Presentation on theme: "Large Scale Implementation of Patient Decision Aids in an Integrated Group Practice: the Group Health Experience David Arterburn, MD, MPH Group Health."— Presentation transcript:
1 Large Scale Implementation of Patient Decision Aids in an Integrated Group Practice: the Group Health ExperienceDavid Arterburn, MD, MPHGroup Health Research InstituteMay 25, 2011“University of Washington SDM Conference - Implementing Shared Decision Making: Lessons from the Front”
2 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.
3 Patient-centered care at Group Health Implementationtimeline201120092007Evaluation of decision aids continuesDecision aids for shared decision making2005Medical home pilotWhat 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 implementation3-year research projectGroup 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 useAssess impact on total health care use and costsEstimate ROI from health plan and purchasers’ viewAim 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 OrthopedicsCardiologyUrologyWomen’s healthBreast cancerBack care123456In 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 OrthopedicsCardiologyUrologyHip osteoarthritisKnee osteoarthritisCoronary artery diseaseBenign prostatic hyperplasiaProstate cancerWomen’s HealthBreast CancerBack CareThe decision tools address treatment choices in for 12 preference-sensitive conditions:Orthopedic: hip and knee osteoarthritisCardiac: coronary artery diseaseUrology: benign prostatic hyperplasia and prostate cancerWomen’s health: uterine fibroids and abnormal uterine bleedingBreast cancer: early-stage breast cancer, breast reconstruction, and ductal carcinoma in situBack care: low back pain resulting from spinal stenosis and herniated discGroup Health providers can discuss their patients’ options with the help of booklets, DVDs, and online videos on these topics.Uterine fibroidsAbnormal uterine bleedingEarly stageDuctal carcinoma in situBreast reconstructionSpinal stenosisHerniated 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 LineVideos 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 videosDistributed, by monthTotal 10, 700
21 Fewer missed opportunities Percentage of procedures for preference sensitive conditions where patient did not receive the videoPreference sensitive conditions: Hips, back, knee, hysterectomy, benign prostatectomy; data from Group Practice21
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 responsesHelped you understand the treatment choicesHelped you prepare to talk with provider
24 Patient assessment Overall rating of decision aid videos Patient survey, September 2010, 975 responsesHow important is it that providers make programs like this available?
25 Patient assessment Rating of decision aid videos, by topic Helped understand treatment choicesHelped prepare to talk with providerHow important that providers make programs like this availableRating of decision aid videos, by topicSeptember 2010Excellent or very goodExtremely or very importantPercent 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 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).
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.