In shared decision making, a doctor shares with his or her patient all relevant information on the possible risks and benefits of detection and treatment options for a particular health condition. And the patient considers what might make him or her prefer or tolerate one treatment, side effect, or outcome more or less than others. Then, in conversations with their doctors, patients clarify their preferences, weigh their options, and make the choice that’s right for them. The goal of shared decision making is to reduce the imbalance in information between the provider and patient when health care decisions are being made. It is not to encourage patients to select any particular treatment option.
The process is especially useful for health conditions where there is more than one treatment option, each treatment option has different pros and cons—and there’s little evidence to say one choice is better than another. In these situations, an individual patient’s own preferences regarding the risks and benefits of the various treatment options should guide their decision. Such “preference-sensitive” treatment situations are common in clinical “gray areas,” including, for example, treatment for low back pain, osteoarthritis in the knees and hips, prostate cancer, or early-stage breast cancer.
Many doctors offer their patients decision aids, such as brochures, DVDs, and online applications, which can help to educate and guide a patient through complex decision making tasks, such as deciding whether or not to have elective surgery or cancer screening. Decision aids are sources of information about a patient’s health condition and the various treatment options including their risks and benefits, and they help facilitate high-quality shared decision making between patients and providers. Patient decision aids do not advise people to choose one option over another, nor are they meant to replace provider consultation. Instead, they prepare patients to make informed, values-based decisions with their provider.
Decision aids have the following characteristics: Evidence-based, frequently updated, and balanced presentations of the treatment options Helpful to patients in clarifying their values and preferences Useful for guiding patients in deliberation and in communication with their doctors
What’s the current evidence regarding the outcomes of using decision aids such as brochures, DVDs, and online tools? A systematic review of 34 randomized controlled trials revealed strong evidence that decision tools can improve the quality of patients’ decisions in these ways: Increased knowledge More active participation in the decision Less feeling of conflict over the decision and a lower proportion of people who remain undecided Better alignment between values and choices More satisfaction with the decision But the impact of patient decision tools on health care utilization, costs, and health outcomes is not so clear. Available evidence from seven randomized controlled trials suggests that decision aids may reduce the proportion who choose to undergo elective surgical procedures. In these seven studies, the rates of use of the most invasive surgical procedures declined by 23% in favor of more conservative surgical or medical options. There was no evidence of harms from missed opportunities for surgical procedures. Two key studies of patient decision aids were performed at Group Health. The first (1995) assessed the impact of a video-based patient decision aid for benign prostatic hyperplasia versus an informational booklet among 227 men with that condition. Patients randomized to the decision aid had significantly better knowledge of their condition and satisfaction with the decision-making process, and overall they chose prostatectomy 26 percent less often. The second study (2000) assessed the impact of a video-based patient decision aid versus a booklet among 393 participants considering elective back surgery. Among patients with lumbar herniated discs, the decision aid group had a 22% lower rate of low back surgery than the control group, and both groups had similar symptomatic and functional outcomes. More research is needed to confirm findings regarding use of shared decision making aids in larger populations and to determine if the related changes in health care translate into cost savings while not diminishing long-term health outcomes. Group Health is currently conducting research on patient decision aids to help answer these questions.
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.
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.
In January 2009, Group Health began making shared decision aids systematically available to patients related to elective surgical procedures in 6 specialty areas.
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.
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.
Provider’s ability to order the DVDs via Epic facilitates usage. This screen shot shows how the DVD order looks in Epic.
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.
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
The figure shows the total volume of DAs delivered at GH since January 19, 2009. As of December 31, 2010, we had distributed a total of 8,808 DAs. Because of changes in our data systems in November 2009, we don’t have data aggregated on DAs viewed through the web from 11/09-12/10; but, the new data system issues were resolved as of 9/9/10 so those data are available to us for our main research analyses. Through November 2009, approximately 80% of the DAs were distributed in DVD format via mail, and 20% were viewed on the web. The figure shows that our delivery of DAs had been generally stable until June 2010 when we experienced a dramatic increase in DA ordering volume. This increase follows behind a series of day-long process improvement workshops that were held with Orthopedics, Women’s Health, Urology, and Neurosurgery in May 2010. The Orthopedic service line continues to lead the way among all specialties in distribution of the DAs, and they distribute about 300 DAs per month (200 knee osteoarthritis; 100 hip osteoarthritis). They are followed by Women’s Health (100-110 DAs per month) and Urology (60-80 DAs per month).
Preference sensitive conditions: Hips, back, knee, hysterectomy, benign prostatectomy ; data from Group Practice
Shared Decision Making
Shared Decision Making Moderator: David McCulloch, MD Panel: Chris Cable, MD Jenny Fry, LPN Charlie Jung, MD Diana Leback, RN, MS
What is shared decision making? Together they make a decision Patients consider options Doctors share information
When is shared decision making most useful? More than one treatment option “ Preference sensitive” conditions Little evidence for one choice over another
What are decision aids? Brochures, DVDs, web tools Resources that help patients make informed decisions with their providers Information about a patient’s health condition Treatment options, risks & benefits
What are the characteristics of decision aids? Evidence-based, frequently updated, balanced Help patients clarify values & preferences Guide patients in communication with doctors
Evidence for using decision aids <ul><ul><li>Increased knowledge </li></ul></ul><ul><ul><li>More active patient participation </li></ul></ul><ul><ul><li>Better alignment between values & choices </li></ul></ul>34 randomized controlled trials <ul><ul><li>Lower surgery rates </li></ul></ul><ul><ul><li>No evidence of harms from not having surgery </li></ul></ul>7 randomized controlled trials <ul><ul><li>Higher patient knowledge & satisfaction </li></ul></ul><ul><ul><li>Lower surgery rates with similar outcomes </li></ul></ul>2 Group Health studies
Research System-wide implementation 2-year research project Foundation support
Patient-centered care at Group Health Shared electronic medical record Medical home pilot Decision aids for shared decision making 2005 2007 2009 Implementation timeline 2011 Evaluation of decision aids continues
Treatment choices in 6 specialty areas Orthopedics Cardiology Urology Women’s health Breast cancer Back care 1 2 3 4 5 6
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 Assess process barriers and facilitators
12 preference-sensitive conditions <ul><li>Hip osteoarthritis </li></ul><ul><li>Knee osteoarthritis </li></ul><ul><li>Coronary artery disease </li></ul><ul><li>Benign prostatic hyperplasia </li></ul><ul><li>Prostate cancer </li></ul><ul><li>Uterine fibroids </li></ul><ul><li>Abnormal uterine bleeding </li></ul><ul><li>Spinal stenosis </li></ul><ul><li>Herniated disc </li></ul><ul><li>Early stage </li></ul><ul><li>Ductal carcinoma in situ </li></ul><ul><li>Breast reconstruction </li></ul>Orthopedics Cardiology Urology Women’s Health Breast Cancer Back Care
What are we learning about use of decision aids at Group Health?
Distributing decision aids DVDs can be ordered for mailing or viewed on the Web
Evaluation Ordering & viewing Provider interviews Patient survey link
Decision aid distribution Number of videos distributed, by month Total: 8,808* *As of 12/31/2010; does not include decision aids viewed on the web after Oct 2009 Jan Apr Jul Oct Jan Apr Jul Oct 2009 2010
Decision aid distribution in Ortho Implementation of PDP work
2009 2010 Percentage of procedures for preference sensitive conditions where patient did not receive the video Fewer missed opportunities
Overall rating of decision aid videos Patient 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 videos Patient survey, September 2010, 975 responses How important is it that providers make programs like this available?
Patient assessment Rating of decision aid videos, by topic September 2010 Helped 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 important Percent of patients rating:
Problems/issues/things to improve…? <ul><li>Getting the right patient at the right time. </li></ul><ul><li>Knowing that the patient watched the DA. </li></ul><ul><li>Knowing that a follow-up conversation took place. </li></ul><ul><li>Tracking which patients watched the DA and decided NOT to have surgery at this time. </li></ul><ul><li>Getting follow-up with patients at 12mo+ to check if they were happy with their decision. </li></ul>