Jahanbakhsh Pourahangarian¹, Babak Masoumi² , Amir Masoud Hashemian³, Farahnaz Bidari Zerepoosh⁴ and Hojjat Derakhshanfar⁴*

¹Department of Educational Research, Tonekabon Branch, Islamic Azad University, Tonekabon, Iran.

²Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

³Department of Emergency Medicine, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

⁴Shahid Beheshti University of Medical Sciences , Tehran , Iran

DOI : https://dx.doi.org/10.13005/bpj/536

Abstract

Physicians’roleinreducinghealth care costsisobvious andundeniable. Therefore, the current studyseeks toSurvey management of residents’ awareness of the cost of hospital paraclinical measures. This studyused avalid and reliablequestionnaire to evaluate the residents’ awareness regarding thecost of tests,including CBC, ESR, U/A,troponin, chest radiography, ultrasound of abdomenand pelvis,CT scan of head.Any estimate in the range of25% ofactual pricewas considered as the correctestimate. Data was analyzed usingt-test,chi-square anddrawing Box Plot. Significancelevel was determined p< 0.05. 90residents(54.4% male) were studied. With the exception ofchest radiography(48/0 = p),averagecostsestimated byresidents in the diagnostic tests of CBC (p<0.0001), ESR (p<0.0001), UA (p<0.0001),troponin(p=0.004),ultrasound(p=0.01)and CTscan ofhead(p<0.0001) differed from theactual price. Also, theaverageerrorinestimating thecosts ofCBC, ESR, UA,troponin, chest radiography, ultrasoundand CTscan ofheadwas 243.6%, 798.2%, 229.8%, 22.3%, 5.7%, 35.1% and 56.1%,respectively.On average, only 24.3%of residentswere awareof thereal cost oflaboratoryfees. The resultsshowed that the management level information of assistantsof internalmedicine, surgery,pediatrics, obstetricsandemergency medicineaboutthe cost of paraclinicalmeasuresis low and the level of education regardingawarenessof these costsis inadequate.

Keywords

Medical Expenses; DiagnosticTests; Residents’ Estimates

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Copy the following to cite this article: Pourahangarian J, Masoumi B, Hashemian A. M, Zerepoosh F. B, Derakhshanfar H. Survey Management of Residents’ Awareness of the Cost of Hospital Paraclinical Measures. Biomed Pharmacol J 2014;7(2)

Copy the following to cite this URL: Pourahangarian J, Masoumi B, Hashemian A. M, Zerepoosh F. B, Derakhshanfar H. Survey Management of Residents’ Awareness of the Cost of Hospital Paraclinical Measures. Biomed Pharmacol J 2014;7(2). Available from: http://biomedpharmajournal.org/?p=3237

Introduction

Costsof healthsystemsaround the worldare increasinglyon the rise and have allocated a significant shareofcountries’Gross 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 physicians 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.

Methodology

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(α=0.705).   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.   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.  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’ 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   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’attitudes were divided intoproper(correct answer to at least threequestions) and improper (correct answer at leasttwoquestions)groups. Then, therelationship betweenresidents’ attitudes anddemographic factorswere examined usingchi-square tests.   Box Plot was drawn to portray the residents’ awareness aboutthecost of tests.P- Valueless than0.05 was set assignificance level.

Results

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%)  pediatric residents.   Their mean and standard deviation of age was estimated 32.7 ± 3.9.  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 ± 3.8 h. It is worth noting that none of the participating residents was evaluated during the residency period   about the rate of information on health care costs (Table 1).

Table1: Demographic characteristics ofparticipantsin current study

Variable		Frequency	Percentage
Age	29-35	69	81.2%
	36-45	16	18.8%
Sex	Male	49	54.4%
	Female	41	45.7%
Specialty	Emergency Medicine	50	55.5%
	Internal	12	13.3%
	Surgery	16	17.8.%
	Obstetrics	6	6.7%
	Pediatrics	6	6.7%
Level of Education	Year 1	32	35.6%
	Year 2	28	31.1%
	Year 3	27	30.0%
	Year 4	3	3.3%
Work Experience	2 years ≥	51	59.3%
	3-10 years	27	31.4%
	< 10 years	3	9.3%
History ofeducationinthe field ofhealthcare costs	No	585	94.4%
	Yes	5	5.6%

 

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 ±6.4, 8.3 ± 5.8,6.8 ± 6.3 and 6.7 ± 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).

Figure 1: Awareness sources of residentsabout health care costs   Click here to View figure

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±3145.1, 3592.7±3600, 2803.4±1742.3, 14028.9±11718.1, 9280.7±6542.6, 22880.9±21872.8 and 47000.0±25822.4, respectively, that hada significant difference betweenthe actual price.  AsFig2 shows, except residents’ estimates for chestradiography which were close to actual price and the price of troponinwhich was underestimated, the prices of remaining laboratorytestswere overestimated.   Star symbolinfigure representsthe actualcost ofdiagnostictests.

Figure 2: Estimatedcosts byvolunteerresidents, * denotes the actualcost ofdiagnostic test   Click here to View figure

According to thestudy,   the estimatedcost ofdiagnostic testswithin 25percent ofactualcosts was considered as the correct estimate. Accordingly, the averageerrorsinestimating thepricesof CBC, 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.   Ascan be seen,the prices of ESR, CBCandUAestimated by residents arevery different from theactualprice. Table 2showsthe responseofphysicians.  Mostresidentswere 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.  But itwas different abouttroponin.  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.

Table 2: Distribution of physicians’ awareness of thecostoflaboratory testsandimagingtests

Variable	Estimate	Frequency	Percentage
CBC	Underestimated	2	2.2%
	Equal to actual price	8	8.9%
	Overestimated	80	88.8%
ESR	Underestimated	1	1.1%
	Equal to actual price	1	1.1%
	Overestimated	88	98.8%
UA	Underestimated	1	1.1%
	Equal to actual price	12	13.3%
	Overestimated	77	85.6%
Troponin	Underestimated	42	46.7%
	Equal to actual price	32	35.6%
	Overestimated	16	17.8%
CXR	Underestimated	29	32.2%
	Equal to actual price	34	37.8%
	Overestimated	27	30.0%
Ultrasoundof the abdomenand pelvis	Underestimated	15	16.7%
	Equal to actual price	42	46.7%
	Overestimated	33	36.6%
Head CT	Underestimated	11	12.2%
	Equal to actual price	23	25.6%
	Overestimated	56	62.2%

Investigating the responses of research unit indicated that more residents possessed a proper perspective on the necessity of promoting physicians’ awareness of healthcare costs and knowing the costs involved in their clinical decisions. Of 4 questions,  83 (92.2%) residents answeredat least three questions correctly (mean and standard deviation 3.5 ± 0.9), indicatingthat theattitude ofresidentsisdesirable.  But their attitude didn’t 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).

Table 3: Estimatedcostsbased onresidents’ attitudes onhealth care costs

Variable	Estimate	Improper attitude	Proper attitude	P
CBC	Overestimated	(0.0%) 0	(100%) 2	99.0
	Equal to actual price	(0.0%) 0	(100%) 8
	Underestimated	(8.8%) 7	(2.91%) 73
ESR	Overestimated	(0.0%) 0	(100%) 1	99.0
	Equal to actual price	(0.0%) 0	(100%) 1
	Underestimated	(0.8%) 7	(0.92%) 81
UA	Overestimated	(0.0%) 0	(100%) 1	62.0
	Equal to actual price	(0.0%) 0	(100%) 12
	Underestimated	(1.9%) 7	(9.90%) 70
Troponin	Overestimated	(5.9%) 4	(5.90%) 38	88.0
	Equal to actual price	(2.6%) 2	(8.93%) 30
	Underestimated	(2.6%) 1	(8.93%) 15
CXR	Overestimated	(9.6%) 2	(1.93%) 27	25.0
	Equal to actual price	(9.2%) 1	(1.97%) 33
	Underestimated	(8.14%) 4	(2.85%) 23
Ultrasoundof the abdomenand pelvis	Overestimated	(0.20%) 3	(0.80%) 12	22.0
	Equal to actual price	(8.4%) 2	(2.95%) 40
	Underestimated	(1.6%) 2	(9.93%) 31
Head CT	Overestimated	(0.0%) 0	(100%) 11	6.0
	Equal to actual price	(4.4%) 1	(6.95%) 22
	Underestimated	(7.10%) 6	(3.89%) 50

Discussion

Survey ofresidents’ awareness of financial burdenimposedon the patient’s clinical by paraclinical measures had a big differencewith theactual rate.  On average, pricesestimated bymedicalresidentswere 176% greater than the actual costs.  On theother hand, only estimating 24.3%of research units incurrent studywerecloser tothe real prices.  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.

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).  These findingstogether with theresultsof this studyindicatethe poorawarenessof physiciansaround the world aboutdiagnosis and treatment costs.

In a systematic review of Allen et al.(19)it was found  that nationality, country, level of education, expertise, and physicians’ other demographic and basic factors  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’ 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’ awareness, becauseexpensivediagnostictests have a larger 25percent range thancheaper ones.

Physicians’attitude 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  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.

(25-26). Therefore, it seems essential to plan trainingprograms in order to improve physicians’ awarenessat alllevels inourcountry.

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.  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’ 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’ awareness of diagnostic tests, their awareness of drug costs was not investigated.  Also, due to the higher cost of laboratory measures in the private centers, if the awareness of physicians’ working in these centers could also be checked, more comprehensive and more accurate results would be obtained from the study.  Unfortunately, it was not possible to study the awareness of physicians’ working in private centers.

Conclusion

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.

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