Beach Mary Catherine, Asch David A, Jepson Christopher, Hershey John C, Mohr Tara, McMorrow Stacey, Ubel Peter A
Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
Med Decis Making. 2003 Sep-Oct;23(5):369-78. doi: 10.1177/0272989X03256882.
To explore public attitudes toward the incorporation of cost-effectiveness analysis into clinical decisions.
The authors presented 781 jurors with a survey describing 1 of 6 clinical encounters in which a physician has to choose between cancer screening tests. They provided cost-effectiveness data for all tests, and in each scenario, the most effective test was more expensive. They instructed respondents to imagine that he or she was the physician in the scenario and asked them to choose which test to recommend and then explain their choice in an open-ended manner. The authors then qualitatively analyzed the responses by identifying themes and developed a coding scheme. Two authors separately coded the statements with high overall agreement (kappa = 0.76). Categories were not mutually exclusive.
Overall, 410 respondents (55%) chose the most expensive option, and 332 respondents (45%) choose a less expensive option. Explanatory comments were given by 82% respondents. Respondents who chose the most expensive test focused on the increased benefit (without directly acknowledging the additional cost) (39%), a general belief that life is more important than money (22%), the significance of cancer risk for the patient in the scenario (20%), the belief that the benefit of the test was worth the additional cost (8%), and personal anecdotes/preferences (6%). Of the respondents who chose the less expensive test, 40% indicated that they did not believe that the patient in the scenario was at significant risk for cancer, 13% indicated that they thought the less expensive test was adequate or not meaningfully different from the more expensive test, 12% thought the cost of the test was not worth the additional benefit, 9% indicated that the test was too expensive (without mention of additional benefit), and 7% responded that resources were limited.
Public response to cost-quality tradeoffs is mixed. Although some respondents justified their decision based on the cost-effectiveness information provided, many focused instead on specific features of the scenario or on general beliefs about whether cost should be incorporated into clinical decisions.
探讨公众对将成本效益分析纳入临床决策的态度。
作者向781名陪审员进行了一项调查，描述了6种临床情况中的1种，即医生必须在癌症筛查测试之间做出选择。他们提供了所有测试的成本效益数据，并且在每种情况下，最有效的测试成本更高。他们指示受访者想象自己是该情况下的医生，并要求他们选择推荐哪种测试，然后以开放式方式解释他们的选择。作者随后通过识别主题对回答进行定性分析，并制定了编码方案。两位作者分别对总体一致性较高的陈述进行编码（kappa = 0.76）。类别并非相互排斥。
总体而言，410名受访者（55%）选择了最昂贵的选项，332名受访者（45%）选择了较便宜的选项。82%的受访者给出了解释性评论。选择最昂贵测试的受访者关注的是收益增加（未直接承认额外成本）（39%），普遍认为生命比金钱更重要（22%），该情况下患者患癌症风险的重要性（20%），认为测试的收益值得额外成本（8%），以及个人轶事/偏好（6%）。在选择较便宜测试的受访者中，40%表示他们认为该情况下的患者患癌症风险不高，13%表示他们认为较便宜的测试足够，或者与较昂贵的测试没有显著差异，12%认为测试成本不值得额外收益，9%表示测试太贵（未提及额外收益），7%回答资源有限。
公众对成本与质量权衡的反应不一。虽然一些受访者根据提供的成本效益信息为自己的决定辩护，但许多人反而关注情况的具体特征或关于是否应将成本纳入临床决策的一般信念。
