David Arterburn, MD, MPH, describes the Group Health experience in implementing decision aids as part of the shared decision making pathway. David also notes his publication in Health Affairs detailing the results of decision aid implementation.

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

2. 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

3. Outline
• Group Health’s pathway to increased demand for shared decision
making (SDM)
• Infrastructure to support SDM
• How did we create a culture of expectation around SDM and
begin to build SDM competencies among providers?
• Measurable outcomes
• Conclusions and next steps

4. Group Health’s pathway to
shared decision making

5. 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)

6. Group Health rates of surgical procedures rising

7. 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

8. Infrastructure elements to
support shared decision
making

10. Twelve preference-sensitive conditions
• Orthopedic Surgery • Women’s Health
– Hip Osteoarthritis – Uterine Fibroids
– Knee Osteoarthritis – Abnormal Uterine Bleeding
• Cardiology • Breast Cancer – General Surgery
– Coronary Artery Disease – Early Stage Breast Cancer
– Breast Reconstruction
• Urology – Ductal Carcinoma In Situ
– Benign Prostatic Hyperplasia
– Prostate Cancer • Neurosurgery
– Spinal Stenosis
– Herniated Disc

11. Epic ordering of patient decision aids

13. 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.”

14. Appropriate staffing for implementation and
ongoing process improvement
Project managers with experience implementing
practice changes at Group Health were hired to
carry out this work
14

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

16. 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.

17. Setting the tone for competency in shared
decision making
“No patient
should undergo
a preference
sensitive procedure
without documented
evidence that they
“Nice to do got all the information
if you have they needed and then
the time and Cultural spectrum
had a conversation with
inclination.” their provider in which
their preferences were
documented before they
made their decision.”
GH leaders want to
push providers right
over here!

18. 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

21. Outcomes

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

27. Comparison of mean costs in 6 months
after index date, control vs. intervention
Hip Osteoarthritis Cohorts Knee Osteoarthritis Cohorts
Control Intervention Control Intervention
N=968 N=820 N=4217 N=3510
Costs (2009 dollars)
Total, Mean $16,557 $13,489 $10,040 $8,041
Inpatient $7,793 $5,774 $3,512 $2,475
Outpatient $8,764 $7,715 $6,528 $5,565
Primary Care $548 $568 $597 $532
Pharmacy $4,894 $4,091 $3,219 $2,591
Specialty Care $2,497 $1,868 $1,460 $951
Orthopedic Surgery $790 $629 $773 $694

28. Conclusions
and next steps

30. Shared decision making with decision aids

31. Next steps for Group Health
• Adding more 5-to-7 more decision aids in 2013
• Moving decision aid ordering and shared decision making
conversations upstream into Primary Care
• Automating pre-visit recording of patient knowledge, values, and
treatment choices in electronic medical record

32. Acknowledgements
• Funding • GH Implementation
• Informed Medical Decisions • Tiffany Nelson Stan Wanezek
Foundation • Charity McCollum Jan Collins
• The Commonwealth Fund • Andrea Lloyd Scott Birkhead
• Health Dialog • Colby Voorhees
• Group Health Foundation
• GH Research Institute
• Emily Westbrook
• GH Physician Leadership • Rob Wellman Carolyn Rutter
• Michael Soman Marc Mora • Tyler Ross Darren Malais
• Paul Sherman Chris Cable • Clarissa Hsu Sylvia Hoffmeyer
• Dave McCulloch Matt Handley • David Liss Jane Anau
• Charlie Jung Nate Green
• Jane Dimer Mark Lowe • External Advisors
• JC Leveque Gerald Kent • Jack Wennberg Michael Barry
• Paul Fletcher Tom Schaff • Doug Conrad Cindy Watts
• Rick Shepard • David Veroff Richard Wexler
• Kate Clay Leah Hole-Curry
• Public Policy
• Karen Merrikin