Should cost considerations be included in medical decisions? Not so sure…

Abstract

Most western healthcare systems are experiencing significant increases in costs that can be attributed to a growing and ageing population that has ever more frequent chronic diseases, and advances in costly healthcare technologies and interventions. These driving factors for increasing costs resonate strongly for intensive care unit (ICU) physicians who see the need for their service grow steadily each year to cope with the rising demands placed upon them. The UK National Health Service (NHS) has required spending increases in real terms of 3.8 % per year throughout its history [1]. This growth is much higher than underlying increases in gross domestic product for the country, with the implication that the status quo is not sustainable in the longer term. This scenario is not unique to the UK and the trend can be seen in many similar western countries.In the current austere economic climate, the direct consequence of increasing healthcare expenditure to ICU managers and clinicians is stark and obvious. Flat-lining (or reducing) budgets with a simultaneous increase in demand means choices need to be made and choosing based upon cost is difficult. Difficult because clinicians often have neither the training nor the knowledge to base such decisions upon, but also because it forces controversial ethical discussions to be had, sometimes with perverse consequences. However, to contain the costs of care, physicians need to know the costs and indications of each of the investigations/drugs that they order.Unfortunately, physicians' awareness of the cost of drug prescriptions (or investigations) is generally very poor [2]. A systematic review of 24 articles, the latest being published in 2005, showed an accuracy in cost estimation of 29 % for the articles with the highest quality and of 38 % for those with lowest [2]. A recent multicentre French study published in Intensive Care Medicine by Hernu et al. [3] compared the costs of drugs, blood products, imaging modalities and laboratory tests estimated by a wide sample of ICU physicians with the true costs. Correct estimation was defined as an estimate within 50 % of the true cost. Drug costs were underestimated and, among drugs, the costs of those exceeding 10 € were all underestimated [3]. We suspect that the same physicians who do not know the costs of the most expensive drugs, the ones that they underestimate the most, will carefully consider a difference of 50 % in prices when they buy a new car! Hernu et al. [3] report results similar to those found in other European countries [4,5]. They also present two clinical situations (septic and haemorrhagic shock) showing how relevant the differences can be between estimated and true costs at ICU, regional, and national level.The lack of any improvement in physicians' awareness of the costs of drugs over time [2,3] agrees with the slow and continuous decrease in the percentage of articles in

Implementation and Evaluation of Two Nudges in a Hospital’s Electronic Prescribing System to Optimise Cost-Effective Prescribing

“…A fourth potential reason why our nudges were not effective is that clinicians may not consider costs to be a relevant part of their decision-making [ 33 ]. Foremost in a clinician’s mind is making the best clinical decisions for their patients, and not how those decisions economically affect the wider health system.…”

Le médecin réanimateur : un consultant extérieur pour un choix éclairé du patient et de ses proches ?

“…Anticiper les potentielles admissions en inscrivant la réanimation dans les projets de soins des patients et définir, le cas échéant, le niveau des suppléances pourraient contribuer à une gestion plus rationnelle de nos ressources. Il ne s'agit pas de chercher à réduire le nombre des admissions en réanimation, mais d'éviter un certain nombre d'admissions, souvent décidées dans l'urgence, parfois non souhaitées et jugées indues a posteriori, tout en élargissant le champ des indications à des patients qui pourraient bénéficier d'une prise en charge souhaitée et adaptée à leur situation [10,17,18].…”