September 15, 2012

How shared decision making works at Group Health

Note: This article was written prior to Kaiser Permanente's acquisition of Group Health. At the time, Kaiser Permanente Washington Health Research Institute was known as Group Health Research Institute.

You’re at a crossroad: get elective surgery, or not? Once, your doctors had all the information—and therefore all the power. You’d do whatever they said, because even if you had their specialized information, how would you decode it?

Now the balance has shifted. More people want to make their own health care decisions in consultation with providers. And health information abounds, including countless websites and direct-to-consumer ads.

“Unfortunately, too much health information is biased and trying to sell you something,” says David E. Arterburn, MD, MPH, a general internist and associate investigator at Group Health Research Institute.

To help counter this, Washington state and Group Health have become leaders in “shared decision making”—a process that provides patients with unbiased information in plain language about the evidence-based benefits and risks of treatment options.

“Providers give patients video-based or printed decision aids,” explains Dr. Arterburn, who is leading an evaluation of Group Health’s effort—and showing impressive results. Information from the decision aid—and the provider—help the patient clarify what matters most to them, weigh their options, and choose the best course for them.

Group Health has distributed more decision aids than any other single health care organization in the world—more than 25,000 by July 2012, adding around 900 more each month.

“After weighing the pros and cons in the context of their own values and preferences,” Dr. Arterburn says, “patients can make the right choice, at the right time, for the right reasons for them.” Because patients “own” their decision, they are likely to be more satisfied with their choice, regardless of the outcome.

Shared decision making is designed for clinical gray areas or “preference-sensitive” decisions, which should reflect what individual patients need and prefer.

“Very few treatment decisions are supported by overwhelming evidence,” says Dr. Arterburn. “And even those that are—such as taking daily aspirin after a heart attack—vary by individual patients, like whether they have a stomach ulcer.”

Shared decision making doesn’t try to encourage patients to select any particular treatment option. But research, including Dr. Arterburn’s, has shown that people tend to choose more conservative, less invasive options when decision aids are given. This matters because, like getting less health care than needed, getting too many tests and treatments can harm patients.

Overtreatment also concerns experts from the Dartmouth Atlas of Health Care, who track nationwide Medicare spending. Their research shows that preference-sensitive care too often varies widely by geographical area, depending most on what local providers happen to want to do—not on what individual patients want or need.

In 2007, Group Health launched the Content of Care initiative, like an in-house version of the Dartmouth Atlas. “Although Group Health has a long tradition of patient-centered care, we found some variation in care that could not be explained by differences in clinical circumstances or patient preferences,” says Matthew Handley, MD, Group Health’s associate medical director for quality and informatics. Shared-decision making may help to reduce this problem by improving communication and engaging patients in conversations about their values.

Also in 2007, Washington became the first state to pass legislation recognizing decision-aid use and shared decision making as a higher standard of informed consent. “This grew out of a fortunate confluence of events,” says Karen Merrikin, JD, Group Health’s senior policy advisor and former executive director of public policy. She was one of several catalysts, including Dartmouth’s John Wennberg, MD, MPH, and the Informed Medical Decisions Foundation’s Benjamin Moulton, JD, MPH. And state policymakers became interested, including Cheryl Pflug (R), Eileen Cody (D), and Governor Chris Gregoire and her office.

In 2009, as part of a quality-improvement program, Group Health leaders, providers, and staff started to implement 12 decision aids in six specialties: orthopedics, cardiology, urology, women’s health, breast cancer, and back care. Patients can watch the videos alone or with their families either on a DVD that is mailed to them or online on Group Health’s secure website for patients. All of Group Health’s specialty leaders, care providers, and staff have seen the decision aids.

“This has helped to improve Group Health’s culture of care so it is centered even more on the individual patient,” says Dr. Arterburn. “None of this, including our research, could have happened without the whole-hearted enthusiasm of Group Health leaders.”

What’s next? “We’re excited about moving conversations about preference choices further upstream, from specialty care into primary care,” says Tiffany Nelson, MPA, director for Content of Care, which helped to implement the decision aids and provide ongoing tracking and support. “For patients seeing an external specialist, exposure to the tools needs to happen within our system to minimize the number of patients who get elective surgery without having seen a decision aid.” Washington state is developing a process for certifying decision aids. And Dr. Arterburn’s team will keep reporting research results. Stay tuned.


by Rebecca Hughes