{"id":3237,"date":"2015-05-03T07:00:07","date_gmt":"2015-05-03T07:00:07","guid":{"rendered":"http:\/\/biomedpharmajournal.org\/?p=3237"},"modified":"2020-04-26T06:27:11","modified_gmt":"2020-04-26T06:27:11","slug":"survey-management-of-residents-awareness-of-the-cost-of-hospital-paraclinical-measures","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol7no2\/survey-management-of-residents-awareness-of-the-cost-of-hospital-paraclinical-measures\/","title":{"rendered":"Survey Management of Residents\u2019 Awareness of the Cost of Hospital Paraclinical Measures"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Costsof healthsystemsaround the worldare increasinglyon the rise and have allocated a significant shareofcountries\u2019Gross National Product to itself(1-3). Risingcostshas led to the increase infinancial burdenimposed onpeople, so thatfamilies, particularlyvulnerable groups, are forcedtocutother essentialexpenses in order tomeettheirmedical expenses(4).this matter hasled toa decline inthe terms ofhousehold welfareandquality of life(5).Health costs, due tothe reducedsavings and less allocation ofhousehold incometo otheruses, especiallyitems likeproperfoodoreducation, which is ashuman capital accumulation(6), reduces householdproductivitypower asthe keyfactor innationalproduction process.In the meantime, doctors whoareundoubtedly oneof theimportant elements ofthe health system play asignificant rolein cost control andlargelydetermine thepatient’s health carecosts(7-8).In developed countries, the importance of this matter was realized long agoandphysicianswereeducatedabout themedical expenses, to the extent thatthesetrainingshave beenmandatoryin some casesand apart of thecurriculum. However,studiesconductedinthesecountries indicatethat\u00a0physicians have lowknowledgeaboutthe diagnostic and therapeuticcosts(1, 9-13) .Our countryisnot excluded from facing thehigh cost ofhealthcareand despitecertaineconomic and politicalconditionsandfinancial constraintsatpresent,optimizing theuse ofhealthbudgets is needed more than ever.So, thephysicians’ awareness regarding thecost ofdiagnosisand treatment measures appliedfortheir patientsisundoubtedlyan important step inachieving thisgoal. The aimof this studyis to assess thelevel of awarenessoflimitedcommunityofdoctors to thecost ofparaclinicalproceduresthatare commonlyperformed.Becauseresidentshavea prominent roleinthe treatment of patientsin university hospitals, and also are futurephysicians, the populationstudied in thisresearchwas considered residents ofinternal medicine, surgery, obstetrics,pediatrics andemergency medicine.<\/p>\n

Methodology<\/strong><\/p>\n

This studyisacross-sectional one which aims to investigate the awarenessof allresidentsininternal medicine, surgery, obstetrics and gynecology,pediatrics andemergency medicine ofImamHussain(AS). In order toachieve theobjectives ofthisresearch,questionnaire usedbyJune A.Leeet al. (14)was translated under the supervisionoftwo specialistsin emergencymedicine and aepidemiologistandits validitywas verifiedby makingsome changesandits reliabilitywasproven by usingCronbach’s alpha coefficient(\u03b1=0.705). \u00a0 The questionnairewasdesigned inthree parts. The first partcontainsbasicdemographicdataof residents, such asage, sex,field of study,work experiencebefore starting theresidency, education level, history ofprior educationandsource of awarenessof test costs. \u00a0 The second partconsists ofquestionsabout thecost of4 casesoflaboratory tests(CBC, ESR, U\/A,troponin) 3 cases ofimagingmeasures(chest radiography, ultrasound of abdomenand pelvis, CT scan ofhead). Residents recorded their estimated prices in each case quantitatively.\u00a0 The third part includes 4 Qualitative questions to assess the residents’ attitudes toward the need for awareness of expenses. In the present study, the awareness of residents in internal medicine, surgery, obstetrics and gynecology, and pediatrics were measured, because these specialties use routine paraclinical measures more than others. We went to residents\u2019 classrooms in different days to access them and gavethem questionnaires in quiet and favorable conditions and 30 minutes to complete. List of priceswas also provided from laboratoryandradiology department. The prices are as follows: CBC: 12.000 Rials\/ U\/A: 8.500 Rials\/ ESR: 4.000 Rials\/ troponin: 17.8500 Rials\/chest radiography: 87.800 Rials\/ ultrasound of abdomenand pelvis: 168,600 Rials\/ CT scan of head: 300.000 Rials.Datafrom thequestionnaireswereentered intoSPSS 21.0 \u00a0 andthen examined descriptively and analyticallyusingSTATA 11.0program. The possibledifferencesin averagecostsestimated byresidents with real costs were examined using thet-test. In present study, any estimate in the range of25% ofactual price was considered as the correctestimate.Upper and lowerestimates were defined as underestimate overestimate, respectively. Residents\u2019attitudes were divided intoproper(correct answer to at least threequestions) and\u00a0improper (correct answer at leasttwoquestions)groups. Then, therelationship betweenresidents’ attitudes anddemographic factorswere examined usingchi-square tests. \u00a0 Box Plot was drawn to portray the residents’ awareness aboutthecost of tests.P- Valueless than0.05 was set assignificance level.<\/p>\n

Results<\/strong><\/p>\n

In this study, 90 residents (54.4% male) were studied including 50 (55.5%) emergency medicine residents, 12 (13.3%) internal medicine residents, 16 (17.8%), surgery residents, 6 (6.7%), 6 (6.7%) obstetricresidents and 6 (6.7%)\u00a0 pediatric residents. \u00a0 Their mean and standard deviation of age was estimated 32.7 \u00b1 3.9.\u00a0 Of these individuals, only five residents (5.6%) have been trained in diagnostic and therapeutic costs and the mean and standard deviation of training timewas equal to 6.8 \u00b1 3.8 h. It is worth noting that none of the participating residents was evaluated during the residency period \u00a0 about the rate of information on health care costs (Table 1).<\/p>\n

Table1: Demographic characteristics ofparticipantsin current study<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Variable<\/strong><\/td>\n\u00a0<\/strong><\/td>\nFrequency<\/strong><\/td>\nPercentage<\/strong><\/td>\n<\/tr>\n
Age<\/strong><\/td>\n29-35<\/td>\n69<\/td>\n81.2%<\/td>\n<\/tr>\n
36-45<\/td>\n16<\/td>\n18.8%<\/td>\n<\/tr>\n
Sex<\/strong><\/td>\nMale<\/td>\n49<\/td>\n54.4%<\/td>\n<\/tr>\n
Female<\/td>\n41<\/td>\n45.7%<\/td>\n<\/tr>\n
Specialty<\/strong>\u00a0<\/strong><\/td>\nEmergency Medicine<\/td>\n50<\/td>\n55.5%<\/td>\n<\/tr>\n
Internal<\/td>\n12<\/td>\n13.3%<\/td>\n<\/tr>\n
Surgery<\/td>\n16<\/td>\n17.8.%<\/td>\n<\/tr>\n
Obstetrics<\/td>\n6<\/td>\n6.7%<\/td>\n<\/tr>\n
Pediatrics<\/td>\n6<\/td>\n6.7%<\/td>\n<\/tr>\n
Level of Education<\/strong><\/td>\nYear 1<\/td>\n32<\/td>\n35.6%<\/td>\n<\/tr>\n
Year 2<\/td>\n28<\/td>\n31.1%<\/td>\n<\/tr>\n
Year 3<\/td>\n27<\/td>\n30.0%<\/td>\n<\/tr>\n
Year 4<\/td>\n3<\/td>\n3.3%<\/td>\n<\/tr>\n
Work Experience<\/strong><\/td>\n2 years \u2265<\/td>\n51<\/td>\n59.3%<\/td>\n<\/tr>\n
3-10 years<\/td>\n27<\/td>\n31.4%<\/td>\n<\/tr>\n
< 10 years<\/td>\n3<\/td>\n9.3%<\/td>\n<\/tr>\n
History ofeducationinthe field ofhealthcare costs<\/strong><\/td>\nNo<\/td>\n585<\/td>\n94.4%<\/td>\n<\/tr>\n
Yes<\/td>\n5<\/td>\n5.6%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

46 (51.1%%) residents stated that no questions have been exchanged on health care costs in their previous 20 visits by Atend, patients, resident him\/herself or other people (nurses, auxiliary nurses, etc.). Mean and standard deviation of the number of times thatAtend, patients, resident him\/herself and others have spoken regarding their treatment costs was 5.4 \u00b16.4, 8.3 \u00b1 5.8,6.8 \u00b1 6.3 and 6.7 \u00b1 5.3, respectively that had no significant difference with each other (p=0.18). The most important awareness sources of residentsabout health care costs are other physicians (30.3%), other people (15.6%), physicians and pharmacists (5.6%, Internet (4.4%), pharmacists (3.3%) and articles (1.1%), respectively (Figure 1).<\/p>\n\n\n\n
\"Figure<\/td>\nFigure 1: Awareness sources of residentsabout health care costs<\/strong><\/p>\n

 <\/p>\n

Click here to View figure<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

The meanand standard deviation ofcostsestimated byresidentsindiagnostic CBC (p<0.0001), ESR (p<0.0001), UA (p<0.0001),troponin(p=0.004), chest radiography (p=0.48)ultrasound of abdomen and pelvis (p=0.01)and CTscan ofhead(p<0.0001) was 4136.1\u00b13145.1, 3592.7\u00b13600, 2803.4\u00b11742.3, 14028.9\u00b111718.1, 9280.7\u00b16542.6, 22880.9\u00b121872.8 and 47000.0\u00b125822.4, respectively, that hada significant difference betweenthe actual price.\u00a0 AsFig2 shows,\u00a0except residents\u2019 estimates for chestradiography which were close to actual price and the price of troponinwhich was underestimated, the prices of remaining laboratorytestswere overestimated. \u00a0 Star symbolinfigure representsthe actualcost ofdiagnostictests.<\/p>\n\n\n\n
\"Figure<\/td>\nFigure 2: Estimatedcosts byvolunteerresidents, * denotes the actualcost ofdiagnostic test<\/strong><\/p>\n

 <\/p>\n

Click here to View figure<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

According to thestudy, \u00a0 the estimatedcost ofdiagnostic testswithin 25percent ofactualcosts was considered as the correct estimate. Accordingly, the averageerrorsinestimating thepricesof\u00a0CBC, ESR, UA,troponin, chest radiography, ultrasound of abdomen and pelvisand CTscan ofhead were observed 243.6%, 798.2%, 229.8%, 22.3%, 5.7%, 35.1% and 56.1%, respectively. \u00a0 Ascan be seen,the prices of ESR, CBCandUAestimated by residents arevery different from theactualprice. Table 2showsthe responseofphysicians. \u00a0Mostresidentswere unawareof thetrue priceof CBC, so that80(88.8%) residentsoverestimated its price. Similarresultswere also obtainedin the prices of ESR andUA; meaning that 88 (98.8%) and 77 (85.6%) residents overestimated their prices. \u00a0But itwas different abouttroponin.\u00a0 Mostresidents(46.7%) underestimated its price. While34(37.8%) residentsestimated the costof radiography equal and 62.2% overestimated thecost ofCT scan. Based on theanalyses, on average,only24.3%ofresidentswere awareof thereal cost oflaboratory fees.<\/p>\n

Table 2: Distribution of physicians’ awareness of thecostoflaboratory testsandimagingtests<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Variable<\/strong><\/td>\nEstimate<\/strong><\/td>\nFrequency<\/strong><\/td>\nPercentage<\/strong><\/td>\n<\/tr>\n
CBC<\/strong><\/td>\nUnderestimated<\/td>\n2<\/td>\n2.2%<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n8<\/td>\n8.9%<\/td>\n<\/tr>\n
Overestimated<\/td>\n80<\/td>\n88.8%<\/td>\n<\/tr>\n
ESR<\/strong><\/td>\nUnderestimated<\/td>\n1<\/td>\n1.1%<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n1<\/td>\n1.1%<\/td>\n<\/tr>\n
Overestimated<\/td>\n88<\/td>\n98.8%<\/td>\n<\/tr>\n
UA<\/strong><\/td>\nUnderestimated<\/td>\n1<\/td>\n1.1%<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n12<\/td>\n13.3%<\/td>\n<\/tr>\n
Overestimated<\/td>\n77<\/td>\n85.6%<\/td>\n<\/tr>\n
Troponin<\/strong><\/td>\nUnderestimated<\/td>\n42<\/td>\n46.7%<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n32<\/td>\n35.6%<\/td>\n<\/tr>\n
Overestimated<\/td>\n16<\/td>\n17.8%<\/td>\n<\/tr>\n
CXR<\/strong><\/td>\nUnderestimated<\/td>\n29<\/td>\n32.2%<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n34<\/td>\n37.8%<\/td>\n<\/tr>\n
Overestimated<\/td>\n27<\/td>\n30.0%<\/td>\n<\/tr>\n
Ultrasoundof the abdomenand pelvis<\/strong><\/td>\nUnderestimated<\/td>\n15<\/td>\n16.7%<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n42<\/td>\n46.7%<\/td>\n<\/tr>\n
Overestimated<\/td>\n33<\/td>\n36.6%<\/td>\n<\/tr>\n
Head CT<\/strong><\/td>\nUnderestimated<\/td>\n11<\/td>\n12.2%<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n23<\/td>\n25.6%<\/td>\n<\/tr>\n
Overestimated<\/td>\n56<\/td>\n62.2%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Investigating the responses of research unit indicated that more residents possessed a proper perspective on the necessity of promoting physicians\u2019 awareness of healthcare costs and knowing the costs involved in their clinical decisions. Of 4 questions,\u00a0 83 (92.2%) residents answeredat least three questions correctly (mean and standard deviation 3.5 \u00b1 0.9), indicatingthat theattitude ofresidentsisdesirable.\u00a0 But their attitude didn\u2019t affect their awareness of the price of any diagnostic tests of CBC (p=0.99), ESR (p=0.99), UA (p=0.62), troponin (p=0.89), chest radiograph (p=0.25), ultrasoundof abdomen and pelvic(p=0.22) and CT scan of head (p=0.6)(table 3).<\/p>\n

Table 3: Estimatedcostsbased onresidents’ attitudes onhealth care costs<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Variable<\/strong><\/td>\nEstimate<\/strong><\/td>\nImproper attitude<\/strong><\/td>\nProper attitude<\/strong><\/td>\nP<\/strong><\/td>\n<\/tr>\n
CBC<\/strong><\/td>\nOverestimated<\/td>\n(0.0%) 0<\/td>\n(100%) 2<\/td>\n99.0<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n(0.0%) 0<\/td>\n(100%) 8<\/td>\n<\/tr>\n
Underestimated<\/td>\n(8.8%) 7<\/td>\n(2.91%) 73<\/td>\n<\/tr>\n
ESR<\/strong><\/td>\nOverestimated<\/td>\n(0.0%) 0<\/td>\n(100%) 1<\/td>\n99.0<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n(0.0%) 0<\/td>\n(100%) 1<\/td>\n<\/tr>\n
Underestimated<\/td>\n(0.8%) 7<\/td>\n(0.92%) 81<\/td>\n<\/tr>\n
UA<\/strong><\/td>\nOverestimated<\/td>\n(0.0%) 0<\/td>\n(100%) 1<\/td>\n62.0<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n(0.0%) 0<\/td>\n(100%) 12<\/td>\n<\/tr>\n
Underestimated<\/td>\n(1.9%) 7<\/td>\n(9.90%) 70<\/td>\n<\/tr>\n
Troponin<\/strong><\/td>\nOverestimated<\/td>\n(5.9%) 4<\/td>\n(5.90%) 38<\/td>\n88.0<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n(2.6%) 2<\/td>\n(8.93%) 30<\/td>\n<\/tr>\n
Underestimated<\/td>\n(2.6%) 1<\/td>\n(8.93%) 15<\/td>\n<\/tr>\n
CXR<\/strong><\/td>\nOverestimated<\/td>\n(9.6%) 2<\/td>\n(1.93%) 27<\/td>\n25.0<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n(9.2%) 1<\/td>\n(1.97%) 33<\/td>\n<\/tr>\n
Underestimated<\/td>\n(8.14%) 4<\/td>\n(2.85%) 23<\/td>\n<\/tr>\n
Ultrasoundof the abdomenand pelvis<\/strong><\/td>\nOverestimated<\/td>\n(0.20%) 3<\/td>\n(0.80%) 12<\/td>\n22.0<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n(8.4%) 2<\/td>\n(2.95%) 40<\/td>\n<\/tr>\n
Underestimated<\/td>\n(1.6%) 2<\/td>\n(9.93%) 31<\/td>\n<\/tr>\n
Head CT<\/strong><\/td>\nOverestimated<\/td>\n(0.0%) 0<\/td>\n(100%) 11<\/td>\n6.0<\/td>\n<\/tr>\n
Equal to actual price<\/td>\n(4.4%) 1<\/td>\n(6.95%) 22<\/td>\n<\/tr>\n
Underestimated<\/td>\n(7.10%) 6<\/td>\n(3.89%) 50<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Discussion<\/strong><\/p>\n

Survey ofresidents’ awareness of financial burdenimposedon the patient’s clinical by paraclinical measures had a big differencewith theactual rate.\u00a0 On average, pricesestimated bymedicalresidentswere 176% greater than the actual costs.\u00a0 On theother hand, only estimating 24.3%of research units incurrent studywerecloser tothe real prices.\u00a0 Althoughresidents in the study had a properattitudetoward the knowledgeof fees, this proper attitudehas not caused them to improvetheir knowledge. One ofthe maincauses oflack of awareness inresidents is their source ofinformation.The mainsource of data forresidentsparticipating in thestudy is their colleagues, namely, other physicians. Becausephysicians, likeresidents, have a lowawarenessin this field. So avicious cycle has been created that not only doesnotimproveresidents’ awareness, but alsoincreasesthe chanceto confusethem.<\/p>\n

The comparison of presentpaperwith the findings ofotherstudiesreflects the highconsistencyofourfindingswith each other. This means thatmostresearchersbelieve thatphysicians’ awareness ofhealth care costsis low(13-19).For example,Allanand his colleaguesshowedin asystematic reviewthat on average;only 31% ofdoctorsare able to estimatethe pricesin the rangeof 25-20 percent ofreal rates(19). The same policyis trueInotherstudies, so that the frequencyof accurate estimateof health carecosts is assessedbetween24-33% (14, 20).\u00a0 These findingstogether with theresultsof this studyindicatethe poorawarenessof physiciansaround the world aboutdiagnosis and treatment costs.<\/p>\n

In a systematic review of Allen et al.(19)it was found \u00a0that nationality, country, level of education, expertise, and physicians\u2019 other demographic and basic factors\u00a0 have a little impact on their knowledge and the only factor affecting accurateestimates ofthe prices ofdrugs and paraclinical testsis their real prices. This means that expensive drugs are underestimated and inexpensive ones are overestimated. This issue has been confirmed in other studies (16, 20-21). The prices of cheap laboratory tests, such as CBC, UA and ESR, have been also overestimatedin our study, but the status of expensive tests was variable. So that the cost of troponin was underestimated and the costs of ultrasound and CT scan were overestimated. The cause of this differencecan beattributed to the fact thatImamHussainhospital is a public one and itscosts are lower thanprivate andsemi-privatesectors.If the cost ofimagingmeasureswerecalculatedbased onnon-publictariffs, thedifferencebetweenthis study andprevious studieswasnot created. Ascan be seen, percentage ofphysicians\u2019 errorsinestimating thecosts ofexpensivediagnostic tests is less than cheaper tests whichisconsistentwith the findings ofotherstudies(21).This issue should be attributed to themethod of calculating theexact price, not to the physicians\u2019 awareness, becauseexpensivediagnostictests have a larger 25percent range thancheaper ones.<\/p>\n

Physicians\u2019attitude towards the need forawarenessof the costsand to applythemin clinical practicehas been studiedinpreviousstudies (1, 13, 22) .For example,in thestudyof TekSehgalet al.physicians have known their awareness ofhealth care costsless, butthey have shown a strong desireto gainthis knowledge(20).In thestudyofBovieret al, conductedin Switzerland, 90% of physicians believed thatawarenessof the costsistheirresponsibility(23) . In our study,theattitude towardsresidents’ awareness ofhealth care costswas positive.Butitis clearthat physicians, despite the interest inhaving more awareness of\u00a0 health care costs, have a limited access totheseresources(9, 24).In the present study, the majority ofresidents(30.3%) receivethe informationfromother doctors, indicating thelack ofofficialinforming. However,theprevious studies showed theeffectiveand useful role of teaching healthcare expenses in reducing health systemcosts andreducescosts30-10percent.<\/p>\n

(25-26). Therefore, it seems essential to plan trainingprograms in order to improve physicians\u2019 awarenessat alllevels inourcountry.<\/p>\n

One limitationofthe present study is the lowfrequency ofobstetric andpediatricresidents. Due to the low frequency of them, it is impossible to make decisions regarding theimpactof major onresidents’ awareness ofhealth care costs.\u00a0 Therefore,it is recommendedthis point to be considered in subsequent research and acceptablevolumeofdifferent specialties to beevaluated. Anotherweaknessofthis study is the lack of examining the residents\u2019 awareness of drugcosts. Since drug therapyisan important part ofhospital costs, the necessity to pay attention tothis issue is obvious. But since the purpose of the present study was to assess the residents\u2019 awareness of diagnostic tests, their awareness of drug costs was not investigated.\u00a0 Also, due to the higher cost of laboratory measures in the private centers, if the awareness of physicians\u2019 working in these centers could also be checked, more comprehensive and more accurate results would be obtained from the study.\u00a0 Unfortunately, it was not possible to study the awareness of physicians\u2019 working in private centers.<\/p>\n

Conclusion<\/strong><\/p>\n

The resultsshowed that themanagement level information of residentsof internalmedicine, surgery,pediatrics, obstetricsandemergency medicineaboutthe cost ofclinicalmeasuresis low andthe level of education regardingawarenessof these costsis inadequate.Accordingly, it can be said that educational systemhas poorlytrainedmedicalresidentsinthe field ofmedical expenses. Yet,residentsacknowledgedthe need tobe aware of thecostsandto applythisinformation whentreating patients andexpresseda strong desireto havemore informationon this subject.<\/p>\n

References<\/strong><\/p>\n

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