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Public Response to Cost-Quality Tradeoffs in Clinical Decisions

Division of General Internal Medicine, Johns Hopkins University School of Medicine, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, mcbeach{at}jhmi.edu

David A. Asch, MD, MBA

Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

Christopher Jepson, PhD

Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

John C. Hershey, PhD

Leonard Davis Institute of Health Economics, University of Pennsylvania, The Wharton School, Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania

Tara Mohr, MSW

Philadelphia Health Management Corporation, Philadelphia, Pennsylvania

Stacey McMorrow, MSW

Health Policy Center, Urban Institute, Washington, DC

Peter A. Ubel, MD

Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, VA Health Services Research & Development Center of Excellence, VA Ann Arbor Healthcare System, Division of General Internal Medicine, University of Michigan, Program for Improving Heath Care Decision Making, Ann Arbor, Michigan

Purpose. To explore public attitudes toward the incorporation of cost-effectiveness analysis into clinical decisions. Methods. The authors presented 781 jurors with a survey de-scribing 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. Results. 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. Conclusions. 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.

Key Words: decision making • public opinion • cost-benefit analysis • health care rationing

Medical Decision Making, Vol. 23, No. 5, 369-378 (2003)
DOI: 10.1177/0272989X03256882


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