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

项目摘要/摘要 基于可靠的随机试验数据，常规的术前(手术前)测试有很强的共识 对于白内障手术患者来说是不合适的。国家专业协会一再发布指导方针 自2002年以来一直不鼓励检查，但自20世纪90年代以来，术前白内障检测率一直保持不变， 使术前测试成为一个典型的例子，说明即使在以下情况下减少低价值护理是多么具有挑战性 人们对证据的看法是一致的。认识到证据本身并不能推动医疗保健决策， 政策制定者和研究团队正在寻找行为经济学领域的方法，以期 医生改变他们的行为。我们假设一个跨学科的电子健康记录(EHR) 在“真实世界”环境中实施的行为经济学干预(包括 医疗系统，而不仅仅是那些同意参与研究的人)将极大地减少术前 做白内障手术的检测。我们的跨学科团队包括医疗服务研究方面的专业知识， 行为科学、经济学、生物统计学，还包括信息学家、质量改进领导力 以及来自眼科、麻醉学和术前医院医学的临床医生领导。我们打算测试一下 我们的假设是在加州大学洛杉矶分校健康中心的一项务实的随机试验中实施我们的干预。这个 干预将包括两种类型的“轻推”：1)带有新的默认操作前备注模板和订单设置的警报 指南；2)负责任的正当理由“硬停止”要求，术前医生命令任何非 推荐的测试必须在图表中写入自由文本，以证明顺序是正确的。我们将随机安排白内障手术 患者1年以上(n=1600)至4种类型的术前探视之一(通常的术前护理，轻推1号，轻推2号， 或两者兼而有之)，并使用2x2析因设计测量和比较每个干预措施的效果。结果 将在12个月时进行测量，包括接受手术前检测的患者百分比的变化(主要 结果)；以及二级患者、医生和系统一级的结果，包括成本节约。这项建议 务实试验将为我们理解行为经济学方法的应用开辟新的天地 在现实世界中，可以用来压制不能促进更好的患者结果的护理。如果 成功后，我们将创建一个工具，可以很容易地免费分发给所有Epic EHR供应商 在全国范围内减少对全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.