Using Behavioral Economics to Reduce Low-Value Care

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

Interventions

BEHAVIORAL

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

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"

BEHAVIORAL

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

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"

BEHAVIORAL

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

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"

OTHER

Usual Care

Patients will receive usual care from their physicians.

Sponsors & Collaborators

• RAND

  collaborator OTHER

• National Institute on Aging (NIA)

  collaborator NIH

• University of California, Los Angeles

  lead OTHER

Principal Investigators

• Catherine A Sarkisian, MD, MSPH · University of California, Los Angeles

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

DOUBLE

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2021-06-24

Primary Completion

2023-04-11

Completion

2023-08-14

Countries

• United States

Study Locations