Helping patient with choices in preference-sensitive care March 3, 2011 | Matt Handley MD Shared Decision Making at Group Health

The History Legislation in 2008 leads to a statewide collaborative Commitment to systematic implementation within the group practice at GHC in 2009 ◦ Aligned leadership ◦ Incorporation into evolving standard work in specialty

Evidence for using decision aids Increased knowledge More active patient participation Better alignment between values & choices 34 randomized controlled trials Lower surgery rates No evidence of harms from not having surgery 7 RCTs Higher patient knowledge & satisfaction Lower surgery rates with similar outcomes 2 Group Health studies

Patient-centered care at Group Health Shared electronic medical record Medical home pilot Decision aids for shared decision making Implementation timeline

Implementation Case for change with specialty leadership ◦ Variable uptake over time Distribution of decision aids ◦ Integration into EMR as an orderable activity – triggers mailing of DVD to home ◦ Tools in EMR to link to streaming decision aids on MyGroupHealth Incorporation into evolving standard work in specialty

Providers can order through Epic

Distributing decision aids DVDs can be ordered for mailing or viewed on the Web

Treatment choices in 6 specialty areas Orthopedics Cardiology Urology Women’s health Breast cancer Back care

12 preference-sensitive conditions OrthopedicsCardiologyUrology Women’s Health Breast Cancer Back Care 1.Hip osteoarthritis 2.Knee osteoarthritis 3.Coronary artery disease 4.Benign prostatic hyperplasia 5.Prostate cancer 6.Uterine fibroids 7.Abnormal uterine bleeding 8.Early stage 9.Ductal carcinoma in situ 10.Breast reconstruction 11.Spinal stenosis 12.Herniated disc

Evaluation Ordering & viewing Provider interviews Patient survey link 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 JanAprJulOctJanAprJulOct

Percentage of procedures for preference sensitive conditions where patient did not receive the video Fewer missed opportunities

Patient assessment Overall rating of decision aid videos Patient survey, March 2010, 400 responses Helped you understand the treatment choices Helped you prepare to talk with provider

Patient assessment Overall rating of decision aid videos Patient survey, March 2010, 400 responses How important is it that providers make programs like this available?

Rating of decision aid videos, by topic March 2010 Patient assessment

First year results Aiming for publication this year, so we are not sharing numbers Impact has led us to deepen our commitment to SDM

Next steps Development of our surgical group’s skills in facilitating SDM conversation ◦ Training in May, co-developed with FIMDM Engagement with back care, general surgery Feedback of information about defects (patients receiving surgery without exposure to the decision aid)

What are we Relearning? Implementation is not a binary event Technical change (distribution of the decision aids) is much easier than Adaptive change (having very different conversations with patients) We have a great medical group Implementation in our network is dramatically more challenging than within our group practice

Questions?