How often are cost considerations documented in clinical notes? The question is posed by these researchers from Beth Israel Deaconess Medical Center (Boston) who seek here in the JAMA Network Open to assess the influence of cost considerations on treatment decisions. The conclusion speaks for itself, with regard to the ICUs (Intensive Care Units) covered by this study, less than 4% of the files include a note relating to the costs of the treatments. The extent to which financial considerations can alter decision-making, particularly in intensive care units (ICUs), remains poorly understood. The study thus raises the broader question of taking health care costs into account when making therapeutic decisions…
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This is a cohort study focusing specifically on the narrative clinical notes appended to the charts corresponding to 4,146 admissions to the intensive care unit (ICU) of a large university medical center. The context is obviously “extreme” since in the ICU, the treatment is dictated by urgency rather than by economic considerations. Many clinicians have also been trained not to take financial data or issues into account when making treatment decisions, however the researchers reiterate an important point: healthcare costs can be a significant concern for patients. and their families.
To study the link between financial concerns and treatment decision-making, the researchers analyzed the clinical notes of these more than 46,000 ICU admissions and their analysis reported that:
- approximately 2,000 patients (4%) have at least one note “on file” reflecting financial considerations during their ICU stay;
- of all admissions, 142 (0.3%) have notes describing a change in discharge plan,
- 142 (0.3%) describing a change in treatment plan;
- 303 (0.7%) describing a change in medication or prior nonadherence to medication. These 3 types of changes based on financial considerations.
The results underline the importance of understanding how financial constraints can modify treatment decisions in the hospital, in intensive care units in particular, but also in the city.
Little evidence of cost consideration:the researchers write that they expected "to find little, if any, evidence of consideration of costs in ICU ratings, reflecting the idea that care is prioritized and driven by urgency rather than economic considerations. Additionally, the authors point out that explicit conversations about costs in clinical encounters are not the norm. It is difficult to compare these data with those of previous studies, as there are few estimates of the prevalence of conversations or financial decisions in the context of intensive care but also broader health care: An analysis of conversations transcribed between patients and physicians in outpatient clinics showed that approximately 1 in 3 conversations, depending on the specialty, includes a discussion of the cost of treatment. Another survey study conducted among 1,379 oncologists revealed that 84% take into account the personal expenses of patients.
This study is therefore a first step in understanding the impact of financial considerations on care and treatment. Much work remains to be done to understand how these considerations can be associated with socio-demographic characteristics.
The results already suggest the need for more systematic research to determine the extent to which patients and their families need to be more involved in these financial considerations, in particular in particular for the best adherence to the course and treatments.
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