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Ann Emerg Med. 2008 Dec;52(6):643-650. doi: 10.1016/j.annemergmed.2008.03.001. Epub 2008 Apr 24.

Influence of patient costs and requests on emergency physician decisionmaking.

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Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, Fairfax, CA 94930, USA.



We examine emergency physician knowledge of, attitudes about, and responses to patient cost-sharing in the emergency department (ED).


A convenience sample of emergency physicians from an integrated delivery system completed a questionnaire including self-report questions about knowledge of and attitudes about cost-sharing and an experimental vignette. The vignette describes a patient with an uncomplicated asthma exacerbation, with a version in which she has a $100 ED visit copayment and a version in which she does not. Subjects responded with their "best judgment" of whether they would order a chest radiograph and their decision after specific patient request. We examined the frequency of responses overall and associated characteristics with chi(2) testing.


Of 204 respondents (349 eligible participants [58%]), 203 answered the vignette questions. No respondent reported that ordering a radiograph was clinically appropriate; however, 85% reported that they would order a radiograph if the patient requested it. There were no significant differences in the percentage of physicians ordering the test across the 2 versions. Overall, 77% of respondents reported having limited awareness of an individual patient's cost-sharing level; 67% reported that patient costs sometimes affect their clinical decisions; only 10% estimated changing their decisions in greater than 20% of encounters in which the cost-sharing level was known.


Emergency physicians are usually not aware of a patient's cost-sharing level and, in instances which they are, report that this knowledge rarely affects their clinical decisions. However, emergency physicians are responsive to patient requests, even when the treatment request differs from their clinical judgment.

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