Patient Preferences to Undergo Low-Value CT Coronary Angiography in the Emergency Department

BackgroundLow-value diagnostic testing adds billions of dollars to the cost of health care in the US annually. Addressing patient preference for these tests is one possible strategy to limit overuse. In previous work, we showed that patient preference for testing can be influenced by test benefit, risk, and financial measures. Our objective was to examine the effect of these variables in another clinical scenario involving chest pain. MethodsIn this cross-sectional survey of patients at the University of Michigan Emergency Department (ED), participants were given a hypothetical scenario involving an ED visit for chest pain, along with information regarding potential benefit (detecting a life-threatening condition; 0.1 or 1%) and risk (developing cancer; 0.1 or 1%) of CTCA, as well as an incentive of $0 or $100 to forego testing. Values for risk, benefit, and financial incentive varied across participants. Our primary outcome was patient preference to undergo testing. We also obtained demographic and numeracy information. Then, we used logistic regression to estimate odds ratios, adjusting for multiple potential confounders. Our sample size was designed to find at least 300 events (test acceptance) to allow for up to 30 covariates in fully adjusted models. We had 85-90% power to detect a 10% absolute difference in testing rate across groups, assuming a 95% significance level. Results913 patients were surveyed. A $100 financial incentive (adjusted OR [AOR] 0.57; 95% Confidence Interval [CI] 0.42-0.78) and increased test risk (AOR 0.61; 95% CI 0.44-0.84) both significantly decreased test acceptance in fully adjusted models, whereas increased test benefit significantly increased test acceptance (AOR 2.45; 95% CI 1.79-3.36). ConclusionsOffering a financial incentive deterred patients from accepting testing despite varying levels of risk and benefit. In the context of previous work, we provide preliminary evidence supporting that financial interventions may impact patient preference more than test risk and benefit.