Implementing decision aids affects care decisions in urology

Fewer invasive treatments after Group Health implemented decision aids

SEATTLE—After Group Health Cooperative implemented video-based decision aids for men with two common prostate conditions, rates of elective surgery for benign prostatic hyperplasia (BPH) and rates of active treatment for localized prostate cancer declined over six months. But the total cost of health care for those patients did not fall significantly, according to a new report called “Decision Aids for Benign Prostatic Hyperplasia and Prostate Cancer” in the American Journal of Managed Care.

“Although professional societies emphasize the role of shared decision making in helping men make treatment decisions about BPH and prostate cancer, evidence is limited about the impact of integrating decision aids into clinical practice to support this approach,” said study leader David Arterburn, MD, MPH, a general internist and associate investigator at Group Health Research Institute.

“We found that implementing video-based decision aids for BPH and localized prostate cancer in a large, multi-site urology group practice setting was associated with fewer men with medically treated BPH choosing to undergo elective surgical intervention and fewer men with localized prostate cancer choosing to undergo hormonal, surgical, or radiation treatment,” Dr. Arterburn added. He wrote a recent blog post on creating a culture at Group Health where shared decision making is the norm. 

For men with medically treated BPH (that is, those who were already receiving prescription medications to treat their BPH), the study found the rate of surgical intervention for BPH declined by 32 percent; but for those with untreated BPH, the rate didn’t fall significantly. And for men with localized prostate cancer, rates of active treatment declined by 27 percent.

Trend toward lower costs

There was a trend toward lower total health care costs after decision aid introduction for these conditions, but this finding was not statistically significant. Possible reasons include small sample sizes, Dr. Arterburn said, even though this observational study included more than 4,000 patients—and is part of the largest study to date of implementing patient decision aids in the context of quality improvement for urologic care. Another possible reason is that choosing nonsurgical treatment for BPH and “active surveillance” for localized prostate cancer may generate costs related to follow-up and testing.

This implementation and evaluation were part of Group Health’s large-scale quality-improvement program, which has achieved the world’s largest distribution of video-based decision aids for any single organization. Since 2009, Group Health has used a multimodal strategy—involving a multidisciplinary team of Group Health leaders, providers, and staff—to give patients more than 50,000 video-based decision aids in 12 preference-sensitive health conditions in six specialties. 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. Delivery of decision aids has been rising with time at Group Health, and implementing provider skills training in shared decision making is helping to ensure high-quality patient conversations. Prior research on this shared decision-making program linked implementing decision aids to lower costs and rates of joint replacement surgery for arthritis.

BPH, which becomes more common with age, means this male reproductive gland is enlarged without raising cancer risk. And localized prostate cancer means it hasn’t been found to have spread throughout the body. For both BPH and localized prostate cancer, no single treatment has been conclusively shown to be best, long-term outcome evidence is limited, alternative treatment options have varying benefit-risk profiles, and informed patients may choose to avoid any treatment whatsoever.

“That means patients with both BPH and localized prostate cancer are good candidates for shared decision making conversations,” Dr. Arterburn said. Decision aids help patients who are at a crossroad: deciding which treatment to pursue when a health condition is in a clinical gray area with more than one treatment option, each with pros and cons—and little evidence to say any one option is better than another.

Prior randomized trials of various decision aids have found that patients are more likely to make informed choices that are aligned with their preferences when they have access to easily understood, evidenced-based information about treatment options’ risks and benefits. They also tended to choose more conservative, less invasive options—and to be more satisfied with what happens to them, regardless of the option they chose. But more research is needed to understand whether these tools can improve long-term patient satisfaction with decision making and quality of life.

The Commonwealth Fund provided the main support for this study (grant #20080479). The Informed Medical Decisions Foundation (grant #0103) and Group Health Foundation funded Group Health’s implementation of decision aids. Health Dialog provided the video-based decision aids that this study used.

Dr. Arterburn’s coauthors were Robert Wellman, MS, a biostatistician, Emily Westbrook, MHA, director of the research project management office, and Tyler Ross, MA, manager of research programming, at Group Health Research Institute; David K. McCulloch, MD, medical director for clinical improvement, Matthew Handley, MD, medical director for quality and informatics, Marc A. Lowe, MD, urology service line chief, Chris Cable, MD, medical director of medical specialties, at Group Health Physicians; Steven B. Zeliadt, PhD, is a core investigator in the Northwest Health Services Research and Development Center of Excellence, Veterans Affairs (VA) Puget Sound Health Care System, in Seattle; and Richard M. Hoffman, MD, MPH, a professor of medicine at the University of New Mexico and a physician at the New Mexico VA Health Care System in Albuquerque. Dr. Arterburn is also an affiliate associate professor of medicine and Dr. McCulloch is a clinical professor of medicine at the University of Washington School of Medicine, and Dr. Zeliadt is a research assistant professor of health services at the UW School of Public Health and an affiliate investigator at the Fred Hutchinson Cancer Research Center and Group Health Research Institute.

The Commonwealth Fund

The Commonwealth Fund is a private foundation that aims to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. 

Informed Medical Decisions Foundation

The Informed Medical Decisions Foundation develops content for patient education programs--including the knee and hip osteoarthritis programs that were the subject of this study. The foundation has an arrangement with a for-profit company, Health Dialog, to coproduce and market these programs to health care organizations.

Health Dialog

Health Dialog Services Corporation is a leading provider of health care analytics and decision support. The firm is a private, wholly owned subsidiary of Bupa, a global provider of health care services. Health Dialog helps health care payors improve health care quality while reducing overall costs. Company offerings include health coaching for medical decisions, chronic conditions, and wellness; population analytic solutions; and consulting services. Health Dialog helps individuals participate in their own health care decisions, develop more effective relationships with their physicians, and live healthier, happier lives.

Group Health Foundation

The Group Health Foundation supports Group Health in providing the best care for its members and creating better health in our communities.

About Kaiser Permanente

Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America’s leading health care providers and not-for-profit health plans. Founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve more than 12.4 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal Permanente Medical Group physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: kp.org/share.