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

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.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Nudge 1, alert highlighting the safety/liability aspects of preoperative tests.ASA: American Society of Anesthesiologists, AAO: American Academy of Ophthalmology, UCLA: University of California, Los Angeles.

Figure 2

Nudge 2, alert highlighting the financial benefits to the patient of not experiencing preoperative tests.ASA: American Society of Anesthesiologists, AAO: American Academy of Ophthalmology, UCLA: University of California, Los Angeles.Disclaimer: the image in the figure does not depict a patient and is license-free.

Figure 3

Nudge 3, alert highlighting the psychological benefits to the patient of not experiencing preoperative tests.ASA: American Society of Anesthesiologists, AAO: American Academy of Ophthalmology, UCLA: University of California, Los Angeles.Disclaimer: the image in the figure does not depict a patient and is license-free.

Figure 4

Randomisation strategy: Randomizing the UCLA Health physicians who perform pre-op testing to one of the three intervention arms or the usual care arm.