Managed Care

 

Renewed Interest In Shared Decision Making

MANAGED CARE April 2013. © MediMedia USA
Cover Story

Renewed Interest In Shared Decision Making

Twenty years after SDM’s introduction, health plans are seizing on it to help patients choose their treatments. The lower costs for these patients are a welcome extra.

Joseph Burns
Contributing Editor

Men viewing one of the first decision aids to help choose the most appropriate treatment option for benign prostatic hypertrophy were shocked. The surgery often resulted in sexual problems, such as impotence, trouble urinating, or both. No wonder many of them chose watchful waiting instead.

That was more than two decades ago. Researchers at Dartmouth and their collaborators produced some of the first tools for patients to use when choosing among various medical treatment options. In 1989, John E. Wennberg, MD, and a team of researchers founded the Center for the Evaluative Clinical Sciences (CECS), now known as the Dartmouth Institute for Health Policy and Clinical Practice.

Weighing the pros and cons

For the first time, BPH patients could evaluate the pros and cons of treatment options by hearing other men talk frankly about their experience. Previously, urologists discussing surgery did not always explain the unwanted outcomes of the procedure. Mainly they emphasized positive outcomes. The result was that men considering surgery were often uninformed about the risk of impotence or incontinence.

Much the same happens today. Whether they do it as a consequence of the fee-for-service payment system or out of genuine regard for the patient, physicians spend more time explaining the advantages of a procedure than they do outlining the disadvantages. No surprise, then, that physicians’ preferences leave the biggest impressions in patients’ minds.

To counterbalance physicians’ preferences, health plans are increasing their efforts to get more patients involved in shared decision making (SDM). In a variety of clinical settings, electronic medical record systems alert physicians about the need to offer patients decision aids. Those aids may be videos seen on the Internet or distributed on DVD by mail. Some are booklets handed out or mailed to patients.

New rules require SDM

As more health plans use SDM tools, patients are choosing less risky and less unpleasant options more often. Federal regulations for accountable care organizations and for the meaningful use of electronic health record (EHR) systems promote SDM as a way to engage patients more fully in making decisions about their care.

Michael Barry, MD

In medicine, the choice among options is rarely clear; for most conditions there are two or more reasonable approaches, says Michael Barry, MD, president of the Informed Medical Decisions Foundation.

“We have been at this work for 24 years and we may be approaching a tipping point,” says Michael Barry, MD, president of the Informed Medical ­Decisions Foundation, an organization founded to promote the early work of the Dartmouth Institute. A primary care physician, Barry also is the medical director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital.

In the late 1980s, researchers in the nascent field of patient outcomes were just learning about the problem of widespread unwarranted variation. Wennberg showed that where patients lived and which physicians they consulted affected how they were treated. But publishing research about medical evidence and best practices had little effect on physicians making decisions in practice and no effect on patients.

Eliminating waste

“We felt the best response to unwarranted variation was to get patients involved in making decisions about their care,” Barry says. In medicine, the choice among options is rarely clear; for most conditions, there are two or more reasonable approaches, and Wennberg and other experts believed patients should have a say in which to pursue.

“That was when we started developing decision aids,” Barry says. “We had some success early on, but it was hard to get traction.”

Instead of seeing a growing demand for decision aids for many conditions, the researchers found that too many patients believed that the doctor knows best.

“The old approach dies hard,” Barry says. “In that approach, doctors are either guessing what the patient wants or perhaps they are using their own preferences. Either way, they were contributing to practice variation.”

Patients also trust their friends and family or what they have read on the Internet. Such inherent prejudices confound efforts to disseminate decision aids today.

Plus, health plans have long been reluctant to introduce decision aids that physicians might consider to be intrusions on the patient-physician relationship.

Peter Goldbach, MD

“…introducing anything that might result in fewer procedures is challenging,” says Peter Goldbach, MD, chief medical officer at Health Dialog.

The built-in incentive under fee-for-service payment also played a role, paying physicians more for surgery than for watchful waiting or for other conservative options, says Peter Goldbach, MD, chief medical officer at Health Dialog, a for-profit company formed in 1997 that sells decision support tools to health plans and large employers.

“The initial forays that involved decision aids for surgical procedures were effective, but when specialists and proceduralists get paid fee for service, introducing anything that might result in fewer procedures is challenging,” says Goldbach.

David E. Arterburn, MD, MPH, a general internist and researcher at Group Health Research Institute, sees another reason for increased interest in SDM. Before buying a car, a camera, or a computer, consumers collect a wide variety of data on the advantages and disadvantages of each, he says. “Yet with health care, we’re OK with providers telling us what they think we should do,” he says. Research by Arterburn and others is helping to foster interest in SDM.

An article in Health Affairs (Arterburn 2012), “Introducing Decision Aids at Group Health Was Linked to Sharply Lower Hip and Knee Surgery Rates and Costs,” reported that after Group Health Cooperative introduced decision aids for patients with knee and hip arthritis, the rates of joint replacement surgeries dropped sharply. Over six months, hip replacements dropped 38 percent and knee replacements dropped 26 percent. Also, costs declined 12 percent for hip replacement and 21 percent for knee replacement patients. The article is online at http://sn.im/26et1b2.

“We know from previous studies, and our research shows as well, that patients tend to be risk-averse and so they often choose less invasive treatment,” Arterburn says. “They tend to be more conservative than providers.”

Failing to get patients involved in making care decisions fosters unwarranted variation, meaning that the wrong patients sometimes get surgery and that costs are needlessly high, Arterburn says. “We knew these variations were large, but we didn’t know what the right tools were to address them. Shared decision making is one seemingly powerful tool to at least start to eliminate unwarranted variation.”

Introducing decision aids

In what Group Health calls the world’s largest implementation of decision aids in any single health care organization, the health plan introduced video decision aids systemwide for 12 preference-sensitive elective surgeries.

“Our work shows that by working closely with providers and by making patient decision aids available, we can get providers to change their practice patterns,” Arterburn says. “Incorporating more shared decision-making conversations into the informed consent process is leading to changes in rates and costs of care.”

Lower rates at Group Health are significant, Arterburn says, because the health plan employs its physicians. “Even here at Group Health, we found significant variation where we have salaried providers working under the same clinical guidelines,” he says. “In the Dartmouth Atlas, if you compare preference-sensitive care in Washington State with any other area of the country, we tend to have lower rates of variation. But then after going through this process with our providers, we saw reductions in rates of variation in preference-­sensitive care.”

Recognizing that patients will make appropriate decisions is just part of the solution to the problem of unwarranted variation, however. Another part involves getting decision aids to patients at the right time and in a way that does not complicate decision making or burden overwhelmed doctors.

Barriers to adoption of SDM

Researchers report in a recent article in Health Affairs (Friedberg 2013), “A Demonstration of Shared Decision Making in Primary Care Highlights Barriers to Adoption and Potential Remedies,” that barriers to wider adoption of SDM include overworked physicians, insufficient provider training, and clinical information systems incapable of prompting or tracking patients through the decision-making process.

Group Health is seeking to overcome these barriers. “It takes a fair amount of organization to decide how to deliver decision aids effectively at the right time to the right patient,” Arterburn says.

Lucy Savitz, PhD

Intermountain Healthcare has begun distributing decision aids for patients with low back pain, says Lucy Savitz, PhD, the plan’s director of research and education. If the program goes well, it might be expanded to other problems.

Intermountain Healthcare also seeks to improve the SDM process by having nurses — Intermountain calls them nurse navigators — work with patients making decisions, says Lucy Savitz, PhD, director of research and education at Intermountain Healthcare’s Institute for Health Care Delivery Research.

In February, Intermountain introduced decision aids for patients with low back pain. If all goes well, it will distribute such tools to patients considering hip and knee replacements and spine surgery, and to patients diagnosed with breast or prostate cancer, diabetes, and congestive heart failure.

“The doctors are excited about shared decision making because it changes the nature of the discussion with patients,” Savitz says. “That’s important because the biggest breakdown is compliance with care. Too often patients don’t follow instructions.” Intermountain employs 1,000 physicians in its Intermountain Medical Group and contracts with 2,500 other physicians. With SDM, patients and physicians work together to choose which steps the patient will follow. Such collaborations are at the heart of patient-centered care. “You have to listen to what patients want,” she says. “If you’re trying to reduce unnecessary emergency department visits or hospital admissions, you can’t ignore the patient component. That’s why there seems to be a groundswell of energy for shared decision making.”

Don Kemper

We need to take advantage of the new role of the engaged patient, says Donald W. Kemper, MPH, chairman and CEO of Healthwise.

Helping patients make care decisions benefits health plans in many ways, says Donald W. ­Kemper, MPH, the chairman and CEO of Healthwise, founded in 1975 to develop patient-education materials and decision aids.

“It’s clear that we need to take advantage of the new role of the engaged patient,” he says. “That’s what our health plans are beginning to see.” Healthwise provides 164 decision aids to health plans and employers.

These and other factors are behind the increased interest in SDM, says Susan Z. Berg, MS, the interim program director of the Center for Shared Decision Making at the Dartmouth-Hitchcock Medical Center in New Hampshire.

“Patients and providers are interested in it as a way to ensure that we provide the care that people need and want and not overuse care. Much of medicine is driven by fee-for-service payment,” she notes. “If we can shift away from that business model, health care providers will be able to focus on helping patients make informed decisions that are also consistent with their personal goals and values. That’s what matters, because it’s more patient-centered. Research has shown that a side effect of the shared decision-making process is that patients often choose a less costly alternative.”

Eventually, more widespread use of SDM will lead to the proper use of all health care resources, Arterburn concludes.

“There’s plenty of agreement that patients should get the right procedure at the right time, but what is the right rate for each procedure?” Arterburn asks. “The right rate is what you get when you have a well informed patient whose preference is clearly elicited and who makes a decision with a clinician.

“That will get us to the right rate and we will no longer have to worry about unwarranted variation. That’s the hope. And since we’re now seeing patients who want balanced information to make informed decisions, we may be on the cusp of what could be a cultural shift,” he adds.

We now know from recent randomized controlled trials that this cultural shift and adoption of shared decision making has the potential to significantly cut costs, improve quality, and increase patient satisfaction, says Goldbach. And for men facing prostate surgery, there’s increased awareness of certain adverse effects.

Patients like shared decision making

In 2011, Group Health Cooperative asked patients what they thought of the company’s shared decision-making program. Twenty-two hundred members responded.

How important is it that providers make programs like this available?

Is shared decision making the next hot area of investment?

Movement toward using aids for shared decision making more widely is likely to accelerate next year, says Sue Lewis, executive vice president and general manager of the payer division at Krames StayWell, which is owned by the company that owns this magazine. For now, health plans are busy preparing for new members and health insurance exchanges.

“This movement to adopt shared decision making now is ahead of where most health plans are focusing now,” she says. Currently, health plans are investing in wellness programs and systems to identify people who will be newly insured and so may need intense wellness and care coordination.

Looking ahead to the January opening of health insurance ­exchanges, health plans are focused on new methods of selling to consumers. “Right now, health plans are developing technology portals and doing product development in disease and care management,” she says.

But once the new members are enrolled, health plans will introduce cost-cutting measures because underwriting restrictions will force them to focus on people with the highest risk. “That’s when they will need shared decision making to help them manage their risks and increase patient satisfaction. That means shared decision making will be the next area of opportunity for content, coaching, and cost savings,” Lewis concludes. “So it might not be a big focus this year, but in 2014, it will be a hot area of investment by health plans.”

Should physicians be asked to implement yet another strategy?

Recent research suggests that physicians are too overwhelmed to introduce shared decision making for their patients.

Researchers writing in Health ­Affairs, “A Demonstration of Shared Decision Making in Primary Care Highlights Barriers to Adoption and Potential Remedies” (Friedberg 2013), found that physicians are already overworked and have insufficient training to make shared decision making (SDM) work. Also, information systems cannot prompt or track patients through the decision-making process, the article said.

Despite these problems, health plans see the value of SDM and are introducing decision aids for patients with various conditions, says Jaan Sidorov, MD, a health care consultant and former Geisinger medical director.

Adding any new process to a physician’s office workflow will be a challenge, particularly for doctors who are seeing dozens of patients a day, concedes Sidorov, a member of Managed Care’s Editorial Advisory Board. “Primary care physicians work very hard, and expecting them to change how they do things is an uphill battle — even if it’s a grand idea such as shared decision making. Primary care settings are already busy, and they are already bom­barded with dozens of good ideas.”

Therefore, health plans need to automate the process so that patients get decision aids based on a certain diagnosis. Or perhaps a nurse or care manager would introduce patients to decision aids. “It needs to be built into the process so the physician doesn’t need to do anything.”

Making SDM a routine part of care delivery is a goal for MaineHealth, says Neil Korsen, MD, the medical director responsible for its shared decision making program. MaineHealth was cited in the Health Affairs research. “We are in the early stages of figuring out the key issues needed to make shared decision making a regular part of patient care. Right now we’re at the qualitative stage of having physicians try it out, see what works, what doesn’t work, and what infrastructure is needed.”

“When I describe shared decision making, many doctors tell me, “We’re already doing it.” Physicians may be talking with patients about the pros and cons of treatment options, but they’re not routinely giving them decision aids from objective, unbiased sources.

Electronic record systems may help solve this problem by prompting a physician to promote a decision aid, but EHRs have not yet achieved all they will or should achieve, Sidorov says. “It’s within the realm of possibility that you could see how the EHR would be able to use decision support to prompt someone to automatically enroll a patient in SDM,” he says. “Until then, we should use nonphysicians to introduce SDM to patients.”

In another article in the February issue of Health Affairs, “Enhanced Support for Shared Decision Making Reduced Costs of Care for Patients With Preference-Sensitive Conditions” (Veroff 2013), researchers from Health Dialog compared patients who received usual support when making medical decisions with patients who received enhanced support. For this study, the researchers defined enhanced support as being more in contact with trained health coaches through telephone, mail, e-mail, and the Internet.

Patients who had enhanced support had 5.3 percent lower overall medical costs, 12.5 percent fewer hospital admissions, and 9.9 percent fewer preference-sensitive surgeries than those in the usual-support group, the researchers said.

“These findings indicate that support for shared decision making can generate savings,” they reported, adding that combining decision aids with coaching over the phone may be a low-cost way to reach patients without directly involving regular members of the medical team.

Savings associated with shared decision making

A study of shared decision making reported recently in Health Affairs found that participants had lower inpatient and total medical costs than did controls.

Study participants’ medical costs and resource use during the intervention, July 2006–June 2007
Usual support Enhanced support Relative difference (%) Absolute difference
Costs (per person per month)
Total medical costs $436.05 $412.78 −5.3 −$23.27**
Inpatient costs $132.73 $116.20 −12.5 −$16.53***
Hospital outpatient costs $96.91 $92.49 −4.6 −$4.42
Resource use (per thousand people per year)
Inpatient admissions 155 135 −12.5 −20****
Emergency department admissions 409 399 −2.6 −10
Surgeries for preference-sensitive conditions 32 29 −9.9 −3**
Advanced imaging studies 400 393 −1.9 −7
Standard imaging studies 1,488 1,458 −2.0 −30
Source: Veroff D, Marr A, and Wennberg DE. Enhanced support for shared decision making reduced costs of care for patients with preference-sensitive conditions. Health Aff 2013;32(2):285–293.

NOTES: Medical costs were capped at $200,000 per year. Advanced imaging includes magnetic resonance imaging, X-ray computed tomography, and positron emission tomography. Standard imaging includes standard X-rays and ultrasound.

**p < 0:05

***p < 0:01

****p < 0:001

For further reading

Arterburn D, Wellman R, Westbrook E, Rutter C, Ross T, et al. Introducing decision aids at Group Health was linked to sharply lower hip and knee surgery rates and costs. Health Aff 2012;31(9):2094–2104.

Friedberg MW, Van Busum K, Wexler R, Bowen M, et al. A demonstration of shared decision making in primary care highlights barriers to adoption and potential remedies. Health Aff 2013;32(2):268–275.

Veroff D, Marr A, Wennberg DE. Enhanced support for shared decision making reduced costs of care for patients with preference-sensitive conditions. Health Aff 2013;32(2):285–293.

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