1. Large Scale Implementation of Patient Decision Aids in an Integrated Group Practice: the Group Health Experience
David Arterburn, MD, MPH
Group Health Research Institute
May 25, 2011
“University of Washington SDM Conference - Implementing Shared Decision Making: Lessons from the Front”

2. About Group Health
Group 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.

3. Patient-centered care at Group Health
Implementation
timeline
2011
2009
2007
Evaluation of decision aids continues
Decision aids for shared decision making
2005
Medical home pilot
What is Group Health’s role in shared decision making?
Group Health has a long history of commitment to patient-centered care. This is most recently shown by its early adoption of shared electronic medical records and current promotion of the medical home model of primary care. Shared decision making is an integral part of these initiatives.
Shared electronic medical record

4. Shared decision making research
System-wide implementation
3-year research project
Group Health (GH) is currently undertaking a system-wide implementation of shared decision making (SDM) with video-based patient decision aids (DA) for 12 preference-sensitive health conditions related to elective surgical procedures.
Assessment of effectiveness of decision aids is funded by grants from The Commonwealth Fund, the Group Health Foundation and the Foundation for Informed Medical Decision Making. A company called Health Dialog is providing the decision aids to Group Health free of charge.
Foundation support

5. Primary aims of the evaluation
Assess impact on surgery use
Assess impact on total health care use and costs
Estimate ROI from health plan and purchasers’ view
Aim 1: To assess the impact of 12 patient decision aids on the use of related surgical procedures. Compare the overall rates of elective surgery among adults with the 12 preference-sensitive health conditions before and after the implementation of patient decision aids.
Aim 2: To assess the impact of 12 patient decision aids on total health care use and costs. Compare total annual health care use and expenditures among adults with 12 preference-sensitive health conditions in the year before and after the implementation of patient decision aids.
Aim 3: To estimate the return-on-investment of implementing a suite of 12 patient decision aids from the perspectives of the health plan and purchaser. Generate estimates of the total cost of implementing patient decision aids and the total one-year healthcare savings associated with implementing patient decision aids from the perspectives of the health plan and purchaser.
Aim 4: To assess the process, barriers, and facilitators for implementing decision aids with physicians in various practice settings in Group Health. Track the implementation of the decision aid intervention and conduct detailed interviews with providers to examine differences in the implementation process across clinics and service lines, provider and clinic staff understanding, and provider and clinic staff buy-in.
Assess process barriers and facilitators

6. How did we implement decision aids at Group Health?

7. Treatment choices in 6 specialty areas
Orthopedics
Cardiology
Urology
Women’s health
Breast cancer
Back care 1 2 3 4 5 6
In January 2009, Group Health began making shared decision aids systematically available to patients related to elective surgical procedures in 6 specialty areas.

8. 12 preference-sensitive conditions
Orthopedics
Cardiology
Urology
Hip osteoarthritis
Knee osteoarthritis
Coronary artery disease
Benign prostatic hyperplasia
Prostate cancer
Women’s Health
Breast Cancer
Back Care
The decision tools address treatment choices in for 12 preference-sensitive conditions:
Orthopedic: hip and knee osteoarthritis
Cardiac: coronary artery disease
Urology: benign prostatic hyperplasia and prostate cancer
Women’s health: uterine fibroids and abnormal uterine bleeding
Breast cancer: early-stage breast cancer, breast reconstruction, and ductal carcinoma in situ
Back care: low back pain resulting from spinal stenosis and herniated disc
Group Health providers can discuss their patients’ options with the help of booklets, DVDs, and online videos on these topics.
Uterine fibroids
Abnormal uterine bleeding
Early stage
Ductal carcinoma in situ
Breast reconstruction
Spinal stenosis
Herniated disc

9. Providers can order DAs through Epic
Provider’s ability to order the DVDs via Epic facilitates usage. This screen shot shows how the DVD order looks in Epic.

10. Patient portal access DVDs can be viewed on the Web
Patients get access to the videos through MyGroupHealth; they must have full, password-authenticated access to MyGroupHealth to view these videos. There patients can choose the video for their health condition and watch in the privacy of their home or office.
Alternatively, patients can also request to have a DVD copy of the video mailed to their home by calling the Group Health Resource Line
Videos can also be ordered through EPIC for delivery to patients by mail.

11. What have we learned about the use of decision aids at Group Health?11

12. Evaluation Ordering & viewing Provider interviews Patient survey link
Group Health Research Institute is evaluating shared decision making with decision aids using both quantitative and qualitative methods.
Since January 2009, we have been capturing data on all decision aids that are ordered through our electronic medical record, viewed online, requested via telephone from our Resource Line, and handed out in clinical settings. We have completed programming procedures to aggregate data on decision aid ordering and viewing from all sources.
To document the impact of the SDM implementation on providers and staff in our Group Practice Division, our research team is interviewing providers, clinic leaders, SDM implementation team project managers.
Patient satisfaction is assessed through the online survey linked from MyGroupHealth

13. Decision aid distribution (4/11)
Number of videos
Distributed, by month
Total 10, 700

14. Decision aid distribution (4/11)

15. Decision aid distribution in Ortho

16. DA distribution in Women’s Health

17. DA distribution in Urology

18. DA distribution for Cardiology

19. DA distribution for Gen Surgery

20. DA distribution for Neurosurgery

21. Fewer missed opportunities
Percentage of procedures for preference sensitive conditions where patient did not receive the video
Preference sensitive conditions: Hips, back, knee, hysterectomy, benign prostatectomy; data from Group Practice 21

22. 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

23. Patient assessment Overall rating of decision aid videos
Patient survey, September2010, 950 responses
Helped you understand the treatment choices
Helped you prepare to talk with provider

24. Patient assessment Overall rating of decision aid videos
Patient survey, September 2010, 975 responses
How important is it that providers make programs like this available?

25. Patient assessment Rating of decision aid videos, by topic
Helped understand treatment choices
Helped prepare to talk with provider
How important that providers make programs like this available
Rating of decision aid videos, by topic
September 2010
Excellent or very good
Extremely or very important
Percent of patients rating:

26. Barriers & Facilitators
Engaging providers in establishing the implementation processes is important for buy-in.
Overall, the amount of time spent by providers talking to patients has not changed
Changing 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).

27. 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.

28. Questions?