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

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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.