Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests: The PRICE Randomized Clinical Trial

Abstract

Importance: Many health systems are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration.

Objective: To test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year.

Design, setting, and participants: The Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions.

Interventions: Inpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record.

Main outcomes and measures: Primary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees.

Results: The sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.05 tests ordered per patient-day; 95% CI, -0.002 to 0.09; P = .06) or associated fees ($0.24 per patient-day; 95% CI, -$0.42 to $0.91; P = .47). Exploratory subset analyses found small but significant differences in tests ordered per patient-day based on patient intensive care unit (ICU) stay (patients with ICU stay: -0.16; 95% CI, -0.31 to -0.01; P = .04; patients without ICU stay: 0.13; 95% CI, 0.08-0.17; P < .001) and the magnitude of associated fees (top quartile of tests based on fee value: -0.01; 95% CI, -0.02 to -0.01; P = .04; bottom quartile: 0.03; 95% CI, 0.002-0.06; P = .04). Adjusted analyses of tests that were performed found a small but significant overall increase in the intervention group relative to the control group over time (0.08 tests performed per patient day, 95% CI, 0.03-0.12; P < .001).

Conclusions and relevance: Displaying Medicare allowable fees for inpatient laboratory tests did not lead to a significant change in overall clinician ordering behavior or associated fees.

Trial registration: clinicaltrials.gov Identifier: NCT02355496.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Patel is supported by career development awards from the Department of Veterans Affairs Health Services Research and Development Service and the Doris Duke Charitable Foundation. Dr Patel is also a principal at Catalyst Health, a technology and behavior change consulting firm. No other disclosures are reported.

Figures

Figure 1.. Randomization Schema

The 3 strata by which laboratory test groups were randomized. Names of the laboratory tests within each arm and strata are available in Supplement 2.

Figure 2.. Unadjusted Number of Inpatient Laboratory Tests Ordered per Patient-Day by Group and Month

Error bars indicate the 95% CIs. Vertical black line delineates the preintervention and intervention periods. Data for April 2016 are not displayed because only 8 days exist within the study period in that month.