Surgeons decrease joint replacement rates, costs
An integrated system assisted providers at five orthopedic clinics in integrating video-based decision aids to support shared decision-making (SDM) into the care of potential candidates for joint replacement surgery. Group Health Cooperative, a Seattle-based system that provides care and coverage to more than 600,000, distributed decision aids to a portion of eligible patients, mostly the best surgical candidates. It was associated with significant reductions in surgery rates and overall healthcare costs among all potential joint replacement candidates.
SDM is a process in which informed patients and providers collaborate on the right course of action. Through SDM, the provider gives information to the patient that facilitates understanding of the possible outcomes and trade-offs associated with various treatment options. Joint replacements are common, costly procedures in which disagreement exists as to which patients are most likely to benefit, and in which patient and physician preferences should play an important role in determining the appropriate action. However, use of SDM and related tools (such as decision aids) remains rare in everyday practice.
After reviewing the available aids, a multidisciplinary committee known as the Shared Decision Making Implementation Team chose to emphasize preference-sensitive health conditions related to elective surgical procedures. To that end, they chose to promote use of decision aids for patients with hip and knee osteoarthritis, abnormal uterine bleeding, uterine fibroids, lumbar herniated disc, lumbar spinal stenosis, chronic stable angina, benign prostatic hyperplasia, early-stage prostate cancer, and early-stage breast cancer.
Key components of the effort by Group Health included the following:
- introductory meetings with department and clinic leaders to explain and win support;
- mandatory viewing of the aids by clinic providers and staff;
- visits to each clinic to review and discuss the aids and how to incorporate them into existing processes;
- iterative communications to develop a formal, customized implementation plan for each clinic;
- post-implementation monitoring and support.
After adjusting for differences in the patient populations, overall hip replacement surgery rates at the five clinics fell by roughly 26% during the two-year period after the go-live date, as compared to the rate among similar patients during the two years before implementation. Use of knee replacement surgery fell by an even greater amount: 38%. The decline in surgeries tended to occur among those who did not receive the aid, and hence appear to have been driven by the intense provider education, training, and monitoring efforts that were part of this program, rather than distribution and use of the aids themselves.
Post-implementation conversations with orthopedic surgeons suggest that this finding stems from their decision to be selective about who received an aid. At least some of the doctors decided not to distribute them to those they thought were a long way from requiring surgery, such as patients presenting with osteoarthritis for the first time.1
Adjusted average total health care costs for patients with hip osteoarthritis fell by 21% in the 180-day period after program implementation, as compared to the costs for similar patients before implementation. For those with knee osteoarthritis, the corresponding decline was 12%. (Both figures represent the geometric mean.) Savings stemmed from fewer hospitalizations, inpatient days, prescriptions, and primary and specialty care visits.1
- Arterburn D, Wellman R, Westbrook E, et al. Introducing decision aids at Group Health was linked to sharply lower hip and knee surgery rates and costs. Health Aff 2012;31(9):2094-2104. Accessed at http://www.ncbi.nlm.nih.gov/pubmed/22949460.