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Implementing Patient Decision Aids for Increased Patient Engagement and Reduced Costs

David Arterburn, MD, MPH, describes the Group Health experience in implementing decision aids as part of the shared decision making pathway. David also notes his publication in Health Affairs detailing the results of decision aid implementation.

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Implementing Patient Decision Aids for Increased Patient Engagement and Reduced Costs

  1. 1. Implementing Patient Decision Aids forIncreased Patient Engagement andReduced CostsDavid Arterburn MD, MPHGroup Health Research Institute
  2. 2. 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
  3. 3. Outline• Group Health’s pathway to increased demand for shared decision making (SDM)• Infrastructure to support SDM• How did we create a culture of expectation around SDM and begin to build SDM competencies among providers?• Measurable outcomes• Conclusions and next steps
  4. 4. Group Health’s pathway toshared decision making
  5. 5. 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)
  6. 6. Group Health rates of surgical procedures rising
  7. 7. Shared decision making – the highest legalstandard 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
  8. 8. Infrastructure elements tosupport shared decisionmaking
  9. 9. Twelve preference-sensitive conditions• Orthopedic Surgery • Women’s Health – Hip Osteoarthritis – Uterine Fibroids – Knee Osteoarthritis – Abnormal Uterine Bleeding• Cardiology • Breast Cancer – General Surgery – Coronary Artery Disease – Early Stage Breast Cancer – Breast Reconstruction• Urology – Ductal Carcinoma In Situ – Benign Prostatic Hyperplasia – Prostate Cancer • Neurosurgery – Spinal Stenosis – Herniated Disc
  10. 10. Epic ordering of patient decision aids
  11. 11. EpicCare “smart phrases” for easier documenting ofshared 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.”
  12. 12. Appropriate staffing for implementation and ongoing process improvement Project managers with experience implementing practice changes at Group Health were hired to carry out this work14
  13. 13. Creating a culture of expectationand building competencies forproviders
  14. 14. But I already DO shared decision-making withmy patients… Of course it is totally up to you, but if it was me, I’d choose to have the surgery.
  15. 15. Setting the tone for competency in shared decision making “No patient should undergo a preference sensitive procedure without documented evidence that they“Nice to do got all the informationif you have they needed and thenthe time and Cultural spectrum had a conversation withinclination.” their provider in which their preferences were documented before they made their decision.” GH leaders want to push providers right over here!
  16. 16. 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
  17. 17. Outcomes
  18. 18. Process measure – “defect measure” showsfewer missed opportunities for DA delivery
  19. 19. Comparison of mean costs in 6 months after index date, control vs. intervention Hip Osteoarthritis Cohorts Knee Osteoarthritis Cohorts Control Intervention Control Intervention N=968 N=820 N=4217 N=3510Costs (2009 dollars)Total, Mean $16,557 $13,489 $10,040 $8,041Inpatient $7,793 $5,774 $3,512 $2,475Outpatient $8,764 $7,715 $6,528 $5,565Primary Care $548 $568 $597 $532Pharmacy $4,894 $4,091 $3,219 $2,591Specialty Care $2,497 $1,868 $1,460 $951Orthopedic Surgery $790 $629 $773 $694
  20. 20. Conclusionsand next steps
  21. 21. Shared decision making with decision aids
  22. 22. Next steps for Group Health• Adding more 5-to-7 more decision aids in 2013• Moving decision aid ordering and shared decision making conversations upstream into Primary Care• Automating pre-visit recording of patient knowledge, values, and treatment choices in electronic medical record
  23. 23. Acknowledgements• Funding • GH Implementation• Informed Medical Decisions • Tiffany Nelson Stan Wanezek Foundation • Charity McCollum Jan Collins• The Commonwealth Fund • Andrea Lloyd Scott Birkhead• Health Dialog • Colby Voorhees• Group Health Foundation • GH Research Institute • Emily Westbrook• GH Physician Leadership • Rob Wellman Carolyn Rutter• Michael Soman Marc Mora • Tyler Ross Darren Malais• Paul Sherman Chris Cable • Clarissa Hsu Sylvia Hoffmeyer• Dave McCulloch Matt Handley • David Liss Jane Anau• Charlie Jung Nate Green• Jane Dimer Mark Lowe • External Advisors• JC Leveque Gerald Kent • Jack Wennberg Michael Barry• Paul Fletcher Tom Schaff • Doug Conrad Cindy Watts• Rick Shepard • David Veroff Richard Wexler • Kate Clay Leah Hole-Curry• Public Policy• Karen Merrikin
  • DonnaLINTON1

    Apr. 13, 2017

David Arterburn, MD, MPH, describes the Group Health experience in implementing decision aids as part of the shared decision making pathway. David also notes his publication in Health Affairs detailing the results of decision aid implementation.

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