Pragmatic Trial of an Electronic Health Record/Behavioral Economics Intervention to Reduce Pre-operative Testing for Cataract Surgery

电子健康记录/行为经济学干预减少白内障手术术前检查的务实试验

• 批准号: 9769613
• 负责人: CATHERINE A SARKISIAN
• 金额: $ 56.11万
• 依托单位: UNIVERSITY OF CALIFORNIA LOS ANGELES
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-09-01 至 2022-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9769613
• 关键词: Academy; American; Anesthesiology; Behavior; Behavioral; Behavioral Sciences; Biometry; Blood Tests; Caring; Cataract; Cataract Extraction; Clinic; Clinical; Communities; Consensus; Cost Savings; Country; Data; Day Surgery; Economics; Electrocardiogram; Electronic Health Record; Exposure to; Guidelines; Health; Health Services Research; Health system; Healthcare; Healthcare Systems; Hospitals; Informatics; Intervention; Investments; Leadership; Learning; Life; Measures; Medical; Medical center; Medicare; Medicine; Names; Operative Surgical Procedures; Ophthalmology; Outcome; Patient-Focused Outcomes; Patients; Physicians; Policy Maker; Policy Research; Procedures; Process; Public Health; Publishing; Quality of Care; Randomized; Research Personnel; Societies; System; Testing; Text; Thallium Myocardial Perfusion Imaging Stress Test; Thoracic Radiography; Time; Vendor; Visit; Writing; base; behavioral economics; beneficiary; care outcomes; comparative efficacy; cost; design; evidence based guidelines; improved; infancy; intervention cost; medical specialties; pragmatic trial; primary outcome; randomized trial; research study; satisfaction; successful intervention; tool; wasting

PROJECT SUMMARY / ABSTRACT There is strong consensus – based on robust randomized trial data - that routine pre-operative (pre-op) testing for cataract surgery patients is inappropriate. National specialty societies have repeatedly published guidelines discouraging testing since 2002, but pre-op cataract testing rates have remained unchanged since the 1990s, making pre-op testing the quintessential example of how challenging it is to reduce low-value care even when there is consensus about evidence. Recognizing that evidence alone does not drive healthcare decisions, policy makers and research teams are looking to the field of behavioral economics to find ways to induce physicians to change their behavior. We hypothesize that an interdisciplinary electronic health record (EHR) behavioral economics intervention implemented in a “real world” setting (that includes all physicians in the healthcare system, not just those who agree to participate in a research study) will dramatically reduce pre-op testing for cataract surgery. Our interdisciplinary team includes expertise in health services research, behavioral science, economics, biostatistics, and also includes informaticists, quality improvement leadership and clinician leaders from ophthalmology, anesthesiology and pre-op hospital medicine. We propose to test our hypothesis by implementing our intervention in a pragmatic randomized trial at UCLA Health. The intervention will include 2 types of “nudges”: 1) alert with new default pre-op note template and order-set with guidelines; 2) accountable justification “hard-stop” requirement that the pre-op physician ordering any non- recommended testing must write free text in the chart to justify the order. We will randomize cataract surgery patients over 1 year (n=1600) 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 at 12-months including change in percentage of patients undergoing pre-op testing (primary outcome); and secondary patient, physician and system-level outcomes, including cost savings. This proposed pragmatic trial would break new ground in our understanding of how behavioral economics approaches applied in real-world settings can be used to tamp down on care that does not promote better patient outcomes. If successful, we will have created a tool that can be easily disseminated free of cost to all Epic EHR vendors across the nation to reduce inappropriate testing for the most common surgical procedure in the country.

项目摘要 /摘要 基于强大的随机试验数据，有强烈的共识 - 术前（前）测试 对于白内障手术，患者是不合适的。国家专业协会一再发布指南 自2002年以来，不鼓励测试，但是自1990年代以来，前白内障测试率一直保持不变， 进行预上操作测试的典型示例，即即使在 关于证据有共识。认识到仅证据并不能推动医疗保健决定， 政策制定者和研究团队正在寻找行为经济学领域，以寻找诱导的方法 医生改变其行为。我们假设跨学科电子健康记录（EHR） 在“现实世界”环境中实施的行为经济学干预措施（其中包括所有医生 医疗保健系统，不仅是那些同意参加研究的人）将大大减少前OP 测试白内障手术。我们的跨学科团队包括健康服务研究专业知识， 行为科学，经济学，生物统计学，还包括信息学家，质量改进领导 以及眼科，麻醉学和前医学医学的临床领导者。我们建议测试 我们的假设是通过在UCLA Health进行务实的随机试验中实施干预措施。这 干预将包括两种类型的“午睡”：1）带有新的默认默认式前注模板的警报，并带有订单集 准则； 2）责任辩解的“硬停车”要求，即预上任何非 - 建议的测试必须在图表中写自由文本以证明订单合理。我们将随机进行白内障手术 1年以上的患者（n = 1600）到4种类型的术前访问之一（通常的前护理，轻推＃1，Nudge＃2， 或同时使用2x2阶乘设计来测量和比较每种干预效率的效率。结果 将在12个月的时间内测量，包括接受前测试的患者百分比变化（主要 结果）;以及次要患者，身体和系统级别的结果，包括节省成本。这提出了 务实的试验将使我们了解行为经济学方法如何应用的新基础 在现实世界中，可以使用无法促进更好的患者预后的护理来挖掘护理。如果 成功，我们将创建一个工具，可以轻松地向所有Epic EHR供应商免费传播成本 全国各地减少对该国最常见的外科手术的不适当测试。