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Shared medical appointments for upstream medical decisions: a proposal for health care savings and performance
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Physicians are taught in groups throughout their training. Whether through traditional lectures, small groups, or with online tools, the group-level dissemination of medical knowledge to medical professionals contrasts sharply with the one-to-one setting with patients. The health care system can reap the cost-saving benefits of efficiency through the appropriate use of group visits for disseminating medical information while enabling patients to make informed choices. Although shared medical appointments (SMAs) are not a completely novel clinical model, it has been applied mostly to the management of chronic disease or established patients. I believe this patient-centered approach has more potential for savings when applied to non-urgent conditions where patient choice is an important factor for guiding upstream health care decisions. I will illustrate this through the recent controversy over prostate-specific antigen (PSA) screening and treatment of localized prostate cancer.
Shared medical appointments increase the productivity of the health care work force. An economic analysis of SMAs in various clinical departments at the Dartmouth-Hitchcock Medical Center found that they generated a higher mean census and hourly profit for the provider leading the SMA when compared to traditional visits matched by diagnosis.1 Beyond the actual gains during the session, the authors suggest that SMAs, which are appropriate for a more homogenous and less complex patient population with a common diagnosis, can increase overall patient access by freeing up clinic time for more complex cases. This has important implications as many more Americans require health care due to demographic processes or health insurance reform.
Prostate cancer is the most common cancer among men. In 2012, an estimated 240,000 American men will be diagnosed with and 28,000 will die from prostate cancer. The annual total expenditure for prostate cancer was an estimated $9.862 billion in the US.2 Most cases of prostate cancer are now detected through blood-based PSA screening, allowing for earlier diagnosis and treatment and reduced mortality. At the same time, since prostate cancer is a heterogeneous disease that commonly has an indolent course, there is significant overdiagnosis (diagnosing a condition which will not become symptomatic or clinically relevant during a patient’s lifetime) and overtreatment. In May 2012, without cost as a consideration, the United States Preventive Services Task Force (USPTF) issued a class D recommendation discouraging PSA-based screening, asserting there “is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”3 In contrast, the American Urological Association (AUA) replied that4
the decision to test for prostate cancer requires an in-depth discussion of the pros and cons of testing where a patient and his healthcare provider can have an honest and frank interchange … In order to be effective and to minimize the risks of over-diagnosis and overtreatment, prostate cancer testing must be individualized based on a man’s risk factors.
Given the hurried nature of many primary care visits, the setting where most PSA blood tests are ordered, it is unclear that actual practice conditions allow such in-depth discussions to flourish.
Group visits can be an effective method of simultaneously reaching multiple patients in similar circumstances, which characterizes potential candidates for screening. By definition they do not currently have the disease and have a discrete decision to make with many important downstream consequences. As “to test or not to test” becomes more than a reflexive following of blanket guidelines, a group setting allows medical professionals to more effectively address the risks and benefits of screening in depth and the possible outcomes of screening. An elevated PSA often triggers a referral to a urologist for a prostate biopsy, with its attendant risks and benefits. Physicians can also educate patients on the potential for overdiagnosis, and elicit patient identification of their own values and concerns regarding medical decision-making. For example, a patient who would absolutely refuse a transrectal prostate biopsy may decide to forgo screening if he knew that was what it would involve, as it would start down a path of unacceptable options. Medical care can become more coordinated, less reactive to a lab or test result in a context of fear and uncertainty, when the upcoming possibilities are discussed.
Similarly, SMAs can be incorporated into the initial counseling of newly diagnosed patients with localized prostate cancer. The cost of the initial treatment of prostate cancer varies significantly, 5 and there is no one definitive optimal treatment. Although characteristics such as age, health status, PSA level, and tumor characteristics are important considerations for medical professionals, the patient’s decision on treatment modality is ultimately highly personal. A recent study found that patient treatment preferences were driven by feelings of fear and uncertainty which contributed to a desire for rapid treatment, and specific preferences were profoundly influenced by misconceptions and anecdotes.6
Therefore, newly diagnosed men might benefit from a streamlined SMA where multiple specialists, perhaps including mental health professionals, are on hand to discuss the various options available. The diagnosing physician can forward the patients’ files to the other specialists for prior review, and at the meeting patients can be supplied with a document with their clinical information to refer to better identify whether certain points might be more pertinent to their individual case. Urologists, medical and radiation oncologists can each speak about the relative merits of the services they provide. Scribes can help document the visit, a task which has fallen more to physicians in electronic medical record systems. Instead of multiple teams of support staff that would be involved with separate appointments, one “SMA team” can allow for more efficient re-allocation of staff, often a fixed cost in medical centers. Patients will receive a more comprehensive understanding of options before having a chance to speak privately with specialists at the end of the presentation. A one-stop multidisciplinary approach to prostate cancer diagnosis and treatment decision reduces duplicative efforts and can provide a better patient experience.
Although the example of prostate cancer screening and initial treatment was used as an example, this model can be applied to other conditions. As preventive screening recommendations undergo revision and sometime divisive debate among experts, most patients are advised to “talk to their doctor.” These conversations can be more engaging and effective during SMAs which have both group and individualized components. For example, Norwegian investigators recently reported that screening mammography may result in 15 to 25% overdiagnosis of breast cancer 7 amid confusing about the optimal age and frequency of screening mammography. Beyond the potential savings derived from the increased productivity and efficiency of the SMA format itself, applying it to situations where patients have multiple competing options and the “best” option depends on patient values can achieve more health care savings. Importantly, end-of-life care represents a large proportion of total health care expenditures but patients and families are not necessarily satisfied, especially with communication and decision-making. 8 A recent New England Journal of Medicine editorial9 calls for moving beyond the current reality of offering patients and their families a menu of technical options during conversations often initiated by trainees during a hospitalization for worsening disease. The group component of an end-of-care SMA can be devoted to explaining what is medically feasible with individual time reserved to discussion for the patient’s specific circumstances. SMAs provide the potential for more humane, proactive, and cost-efficient health care.
References
1. Sidorsky T, Huang Z, Dinulos JH. A business case for shared medical appointments in dermatology improving access and the bottom line. Arch Dermatol. 2010;146(4):374-381.
2. Roehrborn CG and Black LK. The economic burden of prostate cancer. BJU Int. 2011; 108: 806–813.
3. Chou R, Croswell JM, Dana T, et al. Screening for Prostate Cancer: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Int Med. 2011 Dec;155(11):762-771.
4. American Urological Association. Information sheet: Prostate-specific antigen (PSA) testing for the early detection of prostate cancer. http://www.auanet.org/content/media/USPSTF_information_sheet.pdf Accessed June 13, 2012.
5. Snyder CF, Frick KD, Blackford AL, et al. How does initial treatment choice affect short-term and long-term costs for clinically localized prostate cancer? Cancer. 2010;116: 5391–5399.
6. Denberg TD, Melhado TV, and Steiner JF. Patient treatment preferences in localized prostate carcinoma: The influence of emotion, misconception, and anecdote. Cancer. 2006;107: 620–630.
7. Kalager M, Adami HO, Bretthauer M, Tamimi RM. Overdiagnosis of invasive breast cancer due to mammography screening: results from the Norwegian screening program. Ann Intern Med. 2012 Apr 3;156(7):491-9.
8. Baker R, Wu AW, Teno JM, et al. Family satisfaction with end-of-life care in seriously ill hospitalized adults. J Am Geriatr Soc. 2000 May;48(5 Suppl):S61-9.
9. Lamas D, Rosenbaum L. Freedom from the tyranny of choice--teaching the end-of-life conversation. N Engl J Med. 2012 May 3;366(18):1655-7.
Reviewer Notes
