate training in cost awareness.

DISCUSSION

The current financial climate means that cost awareness and the appropriate use of scarce healthcare resources is more paramount than perhaps ever before. Much of the focus of health economics research is on high-cost innovative technologies, yet there is considerable waste in the system with respect to overtreatment and overdiagnosis. Common reasons put forward for this include defensive medicine, poor education, clinical uncertainty and the institution of protocols.

CONCLUSION

Given the role of clinicians in the healthcare system, as agents both for patients and for providers, more needs to be done to remove informational asymmetries and improve clinician cost awareness.

Reliability of Uncertainty Tolerance Scales Implemented Among Physicians and Medical Students: A Systematic Review and Meta-Analysis

PURPOSE

Uncertainty tolerance (UT) is a construct describing individuals' perceptions of, and responses to, uncertainty across their cognition, emotion, and behavior. Various UT scales have been designed for physician and medical student populations. However, links between UT and other variables (e.g., training stages) are inconsistent, raising concerns about scale reliability and validity. As reliability is a precondition for validity, a necessary first step in assessing UT scales' efficacy is evaluating their reliability. Accordingly, the authors conducted a meta-analysis of the reliability of UT scales designed for, and implemented among, physician and medical student populations.

METHOD

In 2020, the authors searched 4 electronic databases alongside a citation search of previously identified UT scales. They included English-language, peer-reviewed studies that implemented UT scales in physician and/or medical student populations and reported reliability evidence. A meta-analysis of studies' Cronbach's alphas evaluated aggregated internal consistency across studies; subgroup analyses evaluated UT scales by named scale, population, and item characteristics.

RESULTS

Among 4,124 records screened, 35 studies met the inclusion criteria, reporting 75 Cronbach's alphas. Four UT scales appeared in at least 3 included studies: Physicians' Reactions to Uncertainty scale 1990 (PRU1990) and 1995 (PRU1995) versions, Tolerance for Ambiguity scale (TFA), and Tolerance of Ambiguity in Medical Students and Doctors scale (TAMSAD). The scores from these scales ranged in reliability from very good (PRU1990: 0.832, PRU1995: 0.818) to respectable (TFA: 0.761, TAMSAD: 0.711). Aggregated internal consistency was significantly higher ( P < .001) among physicians (0.797) than medical students (0.711).

CONCLUSIONS

UT scales generally demonstrated respectable internal consistency when administered among physicians and medical students, yet the reliability among medical students was significantly lower. The authors caution against using UT scores for decision-making purposes (e.g., applicant selection, program evaluation), especially among medical student populations. Future research should explore the reasons underlying these observed population differences.

Cost-consciousness among Chinese medical staff: a cross-sectional survey

BACKGROUND

Rapidly increasing health care costs are a widespread problem in the world. The cost-consciousness among Chinese medical staff is an important topic that needs further investigation. Our study aimed to focus on the cost-consciousness of Chinese medical staff and explore the factors related to their cost-consciousness. Differences regarding cost-consciousness between doctors and nurses were also reported.

METHODS

Eight hospitals in Liaoning Province, China, were surveyed using a self-reporting questionnaire. A total of 1043 respondents, including 635 doctors and 408 nurses, participated in the study. A revised Chinese Cost-consciousness Scale was used to estimate cost-consciousness.

RESULTS

The mean score of the Cost-consciousness Scale was 27.60 and 28.18 among doctors and nurses, respectively, and there were no significant differences in any personal characteristics. Most Chinese medical staff were aware of the treatment costs and considered cost control as their responsibility. Chinese doctors disliked adhering to guidelines more and preferred to remain independent in making or denying a treatment decision; thus, they like autonomously balancing the treatment and cost. Chinese nurses have similar attitudes, but nurses tended to deny costly services and interventions and were more sensitive to the health care costs by rationing decisions and uncertainty in their medical practice.

CONCLUSION

We reveal the attitudes regarding cost-consciousness among Chinese medical staff. Chinese medical staff was aware of their responsibility in health cost control. Chinese doctors and nurses had different tendencies with regard to health care cost containment. Our study highlights the importance of education and professional training on cost-consciousness.

Why clinicians overtest: development of a thematic framework

BACKGROUND

Medical tests provide important information to guide clinical management. Overtesting, however, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are ultimately responsible for test requests, and are therefore ideally positioned to prevent overtesting and its unintended consequences. Through this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference (Sydney, 2019), we aimed to identify and establish a thematic framework of factors that influence clinicians to request non-recommended and unnecessary tests.

METHODS

Articles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development.

RESULTS

The MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed: "Intrapersonal" - fear of malpractice and litigation; clinician knowledge and understanding; intolerance of uncertainty and risk aversion; cognitive biases and experiences; sense of medical obligation "Interpersonal" - pressure from patients and doctor-patient relationship; pressure from colleagues and medical culture; "Environment/context" - guidelines, protocols and policies; financial incentives and ownership of tests; time constraints, physical vulnerabilities and language barriers; availability and ease of access to tests; pre-emptive testing to facilitate subsequent care; contemporary medical practice and new technology CONCLUSION: This thematic framework may raise awareness of overtesting and prompt clinicians to change their test request behaviour. The development of a scale to assess clinician knowledge, attitudes and practices is planned to allow evaluation of clinician-targeted interventions to reduce overtesting.

Cost-consciousness among Iranian internal medicine residents

Background: Study aimed at assessing residents' cost awareness and their attitude about health care costs.Methods: Internal medicine residents at teaching hospitals of Tehran University of Medical Sciences were surveyed during August-December 2016 using a researcher-made questionnaire comprising attitude statements and cost estimation of diagnostic and treatment items.Results: Eighty-nine residents completed the survey (response rate = 56.6%). The results indicate that less than one quarter (23.69%) of cost estimates were in the range of correct answers. The mean (SD) for correct estimation of medications (out of 8 scores), lab tests (out of 20 scores), and total (out of 35 scores) were 1.25 (0.96), 4.92 (0.27), and 7.97 (0.34), respectively. An analysis of variance showed that the level of residency was positively correlated with residents' correct cost estimation (F (3, 77)=9.98, p = 0.029). There was a significant positive correlation between age of residents with the correct estimate of medication prices (p = 0.018, r = 0.261).Conclusions: The internal medicine residents of Tehran University of Medical Sciences have poor knowledge of health care costs, including medications, diagnostic tests, and hospitalization costs. The results of this study explain the necessity of developing a training program for the transfer of cost information to physicians.

Attitudes and awareness of suture anchor cost: a survey of shoulder surgeons performing rotator cuff repairs

BACKGROUND

The cost of health care in the United States accounts for 18% of the nation's gross domestic product and is expected to reach 20% by 2020. Physicians are responsible for 60%-80% of decisions resulting in health care expenditures. Rotator cuff repairs account for $1.2-$1.6 billion in US health care expenditures annually. The purpose of this study is to assess surgeons' cost awareness in the setting of rotator cuff repairs. The hypothesis is that practice environment and training affect cost consciousness and incentivization will lead to more cost-effective choices.

METHODS

In this cross-sectional study, a 21-item survey was distributed via the email list services of the American Shoulder and Elbow Surgeons and Arthroscopy Association of North America. Data collected included demographics, variables regarding rotator cuff repair (technique, number of companies used, procedures per month), and knowledge of costs.

RESULTS

Responses from 345 surgeons in 23 countries were obtained with the majority (89%) being from the United States. Most surgeons were "cost-conscious" (275, 70.7%). Of these surgeons, 62.9% are willing to switch suture anchors brands to reduce overall costs if incentivized. Cost-conscious surgeons were more likely to be fellowship trained in shoulder and elbow (51.81% vs. 38.57%, P = .048), be paid based on productivity (73.53% vs. 61.43%, P = .047), and receive shared profits (85.4% vs. 75%, P = .02).

CONCLUSION

The majority of orthopedic surgeons are both cost-conscious and willing to change their practice to reduce costs if incentivized to do so. A better understanding of implant costs combined with incentives may help reduce health care expenditure.

Cascades of Care After Incidental Findings in a US National Survey of Physicians

IMPORTANCE

Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally.

OBJECTIVE

To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians.

DESIGN, SETTING, AND PARTICIPANTS

Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019.

MAIN OUTCOMES AND MEASURES

Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades.

RESULTS

This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions.

CONCLUSIONS AND RELEVANCE

The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Treatment decision-making in chronic lymphocytic leukaemia: Key factors for healthcare professionals. PRELIC study

OBJECTIVE

To explore the preferences of Spanish healthcare professionals (haematologists and hospital pharmacists) for the treatment selection of active Chronic Lymphocytic Leukaemia (CLL) patients at first relapse, condition that mainly afflicts older adults.

METHODS

A discrete choice experiment (DCE) was conducted among haematologists and hospital pharmacists. A literature review and a focus group informed the DCE design. CLL treatment settings were defined by seven attributes: four patient/disease-related attributes (age, functional status, comorbidities, and risk of the disease) and three treatment-related attributes (efficacy [hazard ratio of progression-free survival, HR-PFS], rate of discontinuations due to adverse events and cost). A mixed-logit model was used to determine choice-based preferences. Relative importance (RI) of attributes was calculated and compared between stakeholders. Willingness-to-pay (WTP) was estimated through the DCE. Besides, nine ad-hoc questions were posed, to explore more in depth CLL treatment decision making.

RESULTS

A total of 130 participants (72 haematologists and 58 hospital pharmacists) answered the DCE. All attributes were significant predictors of preferences (p < 0.05) in the multinomial model. Higher RI was obtained for treatment-related attributes: the highest rated being 'cost' (23.8%) followed by 'efficacy' (20.9%). Regarding patient-related attributes, the highest RI was obtained for 'age' (18.1%). No significant differences (p > 0.05) in RI between haematologists and pharmacists were found. WTP for the treatment was higher for younger CLL patients. Ad-hoc questions showed that patient age and functional status influence treatment decisions.

CONCLUSIONS

For healthcare professionals, 'cost' and 'efficacy' (treatment-related attributes) and age (patient-related attribute) are the main factors that determine CLL treatment selection at first relapse. WTP decreases as patient's age increases.

Differences in cost consciousness between physicians and nurses in German neonatal intensive care units

AIM

This study assessed the cost consciousness of nurses and physicians in German neonatal intensive care units (NICUs) and identified factors affecting cost consciousness.

METHODS

This study on cost consciousness was part of the German Safety4NICU study, a cross-sectional survey conducted from 2015 to 2016. All 224 German NICUs were invited to take part in the survey, and written consent was obtained from the leading physicians and nurses. The various professions were addressed via specific questionnaires. The cost survey tool identified the participants' responsibility and their desired focus on cost consciousness.

RESULTS

Of the 1406 nurses and 496 physicians from 84 NICUs, 64.4% of the nurses and 62.5% of the physicians agreed that they shared responsibility for controlling costs. The computed score to define the overall cost consciousness level was 4.47. We identified a significantly positive association between cost consciousness, longer total clinical work experience and a decreased number of NICU intensive care beds. Increased cost consciousness was found in both men and physicians. Other hospital characteristics did not have an effect.

CONCLUSION

Neonatology is a medical speciality where the tension between economics and the benefit of patients is extremely high. We found a moderate level of cost consciousness among NICU physicians and nurses.

Cost of open and laparoscopic distal gastrectomy: surgeon perceptions versus the reality of hospital spending

BACKGROUND

Rising health care costs have led to increasing focus on cost containment and accountability from health care providers. We sought to explore surgeon awareness of supply costs for open and laparoscopic distal gastrectomy.

METHODS

Surveys were sent in 2015 to surgeons at 8 academic hospitals in Toronto who performed distal gastrectomy for gastric adenocarcinoma. Respondents were asked to estimate the total cost, type and number of disposable equipment pieces required to perform open and laparoscopic distal gastrectomy. We determined the accuracy of estimates through comparisons with procedural invoices for distal gastrectomy performed between Jan. 1, 2011, and Dec. 31, 2015. All values are in 2015 Canadian dollars.

RESULTS

Of the 53 surveys sent out, 12 were completed (response rate 23%). Surgeon estimates of total supply costs ranged from $500 to $3000 and from $1500 to $5000 for open and laparoscopic cases, respectively. Estimated supply costs for requested equipment ranged from $464 to $2055 for open cases and from $1870 to $2960 for laparoscopic cases. Invoices for actual equipment yielded a mean of $821 (standard deviation $543) (range $89-$2613) for open cases and $2678 (standard deviation $958) (range $835-$4102) for laparoscopic cases. Estimates of total cost were within 25% of the median invoice total in 1 response (9%) for open cases and 3 (27%) of those for laparoscopic cases.

CONCLUSION

Respondents failed to accurately estimate equipment costs. The variation in true total costs and estimates of supply costs represents an opportunity for intraoperative cost minimization, efficient equipment selection and value-based purchasing arrangements.

Do we know the cost of orthopaedic care?

INTRODUCTION

The increasingly complex care needs of an expanding and ageing population leave a growing dichotomy between demand and supply. With sustainable cost-efficiency gains paramount, this study explored awareness of trauma and orthopaedic (T&O) care costs among patients and health care providers, alongside the impact of greater cost awareness on care quality, experience, and equality.

MATERIALS AND METHODS

Surveys were distributed over a 2-week period, at a single site, to in/outpatients and health care professionals allied to T&O. They evaluated (1) awareness of the costs of several common aspects of T&O care and (2) opinions on improved cost education.

RESULTS

Most professionals and patients had limited and markedly variable awareness of costs. Expensive items (>£200) were commonly underestimated, and cheap items (≤£200) were overestimated. The majority reported greater cost awareness might influence their approach to care decisions.

DISCUSSION

Cost ignorance restricts cost-efficiency and provision of equitable care. Given the widespread lack of cost education, there is unsurprisingly a lack of cost awareness among patients and professionals alike. Cost savings through "reduced waste" were a commonly highlighted potential benefit of greater cost awareness. Patients and professionals alike must become increasingly accountable for ensuring effective and efficient use of resources.

Comparing GPs' risk attitudes for their own health and for their patients' : a troubling discrepancy?

Background

In this paper, we report the results of risk attitudes elicitation of a French general practitioners national representative sample (N=1568).

Methods

Willingness to take risks in four different domains (daily life, financial matters, own health and patient health) was collected through a large-scale telephone interview of GPs using self-reported 11-point Likert scale questions.

Results

We uncover some specificities of the GPs population regarding their attitudes towards risk. In particular, we detect an important positive gap between their willingness to take risks in the domain of their own health and in the domain of the heath of their patients. This “patient-regarding” risk aversion is discussed with respect to its important consequences regarding medical behavior bias.

Conclusions

We confirm the self-other discrepancy found in the medical literature on physicians’ behaviors and emphasize the utility of the study and measures of personality traits such as “risk attitudes” for the medical professions and for the population they address.

Gender-specific practice styles and ambulatory health care expenditures

This paper explores the role of physician gender in the expenditures for ambulatory care as a potential source of practice style variation. We exploit a large doctor-patient panel dataset based on insurance-claims data from Switzerland to estimate the effect of physician gender on health care expenditures. We find considerable heterogeneity across specialties. In primary care, female doctors are found to produce similar overall expenditures per visit as their male colleagues, but significantly smaller prescribing costs and significantly higher laboratory costs. In secondary-care specialties, we find that women generate lower overall expenditures, which is mainly driven by consultation costs. These findings provide evidence for the existence of sex-specific practice styles that translate into different overall expenditures as well as different compositions of these expenditures.

Emergency Health Care Professionals' Understanding of the Costs of Care in the Emergency Department

Background

Efficiency and fiscal responsibility are important to the equal, safe, and effective delivery of care in the emergency department, where all presenting patients must be evaluated for emergent conditions. Health care professionals' understanding of the costs of care is a first step to developing rational approaches for the efficient distribution of the finite resources hospitals and emergency departments have at their disposal to reduce costs to patients and health care systems.

Objective

To determine emergency department health care professionals' knowledge of the costs to patients of routine care delivered in the emergency department.

Methods

An internet-based survey of currently practicing emergency medicine health care professionals with various levels of training (physicians, residents, physician assistants, and nurse practitioners) was conducted to evaluate their ability to identify the cost of care for 3 common presentations to the emergency department: abdominal pain, dyspnea, and sore throat.

Results

Four hundred forty-one emergency medicine health care professionals participated. In the 3 cases presented, correct costs were determined by 43.0%, 32.0%, and 40.1% of participants, respectively. Geographic region was not related to cost determination. Larger institution size was related to greater cost chosen (P=.01). Higher level of training was significantly correlated with perceived understanding of cost (P<.001); however, it was not related to accurate cost assessment in this study.

Conclusion

Emergency medicine health care professionals have an inadequate understanding of the costs associated with care routinely provided in the emergency department.

Practical motives are prominent in test-ordering in the Emergency Department

Background:

Laboratory test ordering under time pressure may impact test-ordering behavior.

Methods:

To investigate the test-ordering behavior of doctors working under such pressure, we designed a questionnaire for trainees and staff in the Emergency Department (ED). This questionnaire addressed topics such as necessity of requested tests, time spent on ordering, costs and availability of tests, and the time of the day. We hypothesized that ordering behavior would be guided predominantly by the medical need of tests and aimed at identifying practical motives that also have an effect.

Results:

Remarkably, two-third of the respondents (67%) admitted that tests were ordered that would not influence treatment policy directly and 48% of the doctors stated that tests were ordered that do not impact treatment at all. The frequency of such orders was “sometimes” and “frequent” in a 50:50 ratio. Interestingly, tests that could prove relevant at a later stage are often ordered simultaneously to reduce burden on the patient. None of the respondents spent more than 3 min on the ordering process and very few (8%) desired more time for ordering. Most respondents (81%) declared to have limited knowledge of the costs of laboratory tests. A random survey covering four tests confirmed this. Generally, turnaround time did influence ordering behavior while time of the day did not.

Conclusions:

In conclusion, doctors in an ED – besides first of all medical motives – heavily exploit practical (non-medical) reasoning for laboratory test ordering, e.g. taking availability of tests into account and ordering non-immediate tests.

Cost consciousness among physicians in the neonatal intensive care unit

OBJECTIVE

The objectives of this study were (1) to describe the prevalence and correlates of cost consciousness among physician providers in neonatology and (2) to describe knowledge of cost of common medications, laboratory/imaging evaluations, hospitalization costs and reimbursements.

STUDY DESIGN

A 54-item survey was administered to members of the Section on Neonatal-Perinatal Medicine of the American Academy of Pediatrics.

RESULTS

Of the 602 participants, 37% reported cost consciousness in decision making. Adjusting for years in practice, gender, training level, type of practice setting and region of practice, formalized education about costs was associated with increased cost consciousness in practice (adjusted odds ratio (AOR): 3.4; 95% confidence interval (CI): 1.2 to 9.8). Working in a private practice setting was also associated with increased cost consciousness when ordering laboratory (AOR: 3.0; (95% CI: 1.2 to 7.6)) or imaging tests (AOR: 2.0; 95% CI: 1.0 to 4.8).

CONCLUSIONS

We found variation in knowledge of cost. Formal education about costs and working in a private practice setting were associated with increased cost consciousness.

Portuguese Family Physicians' Awareness of Diagnostic and Laboratory Test Costs: A Cross-Sectional Study

Background

Physicians’ ability to make cost-effective decisions has been shown to be affected by their knowledge of health care costs. This study assessed whether Portuguese family physicians are aware of the costs of the most frequently prescribed diagnostic and laboratory tests.

Methods

A cross-sectional study was conducted in a representative sample of Portuguese family physicians, using computer-assisted telephone interviews for data collection. A Likert scale was used to assess physician’s level of agreement with four statements about health care costs. Family physicians were also asked to estimate the costs of diagnostic and laboratory tests. Each physician’s cost estimate was compared with the true cost and the absolute error was calculated.

Results

One-quarter (24%; 95% confidence interval: 23%–25%) of all cost estimates were accurate to within 25% of the true cost, with 55% (95% IC: 53–56) overestimating and 21% (95% IC: 20–22) underestimating the true actual cost. The majority (76%) of family physicians thought they did not have or were uncertain as to whether they had adequate knowledge of diagnostic and laboratory test costs, and only 7% reported receiving adequate education. The majority of the family physicians (82%) said that they had adequate access to information about the diagnostic and laboratory test costs. Thirty-three percent thought that costs did not influence their decision to order tests, while 27% were uncertain.

Conclusions

Portuguese family physicians have limited awareness of diagnostic and laboratory test costs, and our results demonstrate a need for improved education in this area. Further research should focus on identifying whether interventions in cost knowledge actually change ordering behavior, in identifying optimal methods to disseminate cost information, and on improving the cost-effectiveness of care.

Cost awareness of physicians in intensive care units: a multicentric national study

PURPOSE

Physicians play an important role in strategies to control health care spending. Being aware of the cost of prescriptions is surely the first step to incorporating cost-consciousness into medical practice. The aim of this study was to evaluate current intensivists' knowledge of the costs of common prescriptions and to identify factors influencing the accuracy of cost estimations.

METHODS

Junior and senior physicians in 99 French intensive care units were asked, by questionnaire, to estimate the true hospital costs of 46 selected prescriptions commonly used in critical care practice.

RESULTS

With an 83% response rate, 1092 questionnaires were examined, completed by 575 (53%) and 517 (47%) junior and senior intensivists, respectively. Only 315 (29%) of the overall estimates were within 50% of the true cost. Response errors included a 14,756 ± 301 € underestimation, i.e., -58 ± 1% of the total sum (25,595 €). High-cost drugs (>1000 €) were significantly (p < 0.001) the most underestimated prescriptions (-67 ± 1%). Junior grade physicians underestimated more costs than senior physicians (p < 0.001). Using multivariate analysis, junior physicians [odds ratio (OR), 2.1; 95% confidence interval (95% CI), 1.43-3.08; p = 0.0002] and female gender (OR, 1.4; 95% CI, 1.04-1.89; p = 0.02) were both independently associated with incorrect cost estimations.

CONCLUSIONS

ICU physicians have a poor awareness of prescriptions costs, especially with regards to high-cost drugs. Considerable emphasis and effort are still required to integrate the cost-containment problem into the daily prescriptions in ICUs.

Changes in wellbeing and professional values among medical undergraduate students: a narrative review of the literature

BACKGROUND

Educators are concerned by the high prevalence of emotional distress among medical students, and by the alleged decline in their humanitarian values.

OBJECTIVE

To re-examine these concerns by reviewing studies of medical students' wellbeing and development.

METHOD

Narrative review of the literature.

MAIN FINDINGS

(a) Medical students' emotional distress increases during their undergraduate training. However, although higher than in the general population, the prevalence of distress among medical students is similar to that among other university students. (b) Medical students' distress is independently related to endogenous factors (personality traits and life events) and to their perception of the medical learning environment. (c) Medical students do not display a measurable increase in moral reasoning, empathy and tolerance of uncertainty. (d) Students' wellbeing, moral development, reflectivity and tolerance of uncertainty have been shown to be interrelated, and associated with clinical performance.

CONCLUSIONS

The findings of this review endorse the concerns about the wellbeing and development of undergraduate medical students. The design of the reviewed studies does not permit inferences about causality. Yet, these findings are consistent with the hypothesis that medical training causes emotional distress that delays students' development and affects their clinical performance.

Inappropriately repeated lipid tests in a tertiary hospital in Greece: the magnitude and cost of the phenomenon

BACKGROUND

Demand and costs of laboratory testing are increasing worldwide. It seems that a considerable proportion of the tests requested do not follow the published guidelines. Tests comprising the lipid profile are advised for the entire population, as determinants of cardiovascular risk. Published guidelines exist for different groups of the population. This study is an attempt to assess the volume and the cost of the excessive demand for laboratory measurements of lipids concerning inpatients of a tertiary teaching hospital in Athens, Greece.

METHODS

Tests were characterized as inappropriate through revision of guidelines for lipid measurement. The demand for laboratory measurement of lipid blood levels was studied by collecting data from the hospital's test result database. The study was conducted during the trimester October to December 2008 and 20,698 tests from 3,279 inpatients were reviewed+9.

RESULTS

The results of this study are consistent with international observations showing a significant percentage of clinically inappropriate laboratory tests and the consequent financial burden. The inappropriately repeated lipid tests during the trimester reached the number of 7,938 costing € 12,680 to the hospital. Almost half of the inpatients were tested more than twice a month.

CONCLUSIONS

Physicians' behavior is an important factor, as is derived by certain profiles of the wards studied. Guidelines are not followed when ordering lipid tests. Curtailing of these excessive laboratory tests has been shown to be feasible using cheap strategies and will yield considerable benefits for patients and hospitals alike.

Health systems and sustainability: doctors and consumers differ on threats and solutions

BACKGROUND

Healthcare systems face the problem of insufficient resources to meet the needs of ageing populations and increasing demands for access to new treatments. It is unclear whether doctors and consumers agree on the main challenges to health system sustainability.

METHODOLOGY

We conducted a mail survey of Australian doctors (specialists and general practitioners) and a computer assisted telephone interview (CATI) of consumers to determine their views on contributors to increasing health care costs, rationing of services and involvement in health resource allocation decisions. Differences in responses are reported as odds ratios (OR) and 99% confidence intervals (CI).

RESULTS

Of 2948 doctors, 1139 (38.6%) responded; 533 of 826 consumers responded (64.5% response). Doctors were more concerned than consumers with the effects of an ageing population (OR 3.0; 99% CI 1.7, 5.4), and costs of new drugs and technologies (OR 5.1; CI 3.3, 8.0), but less likely to consider pharmaceutical promotional activities as a cost driver (OR 0.29, CI 0.22, 0.39). Doctors were more likely than consumers to view 'community demand' for new technologies as a major cost driver, (OR 1.6; 1.2, 2.2), but less likely to attribute increased costs to patients failing to take responsibility for their own health (OR 0.35; 0.24, 0.49). Like doctors, the majority of consumers saw a need for public consultation in decisions about funding for new treatments.

CONCLUSIONS

Australian doctors and consumers hold different views on the sustainability of the healthcare system, and a number of key issues relating to costs, cost drivers, roles and responsibilities. Doctors recognise their dual responsibility to patients and society, see an important role for physicians in influencing resource allocation, and acknowledge their lack of skills in assessing treatments of marginal value. Consumers recognise cost pressures on the health system, but express willingness to be involved in health care decision making.

[What do doctors think an MR examination costs?]

BACKGROUND

By law, Norwegian physicians are required to evaluate costs and benefits of various medical interventions before patients are subjected to them. A prerequisite for filling this "gate-keeping" role adequately is to be informed about medical benefits and costs. This article examines physicians' knowledge of costs related to an MR (magnetic resonance) examination of a knee.

MATERIAL AND METHODS

In 2006, the Research Institute of the Norwegian Medical Association sent a questionnaire to a representative sample of 1 400 Norwegian physicians. The following question was included: "What do you think is the total cost for a standard MR-examination of a knee (the sum of that paid by patients and the standard reclaimable fee [from health authorities] for this type of examination)". An unpaired t-test was used to compare answers from subgroups of doctors, and Pearson's correlation coefficient was used to establish relationships between cost estimates and other variables.

RESULTS

Physicians' estimates for the costs of an MR examination showed great variation. 57 % of respondents over or underestimated the costs by 50 % or more than the actual price of 1250 NOK. The most common mistake was overestimation; 47 % estimated the cost to be above NOK 1875, while 10 % thought it was below NOK 625.

INTERPRETATION

The results indicate that doctors should know more about costs, they cannot fulfil their role as gate-keepers without such knowledge.

The role of education in improving physicians' professional use of economic evaluations of health interventions: some evidence from a cross-sectional survey in Italy

A cross-sectional survey was carried out on a random sample of Italian physicians through a self-administered questionnaire to describe knowledge, attitudes, and professional behavior toward economic evaluations of health interventions. A response rate of 74.1% was achieved (760 questionnaires). Although many physicians show a positive attitude toward cost-minimization and, to a lesser extent, to cost-effectiveness analysis, they rated their methodological knowledge as unsatisfactory, and the professional use of the economic evaluations of the health interventions in clinical practice is quite low. Multiple logistic regression analysis showed that adequate knowledge and positive attitudes are associated with increased physicians' use of health economic evaluations, as well as time dedicated to continuing medical education and previous training experience about health economics and management. Education and specific training may play an important role in promoting a more cost-conscious behavior of physicians.

Are physicians willing to ration health care? Conflicting findings in a systematic review of survey research

BACKGROUND

Several quantitative surveys have been conducted internationally to gather empirical information about physicians' general attitudes towards health care rationing. Are physicians ready to accept and implement rationing, or are they rather reluctant? Do they prefer implicit bedside rationing that allows the physician-patient relationship broad leeway in individual decisions? Or do physicians prefer strategies that apply explicit criteria and rules?

OBJECTIVES

To analyse the range of survey findings on rationing. To discuss differences in response patterns. To provide recommendations for the enhancement of transparency and systematic conduct in reviewing survey literature.

METHODS

A systematic search was performed for all English and non-English language references using CINAHL, EMBASE, and MEDLINE. Three blinded experts independently evaluated title and abstract of each reference. Survey items were extracted that match with: (i) willingness to ration health care or (ii) preferences for different rationing strategies.

RESULTS

16 studies were eventually included in the systematic review. Percentages of respondents willing to accept rationing ranged from 94% to 9%.

CONCLUSIONS

The conflicting findings among studies illustrate important ambivalence in physicians that has several implications for health policy. Moreover, this review highlights the importance to interpret survey findings in context of the results of all previous relevant studies.

Physician awareness of diagnostic and nondrug therapeutic costs: a systematic review

OBJECTIVES

The aim of this study was to investigate doctors' knowledge of the relative and absolute costs of diagnostic tests, medical consumables (e.g., syringes or intravenous tubing), and healthcare visits as well as to determine factors influencing awareness.

METHODS

For this systematic review, we searched the Cochrane Library, EconoLit, EMBASE, and MEDLINE; reviewed reference lists; and had contact with authors. Studies were included if either doctors or trainees were surveyed, there were >10 survey respondents, costs of diagnostic or therapeutic items were estimated, results were expressed quantitatively, and a clear description was provided of how authors defined Accurate Estimates and determined True Cost. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined due to extensive heterogeneity.

RESULTS

Fourteen articles were included in the final analysis. Cost accuracy was low; 33 percent of estimates were within 20 percent or 25 percent of true cost and 50 percent were within 50 percent or in the 50-200 percent range of the true cost. Country, year of study, level of training, and specialty did not impact accuracy. The cost of items appears to have no impact on the accuracy (Fisher's exact test, p = .41) or pattern of estimation (binomial test, p = .92).

CONCLUSIONS

Doctors have a limited understanding of diagnostic and nondrug therapeutic costs, and we could not identify anything that impacts understanding of these costs. More focus is required in the education of physicians about costs and the access to cost information.

Prevalence of burnout among Swiss cancer clinicians, paediatricians and general practitioners: who are most at risk?

GOALS OF WORK

Increasing economical and administrative constraints and changes in health-care systems constitute a risk for burnout, especially for cancer physicians. However, little is known about differences across medical specialties and the importance of work characteristics.

METHODS

A postal questionnaire addressing burnout, psychiatric morbidity, sociodemographics and work characteristics was administered to 180 cancer physicians, 184 paediatricians and 197 general practitioners in Switzerland.

RESULTS

A total of 371 (66%) physicians participated in the survey. Overall, one third of the respondents expressed signs indicative of psychiatric morbidity and of burnout, including high levels of emotional exhaustion (33%) and depersonalisation/cynicism (28%) and a reduced feeling of personal accomplishment (20%). Workload (>50 h/week), lack of continuing education (<6 h/month) and working in a public institution were significantly associated with an increased risk of burnout. After adjustment for these characteristics, general practitioners had a higher risk for emotional exhaustion (OR: 2.0, 95% CI: 1.1 to 3.6) and depersonalisation (OR: 2.7, 95% CI: 1.4 to 5.3).

CONCLUSION

In this Swiss sample, cancer clinicians had a significant lower risk of burnout, despite a more important workload. Among possible explanations, involvement in research and teaching activities and access to continuing education may have protected them.

Ethically problematic treatment decisions: a physician survey

BACKGROUND

Experiencing ethical problems requires both ethically problematic situations and ethical sensitivity. Ethically problematic treatment decisions are distressing and might reflect health care quality problems. Whether all physicians actually experience ethical problems, what these problems are and how they vary according to physician age, gender and work sector are largely unknown.

METHODS

A mail survey of all non-retired physicians licensed in Finland (n = 17,172, response rate 75.6%).

RESULTS

The proportion of physicians reporting having made ethically problematic treatment decisions decreased in linear fashion from 60% at ages below 30 years to 21% at ages over 63 years. The only problem that did not decrease in frequency with age was having withdrawn necessary treatments. Women and primary care physicians reported problematic decisions most often, although gender differences were small. Primary care physicians most often reported having performed too many investigations or having pressured patients, whereas hospital physicians emphasized having withdrawn necessary treatments. Performing unnecessary treatments or investigations was explained by pressure from patients or relatives, and performing too few treatments or investigations was explained by inadequate resources.

CONCLUSIONS

In general, young physicians felt pressured to do too much, whereas older physicians felt they could not do enough due to inadequate resources. Older physicians might be less exposed to ethically problematic situations, be more able to handle them or have lower ethical sensitivity. Young physicians could benefit from support in resisting pressure to perform unnecessary treatments, whereas older physicians might benefit from training in recognizing ethical issues.

Physician awareness of drug cost: a systematic review

BACKGROUND

Pharmaceutical costs are the fastest-growing health-care expense in most developed countries. Higher drug costs have been shown to negatively impact patient outcomes. Studies suggest that doctors have a poor understanding of pharmaceutical costs, but the data are variable and there is no consistent pattern in awareness. We designed this systematic review to investigate doctors' knowledge of the relative and absolute costs of medications and to determine the factors that influence awareness.

METHODS AND FINDINGS

Our search strategy included The Cochrane Library, EconoLit, EMBASE, and MEDLINE as well as reference lists and contact with authors who had published two or more articles on the topic or who had published within 10 y of the commencement of our review. Studies were included if: either doctors, trainees (interns or residents), or medical students were surveyed; there were more than ten survey respondents; cost of pharmaceuticals was estimated; results were expressed quantitatively; there was a clear description of how authors defined "accurate estimates"; and there was a description of how the true cost was determined. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined in meta-analysis because of extensive heterogeneity. Qualitative data related to physicians and drug costs were also extracted. The final analysis included 24 articles. Cost accuracy was low; 31% of estimates were within 20% or 25% of the true cost, and fewer than 50% were accurate by any definition of cost accuracy. Methodological weaknesses were common, and studies of low methodological quality showed better cost awareness. The most important factor influencing the pattern and accuracy of estimation was the true cost of therapy. High-cost drugs were estimated more accurately than inexpensive ones (74% versus 31%, Chi-square p < 0.001). Doctors consistently overestimated the cost of inexpensive products and underestimated the cost of expensive ones (binomial test, 89/101, p < 0.001). When asked, doctors indicated that they want cost information and feel it would improve their prescribing but that it is not accessible.

CONCLUSIONS

Doctors' ignorance of costs, combined with their tendency to underestimate the price of expensive drugs and overestimate the price of inexpensive ones, demonstrate a lack of appreciation of the large difference in cost between inexpensive and expensive drugs. This discrepancy in turn could have profound implications for overall drug expenditures. Much more focus is required in the education of physicians about costs and the access to cost information. Future research should focus on the accessibility and reliability of medical cost information and whether the provision of this information is used by doctors and makes a difference to physician prescribing. Additionally, future work should strive for higher methodological standards to avoid the biases we found in the current literature, including attention to the method of assessing accuracy that allows larger absolute estimation ranges for expensive drugs.

Stress from uncertainty from graduation to retirement--a population-based study of Swiss physicians

BACKGROUND

Uncertainty shapes many decisions made by physicians everyday. Uncertainty and physicians' inability to handle it may result in substandard care and unexplained variations in patterns of care.

OBJECTIVE

To describe socio-demographic and professional characteristics of reactions to uncertainty among physicians from all specialties, including physicians in training.

DESIGN

Cross-sectional postal survey.

PARTICIPANT

All physicians practicing in Geneva, Switzerland (n = 1,994).

MEASUREMENT

Reaction to medical care uncertainty was measured with the Anxiety Due to Uncertainty and Concern About Bad Outcomes scales. The questionnaire also included items about professional characteristics and work-related satisfaction scales.

RESULTS

After the first mailing and two reminders, 1,184 physicians responded to the survey. In univariate analysis, women, junior physicians, surgical specialists, generalist physicians, and physicians with lower workloads had higher scores in both scales. In multivariate models, sex, medical specialty, and workload remained significantly associated with both scales, whereas clinical experience remained associated only with concern about bad outcomes. Higher levels of anxiety due to uncertainty were associated with lower scores of work-related satisfaction, while higher levels of concern about bad outcomes were associated with lower satisfaction scores for patient care, personal rewards, professional relations, and general satisfaction, but not for work-related burden or satisfaction with income-prestige. The negative effect of anxiety due to uncertainty on work-related satisfaction was more important for physicians in training.

CONCLUSION

Physicians' reactions to uncertainty in medical care were associated with several dimensions of work-related satisfaction. Physicians in training experienced the greatest impact of anxiety due to uncertainty on their work-related satisfaction. Incorporating strategies to deal with uncertainty into residency training may be useful.