CT overuse: should we pay patients to opt out of low-value scans?

Takeaway

• Paying patients to decide against low-value tests could cut costs of emergency department (ED) care.

Why this matters

• Defensive medicine costs the US health system about $46 billion annually.
• Head CTs are often ordered in contradiction to guidelines; about one-third are avoidable.
• Previous research found that rising personal costs deter patients from electing low-value tests.

Key results

• In both unadjusted and fully adjusted analyses, decision to skip CT was associated with lower-benefit, higher-risk, and higher-incentive scenarios.
• Odds of CT acceptance:
  • Incentive vs no incentive: aOR, 0.59 (95% CI, 0.44-0.79).
  • 0.1% vs 1% benefit: aOR, 1.58 (95% CI, 1.18-2.13).
  • 0.1% vs 1% risk: aOR, 0.70 (95% CI, 0.52-0.93).

Study design

• Single-center cross-sectional survey of adult ED patients (n=913).
• Researchers described an imaginary situation: participant is being worked up in an ED after a mild traumatic brain injury.
  • For head CT, they presented risks (0.1% vs 1% risk for brain cancer) and benefits (0.1% vs 1% chance of spotting a bleed).
  • They offered participants $0 vs $100 to skip CT.
• Outcomes: patient preference to undergo CT.
• Funding: NIH.

Limitations

• Researchers evaluated only 1 scenario, which was hypothetical.
• Risks and benefits are seldom so clearly quantifiable.