Large Scale Implementation of Patient Decision Aids in an Integrated Group Practice: the Group Health Experience

David Arterburn, MD, MPHGroup Health Research InstituteMay 25, 2011

“University of Washington SDM Conference - Implementing Shared Decision Making: Lessons from the Front”

About Group HealthGroup Health is an integrated health plan

and care delivery system that provides medical coverage and care to more than 674,900 residents in Washington state and North Idaho.

Nearly two-thirds of members receive care in Group Health-owned/operated medical facilities from Group Health-salaried providers.

Patient-centered care at Group Health

Shared electronic medical record

Medical home pilot

Decision aids for shared decision making

20052005

20072007

20092009

Implementationtimeline 20112011

Evaluation of decision aids continues

Shared decision making research

System-wide implementation

3-year research project

Foundation support

Primary aims of the evaluation

Assess impact on surgery useAssess impact on surgery use

Assess impact on total health care use and costs

Assess impact on total health care use and costs

Estimate ROI from health plan and purchasers’ viewEstimate ROI from health plan and purchasers’ view

Assess process barriers and facilitators

Assess process barriers and facilitators

How did we implement decision aids at Group Health?

Treatment choices in 6 specialty areas

OrthopedicsOrthopedics

CardiologyCardiology

UrologyUrology

Women’s healthWomen’s health

Breast cancerBreast cancer

Back careBack care

1

2

3

4

5

6

12 preference-sensitive conditions

Orthopedics Cardiology Urology

Women’s Health

Breast Cancer Back Care

1. Hip osteoarthritis

2. Knee osteoarthritis

3. Coronary artery disease

4. Benign prostatic hyperplasia

5. Prostate cancer

6. Uterine fibroids

7. Abnormal uterine bleeding

11. Spinal stenosis

12. Herniated disc

8. Early stage9. Ductal

carcinoma in situ

10. Breast reconstruction

Providers can order DAs through Epic

Patient portal access

DVDs can be viewed on the

Web

What have we learned about the use of decision aids at Group Health?

Evaluation

Ordering & viewingOrdering & viewing

Provider interviewsProvider interviews

Patient survey link

Patient survey link

Decision aid distribution (4/11)

Number of videosDistributed, by monthTotal 10, 700

Decision aid distribution (4/11)

Decision aid distribution in Ortho0

100

200

300

Vid

eos

Jan 09 Jul 09 Jan 10 Jul 10 Jan 11Month

Hip Osteoarthritis Knee Osteoarthritis

Orthopedics: Service Line Video Distribution

DA distribution in Women’s Health0

2040

60V

ideo

s

Jan 09 Jul 09 Jan 10 Jul 10 Jan 11Month

Uterine Fibroids Uterine Bleeding

Women's Health: Service Line Video Distribution

DA distribution in Urology0

2040

6080

Vid

eos

Jan 09 Jul 09 Jan 10 Jul 10 Jan 11Month

Enlarged Prostate (BPH) Prostate Cancer

Urology: Service Line Video Distribution

DA distribution for Cardiology0

2040

60V

ideo

s

Jan 09 Jul 09 Jan 10 Jul 10 Jan 11Month

Cardiology: Coronary Artery DiseaseVideo Distribution

DA distribution for Gen Surgery0

510

1520

Vid

eos

Jan 09 Jul 09 Jan 10 Jul 10 Jan 11Month

Early Stage Breast Cancer Breast Reconstruction

DCIS

General Surgery: Service Line Video Distribution

DA distribution for Neurosurgery0

2040

6080

Vid

eos

Jan 09 Jul 09 Jan 10 Jul 10 Jan 11Month

Spinal Stenosis Herniated Disc

Neurosurgery: Service Line Video Distribution

Percentage of procedures for preference sensitive conditions where patient did not receive the video

Fewer missed opportunities

Provider perspectives “It’s almost like you can’t give them too much information. You know? When it

really comes down to it, you need to give people enough information so that they sort of really understand the impact of the decision and all the implications and not just the surgeon’s view.” ~Orthopedics MD

“I don’t have any problem with any kinds of information given to any patients at any time. The more information a patient has, the easier it is for me. Even if it’s wrong, because then they can ask me intelligent questions.” ~Cardio MD

“It’s complicated because you don’t have all the clinical data that you need to make a decision until you’ve taken the angiogram. And there is a strong incentive to deal with it right after you’ve done the angiogram. So, the incentives being: it’s more efficient, it’s more comfortable for the patient, and… if you ask them the question, “Do you want us to just do what we think is best or do you want us to stop and then we can have plenty of time to talk it over later,” they nearly always will tell you, “No, just do what you think is best.” That’s the clear majority view in this.” ~Cardiology MD

“Some patients seem to really appreciate them. Some patients seem really scared after watching the DA and some of the material on there...It really does increase the time I’m spending with them, almost uniformly… It doesn’t save any time at all. And it’s making me run late having to address all the issues the patient has after watching the DA.” ~General Surgery MD

Overall rating of decision aid videosPatient survey, September2010, 950 responses

Helped you understand the treatment choices

Helped you prepare to talk with provider

Patient assessment

Patient assessment

Overall rating of decision aid videosPatient survey, September 2010, 975 responses

How important is it that providers make programs like this available?

Rating of decision aid videos, by topicSeptember 2010

Patient assessmentHelped understand treatment choices

Helped prepare to talk with provider

How important that providers make programs like this available

Excellent or very good Extremely or very importantPercent of patients rating:

Barriers & FacilitatorsEngaging providers in establishing the implementation

processes is important for buy-in.Overall, the amount of time spent by providers talking

to patients has not changedChanging providers’ practice regarding how they talk

with patients about health care choices and personal values needs to be actively cultivated.

Having a mechanism for pre-visit ordering increases distribution of the DAs and allows for efficient follow up conversations about treatment choices with patients.

Using DAs for conditions that are perceived by patients and/or providers as life threatening is more difficult to implement (e.g., DA for coronary artery disease).

Problems/issues/things to improve…?

Getting the right patient at the right time.Knowing that the patient watched the DA.Knowing that a follow-up conversation took

place.Tracking which patients watched the DA and

decided NOT to have surgery at this time.Getting follow-up with patients at 12mo+ to

check if they were happy with their decision.

Questions?