Reducing Low-Value Care: Applying the Intention-Action Framework to Specialty Referrals

Low-value care-services that provide little or no clinical benefit-is a significant problem in the United States. For example, low-value specialty referrals often lead to unnecessary tests, follow-ups, and procedures that burden patients, weaken trust, and reduce access to specialty care for those with greater clinical need.

This study is a six-month, single-site, randomized controlled trial conducted at UCLA Health to evaluate an electronic health record (EHR)-embedded behavioral intervention designed to reduce low-value specialty referrals in cardiology, pulmonology, and gastroenterology. The study focuses on physician decision-making at the point of referral and tests whether structured, real-time decision support can reduce low-value care while maintaining patient safety and access to appropriate specialty services.

The study employs a parallel-arm, randomized design. Physicians are randomized to one of three study arms and will remain in their assigned condition throughout the six-month intervention period. The intervention is delivered automatically within routine clinical workflow.

• Arm 1 - Control: The order composer allows physicians to place referrals with minimal information displayed.
• Arm 2 - Information + Review: The order composer displays criteria for high-value referrals (developed by UCLA Health using professional society guidelines and expert consensus from clinical leadership) and informs physicians that their referral decisions may be reviewed.
• Arm 3 - Information + Review + Checklist: The order composer displays referral criteria and informs physicians that their referral decisions may be reviewed. The order composer also includes cascading checkboxes that prompt physicians to confirm that referral criteria are met before submitting a referral.

The target study population consists of actively practicing UCLA Health physicians who have placed at least one specialty referral to cardiology, pulmonology, or gastroenterology within six months during the baseline period. Randomization will be conducted by the study team prior to trial initiation using a computerized procedure. The study team will generate 100,000 candidate random allocations of providers to one of three study arms in approximately equal proportions. For each candidate allocation, we assess balance across the following five metrics derived from the baseline period: referral volume to each of the three target specialties (cardiology, GI, and pulmonology) during the baseline period, assessed separately for each specialty (using ANOVA F-test p-values); physician's modal target specialty (using chi-square p-values); physician's department group (using chi-square p-values). The top 1% of allocations achieving the best simultaneous balance across all five metrics (maximin criterion) are retained, and the final allocation is selected at random from this set.