The patient's role in surgery choices: More engagement, better care

On September 4, a team of Group Health researchers and physicians published a Health Affairs paper with a dynamic title: “Introducing Decision Aids at Group Health Was Linked to Sharply Lower Hip and Knee Surgery Rates and Costs.”

The study shows that after establishing a program providing patients with evidence-based information videos, Group Health had 26 percent fewer hip replacements, 38 percent fewer knee replacements, and 12–21 percent lower costs for those patients over six months.

While these results alone are impressive, the study may signal something more: By providing care in a way that is more patient centered, Group Health is also demonstrating one way the nation might address an epidemic of overtreatment and medical harm—and its related suffering. Through Group Health’s shared decision making initiative, which uses decision aids, we are helping patients gauge whether elective procedures align with their personal needs, values, and desires. Patients are avoiding surgeries that may expose them to unnecessary risk. Patients and doctors are more satisfied in both the short and long term.

If you question whether such help is needed, see Tara Parker-Pope’s recent New York Times blog (and the hundreds of comments it inspired), “Overtreatment Is Taking a Harmful Toll.” And if you doubt that patients deserve unbiased and evidence-based assessments of their care options—especially for elective procedures with uncertain outcomes—read “Two Arms, Two Choices: If Only I’d Known Then What I Know Now” in the August 2012 Health Affairs. This first-person account from Colorado construction manager Kerry O’Connell—disabled by faulty arm surgery, then suffering a hospital-acquired infection—presents a heartbreaking argument for better disclosure.  

“I often wonder why, in a country that spends nearly $3 trillion a year on health care, there aren’t more systematic efforts to track what works best for patients and what doesn’t, and to inform everybody so that patients can make better choices and the health system itself can improve,” Mr. O’Connell writes.   

Group Health launched its shared-decision making initiative in 2009 to address such needs, knowing that decision aids help patients make more informed choices based on their own values. Previous studies had also shown that patients who used decision aids tend to choose less invasive care and to be more satisfied with their choices.

Some of the first randomized trials on decision aids were conducted among prostate cancer patients at Group Health more than 20 years ago by our own Dr. Ed Wagner, Massachusetts General Hospital’s Dr. Michael J. Barry, and others.  (Dr. Barry later helped establish the Informed Medical Decisions Foundation, which has funded some of Group Health’s research in this area.)  

This week’s study breaks new ground as the first report from a landmark Group Health project exploring how routine use of decision aids can affect health care and costs.

Like any study, our evaluation of the initiative has limitations, which the paper describes. For example, the findings are based on just six months of follow-up; patients who chose to forgo orthopedic surgery may opt for it later. Group Health’s rollout of the patient-centered medical home model of primary care may also have affected surgery rates.

Another caution: This paper reports only on hip and knee surgery. We’ll learn more as evaluation continues and more studies are published. Results may differ for patients and providers in other areas, such as cardiology and women’s health.

Still, many people involved in the initiative say it has caused a real shift in providers’ awareness of patients’ preferences and concerns. Wanting to help our patients, we have a natural bias toward action, and often feel compelled to employ the skills and procedures we’ve been trained to use. But overtreatment isn’t what our patients need—nor is it what most of them want when they are thoroughly informed. So we must always practice within the context of our patients’ needs, desires, and values—making sure that care is as patient-centered as possible.

Fortunately, the Group Health environment fosters this approach. Our non-profit integrated health plan has no financial incentive to do more care than needed. Also, Group Health information technology supports the effort. For example, the electronic medical record prompts providers to order a decision aid for a patient; and the patient can see the decision aid online. In Lean‑speak, our systems “make the right thing to do the easy thing to do.”

So we congratulate the dozens of providers, managers, research team members, and others involved in this transformative Group Health-wide effort. This week, we celebrate lessons we’re just beginning to glean from all their hard work. We do so knowing that the initiative will keep generating knowledge as it benefits patients and providers for many years to come.

—Eric