. 2021 Nov 3;11(11):e049568.

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

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 csarkisian@mednet.ucla.edu.
¹⁵ VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.

PMID: 34732478
PMCID: PMC8572383
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

Alast Ahmadi et al. BMJ Open. 2021.

. 2021 Nov 3;11(11):e049568.

doi: 10.1136/bmjopen-2021-049568.

Authors

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 csarkisian@mednet.ucla.edu.
¹⁵ VA Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.

PMID: 34732478
PMCID: PMC8572383
DOI: 10.1136/bmjopen-2021-049568

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.

PubMed Disclaimer

Conflict of interest statement

Competing interests: None declared.

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.

See this image and copyright information in PMC

References

1. Schein OD, Cassard SD, Tielsch JM, et al. . Cataract surgery among Medicare beneficiaries. Ophthalmic Epidemiol 2012;19:257–64. 10.3109/09286586.2012.698692 - DOI - PMC - PubMed
1. Fleisher LA, Fleischmann KE, Auerbach AD, et al. . 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American heart association Task force on practice guidelines. J Am Coll Cardiol 2014;64:e77–137. 10.1016/j.jacc.2014.07.944 - DOI - PubMed
1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. National Health Statistics Reports 2009;11:1–25. - PubMed
1. Schein OD, Friedman DS, Fleisher LA. Anesthesia management during cataract surgery. Evid Rep Technol Assess 2000;16:1. - PMC - PubMed
1. Cavallini GM, Saccarola P, D'Amico R, et al. . Impact of preoperative testing on ophthalmologic and systemic outcomes in cataract surgery. Eur J Ophthalmol 2004;14:369–74. 10.1177/112067210401400502 - DOI - PubMed

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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

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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

Authors

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Conflict of interest statement

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