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The American Journal of Managed Care February 2015
A Multidisciplinary Intervention for Reducing Readmissions Among Older Adults in a Patient-Centered Medical Home
Paul M. Stranges, PharmD; Vincent D. Marshall, MS; Paul C. Walker, PharmD; Karen E. Hall, MD, PhD; Diane K. Griffith, LMSW, ACSW; and Tami Remington, PharmD
Quality’s Quarter-Century
Margaret E. O'Kane, MHA, President, National Committee for Quality Assurance
How Pooling Fragmented Healthcare Encounter Data Affects Hospital Profiling
Amresh D. Hanchate, PhD; Arlene S. Ash, PhD; Ann Borzecki, MD, MPH; Hassen Abdulkerim, MS; Kelly L. Stolzmann, MS; Amy K. Rosen, PhD; Aaron S. Fink, MD; Mary Jo V. Pugh, PhD; Priti Shokeen, MS; and Michael Shwartz, PhD
Did Medicare Part D Reduce Disparities?
Julie Zissimopoulos, PhD; Geoffrey F. Joyce, PhD; Lauren M. Scarpati, MA; and Dana P. Goldman, PhD
Health Literacy and Cardiovascular Disease Risk Factors Among the Elderly: A Study From a Patient-Centered Medical Home
Anil Aranha, PhD; Pragnesh Patel, MD; Sidakpal Panaich, MD; and Lavoisier Cardozo, MD
Employers Should Disband Employee Weight Control Programs
Alfred Lewis, JD; Vikram Khanna, MHS; and Shana Montrose, MPH
Race/Ethnicity, Personal Health Record Access, and Quality of Care
Terhilda Garrido, MPH; Michael Kanter, MD; Di Meng, PhD; Marianne Turley, PhD; Jian Wang, MS; Valerie Sue, PhD; Luther Scott, MS
Leveraging Remote Behavioral Health Interventions to Improve Medical Outcomes and Reduce Costs
Reena L. Pande, MD, MSc; Michael Morris; Aimee Peters, LCSW; Claire M. Spettell, PhD; Richard Feifer, MD, MPH; William Gillis, PsyD
Currently Reading
Decision Aids for Benign Prostatic Hyperplasia and Prostate Cancer
David Arterburn, MD, MPH; Robert Wellman, MS; Emily O. Westbrook, MHA; Tyler R. Ross, MA; David McCulloch, MD; Matt Handley, MD; Marc Lowe, MD; Chris Cable, MD; Steven B. Zeliadt, PhD; and Richard M. Hoffman, MD, MPH
Differences in Emergency Colorectal Surgery in Medicaid and Uninsured Patients by Hospital Safety Net Status
Cathy J. Bradley, PhD; Bassam Dahman, PhD; and Lindsay M. Sabik, PhD
The Role of Behavioral Health Services in Accountable Care Organizations
Roger G. Kathol, MD; Kavita Patel, MD, MS; Lee Sacks, MD; Susan Sargent, MBA; and Stephen P. Melek, FSA, MAAA
Patients Who Self-Monitor Blood Glucose and Their Unused Testing Results
Richard W. Grant, MD, MPH; Elbert S. Huang, MD, MPH; Deborah J. Wexler, MD, MSc; Neda Laiteerapong, MD, MS; E. Margaret Warton, MPH; Howard H. Moffet, MPH; and Andrew J. Karter, PhD
The Use of Claims Data Algorithms to Recruit Eligible Participants Into Clinical Trials
Leonardo Tamariz, MD, MPH; Ana Palacio, MD, MPH; Jennifer Denizard, RN; Yvonne Schulman, MD; and Gabriel Contreras, MD, MPH
A Systematic Review of Measurement Properties of Instruments Assessing Presenteeism
Maria B. Ospina, PhD; Liz Dennett, MLIS; Arianna Waye, PhD; Philip Jacobs, DPhil; and Angus H. Thompson, PhD
Emergency Department Use: A Reflection of Poor Primary Care Access?
Daniel Weisz, MD, MPA; Michael K. Gusmano, PhD; Grace Wong, MBA, MPH; and John Trombley II, MPP

Decision Aids for Benign Prostatic Hyperplasia and Prostate Cancer

David Arterburn, MD, MPH; Robert Wellman, MS; Emily O. Westbrook, MHA; Tyler R. Ross, MA; David McCulloch, MD; Matt Handley, MD; Marc Lowe, MD; Chris Cable, MD; Steven B. Zeliadt, PhD; and Richard M. Hoffman, MD, MPH
Implementing patient decision aids was associated with lower rates of elective surgery for benign prostatic hyperplasia and of active treatment for localized prostate cancer.
To examine the relationships among implementing decision aids (DAs) for benign prostatic hyperplasia (BPH) and prostate cancer (PRCA), and treatment rates and costs.

Study Design
A pre-post observational evaluation of a quality improvement initiative in a healthcare system in Washington state.

Men with BPH seen in urology clinics and all men diagnosed with localized PRCA were identified for an intervention period, in which urologists were instructed to order a DA for every patient with those conditions, and a historical control period. Outcomes were 6-month rates of surgery for BPH, any active treatment (hormone therapy, radiation, or surgery) for PRCA, and total healthcare costs.

During the intervention, DAs were delivered to 22% of men with recent BPH drug treatment, 24% of men with untreated BPH, and 56% of men with PRCA. DA implementation was associated with a 32% lower rate of surgery among men with treated BPH (rate ratio [RR], 0.68; 95% CI, 0.49-0.94) and a nonsignificant 22% lower rate of surgery among men with previously untreated BPH (RR, 0.78; 95% CI, 0.50-1.22). For PRCA, DA implementation was associated with a 27% lower rate of active treatment (RR, 0.73; 95% CI, 0.57-0.93). We found no significant associations between DA implementation and costs of care for either condition.

Implementing patient DAs was associated with lower rates of elective surgery for previously treated BPH and active treatment for localized PRCA; however, implementation of these DAs was not associated with lower costs of care.

Am J Manag Care. 2015;21(2):e130-e140
The goals of this study were to examine the relationships between implementing decision aids for benign prostatic hyperplasia and prostate cancer on rates of treatment and healthcare costs.
  • A multimodal strategy for implementing patient decision aids was associated with significantly lower rates of elective surgery for men with medically treated benign prostatic hyperplasia and lower rates of active treatment for localized prostate cancer.
  • Decision aid implementation was not associated with cost savings in these populations.
  • More research is needed to understand whether these tools can improve long-term patient satisfaction with decision making and quality of life
Treatment decisions for benign prostatic hyperplasia (BPH) and localized prostate cancer (PRCA) have long been recognized as being sensitive to the preferences of well-informed patients.1,2 In both conditions, no single treatment option has been conclusively shown to be superior, long-term outcome evidence is limited, alternative treatment options have varying benefitrisk profiles, and informed patients may choose to avoid any treatment whatsoever. The current BPH treatment decision is being framed between selecting transurethral resection of the prostate/minimally invasive surgery or no surgery and/or continuing pharmacotherapy. For PRCA, most men have a clinically localized cancer, and more than 90% of them attempt curative therapy with surgery or radiation,3 which can significantly impact quality of life.4 However, the optimal treatment for PRCA is uncertain, because no randomized trials have directly compared surgery with radiotherapy.5 Furthermore, many experts believe that localized, low-risk cancers are unlikely to progress, and that men with these cancers should consider active surveillance—deferring active treatment in favor of serial prostate-specific antigen (PSA) tests, digital rectal examinations, and prostate biopsies to monitor for signs of progression.6,7 Guidelines also recommend observation for men with higher-risk localized cancers who have limited life expectancy.6,8 Because there are significant trade-offs between the risks and benefits of alternative treatments for both BPH and PRCA, treatment decisions should be based on high-quality conversations between patients and healthcare providers, marked by shared decision making, and the final decision for choice of therapy should be in concert with the patient’s stated goals and preferences.

Shared decision-making processes often incorporate patient decision aids (DAs), which are balanced sources of information about treatment options for a particular health condition.9 Numerous randomized trials have shown that use of well-designed DAs can facilitate shared decision making, improve knowledge, increase patient participation, improve the match between patients’ preferences and the interventions selected, and help achieve greater patient satisfaction.9 A 2011 Cochrane review identified 7 randomized trials of DAs for elective surgical procedures9; the pooled evidence suggested that patients receiving a DA were 25% less likely to undergo elective surgery. That Cochrane review included a 1992 study of a BPH DA.10 In that study, men who received the DA were no less likely to choose elective surgery, but they significantly increased their knowledge and were more satisfied with the decision making process. The Cochrane review also identified 2 randomized trials evaluating DAs for PRCA treatment9; however, their applicability is limited because 1 trial included only men with advanced cancers,11 and neither presented the option of active surveillance.12

Professional societies emphasize the role of shared decision making in helping men make BPH and PRCA treatment decisions, but there is limited evidence of the effectiveness of integrating DAs into clinical practice to support shared decision making. Equally important, few studies have examined whether the widespread implementation of DAs in routine clinical practice can influence surgical rates or costs of care. This report summarizes the changes in surgical rates and costs observed in the first 18 months of implementing DAs for BPH and localized PRCA among urologists in a large integrated health system.


Context of Evaluation

This evaluation occurred in the context of implementing a systemwide quality improvement project at Group Health (GH), an integrated health system that provides care and insurance coverage for more than 600,000 Washington state residents. Greater detail on the execution of the quality improvement project has been published elsewhere and is briefly summarized here.13,14 The project goal was to integrate 12 high-quality video-based patient DAs (developed by the Informed Medical Decisions Foundation and Health Dialog) into standard clinical practice for 6 specialties: orthopedics, gynecology, neurosurgery, urology, general surgery, and cardiology. GH leadership encouraged providers to distribute these DAs to all patients with the health conditions, emphasizing the importance of improving patient knowledge and informed consent.9,13-15 All urology personnel were required to watch both DAs, attend multiple meetings explaining the purpose of the DA rollout, review care processes related to delivering DAs, and review monthly DA distribution reports and surgery volumes over time.

Study Design

We conducted an observational evaluation of this quality improvement initiative with a pre-post design to assess whether rates of prostate procedures for BPH and PRCA and costs of care changed after implementing DAs. The evaluation plan and all study activities were reviewed and approved by the Group Health Human Subjects Research Committee (Institutional Review Board).

Clinical Setting

The GH urology service line includes 14 staff surgeons in 5 specialty clinical sites. Primary care providers can refer patients to urology for evaluation and treatment of BPH symptoms, and many patients also self-refer. Although GH does not currently recommend routine PSA screening, primary care providers can offer screening and refer patients to urology for elevated PSA tests, suspicious digital rectal examination findings, or other symptoms of cancer. PRCA is most often diagnosed at the time of prostate biopsy by a urologist.16 GH surgeons are salaried care providers; they do not receive surgical productivity incentives.


Our study population included all patients with BPH (identified via the International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 600, 600.01, 600.2, 600.21, 600.9, and 600.91) who were aged 45 years or more17 and seen by a GH urologist in an outpatient clinic. We divided our BPH cohort into 2 groups: those who had received BPH pharmacotherapy (alpha-1 adrenergic blocker, a 5-alpha reductase inhibitor, or an anticholinergic medication) in the past year, and those who had not. For our PRCA analyses, we identified all patients from the Surveillance, Epidemiology, and End Results (SEER) cancer registry at GH who were newly diagnosed with localized PRCA (stage 1 or 2) during the study window. We extracted data on demographics, enrollment, diagnoses, procedures, and medical treatments from the GH electronic medical and administrative databases. We excluded patients who, in the 12 months before their index visit, had either a prostate procedure or diagnosis for PRCA in our SEER registry.

We divided the populations into two 18-month periods: the historical control period before DA implementation, from July 1, 2007, to December 31, 2008, and the intervention period after implementation, from July 1, 2009, to December 31, 2010. All subjects had to be enrolled continuously in GH for 12 months before their index visit (their first visit with a GH urology provider during the control or intervention period). Our cohort included all patients who were potentially eligible to receive a DA during either period.

Decision Aids

The DAs used were video-based tools with accompanying written information in booklet format. The content of the decision aids is reviewed annually to ensure that the evidence presented is up-to-date, and the DAs discuss all common medical and surgical treatment options for BPH and PRCA in plain, balanced language. Decision aids were distributed primarily by mail in DVD format; clinical staff could order the DVD versions through the electronic health record. Patients could also view the DAs online on the secure website for members, and providers could embed a link to the online DA in the patient’s aftervisit summary.

Outcome Definitions: Surgical Procedures and Healthcare Costs

The primary outcomes of interest were: 1) a transurethral prostate procedure for BPH patients, or receipt of hormone therapy, radiation, or radical prostatectomy for PRCA patients, during the 6 months after the index visit or diagnosis date (identified by procedure codes); and 2) total healthcare costs in the 6 months after the index visit or diagnosis date. We defined total healthcare costs as the sum of costs (in 2009 dollars) of inpatient (including surgical costs), outpatient, pharmacy, radiology, laboratory, and ancillary services (ie, home healthcare, hospice, durable medical equipment). We defined healthcare use during this period as the number of inpatient hospitalizations, inpatient days, prescription drug fills, and primary and specialty care visits.

Analytic Methods: Rates of BPH Surgery and PRCA Active Treatment

We estimated adjusted rate ratios (RRs) and 95% confidence intervals of surgery and active treatment in the intervention (DA implementation) period relative to the control period. BPH and PRCA outcomes were analyzed separately, and the BPH cohort was stratified on prior treatment.

We used Poisson regression to compare 180-day rates and RRs for all treatment outcomes for both cohorts.18 For each separate analysis, the dependent variable was whether a patient underwent treatment after his index visit/diagnosis date. Patients were followed from their index visit until surgery, disenrollment, death, or end of the 180-day follow-up period. Covariates included age at index date, body mass index, clinic location, number of prior urology visits, insurance type, and total prioryear costs (log scale). BPH models also included whether a patient underwent PSA testing in the prior year and whether BPH had been diagnosed before the index date. Additional variables in our PRCA analysis included the PSA value before cancer diagnosis (categorized as <4, 4-9, and 10+ ng/mL) and the biopsy Gleason score (categorized as 2-6, 7, and 8-10). Because we expected the effect of the decision aid to differ across PRCA risk groups, we conducted subgroup analyses examining the effect of the DA implementation among patients with low-risk PRCA (ie, those with Gleason <7 and PSA ≤10 ng/mL) and intermediate- to high-risk (Gleason ≥7 and/or PSA >10). Secondary analyses evaluated the impact of receiving a DA on the use of related surgical procedures.

Analytic Methods: Costs and Utilization

We used regression models to compare total healthcare costs in the 6-month period following the index visit or diagnosis date before and after DA implementation. We used a generalized linear model with normally distributed errors to estimate the relationship between implementing DAs and the arithmetic mean of total costs. As a sensitivity analysis, we used a linear model with normally distributed errors for log-transformed costs to estimate the relationship between implementing DAs and geometric mean costs. For both models, we used robust standard error estimation to account for deviations from model-based assumptions of common variance (homoscedasticity).

All analyses were conducted using SAS software, version 9.2 (Cary, North Carolina).


Benign Prostatic Hyperplasia Cohorts

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