Can Emergency Medicine Residents Predict Cost of Diagnostic Testing?

Introduction Diagnostic testing represents a significant portion of healthcare spending, and cost should be considered when ordering such tests. Needless and excessive spending may occur without an appreciation of the impact on the larger healthcare system. Knowledge regarding the cost of diagnostic testing among emergency medicine (EM) residents has not previously been studied. Methods A survey was administered to 20 EM residents from a single ACGME-accredited three-year EM residency program, asking for an estimation of patient charges for 20 commonly ordered laboratory tests and seven radiological exams. We compared responses between residency classes to evaluate whether there was a difference based on level of training. Results The survey completion rate was 100% (20/20 residents). We noted significant discrepancies between the median resident estimates and actual charge to patient for both laboratory and radiological exams. Nearly all responses were an underestimate of the actual cost. The group median underestimation for laboratory testing was $114, for radiographs $57, and for computed tomography exams was $1,058. There was improvement in accuracy with increasing level of training. Conclusion This pilot study demonstrates that EM residents have a poor understanding of the charges burdening patients and health insurance providers. In order to make balanced decisions with regard to diagnostic testing, providers must appreciate these factors. Education regarding the cost of providing emergency care is a potential area for improvement of EM residency curricula, and warrants further attention and investigation.


INTRODUCTION
Healthcare expenditures continue to escalate at a significant rate, now representing 17.5% of the gross domestic product (GDP) in the United States. 1 Diagnostic testing is a large proportion of this increase, perhaps prompted by a desire to avoid malpractice claims. 2 This desire must be balanced with cost avoidance to the patient and the healthcare system. Increased awareness of the cost of diagnostic testing may change practice patterns. 3,4 During post-graduate training, emergency medicine (EM) residents learn how diagnostic testing (e.g., laboratory evaluation and radiologic testing) can influence their clinical decision-making. There is a focus on how these tests are interpreted based on current scientific evidence, knowledge of pathophysiology, and emulation of faculty practice patterns. However, often little attention is paid to the potentially detrimental effects of these strategies. In addition to falsepositive results, which may lead to unnecessary procedures or

Predicting the Cost of Common Diagnostic Testing
Tainter et al.
additional testing, these tests represent a significant source of resource utilization for the hospital, increased length of stay, and financial burden to the patient and/or health insurance provider. Needless and excessive spending may occur without an appreciation of the impact on the larger healthcare system. The Accreditation Council for Graduate Medical Education (ACGME) includes cost awareness as a core competency of EM training, although this is recognized as an area of improvement. 5,6 Knowledge of the actual cost of diagnostic testing among EM residents has not been studied, and the specific educational needs in this area are not known.

METHODS
An anonymous survey was administered to 20 residents from a single ACGME-accredited three-year EM residency program at a hospital-based emergency department (ED) with approximately 60,000 annual visits. The survey consisted of a fill-in-the-blank questionnaire listing 20 commonly ordered laboratory tests and seven radiological exams. It was administered during a single didactic conference during the 2012-2013 academic year. Residents provided their best estimation of the cost of each to the patient. Cost basis was provided by the laboratory billing coordinator and represents patient charges (not institutional cost). Radiology charges did not include a radiologist interpretation fee. We compared responses between residency classes to evaluate whether there was a difference based on level of training. All protocols were reviewed and approved by the institutional review board.
We noted significant discrepancies between the median resident estimates and actual charge to patient for both laboratory testing (Table 1) and radiological exams ( Table 2) among every residency class, and as a whole. Nearly all estimates were below the actual cost, with only a few estimates above. The group median underestimation for laboratory testing was $114, for radiographs $57, and for computed tomography (CT) exams was $1,058.
The urine drug screen assay was noted to be a particularly expensive test, as it incorporates individual screening tests for

DISCUSSION
Previous investigations have described a lack of knowledge regarding the cost of testing among internal medicine residents and faculty, 5,6 as well as pediatric residents and faculty, 7 and awareness may be improved with education. 8 There is almost no data to describe if this knowledge deficit exists among EM trainees. The reliance on diagnostic testing in the ED, as well as the escalating costs of providing care make this a particularly important arena in which to improve this knowledge.
Providers cannot make a balanced decision when ordering diagnostic tests without an understanding of costs. Decisions regarding diagnostic evaluation are particularly salient to the ED, where the focus is often diagnosis of undifferentiated complaints. Pursuit of every possible diagnosis in every patient is cost-prohibitive, but cost concerns must be weighed against the possibility of patient harm from missed diagnoses that could require immediate intervention. Charges do not always reflect hospital cost, but they do represent a cost to the healthcare system as a whole. In addition, they may have a significant impact on individuals who do not have the negotiating power of large insurance providers, and may be burdened by the entirety of these charges. Therefore, it is prudent to involve patients in shared decision-making, and this can only be achieved if that information is known by the treating provider.

LIMITATIONS
This investigation is limited to a single institution and has a small sample size. It reflects similar findings from previous investigations in other specialties. Knowledge about the cost of diagnostic testing is lacking in many EM training programs. However, the improved accuracy demonstrated with increased level of training is encouraging.
It is apparent that some degree of familiarity is attained through clinical experience, even if cost estimation is not included as a part of the didactic curriculum.
It is worth noting that the survey results may not reflect the thought process used for clinical decision-making among these residents. Because the participants realized that the aim of the survey was to elicit their knowledge regarding the cost of diagnostic testing, they may have minimized or exaggerated their estimates relative to what they have in mind when ordering a test in the ED. However, it is also likely that the demonstrated lack of awareness may represent the possibility that this does not play a large role in their decision-making process. Finally, it should be noted that the exact charges studied at this institution may not reflect the charges for testing at other institutions.

CONCLUSION
This pilot study demonstrates that EM residents have a poor understanding of the charges burdened by patients and health insurance providers. In order to make balanced decisions regarding diagnostic testing, providers must appreciate these factors. Education regarding the cost of providing emergency care is a potential area for improvement of EM residency curricula and warrants further attention and investigation.