Large Scale Implementation of Patient Decision Aids in an Integrated Group Practice: the Group Health Experience

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 Shared electronic medical record

4. Shared decision making research System-wide implementation 3-year research project 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 Assess process barriers and facilitators

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

7. Treatment choices in 6 specialty areas Orthopedics 1 Cardiology 2 Urology 3 Women’s health 4 Breast cancer 5 Back care 6

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 Uterine fibroids Abnormal uterine bleeding Early stage Ductal carcinoma in situ Breast reconstruction Spinal stenosis Herniated disc

9. Providers can order DAs through Epic

10. Patient portal access DVDs can be viewed on the Web

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

12. Evaluation Ordering & viewing Provider interviews Patient survey link

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

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 September 2010 Excellent or very good Extremely or very important Helped understand treatment choices Helped prepare to talk with provider How important that providers make programs like this available 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?