Protocol for pragmatic randomised trial: integrating electronic health record-based behavioural economic 'nudges' into the electronic health record to reduce preoperative testing for patients undergoing cataract surgery

Alast Ahmadi; Andrea Sorensen; Chad Wes A Villaflores; John N Mafi; Sitaram S Vangala; Ira S Hofer; John D Bartlett; Eric M Cheng; Victor F Duval; Cheryl Damberg; David Elashoff; Noah J Goldstein; Joseph A Ladapo; James M Moore; Antonio M Pessegueiro; Suzanne B Shu; Samuel A Skootsky; Ashley Turner; Catherine A Sarkisian

doi:10.1136/bmjopen-2021-049568

Protocol for pragmatic randomised trial: integrating electronic health record-based behavioural economic 'nudges' into the electronic health record to reduce preoperative testing for patients undergoing cataract surgery

BMJ Open. 2021 Nov 3;11(11):e049568. doi: 10.1136/bmjopen-2021-049568.

Authors

Alast Ahmadi^{1

2}, Andrea Sorensen³, Chad Wes A Villaflores³, John N Mafi⁴, Sitaram S Vangala⁵, Ira S Hofer⁶, John D Bartlett⁷, Eric M Cheng⁸, Victor F Duval⁶, Cheryl Damberg⁹, David Elashoff⁵, Noah J Goldstein^{1

10}, Joseph A Ladapo⁴, James M Moore⁶, Antonio M Pessegueiro⁴, Suzanne B Shu^{11

12}, Samuel A Skootsky⁴, Ashley Turner¹³, Catherine A Sarkisian^{14

15}

Affiliations

¹ University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.
² Internal Medicine, University of California Irvine School of Medicine, Irvine, California, USA.
³ Division of Geriatrics, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.
⁴ Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.
⁵ Department of Medicine Statistics Core, Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.
⁶ Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.
⁷ Department of Ophthalmology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.
⁸ Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA.
⁹ RAND Corp, Santa Monica, California, USA.
¹⁰ UCLA Anderson School of Management, Los Angeles, California, USA.
¹¹ SC Johnson College of Business at Cornell University, Ithaca, New York, USA.
¹² The Charles H. Dyson School of Applied Economics and Management, Ithaca, New York, USA.
¹³ Pharmacogenomics, Mayo Clinic Rochester, Rochester, Minnesota, USA.
¹⁴ Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA [email protected].
¹⁵ VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.

Abstract

Introduction: Robust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory.

Methods and analysis: This pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings.

Ethics and dissemination: The study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country.

Trial registration number: ClinicalTrials.gov identifier: NCT04104256.

Keywords: anaesthesia in ophthalmology; cataract and refractive surgery; geriatric medicine; health economics; quality in health care.

Publication types

Clinical Trial Protocol
Research Support, N.I.H., Extramural

MeSH terms

Cataract Extraction*
Cataract*
Economics, Behavioral
Electronic Health Records
Humans
Low-Value Care
Randomized Controlled Trials as Topic

Associated data

ClinicalTrials.gov/NCT04104256

Abstract

Publication types

MeSH terms

Associated data

Grants and funding