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It's More Than a Nudge

2019-10-01 07:55:09 | BioPortfolio

Summary

There is strong consensus - based on robust randomized trial data - that routine pre-operative (pre-op) testing for cataract surgery is inappropriate. Yet despite these widely endorsed evidence-based recommendations, most seniors undergoing cataract surgery still receive unnecessary blood testing, EKGs, and chest X-rays (CXRs); another substantial percentage even undergo non-indicated cardiac stress tests. A quality improvement initiative will integrate a 3-pronged behavioral economics intervention into the University of California, Los Angeles (UCLA) Health EHR. The first nudge is an alert focused on safety. The second nudge is an alert focused on patient financials. The third nudge is an alert focused on patient's psychological stresses. We will evaluate a quality improvement initiative that would reduce low-value pre-operative testing for cataract surgery.

Description

There is strong consensus - based on robust randomized trial data - that routine pre-operative (pre-op) testing for cataract surgery is inappropriate.1-4 Because pre-op testing provides no benefit to patients, the American Academy of Ophthalmology even named reducing routine pre-op testing for cataract surgery as their #1 issue that patients and physicians should question as part of the Choosing Wisely™ campaign.5 Yet despite these widely endorsed evidence-based recommendations, most seniors undergoing cataract surgery still receive unnecessary blood testing, EKGs, and chest X-rays (CXRs); another substantial percentage even undergo non-indicated cardiac stress tests.6

With cataract surgery being the most common medical procedure among Medicare beneficiaries (predicted 4.4 million per year by the year 2030),7 widespread reduction of routine pre-op testing for cataract surgery would save billions of dollars, reduce exposure to unnecessary and potentially harmful tests, and allow millions of seniors to spend more time enjoying life rather than wasting their time receiving inappropriate health care.

We hypothesize that an interdisciplinary electronic health record (EHR)-based intervention that applies behavioral economics approaches (i.e., "nudges") will dramatically reduce pre-op testing for cataract surgery in a real-world clinical setting. We propose to test this hypothesis by conducting a pragmatic randomized trial, implementing our intervention at UCLA Health (Ronald Reagan UCLA Medical Center, where ~3200 cataract surgeries are performed per year). Our specific aims are to:

1. Integrate a 2-pronged behavioral economics intervention into the UCLA Health EHR. The intervention will include two types of behavioral nudges to promote the desired reduction in low value care:

- Nudge #1: Alert with new default tailored pre-op note template and order-set: EHR clinical decision alert to pre-op clinic physician with a default tailored pre-op note template (that will include text referencing national guidelines making it clear that most patients do not benefit from pre-op testing) and a "smart" order-set with testing guidelines.

- Nudge #2: Accountable justification "hard stop" for orders: EHR requirement that the preop physician ordering any non-recommended testing must write free text in the chart to justify the order.

2. Randomize cataract surgery patients over a one-year period 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 12-months after the intervention start including:

a. Primary outcome = change in percentage of patients undergoing pre-op testing (labs, EKG, CXR) b. Secondary patient, physician, and system-level outcomes i. Patients: perceived benefit/harm of not getting tested ii. Physicians: perceived change in workflow, autonomy, satisfaction iii. System: day of surgery cancellations, median time to surgery, costs saved, return on investment

Reducing patient exposure to unnecessary care is central to improving patient outcomes and value. This project is fully aligned with UCLA Health leadership's current priority on supporting cross-departmental system change to improve quality of care, outcomes, and value for UCLA patients. Because of the close partnership between our UCLA Informatics co-Investigators and the EHR vendor (Epic), the low-cost intervention that we propose to implement and test would be easily available to all Epic-based health systems, with potential to dramatically reduce inappropriate pre-op testing across the nation.

EHRs are in their infancy, and we as a scientific community are only beginning to learn how to use them as tools to promote desired care processes.8 This proposed pragmatic trial would break new ground in our understanding of how behavioral economics approaches can be used to tamp down on care that does not promote better patient outcomes.

Study Design

Conditions

Pre-Operative Testing for Cataract Surgery

Intervention

Nudge #1: Alert with new default tailored pre-op note template and order-set, Nudge #2: Accountable justification "hard stop" for orders, Usual Care

Status

Not yet recruiting

Source

University of California, Los Angeles

Results (where available)

View Results

Links

Published on BioPortfolio: 2019-10-01T07:55:09-0400

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