Tierney W M, Miller M E, McDonald C J
Department of Medicine, Indiana University School of Medicine, Indianapolis.
N Engl J Med. 1990 May 24;322(21):1499-504. doi: 10.1056/NEJM199005243222105.
We studied the effect of informing physicians of the charges for outpatient diagnostic tests on their ordering of such tests in an academic primary care medical practice. All tests were ordered at microcomputer workstations by 121 physicians. For half (the intervention group), the charge for the test being ordered and the total charge for tests for that patient on that day were displayed on the computer screen. The remaining physicians (control group) also used the computers but received no message about charges. The primary outcomes measured were the number of tests ordered and the charges for tests per patient visit. In the 14 weeks before the study, the number of tests ordered and the average charge for tests per patient visit were similar for the intervention and control groups. During the 26-week intervention period, the physicians in the intervention group ordered 14 percent fewer tests per patient visit than did those in the control group (P less than 0.005), and the charges for tests were 13 percent ($6.68 per visit) lower (P less than 0.05). The differences were greater for scheduled visits (17 percent fewer tests and 15 percent lower charges for the intervention group; P less than 0.01) than for unscheduled (urgent) visits (11 percent fewer tests and 10 percent lower charges; P greater than 0.3). During the 19 weeks after the intervention ended, the number of tests ordered by the physicians in the intervention group was only 7.7 percent lower than the number ordered by the physicians in the control group, and the charges for tests were only 3.5 percent lower (P greater than 0.3). Three measures of possible adverse outcomes--number of hospitalizations, emergency room visits, and outpatient visits during the study period and the following six months--were similar for the patients seen by the physicians in both groups. We conclude that displaying the charges for diagnostic tests significantly reduced the number and cost of tests ordered, especially for patients with scheduled visits. The effects of this intervention did not persist after it was discontinued.
我们在一家学术性初级保健医疗诊所研究了告知医生门诊诊断检查费用对其开具此类检查医嘱的影响。所有检查均由121名医生在微机工作站上开具。对于其中一半医生（干预组），在电脑屏幕上显示正在开具检查的费用以及该患者当天检查的总费用。其余医生（对照组）也使用电脑，但未收到有关费用的信息。所测量的主要结果是开具检查的数量以及每次患者就诊的检查费用。在研究前的14周，干预组和对照组开具检查的数量以及每次患者就诊的平均检查费用相似。在为期26周的干预期内，干预组医生每次患者就诊开具的检查比对照组少14%（P<0.005），检查费用低13%（每次就诊6.68美元）（P<0.05）。对于预约就诊，差异更大（干预组检查少17%，费用低15%；P<0.01），而对于非预约（紧急）就诊，差异较小（检查少11%，费用低10%；P>0.3）。在干预结束后的19周内，干预组医生开具检查的数量仅比对照组低7.7%，检查费用仅低3.5%（P>0.3）。两组医生诊治的患者在三项可能的不良结局指标——研究期间及随后六个月的住院次数、急诊就诊次数和门诊就诊次数——方面相似。我们得出结论，显示诊断检查费用显著减少了开具检查的数量和费用，尤其是对于预约就诊的患者。这种干预措施停止后效果未持续存在。
