Shared Decision-Making
Doctors and hospitals give patients the tools to actively share in making decisions about their care
The staff physicians of Group Health Cooperative, a Seattle-based multispecialty group practice and health plan, pride themselves on practicing evidence-based medicine. That's why they were shocked when they found up to twofold differences among themselves in the use of 12 elective surgical procedures such as hysterectomy and knee replacement.
The data suggested some doctors' rates were too high, or too low. The differences were particularly stark between doctors in the Seattle area, who generally had low rates, and those in Spokane, who had high rates. Group Health's internal findings were consistent with overall clinical disparities around the state reported by the state-run Washington Inpatient Atlas.
"When we showed the doctors the variations in care, the hairs stood up on the back of their necks," says David Arterburn, M.D., assistant investigator at the Group Health Research Institute. "That showed we needed to improve the quality of decisions."
Partly because of those findings, Group Health launched a shared decision-making program last January to better educate its 600,000 members in Washington and Idaho about the risks and benefits of various treatment options. Patients with any of 13 conditions are asked to watch a video and read a booklet on that condition produced by Health Dialog, a company in Boston. Then they discuss it with their medical specialist.
The selected conditions involve "preference-sensitive" care—where there's no clear scientific evidence that one treatment is more effective than the alternatives, and much depends on the patient's values and goals.
A key challenge is giving patients access to the videos at just the right time in the care process—ideally, before they visit the specialist so they can have a well-informed discussion with the doctor.
Group Health's two-year demonstration is one of the nation's largest tests of the highly touted shared decision-making model pioneered at Dartmouth University. Hospital systems, clinics, physician groups and academic medical centers are participating in similar tryouts around the country. They include Massachusetts General Hospital, Dartmouth-Hitchcock Medical Center, Virginia Mason Medical Center and Multicare Health System and the University of California, San Francisco.
Health Dialog and its affiliated nonprofit, the Foundation for Informed Medical Decision Making, are helping fund the demonstrations at Group Health and other sites. Adding to the momentum are Washington, Vermont and Maine, which have passed laws to promote shared decision-making demonstrations, while other states are considering similar bills. Oregon Sen. Ron Wyden has proposed shared decision-making for Medicare.
Already, most of the nation's largest health plans, and about 300 hospitals, offer patients similar decision-aid tools—interactive Web-based programs produced by Healthwise—for dozens of medical conditions, according to Don Kemper, CEO of the nonprofit Healthwise, Boise, Idaho. Many of these plans and providers follow up with patients by providing coaching to help them reach a decision.
The twin goals of these shared decision-making initiatives are to help patients make better choices for themselves in collaboration with their doctors, and to reduce inappropriate treatments and save money. Shared decision-making is one piece of a broader health delivery reform effort, much discussed during the health overhaul debate in Congress, to improve quality, boost patient satisfaction and curb costs.
Previous smaller studies of shared decision-making have found utilization declines for some procedures. "Our experience pretty consistently is that when patients are well-informed, they and their doctors tend to make more conservative choices, and we see a 25 percent reduction in the choice of surgery," says Lance Lang, M.D., senior medical director at the for-profit Health Dialog.
A Lewin Group report last February estimated that use of patient decision aids, such as videos, could save Medicare $4 billion a year on 11 conditions, including 12 percent savings for angina, 16 percent for hysterectomy and 20 percent for low back pain.
Indeed, Group Health's early results show knee replacements dropping 15 percent, according to David McCulloch, M.D., medical director for clinical improvement. "The theory is that if you could give all patients access to the information they need in ways they can understand at the appropriate time, they'd pick what's best for them and you'd know a few years from now what the correct rate for each procedure is," he says.
At this point, however, the impact on utilization remains uncertain. McCulloch says that the number of hip and knee replacements could actually increase if all osteoarthritis patients see the video and become more aware of the surgical options.
The more certain benefit of shared decision-making, advocates say, is that patients will work with their doctors to make treatment decisions with which they are happier overall. That's good for everyone. Patients will better understand the likely treatment outcomes and feel more satisfied with their care. Doctors will have more focused discussions with patients, rather than having to offer lengthy primers. It might even reduce medical malpractice suits.
Even Group Health patients who decided on surgery before watching the video say it helped by thoroughly addressing their questions and fears, better preparing them to talk with their doctor and making them more confident about their choice.
"My biggest fear was developing a blood clot, because I know someone that happened to," says Beverly Baumgartner, 74, of Lynwood, Wash., who had her left knee replaced in October. "From watching the video, I found out that's very rare, and the doctors would prevent that with anticoagulants and exercises."
Bill Cunningham, 67, of Bremerton, Wash., admits he didn't know much about prostate cancer or its treatment options before deciding on surgery. After making the decision, he watched the video "over and over" with his wife. He says it gave him far more information than his urologist provided.
"It reinforced my decision to have surgery," he says. "Hearing how patients in the DVD reached their decision was very helpful for me. It ruled out some of the other options, like watchful waiting. That didn't sound too good to me." He had prostate surgery last July.
Group Health rolled out shared decision-making for more conditions and procedures than most other organizations initially are tackling. These include herniated disc, spinal stenosis, knee and hip osteoarthritis, prostate enlargement, prostate cancer, PSA testing, uterine fibroids, abnormal uterine bleeding, chronic stable angina, early stage breast cancer, and reconstructive surgery after a mastectomy. That covers a large percentage of all elective surgeries.
Each video, which lasts about 45 minutes, features doctors explaining the condition and treatment options, and real patients discussing their own condition, the different treatment choices they made, and why.
On the prostate cancer video, one patient who chose surgery says: "Fix it and get it over with." A second patient, who chose watchful waiting, says: "All of life is uncertain.… I want to enjoy what I have."
Group Health members can either get a free DVD copy or watch the video online. Health Dialog is donating the videos, which are updated every six months or so. Most are not available in Spanish, though the company does offer one Spanish-language video on diabetes.
Getting the videos to patients at the right time can be tricky. For members who see Group Health staff doctors, the primary care physician's office informs the patient about the availability of the video when the patient is referred to a specialist.
Sometimes, though, the primary care doctor engages in the shared decision-making process with the patient, as with knee osteoarthritis.
In other cases, the specialist's office alerts the patient to the video. The goal is to have all appropriate patients watch the video before the visit to the specialist and be ready to discuss it with the doctor.
For the 150,000 members who see contracting physicians, many in Eastern Washington, Group Health's organizational challenge is greater. For now, it's using shared decision-making for only six conditions, rather than 13, leaving out life-threatening conditions like breast cancer and heart disease.
Whenever a primary care doctor refers a patient to a contracting specialist for one of those six conditions, or a patient is referred for an MRI or CT scan, Group Health notifies the patient with a postcard to watch the video online or get it by calling a toll-free number.
The health plan is sending 120 postcards a week, with most going to patients suffering knee, hip or back problems, and many of the rest going to gynecological patients, says Rick Shepard, M.D., Group Health's utilization management director for network services. The target is to get 25 percent of these patients to watch the video and discuss it with their doctor, though Shepard acknowledges that may be too ambitious. If the postcard method doesn't work, he'll try something else.
While contracting physicians around the state generally support the program, he says, it isn't realistic to ask those doctors to take the lead in giving patients the videos or scheduling their consultations around the videos. Group Health patients only account for a small percentage of their practices, Shepard says, and they can't restructure their practices just for those patients.
Another challenge is that the contracting doctors, unlike Group Health's salaried doctors, work in a fee-for-service system that encourages them to do more procedures. That works against efforts to reduce surgery, Arterburn says.
Still, both staff and contracting physicians have expressed enthusiasm about the program, saying well-informed patients save them time and the hassle of explaining everything from scratch. "It's something we've welcomed with open arms," says Charles Jung, M.D., Group Health's orthopedic services chief. "Surgeons try to see 24 to 36 patients a day, so any education the patient can get outside the clinic is time well spent."
On top of that, he says, the fuller information process—particularly the people in the videos telling stories about their own medical experience—helps patients in the recovery period. "As a surgeon, you don't want patients blindsided by how much it hurts or how difficult it is to get around," Jung says.
Jung would like to see a new video produced for knee arthroscopy, which he says is a significantly overused procedure.
Jane Dimer, M.D., Group Health's chief of women's services, hopes shared decision-making for uterine fibroids and abnormal bleeding will sharply reduce hysterectomies, which often are done on healthy younger women with benign conditions. The videos "make the conversation much easier on both sides," she says. "It's pretty cool; patients will use the language we use. 'Endometrial ablation' rolls right off their tongue. They know what they're talking about."
She'd like to see additional videos for vaginal births after a cesarean section, circumcision, and hormone therapy after menopause.
A few physicians have expressed reservations about how the DVDs describe the surgical options; Group Health and other participating organizations encourage them to provide their own additional information to patients during consultation.
Some doctors also fret about diverging from the local practice patterns, how much time shared decision-making will take, and how it fits into their practice flow.
That's in line with a 2009 Foundation for Informed Medical Decision Making survey of primary care doctors. While nearly all the doctors endorsed the concept of shared decision-making, some said time pressure and patients who want the doctor to make the treatment decision are barriers to use.
Most said they'd be more interested if they were paid for the time they spent with patients during the process.
Whether it takes more time depends on how much discussion doctors previously were having with their patients. Dimer says her ob-gyns who use the shared decision-making process are spending the same amount of time as before, but it's "higher quality time."
At Virginia Mason Medical Center's breast cancer center in downtown Seattle, which is launching a shared decision-making demonstration in late January, the salaried doctors and staff already spend a lot of time explaining the treatment options, risks and benefits.
By using the Health Dialog video, "we're anticipating a richer conversation about that specific patient," says Sherry Stoll, the administrative director for clinics.
Virginia Mason is one of four Washington sites participating in a two-year pilot that will be studied by University of Washington researchers. The other sites are Multicare Health System in Tacoma, Everett Clinic and the Carol Milgard Breast Center in Tacoma.
The four sites will use the Health Dialog videos for different types of patients. For example, one Multicare primary care clinic will use them for diabetes, chronic pain, acute and chronic back pain, and depression, according to Andrew Baron, M.D., Multicare's medical director for primary care services. He predicts a reduction in back surgery.
At both Multicare and Virginia Mason, the particular clinic sites were chosen because the doctors were excited about the program and volunteered. "It's always easiest to implement something new with early adopters," Stoll says.
Caroline Watts, a University of Washington health economist who is heading the four-site study, says it's easier to organize a shared decision-making model within an integrated system like Group Health, with salaried doctors and an electronic health record.
But Stoll says even hospitals without employed doctors have a strong interest in helping patients make the best choice for themselves and being happier with the outcome of care.
Group Health's Jung agrees. "The worst thing is to have the wrong patients in your OR," he says. "If someone is ambivalent and not ready for surgery, that's not a good patient to have. That patient is more likely to question everything and end up in a lawsuit."
Group Health member Diana Sumis, 57, of Seattle says that even though she made up her mind to have surgery in November before watching the knee osteoarthritis video, she thinks the program is valuable.
"Knee replacement maybe is not for everyone," she says. "It's an individual choice. People should be aware there are other choices to make."
This article 1st appeared in the February 2010 issue of HHN Magazine.
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