In 2009, Group Health Cooperative (GHC), a consumer-governed, non-profit health system, committed itself to integrating patient decision aids and shared decision making processes into routine clinical practice to improve the quality of patient’s decisions regarding elective surgery. These changes required strong organizational leadership and an ongoing commitment to quality improvement. To date, GHC has distributed over 40,000 video-based decision aids – more than any other healthcare organization in the world. The work has generated evidence of high patient satisfaction as well as lower rates of elective surgical treatment and costs of care for some high-cost, high-variation health conditions.
Decades of research from the Dartmouth Atlas have shown that unwarranted variations in elective surgery are pervasive in the United States. Decision aids are evidence-based sources of health information that can help patients make informed treatment decisions about elective surgery. Growing evidence suggests that using decision aids improves the quality of patient decision making and potentially reduces unwarranted variations in care, mitigating unnecessary health expenditures. Unfortunately, little is known about how decision aids affect patient satisfaction and healthcare use, and few health systems have attempted large-scale implementation of DAs to support shared decision making.
To help address the persistent problem of unwarranted variations in health care, Washington in 2007 became the first state to enact legislation encouraging use of shared decision making and decision aids to address deficiencies in the informed consent process. Group Health Cooperative a Seattle-based, consumer-governed, integrated health system that provides insurance coverage and care for more than 600,000 residents of Washington State and Northern Idaho, volunteered to fulfill a legislated mandate to study the costs and benefits of integrating decision aids across a wide range of health conditions. The GHC Shared Decision Making Demonstration Project, begun in 2009, implemented video-based decision aids for 12 preference-sensitive conditions related to elective surgical procedures in six specialties, including orthopedics, urology, gynecology, general surgery, cardiology and neurosurgery.
The primary innovation was integrating decision aids into standard clinical practice across multiple specialties. Two senior Group Health Cooperative project management consultants planned and guided the implementation, tailored to the unique patient needs and work flow of each specialty service line and clinical location. Consultants and service line leaders drafted distribution processes that were shared with frontline providers and staff. Provider and staff reactions and input helped revise the distribution process, usually in one meeting, but in multiple meetings, if necessary. Negotiation periods ranged from six weeks to three or four months. After the implementation process was established, a “go-live” data was set, with project managers visiting each clinic site at least once to monitor implementation progress. Additional visits and calls to sites were conducted by clinical leaders and project managers as needed based on the volume of decision aids distributed and the proportion of patients who underwent elective surgery without receiving a decision aid.
The implementation process used electronic health record innovations to order decision aids for delivery to patients’ homes as mailed DVDs, distribute decision aids for viewing online, track decision aid delivery, and document conversations with patients. In May 2010, over 90 percent of specialist physicians participated in a half-day, continuing medical education training on the six steps of shared decision making and best practices for incorporating decision aids into patient communication and conversations. Sixteen months into the implementation process a process improvement effort occurred resulting in major revisions of workflows in several service lines. These changes were associated with significant increases in decision aid distribution. Then in fall 2010, a modification in the electronic medical record referral process resulted in a strong shift towards primary care providers ordering decision aids, although emphasis remained on specialists having shared decision making conversations. Recent innovations for 2013-14 have incorporated secure, web-based knowledge and preference assessments related to elective surgical conditions that patients can complete in advance of a visit with their provider. The assessments provide real-time information to enhance patient engagement in decision making at the point of care.
In the past five years, Group Health Cooperative has distributed over 40,000 video-based decision aids – more than any other single healthcare organization in the United States. Today, more than 70 percent of patients undergoing elective surgery related to 12 health conditions at GHC receive a decision aid. Member satisfaction with decision aids has been high with more than 95 percent surveyed reporting that the decision aids helped them better understand their condition and treatment options. Members were also less conflicted about their treatment decisions and expressed more satisfaction with their decisions.
The Group Health Research Institute conducted an observational study of nearly 10,000 patients in 2012 to examine the relationships between introducing decision aids for hip and knee osteoarthritis and rates of joint replacement surgery and costs. Consistent with prior randomized trials, the introduction of decision aids at Group Health was associated with 26 percent fewer hip replacement surgeries, 38 percent fewer knee replacements, and 12 to 21 percent lower costs over six months.
Group Health Cooperative has identified several key components for successful decision aid implementation, including:
- Introductory meetings with clinical leaders to build support and identify champions; mandatory viewing of the decision aids by clinic providers and staff
- Iterative communications to develop a formal, customized implementation plan for each clinic
- Post-implementation monitoring and support to identify best practices for quality improvement and fostering changes in physician culture through continuing medical education on SDM conversations.
At Group Health Cooperative, we believe that the use of patient decision aids, and the promotion of shared decision making between providers and patients is the cornerstone of patient-centered care, improves the quality of medical decisions, and helps to mitigate unwarranted variations in care. The lessons learned by Group Health Cooperative should guide other states and healthcare organizations toward adopting shared decision making with decision aids as the highest standard of care for informed consent and patient engagement in decision making related to elective surgery.