Public response to cost-quality tradeoffs in clinical decisions.
OBJECTIVE
To explore public attitudes toward the incorporation of cost-effectiveness analysis into clinical decisions.


METHODS
The authors presented 781 jurors with a survey describing 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.
Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA. mcbeach@jhmi.edu
Mary Catherine
MC
Beach
David A
DA
Asch
Christopher
C
Jepson
John C
JC
Hershey
Tara
T
Mohr
Stacey
S
McMorrow
Peter A
PA
Ubel
D000328:Adult; D003362:Cost-Benefit Analysis; D003430:Cross-Sectional Studies; D003657:Decision Making; D005260:Female; D015276:Health Care Rationing / Q000191:economics; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D009369:Neoplasms / Q000175:diagnosis* / Q000191:economics*; D010818:Practice Patterns, Physicians' / Q000191:economics; D011639:Public Opinion; D018570:Risk Assessment / Q000191:economics; D011795:Surveys and Questionnaires; D014481:United States; D026712:Value of Life / Q000191:economics