Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making May 24, 2013

1. I m p l e m e n t a t i o n o f S h a r e d D e c i s i o n M a k i n g : M e a s u r i n g S u c c e s s
Aligning Incentives for Patient
Engagement
May 24, 2013

2. Implementing Shared Decision Making
in Primary Care
_____________________________________________
Barriers, Solutions, and Measurement
Mark W. Friedberg, MD, MPP1
Kristin Van Busum, MPA1
Richard Wexler, MD2
Megan Bowen2
Eric C. Schneider, MD, MSc1
1RAND Corporation
2Informed Medical Decisions Foundation
Sponsor: Informed Medical Decisions Foundation

3. We Evaluated a Demonstration of Shared
Decision Making
3
• 8 sites containing 34 primary care clinics
- Selected for prior quality improvement experience
- Some without prior decision aid experience
• July 2009-June 2012
• Sponsored by the Informed Medical Decisions
Foundation
- Free decision aids
- Technical assistance
- Learning collaborative
• Qualitative evaluation at 18 months

4. Objectives of Evaluation
1. Identify barriers and facilitators to
implementing shared decision
making in primary care settings
2. Develop options for near-term
quantitative evaluation
4

5. Semi-Structured Interviews
5
• 23 leaders and clinicians from all demonstration
sites
• 10 patients from 1 site who had each received a
decision aid during the demonstration
• Protocol investigated facilitators and barriers to:
-Engaging clinicians
-Integrating decision aids into key operational tasks
• Interview responses analyzed inductively for
recurrent themes

6. Key Steps of Shared Decision Making Based
on Decision Aids
Decision
opportunity
identification
Opportunity
recognized
DA matched
to
opportunity
Decision aid
use
DA
distributed
Patient uses
DA
Post-DA
conversation
Clarify
medical
information
Elicit values
and
preferences
Make shared
decision
Health care
delivery
Care
consistent
with final
shared
decision

7. Barriers to Shared Decision Making
7
• Overworked physicians do not recognize decision
opportunities and distribute decision aids reliably
“Patients come in and doctors are seeing them for four or
five different problems. And then they have to remember if
there is a decision aid for each particular decision.”
“We hear physicians say…I seem to be the problem here,
how do I get myself out of the loop so we can get [the
decision aids] to people that need to get them?”
“In the real world . . I’m not sure we can expect the
physicians to identify patients.”

8. Barriers to Shared Decision Making
8
• Overworked physicians do not recognize decision
opportunities and distribute decision aids reliably
• Insufficient provider training
-Recognizing decision opportunities and having post-decision
aid conversations are skills providers must learn
“Physicians felt that they were already doing shared
decision making [before introducing decision aids].”
“You really have to pay attention to the clinicians in
this equation. You can’t just ask them to do something
and assume that they’ll know what you mean…we
under-attended the training of our clinicians.”

9. Barriers to Shared Decision Making
9
• Overworked physicians do not recognize decision
opportunities and distribute decision aids reliably
• Insufficient provider training
• Inadequate clinical information systems
-Not able to track the full sequence of steps involved in shared
decision making
-Not able to integrate with decision aids
“All of the information from the [decision aid
questionnaires] is off the chart. There is documentation
that a decision aid was given…but anything from the
surveys is kept completely separate.”

10. Solutions Sites Employed
10
• Automatic triggers for decision aid distribution
-Trigger on patient age and gender (for screening)
-Trigger on specialist referrals (for surgical procedures)
Relative greater focus of specialist visits may facilitate
more reliable performance of post-decision aid
conversation
• Engage team members other than physicians
-Example: “decision coach” to introduce the decision aid
Patient: “When you’re with the doctor, you don’t get a
chance to ask a lot of questions. …A nurse I had
never met [before] came in and introduced me to [the
decision aid]. She had a CD and a book about the
surgery. …Of course I was interested in that.”

11. Measuring the Successfulness of
Implementing Shared Decision Making
11
• Process measures should capture all steps of
shared decision making
- “All-or-none” measures may be appropriate

12. Vulnerability in Later Steps of
Shared Decision Making
Decision
opportunity
identification
Opportunity
recognized
DA matched
to
opportunity
Decision aid
use
DA
distributed
Patient uses
DA
Post-DA
conversation
Clarify
medical
information
Elicit values
and
preferences
Make shared
decision
Health care
delivery
Care
consistent
with final
shared
decision
Rate-limiting steps = targets for measurement

13. Measuring the Successfulness of
Implementing Shared Decision Making
13
• Process measures should capture all steps of
shared decision making
- “All-or-none” measures may be appropriate
• Measures of decision quality
- In the end, was care consistent with the patient’s values
and preferences?

14. Measuring the Successfulness of
Implementing Shared Decision Making
14
• Process measures should capture all steps of
shared decision making
- “All-or-none” measures may be appropriate
• Measures of decision quality
- In the end, was care consistent with the patient’s values
and preferences?
• Indirect measures of shared decision making
performance
- In theory, shared decision making should produce
variability that is driven entirely by patients, not providers
- If each provider in an organization has a PSA screening
rate of 100% or 0%, the organization is unlikely to have
implemented shared decision making successfully

15. Implications
15
• Achieving shared decision making will require “new
operating systems” for primary care practices
- Major investments in developing and improving
educational, operational, and informatics systems
- Payment reform may be necessary
• Key issue for policy makers: How high to set the bar
for deciding what counts as “engagement” in
shared decision making
- Lower bar: count or rate of decision aid distribution
- Higher bar: all-or-none process measures including all
steps of shared decision making

16. Thank you
16
Mark Friedberg, MD, MPP
mfriedbe@rand.org

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

18. 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

19. 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)
• Two-thirds of our members get most of their care
within our Integrated Group Practice from salaried
Group Health providers

20. Outline
1. What was Group Health’s pathway to large-scale implementation
of Shared Decision Making?
2. What infrastructure elements did Group Health put in place to
support Shared Decision Making?
3. What did Group Health leadership do to create a culture of
expectation around Shared Decision Making and begin to build
competencies among providers?
4. What outcomes have we observed?
5. What steps are we taking now to optimize Shared Decision
Making at Group Health?

21. Group Health’s pathway to
shared decision making

22. Group Health rates of surgical procedures rising

23. 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

24. Infrastructure elements to
support shared decision
making

26. 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

27. Epic ordering of patient decision aids

29. 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.”

30. Appropriate staffing for implementation and
ongoing process improvement
30
Project managers with experience implementing
practice changes at Group Health were hired to
carry out this work

31. Creating a culture of expectation
and building competencies for
providers

32. 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.

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

34. 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

37. Outcomes

39. Process measure – “defect measure” shows
fewer missed opportunities for DA delivery

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

44. Our next steps optimize
Shared Decision Making

45. Adding new decision aids
• Already implemented:
– Acute Low Back Pain
– Chronic Low Back Pain
– Weight Loss Surgery
• Planned:
– End of Life Care
– End Stage Renal Disease Treatment Options
– Maternity Suite (Suspected Macrosomia, Elective Induction,
and Vaginal Birth After Cesearian)

46. Moving “upstream” into Primary Care
Four primary care clinics began Jan 2013 (system-wide by Dec 2013)
– Two in Spokane; One each in Olympia and north Seattle
Any patient diagnosed with a condition where we have a decision aid
- Primary care provider lets know that there is a decision aid that they want
them to watch to understand the risk/benefits of treatment choices
- Ask patient their preference for viewing video: Online or having DVD mailed
to them.
- Let patient know you’ll have a follow up conversation once they’ve viewed it
Follow up conversation
– Have discussion via email or by phone
– Review their knowledge, ask for questions/concerns, ask for their preference
regarding treatment choice; consider need for referral

47. Creating EpicCare based tools to support SDM

48. Implementing Feed Forward Questionnaires
• Implementing standardized measures of patient symptoms, prior
treatment, knowledge, values, and treatment preferences
• Patients will be prompted to complete the questionnaires online
after viewing a decision aid and before their next visit
• Questionnaire results summary will be imported into Epic as either
an “encounter”, a “flowsheet”, or both
• Provider can review results at the point of care

49. Conclusions

51. Shared decision making with decision aids

52. 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

54. Implementation of Shared Decision
Making: Measuring Success
Results of a large scale randomized trial
testing two levels of shared decision making
support

55. Background
Important deficits in patient
participation in decisions about
their care.
Shared Decision Making improves
care and patient experiences
Conducted a randomized trial
comparing two levels of telephonic
support for people with conditions
that involve multiple treatment
options

56. Previously published study
Largest study of population
care management to date
 Collaboration between Health Dialog
and two clients
 Randomized study of 174,120
individuals
 Compared medical costs and
utilization of two different care
support strategies
Overall results:
 Total costs reduced by over 3.6%
 Total population admissions reduced
by 10.1%

57. Structured stratified random sampling
Predictive models and real time data were used to assess the likelihood of
using or needing health care services
Rank-order lists of individuals likely to have support needs were used to
generate:
 Outbound mail
 Interactive voice response calls
 Calls by health coaches
Study Design

58. EnhancedSupportUsualSupportEnhancedSupport
Difference driven by who was targeted for engagement
Enhanced support versus
usual support
High
Risk
Low
Risk
Health Continuum
Chronic
Preference
Sensitive
Care
Other
High Risk Healthy
Focus on Preference
Sensitive Conditions
N = 60,185

59. Based on original randomized trial
• Baseline data on the 60,185 identified as potential candidates for
Shared Decision Making
Preference Sensitive Focus
Usual Support Enhanced Support
Number 30,240 29,945
Costs
Total medical costs (PMPM) $371.92 $371.73
Inpatient costs (PMPM) $106.77 $106.05
Resource Use
Inpatient admissions (per 1,000/yr) 131 129
Emergency department (per 1,000/yr) 377 379
Surgeries for PSC (per 1,000/yr) 32 30
Advanced imaging studies (per 1,000/yr) 372 382
Standard imaging studies (per 1,000/yr) 1,396 1,394

60. Outreach activity
0
200
400
600
800
1000
Any PSC Heart ConditionBenign Uterine CondBenign Prostatic Cond Hip Pain Knee Pain Back Pain
Coach Contacts Usual
Enhanced
0
10
20
30
40
50
60
70
Any PSC Heart ConditionBenign Uterine CondBenign Prostatic Cond Hip Pain Knee Pain Back Pain
Videos Sent
Usual
Enhanced

61. Cost and utilization
Usual
Support
Enhanced
Support
Relative
diff (%)
Absolute
diff
Number 30,240 29,945
Costs
Total medical costs (PMPM) $436.05 $412.78 (5.3%) ($23.27)
Inpatient costs (PMPM) $132.73 $116.20 (12.5%) ($16.53)
Outpatient costs (PMPM) $96.91 $92.49 (4.6%) ($4.42)
Resource Use (per 1,000/yr)
Inpatient admissions (per 1,000/yr) 155 135 (12.5%) (20)
Emergency department (per 1,000/yr) 409 399 (2.6%) (10)
Surgeries for PSC (per 1,000/yr) 32 29 (9.9%) (3)
Advanced imaging studies (per
1,000/yr)
400 393 (1.9%) (7)
Standard imaging studies (per 1,000/yr) 1,488 1,458 (2.0%) (30)

62. Implications
Lower overall costs speaks to the power of SDM well
beyond surgical decisions
When physician adoption comes slowly, independent
telephonic support model can get the process started
and can be effective