Beauty Health for Life

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. Whats 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 er 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 perences, needs, and values and ensures that patient values guide all clinical decisions, the premise is that by giving patients the information they need, theyll 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.

Thats 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 Healths 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, thats 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.  Whats more, this didnt 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 thats correct, the average SDM knee patient erred 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 prestigious medical journal JAMA, Georgetown Universitys William Novelli, Kaiser CEO George Halvorson and Consumer Reports John Santa summarize the results of a patient survey and focus group results on the topic of shared decision making. The study was sponsored by the prestigious Institute of Medicine.

The results show that when it comes to treatment, patients want their doctors to present all relevant options, including the option of doing nothing.  Most also want to know each options risk.  Once they have good understanding, the majority are comfortable with letting their physician lead on chosing the "best" decision.  This approach is likewise associated with greater patient satisfaction.

Yet, despite their perence on how to best reconcile competing treatment options, few can recall it actually happening that way.

While this may be newsworthy to JAMA readers, the results should be of no surprise to anyone working in the population health management (PHM) field.  PHM service providers have been advocating for shared decision making for years. Theyve also developed business models that bridge the gap between JAMAs academic ideals and the real world inhabited by flesh and blood patients with busy doctors who need help now.

As testimony to the blurring between the theoretical and the possible, the Disease Management Care Blog has pasted 4 quotes below.  One is from a concluding paragraph of the JAMA paper, while the remainder are from the web sites associated some commercial care management vendors.

See if you can spot which is which:

physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health (link)

can ensure that in the trilogy of opinions, the patients opinion and perspective are core, helping fulfill the promise of better health at lower cost (link)

constantly make decisions that impact their health and provides them with the tools they need to make the decisions that are right for them (link)

based on each individuals readiness-to-change and what health issues they want to address, personalized interventions connect the widest range of health management solutions, devices and diagnostic tests (link)

"Shared decision making" (SDM) is a good thing, right? Defined as "model of patient-centered care that enables and encourages people to play a role in the management of their own health" its achieved a level of admiration only exceeded by the Cat Daddy dance and owning Facebook stock.  Yet, while theres considerable research to support the immediate use of SDM in doctors offices, it seems theres a problem.

No one asked patients what they think.

Well, this just published Health Affairs study summarizes the opinions about SDM that were gleaned from six focus groups involving 48 health care consumers (out of 458 patients contacted) who resided close to San Francisco.  Participants first watched a video that showcased how shared decision making worked and how it could be used to empower consumers to choose among several recommended treatment options. Then they were asked about their opinions.
The DMCB thought the results were disappointing.

Patients feel vulnerable.  They reported that:

1. they feel pressured to "conform" to a "role" that was subservient not only to the expertise of the physician, but his or her good will. Patients didnt want to be viewed as being "uncooperative."

2. it can be futile to overcome the authoritarian demeanor of their physicians. Patients feel powerless.

3.  there isnt enough time to reconcile the information theyve collected on their own with the information at their physicians fingertips.

4. They need to have at least one other family member or friend at the encounter. Patients are unable to absorb all the information they need to make an truly informed decision.

Up until now, the DMCB has assumed that the relatively low uptake of SDM in mainstream clinical care was a function of provider skepticism if not outright hostility. It seems another problem may be lingering patient doubts too.

Based on their results and a review of the peer reviewed literature, the authors offer some suggestions on how to foster the use of SDM including 1) increasing physician reimbursement, 2) developing efficient decision support tools, 3) increasing patient-physician face-to face time, 4) helping physicians become aware of the need for more open communication and 5) creating "signals" by the "system" that patient "engagement" is important.

The DMCB agrees, but points out that the road to SDM is not necessarily lined with physicians. Theyre busy and theres little room in the course of a clinic day for more disruptions of their work flow.  Thats why it makes sense to think about SDM through the prism of population health management.  Heres why.

More on the topic in a future post.

Image from the SAMHSA website.