Pragmatic Trial of an Electronic Health Record/Behavioral Economics Intervention to Reduce Pre-operative Testing for Cataract Surgery

项目总结/摘要 基于强大的随机试验数据，人们达成了强烈的共识，即常规术前（术前）检查 对于白内障手术患者是不合适的。国家专业协会多次发布指导方针， 自2002年以来，白内障检查一直不受欢迎，但自20世纪90年代以来，术前白内障检查率一直保持不变， 使术前测试成为典型的例子，说明即使在 对证据有共识。认识到单靠证据并不能推动医疗保健决策， 政策制定者和研究团队正在寻求行为经济学领域的方法，以诱导 医生改变他们的行为。我们假设跨学科的电子健康记录（EHR） 在“真实的世界”环境中实施的行为经济学干预（包括 医疗保健系统，而不仅仅是那些同意参加研究的人）将大大减少术前 白内障手术的测试我们的跨学科团队包括卫生服务研究， 行为科学，经济学，生物统计学，还包括信息学家，质量改进领导 以及来自眼科、麻醉科和术前医院医学的临床医生领导。我们建议测试 通过在加州大学洛杉矶分校健康中心的一项实用随机试验中实施我们的干预，我们的假设。的 干预将包括2种类型的“轻推”：1）使用新默认术前记录模板的警报和 指南; 2）负责的理由“硬停”要求，术前医生订购任何非 推荐的测试必须在图表中写入自由文本以证明顺序。我们将随机进行白内障手术 1年以上的患者（n=1600）接受4种类型的术前访视（常规术前护理，轻推#1，轻推#2， 或两者）并使用2 × 2析因设计测量和比较每种干预的功效。成果 将在12个月时进行测量，包括接受术前检查的患者百分比变化（主要 结果）;以及次要患者、医生和系统级结果，包括成本节约。这一拟议 务实的尝试将为我们理解行为经济学方法的应用开辟新的天地 在现实世界的设置中，可以用来压制不能促进更好的患者结果的护理。如果 如果成功，我们将创建一个工具，可以轻松地免费分发给所有Epic EHR供应商 在全国范围内，以减少对该国最常见的外科手术的不适当测试。

PROJECT SUMMARY / ABSTRACT There is strong consensus – based on robust randomized trial data - that routine pre-operative (pre-op) testing for cataract surgery patients is inappropriate. National specialty societies have repeatedly published guidelines discouraging testing since 2002, but pre-op cataract testing rates have remained unchanged since the 1990s, making pre-op testing the quintessential example of how challenging it is to reduce low-value care even when there is consensus about evidence. Recognizing that evidence alone does not drive healthcare decisions, policy makers and research teams are looking to the field of behavioral economics to find ways to induce physicians to change their behavior. We hypothesize that an interdisciplinary electronic health record (EHR) behavioral economics intervention implemented in a “real world” setting (that includes all physicians in the healthcare system, not just those who agree to participate in a research study) will dramatically reduce pre-op testing for cataract surgery. Our interdisciplinary team includes expertise in health services research, behavioral science, economics, biostatistics, and also includes informaticists, quality improvement leadership and clinician leaders from ophthalmology, anesthesiology and pre-op hospital medicine. We propose to test our hypothesis by implementing our intervention in a pragmatic randomized trial at UCLA Health. The intervention will include 2 types of “nudges”: 1) alert with new default pre-op note template and order-set with guidelines; 2) accountable justification “hard-stop” requirement that the pre-op physician ordering any non- recommended testing must write free text in the chart to justify the order. We will randomize cataract surgery patients over 1 year (n=1600) to one of 4 types of pre-operative visits (usual pre-op care, Nudge #1, Nudge #2, or both) and measure and compare the efficacy of each intervention using a 2x2 factorial design. Outcomes will be measured at 12-months including change in percentage of patients undergoing pre-op testing (primary outcome); and secondary patient, physician and system-level outcomes, including cost savings. This proposed pragmatic trial would break new ground in our understanding of how behavioral economics approaches applied in real-world settings can be used to tamp down on care that does not promote better patient outcomes. If successful, we will have created a tool that can be easily disseminated free of cost to all Epic EHR vendors across the nation to reduce inappropriate testing for the most common surgical procedure in the country.