Physician variation in test ordering in the management of gastroenteritis in children

Objectives: To describe the variation among physicians in test ordering when caring for children with gastroenteritis and to explore the effect of hospital charge information on such variation. Design: Prospective, nonmasked, observational study and controlled trial of price information. Setting: Urban, university-affiliated pediatric emergency department. Participants: Pediatric emergency medicine faculty (n = 10) and fellows (n = 5). Methods: Test-ordering practices were reviewed during 3 periods: control, intervention, and washout. During the intervention period, test charge information was placed on patients' emergency department records. Telephone contact with families was initiated 7 days after care. Results: We included 3198 visits. Individual physician mean test charges varied more than 2-fold during the control period (mean, $127; range, $82-$185). Based on their test charges (control period), physicians were assigned to the "high" (n = 8) or "low" (n = 7) test user group. Differences in mean charges in high vs low test users during the control period ($144 vs $112) persisted in the intervention period ($80 vs $52; Mann-Whitney P = .01), as did rates of intravenous fluid use (20% vs 14% in both periods). Among the lowest-acuity patients, low test users exhibited greater price sensitivity (vs high users). Patients treated by low test users did not differ in improved condition (82% vs 86%) or family satisfaction (93% vs 92%); they had more unscheduled follow-up (25% vs 17%; P<.01), but were no more often admitted (5% vs 3%; P=.11). Conclusions: Physicians varied in resource use when treating children with gastroenteritis. High and low test users were sensitive to price information. This intervention did not seem to compromise patient outcome.