Implementing Shared Decision Making In The Real World

You read the Disease Management Care Blog and use its literature-based links.  As a result, you know a lot about shared decision making (SDM).   Based on the randomized control clinical trial data that are regularly linked by the DMCB, you're ready to implement it in your network of primary care clinics.  You call your physicians together for a meeting, explain SDM is the best thing since the invention of the Woods lamp and ask them to refer patients to the program.

Except for the part about the DMCB, that's what basically happened at the eight highly regarded medical institutions: Dartmouth-Hitchcock Medical Center, MaineHealth, Massachusetts General Hospital, Mercy Clinics in Iowa, the Oregon Rural Practice–Based Research Network, the Palo Alto Medical Foundation, the Stillwater Medical Group in Minnesota and the University of North Carolina at Chapel Hill.  The decision aids covered approximately 50 common conditions such as knee arthritis and prostate enlargement

And it didn't work out.

To investigate what happened, investigators at RAND interviewed 23 "key informants" from the 34 primary care sites that had implemented the Informed Medical Decision Foundation's shared decision making program. The interviews were conducted between December 2010 and March 2011.  Their study is published in the February issue of Health Affairs.

Three barriers were identified:

Overworked physicians: given all the other health care needs of their patients, it was difficult to count on physicians to distribute the decision aids.  As a result, only 10%-30% of eligible patients participated.

Overconfident physicians: many doctors felt that they were already providing sufficient patient education or that their patients would not benefit from the decision aids.  Just telling the docs that this worked was not enough.

Underperforming EHRs: the state-of-the-art information technology could not flag potential patents, remember which individuals had been exposed to the decision aids or record the patients' preferences.

The answers?

Well, if the someone from the eight institutions had simply called the DMCB and asked, it would have told them about the many times it explained stuff to a roomful of physicians and had zero impact.  There also good peer-reviewed literature on why it's so difficult to change physician behavior. 

The DMCB ultimately found the answer is to take physicians out of the work flow.

That's what the RAND researchers found.  Based on their interviews, they recommend that if you're going to implement SDM in your clinics:

 Automate the process as much as possible and remove human decision-making from the process the triggered the decision aid.  That could be done on the basis of pre-existing clinical criteria or when a specialist referral had been arranged.

 If automation was not feasible, rely on non-physicians to trigger the decision-aid.  For example, office assistants could offer SDM to patients in the course of check-out.

Image from Wikipedia

Shared Decision Making for Hip and Knee Replacement Candidates

Osteoarthritis (a.k.a "degenerative arthritis) of the hip and knee just... sucks. Characterized by activity-related pain in the affected joint, many otherwise physically fit persons have to resort to pills, injections and, finally, an appointment with an orthopedic surgeon to talk about joint replacement surgery.

What is less appreciated is that osteoarthritis can have a waxing and waning course with periods of relative remissions. What's more, conservative treatment options can lessen or delay the need for surgery. Last but not least, the surgery itself involves months of recovery and the possibility of a nasty complication.

The primary care physician Disease Management Care Blog presided over this many times with its arthritis patients.  It was generally reluctant to refer a patient to an orthopedic surgeon because it knew that the patients would be more interested in the potential benefits and pay less attention to the downsides of surgery.

Enter shared decision making (SDM). Defined as care that is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions, the premise is that by giving patients the information they need, they'll be able to ultimately determine the course of their care.  That would include patients with severe hip or knee osteoarthritis who are thinking about surgery but who also need to consider the option of conservative management.

That's why this just-published Health Affairs study is noteworthy. All the 27 orthopedic surgeons in the 5 Group Health Cooperative clinics introduced shared decision making (SDM) for patients who were being evaluated with knee or hip osteoarthritis.  The intervention consisted of DVDs and booklets (from this company) that were ordered by the surgeon prior to an appointment.  The materials could also be viewed on Group Health's website at any time.

The study itself was quasi-experimental.  To be included in the study, patients had to 1) have knee or hip arthritis, 2) ) be continuously enrolled in the Group Health Plan for 12 months prior to the orthopedic clinic visit and 3) have a visit itself that was first index visit by the patient for that problem being evaluated by that particular specialty.

Outcomes from the 18 months of the SDM intervention period (January 2009 through July of 2010) were compared to the observation period of January 2007 through July of 2008.

Recall that the surgeon had to proactively order the SDM prior to the visit.  As a result, only 41% of the hip patients and 28% of the knee patients received the DVD, pamphlet or viewed the on-line materials.
 
Nonetheless, during the 6 months after the initial visit, the SDM patient population had 0.34 hip operations per 180 person-days (your DMCB offers an explanation of this counter-intuitive metric below*), compared to the control population of 0.46.  The difference was statistically significant. 

There was also a statistically significant reduction in knee operations: 0.09 per 180 person-days vs 0.16 per 180 person-days. 

All the differences held up after the authors statistically adjusted for differences in age, sex, obesity, co-morbid conditions, use of prior x-rays, joint injections, insurance factors and the clinic site.

Like all good authors writing in a high quality journal, they point out that this research was not pristine. The comparison period may not have been a representative baseline and, from 2008 to 2009, other factors may have caused a drop in hip and knee surgeries.

Nonetheless, this is an example of a "real world" study that credibly demonstrates that when osteoarthritis patients are exposed to SDM, more will opt for conservative management.  While that helps decrease health care utilization and ultimately costs, that's not the most important point: the patients who really wanted surgery got it and the patients who were less sure about the benefits of surgery chose not to have it.  What's more, this didn't involve a lot of expensive face-to-face care management, it involved some DVDs.

The DMCB cautions that this successful study was carried out in a highly integrated delivery system and may not be transferable to other practice settings.  That being said, as Accountable Care Organizations struggle to meet their patients' expectations and save money, this application of SDM may represent an important option.

*The DMCB interprets "180 patient days" as one patient being followed for the entire 6 months of the study.  If that's correct, the average SDM knee patient referred to a Group Health orthopedist had a 34% chance of getting surgery versus a 46% chance in the prior control group.  For the knee patients, it was 9% vs. 16%

In the terse style of KevinMD Blog

More aggregation. No graphics. Read and run. The DMCB tries it out:

Opting out Brit style

Stormy seas for Health Dialog in the North Atlantic.

Registries. Really really big registries.

Speaking of Health Dialog, disease management and chronic care improvement. What does RHIO stand for again? Medicare and its cutting edge technologies can't, um, be far behind.

Let’s rethink that business model.

HT to the Wall Street Journal Blog. Mr. Reality, may I introduce you to Mr. Revolution. Oh, and look there is Mr. PHR, let’s go over and talk to him and his buddies next.

Health insurers never leave money on the table.

Co-pays go to the PROVIDER. Hmmm, have to wonder at the motivation of the Minute Clinics. It's such a good idea, DMCB is waiting for the physicians to also do the same.

Health Dialog takes the World Health Care Congress on a Deep Dive and We Liked It

A thoroughly caffeinated and excited-to-learn Disease Management Care Blog attended the first day of the World Health Care Congress. While there were a host of sessions presided over by the lesser and greater gods of the health care cosmos, the most interesting was hosted by Susan Dentzer (soon-to-be Editor in Chief, Health Affairs) on the “Deep Dive” clinical trial. The two presenters were David Wennberg MD, MPH of Health Dialog and Lance Lang MD of Health Net, Inc. Almost 190,000 (not a mistake, that’s 190 thousand) commercially insured patients from Highmark Blue Cross Blue Shield (east coast) Health Net (west coast) were randomly assigned to 'usual' care management (serving as the control group) versus “enhanced” care management (the intervention group).

What difference in between the two groups? According to Dr. Wennberg, the intevention group was the subject of 'analytics on steroids.' As the DMCB understands it, this consisted of a later-generation predictive modeling capability that was hypothesized to do a better job of identifying which patients would benefit from Health Dialog’s remote patient coaching.

As many in the population-care ‘business’ already intuitively know, not all patients with a chronic condition necessarily benefit from disease management. For example, many patients implacably prefer not to be called, many have already achieved maximum self-care, others are not ready to make any life-style changes, many are victims of other random illness, many have severe disease that may not benefit from remote coaching and many have other concurrent conditions that are not amenable to any intervention. The DMCB suspects that Heath Dialog used its prior experience in the art and science of patient engagement to develop a predictive modeling tool that culled subjects who would be most a) open to and b) likely to benefit from its care programs. By targeting the “health coaching” at the ‘optimum’ patients in the intervention group, the researchers suspected total health care costs would be lower versus a control group that received the relatively untargeted health coaching.

The content of the health coaching was not different in the two groups; what was different is that the Health Dialog nurses received different lists of patients to call. The patient randomization occurred at a household level. Following randomization, the control and intervention groups were statistically similar by mean age, male-female ratio, disease burden and baseline costs. In classic Health Dialog style, the two groups were also similar according to the proportion of persons with the a) ‘big 5’ diseases, b) ‘preference sensitive conditions’ (examples include heart disease amenable to surgery, hip and knee arthritis, back problems and uterine disorders) and c) ‘coachable’ conditions (examples include obesity, hyperlipidemia, migraine and abdominal pain).

Bottom line: compared to the control group, costs were significantly lower in the intervention group. The majority of savings appeared to be due to lower inpatient utilization, but this was also true across the board including emergency room visits and outpatient visits. The savings weren’t huge, but enough to cover the cost of the program and then some. What’s more, Lance Lang presented evidence from Health Net showing a compelling impact on overall trend. As a result of these data, Health Net and Highmark have moved their control patients into the ‘analytics on steroids.’

While the DMCB and its readers will need to await release of the detailed information in a public peer review setting, this preview is interesting at several levels. First of all, Health Dialog and its partners are showing “applied” health services research is possible in the business setting. Secondly, while critics of disease management fault the industry for failing to show any 'return on investment,” that criticism is really being directed at Ver. 1 programs that are long gone. The industry has already moved beyond those early approaches with new programs. Third, modern strategies for persons with chronic illness may need to rely more on ‘market segmentation’ than on finding new remote engagement strategies. Fourth, there is no good news here on how this might work in Medicare population: this information doesn’t appear to be generalizable to that group.

Last but not least, Drs. Wennberg and Lang noted the success in this trial is not the “magic bullet,” but is an important consideration in a broader multi-pronged strategy aimed at controlling health care costs. I am pleased to report that Ms. Dentzer and the audience did not appear to disagree.

Just what IS a "Demo" you ask? Read on......

Health Dialog landed a demo!

This announcement made the Disease Management Blog ask just what is the species known as a Medicare/Medicaid “demonstration?” With the aid of some buddies, I was able to take a guided bus tour of the topic around the web. I’ve learned to think of them as “field tests” that typically involve a waiver of existing CMS regulations that assess whether a change will lead to better efficiency or quality. Referred to as “demos” for short, they can be approved by Congress (usually as a part of a legislative package) or initiated by CMS under a provision in the law that gives the Secretary of HHS “demonstration authority.” Even if a demo is approved, however, funding is by no means guaranteed. Those bucks may have to come via Congress through a separate bill. Funding may also come out of other existing pots of money, but they often need approval by other entities such as the Office of Management and Budget. (As an aside, the disease management blog wonders if this could account for some of the radio silence on the Medical Home Demo, but I digress)

Then it’s up to CMS to author the specific language that actually kicks off the demo. This language includes the request for proposals (RFP), which are published in the Federal Register. It takes full-time insiders to anticipate coming demos or read the Register. Either that or a prescription for Ritalin. Not all demos are necessarily awarded through a public bidding process. They can be awarded to a specific entity (a favorite approach is earmarks) or written so narrowly that any competition is nil.

Companies pursue RFPs for several reasons, including the chance to prove to CMS that a waiver should be made permanent or their product or service deserves to be permanently covered by Medicare. It can also lead to other demos, especially if the previous track record is good. It can also generate some important PR, such as the attention of the Disease Management Care Blog. Companies also gain considerable experience in delivering their product or service. While the economic payoff in the short term may not be that great, if CMS ultimately decides to include the product or service as a permanent part of the Medicare benefit, the payoff can be huge.

With some trepidation, the Disease Management Blog donned his trusty dive suit and entered the CMS demo web site. It found a ten page list of 52 demos (5 are closed). More details on the Health Dialog announcement can be found here. It looks like this will be a three arm randomized trial where beneficiaries will be assigned to either 1) a health risk assessment (HRA) questionnaire plus generic healthy life style advice, 2) an HRA plus advice tailored to the HRA or 3) an HRA plus intensive counseling. Participants will also be linked to other community based health promotion programs.

It appears Health Dialog was not only awardee. The others are Focused Health Solutions, HealthPartners, Pfizer Health Solutions and StayWell Health Management. It begins in April of 2008, and will end in September of 2011.

Disease Management, Wellness, Benefit Design, Innvovation & Coalitions - The Path to Real Shareholder Value

In addition to being notified by email of having won the "UK NATIONAL LOTTERY," the disease management weekend blog received this interesting tidbit from the Google Alerts: AstraZeneca grants $1.5M to NCDOT.

The disease management blog's clickclickclicking revealed that the ERISA-exempted North Carolina State Health Plan covers over 600,000 state employees, teachers, retirees, current and former lawmakers, state university and community college personnel, state hospital staff and their dependents. The Plan also includes disease management programs. The provider those programs? Health Dialog.

Thanks to AstraZeneca (AZ for short), a segment of the state employees, i.e. those in the North Carolina Department of Transportation (NCDOT) are being given an additional benefit: "wellness programs" that are targeting tobacco use, stress, physical activity and nutrition habits. It appears to this blog that the grant from AZ is really going NC Prevention Partners, a statewide coalition that includes the North Carolina hospitals, Blues, State Department of Insurance and State Medical Society. I suspect that Health Dialog will not only have a role in evaluating the "impact" of this initiative but actually delivering some of the services: hint: and 800 number and the use of the word "coaches."

Thoughts:

Once again, it's the ERISA-exempted plans outside the DC beltwayosphere that are taking the leadership in piloting novel benefit designs that include population care.

The disease management industry is morphing. Wellness embedded in a multi-dimensional care management program is just one example. It ain't your mother's call center for diabetes anymore.

The disease management industry, despite what its detractors say, is not all about grabbing a piece of the insurance premium and returning value to its shareholders. It can be about coalitions that lead to something being greater than the sum of its parts. THAT is shareholder value.

The press release heralds the coming achievement of "cost savings through reduced health care claims and improved employee outcomes." If the North Carolina State Health Plan was so confident of that, why did it take outside money to make that happen? If they truly believe in the value of wellness in the preservation of human capital leading to reduced claims expense down the road, the taxpayers shouldn't mind the investment.

What happens when the money runs out in three years? Suppose there aren't any hard savings but NCDOT employees are abusing less tobacco, exercising more and eating their veggies? How will past savings translate into future administrative expense?

The answer to that may lie in the evaluation of outcomes. I can only hope our friends in Health Dialog do a transparent and complete job of evaluating the impact of this initiative. Given the degree of skepticism out there about disease management outcomes, it may take a neutral independent third party and an upfront commitment to share the results in a peer reviewed public forum.

As an aside, I looked at the North Carolina State Health Plan formulary and did not discern favorable placement of AZ's products for the state employees. Maybe the grant truly is motivated by a desire to do good. And good thing they're not relying on the UK NATIONAL LOTTERY for financial support - I'm keeping all that money and have no intention of sharing it.

Here's to Health Dialog's and the NCDOT's and the NC Prevention Partners' success. Cheers!

Health Dialog News...

Marchons!

Zout alors. 50 million! 136 thousand persons with diabetes! Combien d'euros?