Implementing Patient Decision Aids for Increased Patient Engagement and Reduced Costs. David Arterburn MD, MPH Group Health Research Institute

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1 Implementing Patient Decision Aids for Increased Patient Engagement and Reduced Costs David Arterburn MD, MPH Group Health Research Institute

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 The Informed Medical Decisions Foundation is a non-profit organization that receives much of its funding through partnership with HealthDialog, a for-profit health coaching and disease management company

3 Group Health s pathway to shared decision making

4 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)

5 Group Health rates of surgical procedures rising

6 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

7 Infrastructure elements to support shared decision making

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9 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

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12 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.

13 Appropriate staffing for implementation and ongoing process improvement Project managers with experience implementing practice changes at Group Health were hired to carry out this work Approach service line leaders Meet with service line providers Go live Meet with individual clinics Pre/ During/ Post QI 13

14 Creating a culture of expectation and building competencies for providers

15 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.

16 Setting the tone for competency in shared decision making Nice to do if you have the time and inclination. Cultural spectrum 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. GH leaders want to push providers right over here!

17 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

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20 Outcomes

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22 Process measure defect measure shows fewer missed opportunities for DA delivery

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26 Comparison of mean costs in 6 months after index date, control vs. intervention Costs (2009 dollars) Hip Osteoarthritis Cohorts Control N=968 Intervention N=820 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

27 Conclusions and next steps

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29 Shared decision making with decision aids

30 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

31 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

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