Currently Viewing:
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.
Patient characteristics were similar for both control and intervention cohorts (Table 1), including age, clinic visits, PSA testing, prescription medications, and comorbidity. However, among men with previously untreated BPH, the intervention group was slightly younger than the control group, had slightly higher frequencies of prior BPH diagnosis, and had higher Charlson Comorbidity Index (CCI) scores.

Prostate Cancer Cohorts

The characteristics of PRCA men were similar in both cohorts, including age, body mass index (BMI), and urology visits (Table 2). Before diagnosis, about a quarter of the men had a PSA value ≥10 ng/mL, though more than half had low-grade Gleason scores. Few men had CCI scores of 3 or more.

Receipt of Decision Aids

Decision aids were delivered (by mail or online) to 258 (24%) eligible patients without any treatment for BPH in the previous year, 179 (22%) eligible patients with recent treatment for BPH, and 117 (56%) eligible patients with localized PRCA.

Impact of Decision Aid Implementation on Rates of Procedures

In the BPH cohort, the effects of implementing DAs differed according to whether the patient had received pharmacotherapy in the year before the index date (Table 3). The untreated BPH group had 0.03 procedures per 180 person-days in the intervention group and 0.04 procedures per 180 person-days in the control group, an adjusted relative rate (intervention/control) for surgery of 0.78 (95% CI, 0.50-1.22; P = .27). However, in the previously treated BPH group, the procedure rate was 0.07 per 180 person-days in the intervention group and 0.10 per 180 person-days in the control group, an adjusted relative rate for surgery of 0.68 (95% CI, 0.49-0.94; P = .02).

In the PRCA cohorts (Table 3), the adjusted rate of undergoing any treatment for PRCA was 0.69 per 180 person-days in the intervention group and 0.94 per 180 person-days in the control group, an adjusted relative risk of 0.73 (95% CI, 0.57-0.93; P = .01). Among the subgroup of men with low-risk cancers (PSA ≤10 ng/mL and Gleason <7), the intervention and control groups had comparable rates of active treatment (adjusted RR, 0.80; 95% CI, 0.50-1.29; P = .35), although among the subgroup of men with intermediate- to high-risk cancers, the intervention group had a lower rate of receiving any treatment (adjusted RR, 0.64; 95% CI, 0.48-0.85; P = .002).

Impact of Decision Aid Implementation on Total Healthcare Use and Care Costs

In our multivariable adjusted models, we observed no significant difference in arithmetic mean total healthcare cost in the intervention versus control period for previously treated and previously untreated BPH patients (Table 4). We also observed no significant difference in total healthcare costs for PRCA patients in the intervention versus control periods. Similar findings were found for geometric mean costs (data not presented). Additionally, mean costs were similar across the intervention and control cohorts for men with low-risk PRCA. eAppendix Tables 1 and 2 (available at show the unadjusted costs of care and healthcare use in the 180 days following the index urology visit for our intervention and control groups.

Secondary Analyses

Secondary analyses evaluated the impact of receiving a DA on the use of related surgical procedures. Among previously untreated BPH patients, receiving a DA was associated with a nonsignificantly higher 180-day rate of transurethral prostate procedures (RR, 1.69; 95% CI, 0.85-3.37; P = .13). However, among previously treated BPH patients, receiving a DA was associated with a significantly higher 180-day rate of transurethral prostate procedures (RR, 2.80; 95% CI, 1.62-4.85; P = .0002). Similarly, for patients with localized PRCA, receiving the DA was associated with a nonsignificantly higher 180- day rate of initiating any treatment (RR, 1.23; 95% CI, 0.64-2.39; P = .53).


DAs are designed to deliver unbiased, comprehensive information about the risks and benefits of all available treatment options and to help clarify patient preferences and align them with the final treatment choice. Healthcare systems, policy makers, and payers alike are looking for system-level interventions to improve the quality of care in the United States. Underuse, overuse, and misuse of healthcare procedures are often cited as areas of opportunity for improving quality, and it has been hypothesized that using patient DAs might help ensure that rates of care reflect the preferences of well-informed patients, rather than provider-driven preferences or incentives. In addition, it has been suggested that DAs might also reduce the costs of care from the payer and purchaser perspective19; however, little empirical evidence exists to support this theory.20

Our observational study is the largest to date of patient DA implementation in the context of quality improvement for elective surgical care.13,14,21 We found that implementing DAs for BPH in a large, multi-site urology group practice setting was associated with a significant 32% lower rate of transurethral prostate procedures among men who had previously received pharmacological treatment for BPH and a nonsignificant 22% lower rate among men who had not received previous pharmacological treatment for BPH. Furthermore, we found that implementing DAs for localized PRCA was associated with a significant 27% reduction in actively treating PRCA. Surprisingly, the greatest reduction in active treatment was seen among men with a Gleason ≥7 and/or PSA >10 ng/mL. Treatment patterns might change with longer-term follow-up, but a more likely explanation is that our available data led to some misclassification of the risk groups. We used only Gleason and PSA to classify risk because we lacked detailed data on clinical stage or biopsy results. This may have prevented us from accurately classifying some low-risk men according to guidelines for active surveillance.7

Our results for BPH and PRCA are supportive of prior randomized studies, which suggest that receiving DAs may lower use of elective surgery, at least in the short term.9 Our findings also suggest that the overall DA implementation strategy—which required all urology personnel 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—was responsible for the changes in rates of treatment initiation that we observed, rather than any direct influence of DAs on patient decisions. Notably, implementing DAs was not associated with changes in healthcare costs in these populations. The lack of association with cost savings should not undermine the notion of implementing DAs to support decision making for urologic conditions. The primary motivating factors for implementing DAs should be improving the quality of decision making, not reducing costs.20


Our analysis is based on observational data and is subject to potential biases and limitations of the study design. Our BPH cohort definitions may misclassify some patients, because providers may indiscriminately use the BPH ICD-9-CM code as an indicator for any male lower urinary tract symptoms that may be resulting from other pathologies such as urethral stricture or overactive bladder. However, any misclassification of these conditions is unlikely to be unequally distributed across our intervention and control populations, and is therefore unlikely to influence our study results. Furthermore, we were unable to classify BPH patients according to the severity of their BPH symptoms, because those clinical symptom data were not available to us; therefore, we used prior medical treatment of BPH as one way of stratifying our cohort into groups with higher and lower BPH symptom severity/acuity.

We did not have data on quality of life in this study, and we are unable to assess whether the quality of life of the patients who chose against early intervention was improved or perhaps diminished as a result of their decisions. Patients in the intervention and control periods had similar characteristics at the time of the index exam, and we adjusted for many clinical factors related to treatment decisions (eg, age, BMI, disease severity [including SEER stage, Gleason score, and PSA for PRCA patients], and comorbidity). However, unmeasured factors may have affected our findings, including changes to the economy, secular changes in attitude towards prostate treatment, and other concurrent changes in GH policy or structure influencing care patterns. For prostate cancer, interest in active surveillance has been growing in the past decade, and this trend may have impacted our results. Given the limitations of our study design, our intervention should be replicated in other settings to confirm these findings.

DA delivery was suboptimal in the first 18 months of implementation, with only a quarter of BPH patients and half of PRCA patients receiving a DA. In our published qualitative research, urology providers expressed several early reservations about DA implementation—including concerns about the accuracy of the DA content—which may have resulted in the low rates of DA delivery.13 Other commonly mentioned barriers to DA implementation include the perception among clinicians that they already practice good shared decision making; that their patients don’t want or can’t cope with the information; and that they lack the time, incentive, and organizational support to do it.22 In secondary analysis, patients with treated BPH who received a DA were significantly more likely to undergo a transurethral procedure. We think it unlikely that receiving a DA increased rates of intervention; we think, rather, that clinicians were selectively ordering DAs only for patients considered to be surgical candidates. Importantly, our intervention involved both the DAs and the broader quality-improvement effort that motivated urology providers to use these tools in clinical practice. Because DA implementation and system changes co-occurred, we cannot disentangle the effect of DAs from the effect of direct intervention on providers through education and active monitoring.

Further investigation is necessary to understand how the differences between types of medical practices influence the uptake and effectiveness of DAs. GH is an integrated health plan and care delivery system that salaries its urology providers. GH surgeons do not have the same monetary incentives for performing surgery as their colleagues in fee-for-service settings. Other experts have noted that implementing DAs in fee-for-service settings may be more challenging, especially if it reduces surgical procedure volume.23-25 Finally, the study does not address whether patients who received mailed DAs actually viewed them. Nor does it address whether the conversations between patients and providers changed as result of implementing these DAs.


Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up