I m p l e m e n t a t i o n o f S h a r e d D e c i s i o n M a k i n g : M e a s u r i n g S u c c e s s
Aligning Incenti...
Implementing Shared Decision Making
in Primary Care
_____________________________________________
Barriers, Solutions, and...
We Evaluated a Demonstration of Shared
Decision Making
3
• 8 sites containing 34 primary care clinics
- Selected for prior...
Objectives of Evaluation
1. Identify barriers and facilitators to
implementing shared decision
making in primary care sett...
Semi-Structured Interviews
5
• 23 leaders and clinicians from all demonstration
sites
• 10 patients from 1 site who had ea...
Key Steps of Shared Decision Making Based
on Decision Aids
Decision
opportunity
identification
Opportunity
recognized
DA m...
Barriers to Shared Decision Making
7
• Overworked physicians do not recognize decision
opportunities and distribute decisi...
Barriers to Shared Decision Making
8
• Overworked physicians do not recognize decision
opportunities and distribute decisi...
Barriers to Shared Decision Making
9
• Overworked physicians do not recognize decision
opportunities and distribute decisi...
Solutions Sites Employed
10
• Automatic triggers for decision aid distribution
-Trigger on patient age and gender (for scr...
Measuring the Successfulness of
Implementing Shared Decision Making
11
• Process measures should capture all steps of
shar...
Vulnerability in Later Steps of
Shared Decision Making
Decision
opportunity
identification
Opportunity
recognized
DA match...
Measuring the Successfulness of
Implementing Shared Decision Making
13
• Process measures should capture all steps of
shar...
Measuring the Successfulness of
Implementing Shared Decision Making
14
• Process measures should capture all steps of
shar...
Implications
15
• Achieving shared decision making will require “new
operating systems” for primary care practices
- Major...
Thank you
16
Mark Friedberg, MD, MPP
mfriedbe@rand.org
Implementing Patient Decision Aids for
Increased Patient Engagement and
Reduced Costs
David Arterburn MD, MPH
Group Health...
Financial disclosure
• I have received research funding and salary support from the
Informed Medical Decisions Foundation
...
What is Group Health?
• Group Health is a consumer-governed, non-profit
health system that integrates care and coverage fo...
Outline
1. What was Group Health’s pathway to large-scale implementation
of Shared Decision Making?
2. What infrastructure...
Group Health’s pathway to
shared decision making
Group Health rates of surgical procedures rising
Shared decision making – the highest legal
standard in Washington state
• 2007 Washington state legislation:
– Recognized ...
Infrastructure elements to
support shared decision
making
Twelve preference-sensitive conditions
• Orthopedic Surgery
– Hip Osteoarthritis
– Knee Osteoarthritis
• Cardiology
– Coro...
Epic ordering of patient decision aids
EpicCare “smart phrases” for easier documenting of
shared decision making conversations
• Before Decision Aid Viewing
“The...
Appropriate staffing for implementation and
ongoing process improvement
30
Project managers with experience implementing
p...
Creating a culture of expectation
and building competencies for
providers
But I already DO shared decision-making with
my patients…
Of course it is totally
up to you, but if it was
me, I’d choose ...
Setting the tone for competency in shared
decision making
“Nice to do
if you have
the time and
inclination.”
“No patient
s...
Key culture change steps
• Required all providers to watch the relevant decision aids
• ½-day CME with outside experts tra...
Outcomes
Process measure – “defect measure” shows
fewer missed opportunities for DA delivery
Comparison of mean costs in 6 months
after index date, control vs. intervention
Hip Osteoarthritis Cohorts
Control
N=968
I...
Our next steps optimize
Shared Decision Making
Adding new decision aids
• Already implemented:
– Acute Low Back Pain
– Chronic Low Back Pain
– Weight Loss Surgery
• Plan...
Moving “upstream” into Primary Care
Four primary care clinics began Jan 2013 (system-wide by Dec 2013)
– Two in Spokane; O...
Creating EpicCare based tools to support SDM
Implementing Feed Forward Questionnaires
• Implementing standardized measures of patient symptoms, prior
treatment, knowle...
Conclusions
Shared decision making with decision aids
Acknowledgements
• Funding
• Informed Medical Decisions
Foundation
• The Commonwealth Fund
• Health Dialog
• Group Health ...
Implementation of Shared Decision
Making: Measuring Success
Results of a large scale randomized trial
testing two levels o...
Background
Important deficits in patient
participation in decisions about
their care.
Shared Decision Making improves
care...
Previously published study
Largest study of population
care management to date
 Collaboration between Health Dialog
and t...
Structured stratified random sampling
Predictive models and real time data were used to assess the likelihood of
using or ...
EnhancedSupportUsualSupportEnhancedSupport
Difference driven by who was targeted for engagement
Enhanced support versus
us...
Based on original randomized trial
• Baseline data on the 60,185 identified as potential candidates for
Shared Decision Ma...
Outreach activity
0
200
400
600
800
1000
Any PSC Heart ConditionBenign Uterine CondBenign Prostatic Cond Hip Pain Knee Pai...
Cost and utilization
Usual
Support
Enhanced
Support
Relative
diff (%)
Absolute
diff
Number 30,240 29,945
Costs
Total medic...
Implications
Lower overall costs speaks to the power of SDM well
beyond surgical decisions
When physician adoption comes s...
Implementation of Shared Decision Making: Measuring Success
Implementation of Shared Decision Making: Measuring Success
Implementation of Shared Decision Making: Measuring Success
Implementation of Shared Decision Making: Measuring Success
Implementation of Shared Decision Making: Measuring Success
Implementation of Shared Decision Making: Measuring Success
Implementation of Shared Decision Making: Measuring Success
Implementation of Shared Decision Making: Measuring Success
Implementation of Shared Decision Making: Measuring Success
Implementation of Shared Decision Making: Measuring Success
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Implementation of Shared Decision Making: Measuring Success

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Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making
May 24, 2013

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  • Patient satisfaction and overall rating of decision aid videos:(from 2,156 respondents)Helped me understand my treatment choices:25% Excellent48% Very good23% Good
  • Patient satisfaction and overall rating of decision aid videos:(from 2,139 respondents)Helped me prepare to talk with my provider:24% Excellent47% Very good24% Good
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  • Implementation of Shared Decision Making: Measuring Success

    1. 1. I m p l e m e n t a t i o n o f S h a r e d D e c i s i o n M a k i n g : M e a s u r i n g S u c c e s s Aligning Incentives for Patient Engagement May 24, 2013
    2. 2. Implementing Shared Decision Making in Primary Care _____________________________________________ Barriers, Solutions, and Measurement Mark W. Friedberg, MD, MPP1 Kristin Van Busum, MPA1 Richard Wexler, MD2 Megan Bowen2 Eric C. Schneider, MD, MSc1 1RAND Corporation 2Informed Medical Decisions Foundation Sponsor: Informed Medical Decisions Foundation
    3. 3. We Evaluated a Demonstration of Shared Decision Making 3 • 8 sites containing 34 primary care clinics - Selected for prior quality improvement experience - Some without prior decision aid experience • July 2009-June 2012 • Sponsored by the Informed Medical Decisions Foundation - Free decision aids - Technical assistance - Learning collaborative • Qualitative evaluation at 18 months
    4. 4. Objectives of Evaluation 1. Identify barriers and facilitators to implementing shared decision making in primary care settings 2. Develop options for near-term quantitative evaluation 4
    5. 5. Semi-Structured Interviews 5 • 23 leaders and clinicians from all demonstration sites • 10 patients from 1 site who had each received a decision aid during the demonstration • Protocol investigated facilitators and barriers to: -Engaging clinicians -Integrating decision aids into key operational tasks • Interview responses analyzed inductively for recurrent themes
    6. 6. Key Steps of Shared Decision Making Based on Decision Aids Decision opportunity identification Opportunity recognized DA matched to opportunity Decision aid use DA distributed Patient uses DA Post-DA conversation Clarify medical information Elicit values and preferences Make shared decision Health care delivery Care consistent with final shared decision
    7. 7. Barriers to Shared Decision Making 7 • Overworked physicians do not recognize decision opportunities and distribute decision aids reliably “Patients come in and doctors are seeing them for four or five different problems. And then they have to remember if there is a decision aid for each particular decision.” “We hear physicians say…I seem to be the problem here, how do I get myself out of the loop so we can get [the decision aids] to people that need to get them?” “In the real world . . I’m not sure we can expect the physicians to identify patients.”
    8. 8. Barriers to Shared Decision Making 8 • Overworked physicians do not recognize decision opportunities and distribute decision aids reliably • Insufficient provider training -Recognizing decision opportunities and having post-decision aid conversations are skills providers must learn “Physicians felt that they were already doing shared decision making [before introducing decision aids].” “You really have to pay attention to the clinicians in this equation. You can’t just ask them to do something and assume that they’ll know what you mean…we under-attended the training of our clinicians.”
    9. 9. Barriers to Shared Decision Making 9 • Overworked physicians do not recognize decision opportunities and distribute decision aids reliably • Insufficient provider training • Inadequate clinical information systems -Not able to track the full sequence of steps involved in shared decision making -Not able to integrate with decision aids “All of the information from the [decision aid questionnaires] is off the chart. There is documentation that a decision aid was given…but anything from the surveys is kept completely separate.”
    10. 10. Solutions Sites Employed 10 • Automatic triggers for decision aid distribution -Trigger on patient age and gender (for screening) -Trigger on specialist referrals (for surgical procedures) Relative greater focus of specialist visits may facilitate more reliable performance of post-decision aid conversation • Engage team members other than physicians -Example: “decision coach” to introduce the decision aid Patient: “When you’re with the doctor, you don’t get a chance to ask a lot of questions. …A nurse I had never met [before] came in and introduced me to [the decision aid]. She had a CD and a book about the surgery. …Of course I was interested in that.”
    11. 11. Measuring the Successfulness of Implementing Shared Decision Making 11 • Process measures should capture all steps of shared decision making - “All-or-none” measures may be appropriate
    12. 12. Vulnerability in Later Steps of Shared Decision Making Decision opportunity identification Opportunity recognized DA matched to opportunity Decision aid use DA distributed Patient uses DA Post-DA conversation Clarify medical information Elicit values and preferences Make shared decision Health care delivery Care consistent with final shared decision Rate-limiting steps = targets for measurement
    13. 13. Measuring the Successfulness of Implementing Shared Decision Making 13 • Process measures should capture all steps of shared decision making - “All-or-none” measures may be appropriate • Measures of decision quality - In the end, was care consistent with the patient’s values and preferences?
    14. 14. Measuring the Successfulness of Implementing Shared Decision Making 14 • Process measures should capture all steps of shared decision making - “All-or-none” measures may be appropriate • Measures of decision quality - In the end, was care consistent with the patient’s values and preferences? • Indirect measures of shared decision making performance - In theory, shared decision making should produce variability that is driven entirely by patients, not providers - If each provider in an organization has a PSA screening rate of 100% or 0%, the organization is unlikely to have implemented shared decision making successfully
    15. 15. Implications 15 • Achieving shared decision making will require “new operating systems” for primary care practices - Major investments in developing and improving educational, operational, and informatics systems - Payment reform may be necessary • Key issue for policy makers: How high to set the bar for deciding what counts as “engagement” in shared decision making - Lower bar: count or rate of decision aid distribution - Higher bar: all-or-none process measures including all steps of shared decision making
    16. 16. Thank you 16 Mark Friedberg, MD, MPP mfriedbe@rand.org
    17. 17. Implementing Patient Decision Aids for Increased Patient Engagement and Reduced Costs David Arterburn MD, MPH Group Health Research Institute
    18. 18. Financial disclosure • I have received research funding and salary support from the Informed Medical Decisions Foundation • I serve as a Medical Editor for the Informed Medical Decisions Foundation in the area of bariatric surgery
    19. 19. What is Group Health? • Group Health is a consumer-governed, non-profit health system that integrates care and coverage for over 600,000 residents of Washington state and Northern Idaho (1 in 10 Washington residents) • Two-thirds of our members get most of their care within our Integrated Group Practice from salaried Group Health providers
    20. 20. Outline 1. What was Group Health’s pathway to large-scale implementation of Shared Decision Making? 2. What infrastructure elements did Group Health put in place to support Shared Decision Making? 3. What did Group Health leadership do to create a culture of expectation around Shared Decision Making and begin to build competencies among providers? 4. What outcomes have we observed? 5. What steps are we taking now to optimize Shared Decision Making at Group Health?
    21. 21. Group Health’s pathway to shared decision making
    22. 22. Group Health rates of surgical procedures rising
    23. 23. Shared decision making – the highest legal standard in Washington state • 2007 Washington state legislation: – Recognized the use of shared decision making along with high-quality patient decision aids as the highest standard of informed consent – Mandated, but did not fund, the state Health Care Authority (HCA) to implement shared decision making demonstration projects • 2012 Washington state legislation: – Authorized the WA state HCA to certify high-quality decision aids
    24. 24. Infrastructure elements to support shared decision making
    25. 25. Twelve preference-sensitive conditions • Orthopedic Surgery – Hip Osteoarthritis – Knee Osteoarthritis • Cardiology – Coronary Artery Disease • Urology – Benign Prostatic Hyperplasia – Prostate Cancer • Women’s Health – Uterine Fibroids – Abnormal Uterine Bleeding • Breast Cancer – General Surgery – Early Stage Breast Cancer – Breast Reconstruction – Ductal Carcinoma In Situ • Neurosurgery – Spinal Stenosis – Herniated Disc
    26. 26. Epic ordering of patient decision aids
    27. 27. EpicCare “smart phrases” for easier documenting of shared decision making conversations • Before Decision Aid Viewing “The patient and I engaged in a shared decision making conversation. I recommended that the patient review a Health Dialog decision aid and make an appointment with me to finalize a treatment plan.” • After Decision Aid Viewing “The patient and I engaged in a shared decision making conversation. The patient had previously reviewed the Health Dialog patient decision aid. We discussed the content of the decision aid, clarified the patient’s treatment preferences, and I answered the patient’s questions. We agreed to the following treatment/services(s): *** and ***. The patient signed the applicable consent form.”
    28. 28. Appropriate staffing for implementation and ongoing process improvement 30 Project managers with experience implementing practice changes at Group Health were hired to carry out this work
    29. 29. Creating a culture of expectation and building competencies for providers
    30. 30. But I already DO shared decision-making with my patients… Of course it is totally up to you, but if it was me, I’d choose to have the surgery.
    31. 31. Setting the tone for competency in shared decision making “Nice to do if you have the time and inclination.” “No patient should undergo a preference sensitive procedure without documented evidence that they got all the information they needed and then had a conversation with their provider in which their preferences were documented before they made their decision.” Cultural spectrum GH leaders want to push providers right over here!
    32. 32. Key culture change steps • Required all providers to watch the relevant decision aids • ½-day CME with outside experts trained 90% of our specialty providers and surgeons • Monthly feedback to leaders and providers – Volume of decision aids ordered – Volume of surgical procedures and total costs of surgical procedures – Number and percent of surgical patients in each specialty who had surgery without receiving a decision aid • Patient satisfaction data related to decision aid use
    33. 33. Outcomes
    34. 34. Process measure – “defect measure” shows fewer missed opportunities for DA delivery
    35. 35. Comparison of mean costs in 6 months after index date, control vs. intervention Hip Osteoarthritis Cohorts Control N=968 Intervention N=820 Costs (2009 dollars) Total, Mean $16,557 $13,489 Inpatient $7,793 $5,774 Outpatient $8,764 $7,715 Primary Care $548 $568 Pharmacy $4,894 $4,091 Specialty Care $2,497 $1,868 Orthopedic Surgery $790 $629 Knee Osteoarthritis Cohorts Control N=4217 Intervention N=3510 $10,040 $8,041 $3,512 $2,475 $6,528 $5,565 $597 $532 $3,219 $2,591 $1,460 $951 $773 $694
    36. 36. Our next steps optimize Shared Decision Making
    37. 37. Adding new decision aids • Already implemented: – Acute Low Back Pain – Chronic Low Back Pain – Weight Loss Surgery • Planned: – End of Life Care – End Stage Renal Disease Treatment Options – Maternity Suite (Suspected Macrosomia, Elective Induction, and Vaginal Birth After Cesearian)
    38. 38. Moving “upstream” into Primary Care Four primary care clinics began Jan 2013 (system-wide by Dec 2013) – Two in Spokane; One each in Olympia and north Seattle Any patient diagnosed with a condition where we have a decision aid - Primary care provider lets know that there is a decision aid that they want them to watch to understand the risk/benefits of treatment choices - Ask patient their preference for viewing video: Online or having DVD mailed to them. - Let patient know you’ll have a follow up conversation once they’ve viewed it Follow up conversation – Have discussion via email or by phone – Review their knowledge, ask for questions/concerns, ask for their preference regarding treatment choice; consider need for referral
    39. 39. Creating EpicCare based tools to support SDM
    40. 40. Implementing Feed Forward Questionnaires • Implementing standardized measures of patient symptoms, prior treatment, knowledge, values, and treatment preferences • Patients will be prompted to complete the questionnaires online after viewing a decision aid and before their next visit • Questionnaire results summary will be imported into Epic as either an “encounter”, a “flowsheet”, or both • Provider can review results at the point of care
    41. 41. Conclusions
    42. 42. Shared decision making with decision aids
    43. 43. Acknowledgements • Funding • Informed Medical Decisions Foundation • The Commonwealth Fund • Health Dialog • Group Health Foundation • GH Physician Leadership • Michael Soman Marc Mora • Paul Sherman Chris Cable • Dave McCulloch Matt Handley • Charlie Jung Nate Green • Jane Dimer Mark Lowe • JC Leveque Gerald Kent • Paul Fletcher Tom Schaff • Rick Shepard • Public Policy • Karen Merrikin • GH Implementation • Tiffany Nelson Stan Wanezek • Charity McCollum Jan Collins • Andrea Lloyd Scott Birkhead • Colby Voorhees • GH Research Institute • Emily Westbrook • Rob Wellman Carolyn Rutter • Tyler Ross Darren Malais • Clarissa Hsu Sylvia Hoffmeyer • David Liss Jane Anau • External Advisors • Jack Wennberg Michael Barry • Doug Conrad Cindy Watts • David Veroff Richard Wexler • Kate Clay Leah Hole-Curry
    44. 44. Implementation of Shared Decision Making: Measuring Success Results of a large scale randomized trial testing two levels of shared decision making support
    45. 45. Background Important deficits in patient participation in decisions about their care. Shared Decision Making improves care and patient experiences Conducted a randomized trial comparing two levels of telephonic support for people with conditions that involve multiple treatment options
    46. 46. Previously published study Largest study of population care management to date  Collaboration between Health Dialog and two clients  Randomized study of 174,120 individuals  Compared medical costs and utilization of two different care support strategies Overall results:  Total costs reduced by over 3.6%  Total population admissions reduced by 10.1%
    47. 47. Structured stratified random sampling Predictive models and real time data were used to assess the likelihood of using or needing health care services Rank-order lists of individuals likely to have support needs were used to generate:  Outbound mail  Interactive voice response calls  Calls by health coaches Study Design
    48. 48. EnhancedSupportUsualSupportEnhancedSupport Difference driven by who was targeted for engagement Enhanced support versus usual support High Risk Low Risk Health Continuum Chronic Preference Sensitive Care Other High Risk Healthy Focus on Preference Sensitive Conditions N = 60,185
    49. 49. Based on original randomized trial • Baseline data on the 60,185 identified as potential candidates for Shared Decision Making Preference Sensitive Focus Usual Support Enhanced Support Number 30,240 29,945 Costs Total medical costs (PMPM) $371.92 $371.73 Inpatient costs (PMPM) $106.77 $106.05 Resource Use Inpatient admissions (per 1,000/yr) 131 129 Emergency department (per 1,000/yr) 377 379 Surgeries for PSC (per 1,000/yr) 32 30 Advanced imaging studies (per 1,000/yr) 372 382 Standard imaging studies (per 1,000/yr) 1,396 1,394
    50. 50. Outreach activity 0 200 400 600 800 1000 Any PSC Heart ConditionBenign Uterine CondBenign Prostatic Cond Hip Pain Knee Pain Back Pain Coach Contacts Usual Enhanced 0 10 20 30 40 50 60 70 Any PSC Heart ConditionBenign Uterine CondBenign Prostatic Cond Hip Pain Knee Pain Back Pain Videos Sent Usual Enhanced
    51. 51. Cost and utilization Usual Support Enhanced Support Relative diff (%) Absolute diff Number 30,240 29,945 Costs Total medical costs (PMPM) $436.05 $412.78 (5.3%) ($23.27) Inpatient costs (PMPM) $132.73 $116.20 (12.5%) ($16.53) Outpatient costs (PMPM) $96.91 $92.49 (4.6%) ($4.42) Resource Use (per 1,000/yr) Inpatient admissions (per 1,000/yr) 155 135 (12.5%) (20) Emergency department (per 1,000/yr) 409 399 (2.6%) (10) Surgeries for PSC (per 1,000/yr) 32 29 (9.9%) (3) Advanced imaging studies (per 1,000/yr) 400 393 (1.9%) (7) Standard imaging studies (per 1,000/yr) 1,488 1,458 (2.0%) (30)
    52. 52. Implications Lower overall costs speaks to the power of SDM well beyond surgical decisions When physician adoption comes slowly, independent telephonic support model can get the process started and can be effective

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