Patients' attitudes towards cost feedback to doctors to prevent unnecessary testing: a qualitative focus group study

© 2020 The Authors Objectives: There is a need to improve efficiency in healthcare delivery without compromising quality of care. One approach is the development and evaluation of behavioural strategies to reduce unnecessary use of common tests. However, there is an absence of evidence on patient attitudes to the use of such approaches in the delivery of care. Our objective was to explore patient acceptability of a nudge-type intervention that aimed to modify blood test requests by hospital doctors. Study design: Single-centre qualitative study. Methods: The financial costs of common blood tests were presented to hospital doctors on results reports for 1 year at a hospital. Focus group discussions were conducted with recent inpatients at the hospital using a semi-structured question schedule. Discussions were transcribed and analysed using qualitative content analysis to identify and prioritise common themes explaining attitudes to the intervention approach. Results: Three focus groups involving 17 participants were conducted. Patients were generally apprehensive about the provision of blood test cost feedback to doctors. Attitudes were organised around themes representing beliefs about blood tests, the impact on doctors and their autonomy, and beliefs about unnecessary testing. Patients thought that blood tests were important, powerful and inexpensive, and cost information could place doctors under additional pressure. Conclusion: The findings identify predominantly positive beliefs about testing and negative attitudes to the use of financial costs in the decision-making of hospital doctors. Public discussion and education about the possible overuse of common tests may allow more resources to be allocated to evidence-based healthcare, by reducing the perception that such strategies to improve healthcare efficiency negatively impact on quality of care

Hospital doctors’ attitudes to brief educational messages that aim to modify diagnostic test requests: a qualitative study

Background: Avoidable use of diagnostic tests can both harm patients and increase the cost of healthcare. Nudge-type educational interventions have potential to modify clinician behaviour while respecting clinical autonomy and responsibility, but there is little evidence how this approach may be best used in a healthcare setting. This study aims to explore attitudes of hospital doctors to two nudge-type messages: one concerning potential future cancer risk after receiving a CT scan, another about the financial costs of blood tests. Methods: We added two brief educational messages to diagnostic test results in a UK hospital for one year. One message on the associated long-term potential cancer risk from ionising radiation imaging to CT scan reports, and a second on the financial costs incurred to common blood test results. We conducted a qualitative study involving telephone interviews with doctors working at the hospital to identify themes explaining their response to the intervention. Results: Twenty eight doctors were interviewed. Themes showed doctors found the intervention to be highly acceptable, as the group had a high awareness of the need to prevent harm and optimise use of finite resources, and most found the nudge-type approach to be inoffensive and harmless. However, the messages were not seen as personally relevant because doctors felt they were already relatively conservative in their use of tests. Cancer risk was important in decision-making but was not considered to represent new knowledge to doctors. Conversely, financial costs were considered to be novel information that was unimportant in decision-making. Defensive medicine was commonly cited as a barrier to individual behaviour change. The educational cancer risk message on CT scan reports increased doctors’ confidence to challenge decisions and explain risks to patients and there were some modifications in clinical practice prompted by the financial cost message. Conclusion: The nudge-type approach to target avoidable use of tests was acceptable to hospital doctors but there were barriers to behaviour change. There was evidence doctors perceived this cheap and light-touch method can contribute to culture change and form a foundation for more comprehensive educational efforts to modify behaviour in a healthcare environment

An evaluation of a price transparency intervention for two commonly prescribed medications on total institutional expenditure: a prospective study

Importance: Providing cost feedback has been demonstrated to decrease demand from clinicians. Objective: We tested the hypothesis that providing the cost of drugs to clinicians would modify total expenditure. Design: A prospective study design with a step-wise intervention. Setting/Participants: Individuals who were admitted to the XXX from November 2013 to November 2015 under the physicians. Intervention: The cost of all antibiotics and inhaled corticosteroids was added to the electronic prescribing system. Main outcomes: The weekly cost for antibiotics and inhaled corticosteroids in the intervention period compared to baseline. Results: Mean weekly expenditure on antibiotics per patient decreased by £3.75 (95% confidence intervals CI: -6.52 to -0.98) after the intervention from a pre-intervention mean of £26.44, and then slowly increased subsequently by £0.10/week (95%CI: +0.02 to +0.18). Mean weekly expenditure on inhaled corticosteroids per patient did not substantially change after the intervention (-£0.03, 95%CI: -0.06 to -0.01 after the intervention from a pre-intervention mean of £5.29 per person). New clinical guidelines for inhaled corticosteroids were associated with a decrease in weekly expenditure. Conclusions and relevance: Provision of cost feedback resulted in no sustained change in institutional expenditure. However, clinical guidelines have potential for modifying clinical prescribing behaviour

Frequency of stepping down antibiotics and nebuliser treatment is lower at weekends compared to weekdays: an observational study

We hypothesised that delays in providing non-urgent medication step-downs at weekends to medical management may be associated with increased length of stay.In a novel use of electronic prescribing data, we analysed emergency admissions from a busy acute medical hospital over 52 weeks from November 2014 to October 2015. The main outcomes of interest were switching from intravenous antibiotics to oral antibiotics and stopping nebulised bronchodilators. The rate of switching from intravenous to oral antibiotics was lower on Saturdays and Sundays compared with weekdays, and the rate of stopping nebulised bronchodilators was similarly lower at weekends (p<0.001). Median length of stay was shorter in those whose antibiotic treatment was stepped down at weekends compared with weekdays (4 days versus 5 days, p<0.001). Reduced medication step-downs at weekends may represent a bottleneck in patient flow. Electronic prescribing data are a valuable resource for future health services research

Statins as potential chemoprevention or therapeutic agents in cancer: A model for evaluating repurposed drugs

Purpose of Review: Repurposing established medicines for a new therapeutic indication potentially has important global and societal impact. The high costs and slow pace of new drug development have increased interest in more cost-effective repurposed drugs, particularly in the cancer arena. The conventional drug development pathway and evidence framework are not designed for drug repurposing and there is currently no consensus on establishing the evidence base before embarking on a large, resource intensive, potential practice changing phase III randomised controlled trial (RCT). Numerous observational studies have suggested a potential role for statins as a repurposed drug for cancer chemoprevention and therapy, and we review the strength of the cumulative evidence here. Recent Findings: In the setting of cancer, a potential repurposed drug, like statins, typically goes through a cyclical history, with initial use for several years in another disease setting, prior to epidemiological research identifying a possible chemo-protective effect. However, further information is required, including review of RCT data in the initial disease setting with exploration of cancer outcomes. Additionally, more contemporary methods should be considered, such as Mendelian randomization and pharmaco-epidemiological research with “target” trial design emulation using electronic health records. Pre-clinical and traditional observational data potentially support the role of statins in the treatment of cancer; however, randomised trial evidence is not supportive. Evaluation of contemporary methods provides little added support for the use of statin therapy in cancer. Summary: We provide complementary evidence of alternative study designs to enable a robust critical appraisal from a number of sources of the go/no-go decision for a prospective phase III RCT of statins in the treatment of cancer

Evaluation of the impact of a brief educational message on clinicians’ awareness of risks of ionising-radiation exposure in imaging investigations:a pilot pre-post intervention study

Background:In the context of increasing availability of computed tomography (CT) scans, judicious use of ionising radiation is a priority to minimise the risk of future health problems. Hence, education of clinicians on the risks and benefits of CT scans in the management of patients is important. Methods:An educational message about the associated lifetime cancer risk of a CT scan was added to all CT scan reports at a busy acute teaching hospital in the UK. An online multiple choice survey was completed by doctors before and after the intervention, assessing education and knowledge of the risks involved with exposure to ionising radiation.Results:Of 546 doctors contacted at baseline, 170 (31%) responded. Over a third (35%) of respondents had received no formal education on the risks of exposure to ionising radiation. Over a quarter (27%) underestimated (selected 1 in 30 000 or negligible lifetime cancer risk) the risk associated with a chest, abdomen and pelvis CT scan for a 20 year old female. Following exposure to the intervention for one year there was a statistically significant improvement in plausibleestimates of risk from 68.3% to 82.2% of respondents (p < 0.001). There was no change in the proportion of doctors correctly identifying imaging modalities that do or do not involve ionising radiation.Conclusions:Training on the longterm risks associated with diagnostic radiation exposure is inadequate among hospital doctors.Exposure to a simple non-directional educational message for one year improved doctors’ awareness of risks associated with CT scans. This demonstrates the potential of the approach to improve knowledge that could improve clinical practice. This approach is easily deliverable and may have applications in other areas of clinical medicine. The wider and longer term impact on radiation awareness is unknown, however, and there may be a need for regular mandatory training in the risks of radiation exposure

An evaluation of a price transparency intervention for two commonly prescribed medications on total institutional expenditure: a prospective study

Importance: Providing cost feedback has been demonstrated to decrease demand from clinicians.Objective: We tested the hypothesis that providing the cost of drugs to clinicians would modify total expenditure.Design: A prospective study design with a step-wise intervention.Setting/Participants: Individuals who were admitted to the XXX from November 2013 to November 2015 under the physicians.Intervention: The cost of all antibiotics and inhaled corticosteroids was added to the electronic prescribing system.Main outcomes: The weekly cost for antibiotics and inhaled corticosteroids in the intervention period compared to baseline.Results: Mean weekly expenditure on antibiotics per patient decreased by £3.75 (95% confidence intervals CI: -6.52 to -0.98) after the intervention from a pre-intervention mean of £26.44, and then slowly increased subsequently by £0.10/week (95%CI: +0.02 to +0.18). Mean weekly expenditure on inhaled corticosteroids per patient did not substantially change after the intervention (-£0.03, 95%CI: -0.06 to -0.01 after the intervention from a pre-intervention mean of £5.29 per person).New clinical guidelines for inhaled corticosteroids were associated with a decrease in weekly expenditure.Conclusions and relevance: Provision of cost feedback resulted in no sustained change in institutional expenditure. However, clinical guidelines have potential for modifying clinical prescribing behaviour

Does cost feedback modify demand for common blood tests in secondary care? A prospective controlled intervention study

Background: Behavioural insights or ‘nudge’ theory suggests that non-directional interventions may be used to modify human behaviour. We have tested the hypothesis that the provision of the cost of common blood tests with their results may modify subsequent demand for blood assays.Methods: The study design was a prospective controlled intervention study. The individual and annual institutional cost of full blood count (FBC), urea and electrolytes (U&E) and liver function test (LFT) blood assays were added to the electronic results system for inpatients at the intervention teaching hospital, but not the control hospital.Results: In the 12 months after the intervention was implemented, demand for FBC dropped by 3% (95% confidence intervals [CI]: 1 to 5, p less than 0.001), U&E by 2% (95%CI: 0 to 4, p=0.054) and there was no change in demand for LFT compared to the control institution.Conclusions: Providing cost feedback to clinicians for commonly used blood tests is a viable intervention that is associated with small reductions in demand for some, but not all blood assays. As this is an easily scalable approach, this has potential to enable efficient health care delivery, while also minimising the morbidity experienced by the patient

Clinical and cognitive characteristics of children with attention-deficit hyperactivity disorder, with and without copy number variants

Background Submicroscopic, rare chromosomal copy number variants (CNVs) contribute to neurodevelopmental disorders but it is not known whether they define atypical clinical cases. Aims To identify whether large, rare CNVs in attention-deficit hyperactivity disorder (ADHD) are confined to a distinct clinical subgroup. Method A total of 567 children with ADHD aged 5–17 years were recruited from community clinics. Psychopathology was assessed using the Child and Adolescent Psychiatric Assessment. Large, rare CNVs (>500 kb, <1% frequency) were defined from single nucleotide polymorphism data. Results Copy number variant carriers (13.6%) showed no differences from non-carriers in ADHD symptom severity, symptom type, comorbidity, developmental features, family history or pre-/perinatal markers. The only significant difference was a higher rate of intellectual disability (24% v. 9%, χ2 = 15.5, P = 0.001). Most CNV carriers did not have intellectual disability. Conclusions Large, rare CNVs are not restricted to an atypical form of ADHD but may be more highly enriched in children with cognitive problems

Abstracts from the NIHR INVOLVE Conference 2017

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