Using Behavioral Economics to Reduce Low-Value Care

NCT04104256 | Completed Results DMC

• 2 other identifiers: R01AG059815-015R01AG059815
• Study Type: interventional
• Target: 1,045
• Locations: 1 country
• Sites: 1

Brief Summary

There is strong consensus - based on robust randomized trial data - that routine pre-operative (pre-op) testing for cataract surgery is inappropriate. 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 nonindicated cardiac stress tests. We will integrate three new best practice alert (BPA) nudges into the University of California, Los Angeles (UCLA) Health electronic health record (EHR). The nudges are informed by behavioral economic theory and are designed to alter the choice architecture for physicians to decrease the rate of pre-op test ordering while still preserving clinician autonomy. We will conduct a pragmatic trial to evaluate whether these BPA nudges reduce low-value pre-op testing for cataract surgery.

Conditions

Pre-Operative Testing for Cataract Surgery

Keywords

Low Value Care; Cataract Surgery; Behavioral Economics

Outcome Measures

Primary Outcomes (1)

• Pre-Operative Testing Change

  Change in percentage of patients undergoing pre-operative testing (labs, EKG, CXR)

  Pre-intervention (Baseline), Post-Intervention (12 months)

Secondary Outcomes (6)

• Pre-Operative Testing Change

  Pre-intervention (Baseline), Post-Intervention (12 months)

• Pre-Operative Testing Change for Specific Categories of Tests

  Pre-intervention (Baseline), Post-Intervention (12 months)

• Physician Experience Survey Results

  Post-Intervention (12 months)

• System-level Change - Surgery Cancellations

  Baseline, 12 months

• System-level Change - Cost Savings

  Pre-intervention (Baseline), Post-Intervention (12 months)

Study Arms (4)

Alert 1

EXPERIMENTAL

Patients with a pre-op encounter in which the physician attempts to place an order for a pre-op test. Physician has been assigned to the Nudge #1 group.

Behavioral: Nudge #1: Alert highlighting the safety/potential harms to patients of undergoing pre-op tests

Alert 2

EXPERIMENTAL

Patients with a pre-op encounter in which the physician attempts to place an order for a pre-op test. Physician has been assigned to the Nudge #2 group.

Behavioral: Nudge #2: Alert highlighting the financial harms to the patient experiencing pre-op tests

Alert 3

EXPERIMENTAL

Patients with a pre-op encounter in which the physician attempts to place an order for a pre-op test. Physician has been assigned to the Nudge #3 group.

Behavioral: Nudge #3: Alert highlighting potential psychological harms to the patient of experiencing pre-op tests

Control

EXPERIMENTAL

Patients with a pre-op encounter in which the physician attempts to place an order for a pre-op test. Physician has been assigned to the Control group. Encounter continues as usual.

Other: Usual Care

Interventions

Usual Care OTHER

Patients will receive usual care from their physicians.

Also known as: Control

Control

Nudge #1: Alert highlighting the safety/potential harms to patients of undergoing pre-op tests BEHAVIORAL

Nudge 1: * UCLA Ophthalmologists and Anesthesiologists ADVISE AGAINST routine pre-op testing. * UCLA Pre-op Eval and Planning Center (PEPC) will order any needed labs on the day of surgery. * Routine pre-op tests are inappropriate. * Routine pre-op tests do NOT increase patient safety and go AGAINST local and national guidelines Hard stop before allowing the ordering of a pre-op test where physicians must provide accountable justification: "EXPLAIN WHY GOING AGAINST GUIDELINES"

Alert 1

Nudge #2: Alert highlighting the financial harms to the patient experiencing pre-op tests BEHAVIORAL

Nudge #2: * UCLA Ophthalmologists and Anesthesiologists ADVISE AGAINST routine pre-op testing. * UCLA Pre-op Eval and Planning Center (PEPC) will order any needed labs on the day of surgery. * Routine pre-op tests are inappropriate. * Routine pre-operative tests can increase the patient's out-of-pocket costs without improving the safety or medical outcomes of cataract surgery and go AGAINST local and national guidelines * Nudge includes "hard stop" before allowing the ordering of a pre-op test where physicians must provide accountable justification: "EXPLAIN WHY GOING AGAINST GUIDELINES"

Alert 2

Nudge #3: Alert highlighting potential psychological harms to the patient of experiencing pre-op tests BEHAVIORAL

Nudge 3: * UCLA Ophthalmologists and Anesthesiologists ADVISE AGAINST routine pre-op testing. * UCLA Pre-op Eval and Planning Center (PEPC) will order any needed labs on the day of surgery. * Routine pre-op tests are inappropriate. * Routine pre-operative tests can cause aggravation and psychological stress for the patient without improving the safety or medical outcomes of cataract surgery and go AGAINST local and national guidelines * Hard stop before allowing the ordering of a pre-op test where physicians must provide accountable justification: "EXPLAIN WHY GOING AGAINST GUIDELINES"

Alert 3

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Patient at UCLA undergoing cataract surgery, and receives pre-operative evaluation at UCLA Health

You may not qualify if:

• Cataract surgery patients who get their pre-operative evaluation from non-UCLA physicians

Sponsors & Collaborators

• University of California, Los Angeles: lead
• RAND: collaborator
• National Institute on Aging (NIA): collaborator

Study Sites (1)

UCLA Health

Los Angeles, California, 90095, United States

Location

Related Publications (8)

• Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007293. doi: 10.1002/14651858.CD007293.pub2.

  PMID: 19370681 BACKGROUND

• Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 2012 Mar 14;3(3):CD007293. doi: 10.1002/14651858.CD007293.pub3.

  PMID: 22419323 BACKGROUND

• Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, Petty BG, Steinberg EP. The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. N Engl J Med. 2000 Jan 20;342(3):168-75. doi: 10.1056/NEJM200001203420304.

  PMID: 10639542 BACKGROUND

• Chen CL, Lin GA, Bardach NS, Clay TH, Boscardin WJ, Gelb AW, Maze M, Gropper MA, Dudley RA. Preoperative medical testing in Medicare patients undergoing cataract surgery. N Engl J Med. 2015 Apr 16;372(16):1530-8. doi: 10.1056/NEJMsa1410846.

  PMID: 25875258 BACKGROUND

• Schein OD, Cassard SD, Tielsch JM, Gower EW. Cataract surgery among Medicare beneficiaries. Ophthalmic Epidemiol. 2012 Oct;19(5):257-64. doi: 10.3109/09286586.2012.698692.

  PMID: 22978526 BACKGROUND

• Rumball-Smith J, Shekelle PG, Bates DW. Using the Electronic Health Record to Understand and Minimize Overuse. JAMA. 2017 Jan 17;317(3):257-258. doi: 10.1001/jama.2016.18609. No abstract available.

  PMID: 28114561 BACKGROUND

• Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, Knight TK, Hay JW, Doctor JN. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial. JAMA. 2016 Feb 9;315(6):562-70. doi: 10.1001/jama.2016.0275.

  PMID: 26864410 BACKGROUND

• Ahmadi A, Sorensen A, Villaflores CWA, Mafi JN, Vangala SS, Hofer IS, Bartlett JD, Cheng EM, Duval VF, Damberg C, Elashoff D, Goldstein NJ, Ladapo JA, Moore JM, Pessegueiro AM, Shu SB, Skootsky SA, Turner A, Sarkisian CA. 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.

  PMID: 34732478 DERIVED

Related Links

• Choosing Wisely®. American Academy of Ophthalmology: Five Things Physicians and Patients Should Question. 2013

Results Point of Contact

• Title: Project Manager
• Organization: University of California Los Angeles, Division of General Internal Medicine and Health Services Research

cvillaflores@mednet.ucla.edu

310-825-8253

Study Officials

• Catherine A Sarkisian, MD, MSPH

  University of California, Los Angeles

  PRINCIPAL INVESTIGATOR

Publication Agreements

• PI is Sponsor Employee: Yes

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: DOUBLE
• Who Masked: PARTICIPANT, CARE PROVIDER
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Principal Investigator

Study Record Dates

• First Submitted: September 24, 2019
• First Posted: September 26, 2019
• Study Start: June 24, 2021
• Primary Completion: April 11, 2023
• Study Completion: August 14, 2023
• Last Updated: September 19, 2024
• Results First Posted: September 19, 2024

Record last verified: 2024-08

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)