PROMOTING USE OF PATIENT DECISION SUPPORT INTERVENTIONS IN A LARGE COMMUNITY-BASED MULTI-SPECIALTY GROUP PRACTICE

Purpose: To describe strategies for successfully implementing patient decision support intervention (DESIs) in a large, community-based, multi-specialty group practice setting.

Method: Working with four diverse primary care practices associated with the Palo Alto Medical Foundation in northern California, we implemented 7 different DESIs.  The implementation process included identifying physician and administrative champions, collaboratively designing clinic-specific workflows for distribution, introducing DESIs and workflows to clinic physicians and staff, and continuous social marketing of the programs to staff and patients. We identified barriers to and facilitators of successful distribution through rapid Plan, Do, Study, Act cycles, which included analysis of feedback from key stakeholders, ethnographic observation, and field notes.

Result: Different strategies for DESI distribution were piloted in each clinic, resulting in variable distribution success. For a colon cancer screening DESI (2 clinics), eligible patients were identified from rosters of 5 physicians and mailed a personalized letter inviting them to obtain and watch the DESI.  Of 790 patients, only 2.9% (n=22) requested the DESI.  In-clinic distribution by physicians of the colon cancer screening DESI (2 clinics) initially resulted in an average distribution of 3 DESIs per week; introduction of a self-screening questionnaire, distributed to patients by front desk staff, increased average distribution to 29 DESIs per week. In-clinic distribution of four back pain DESIs (1 clinic) by medical assistants after physician prescription was also a successful strategy, with an average of 17 DESIs distributed per week. Distribution of hip and knee osteoarthritis DESIs through a health library (1 clinic) resulted in an average distribution of <1 DESIs per week, even with physician prescription.  DESI distribution increased with a social marketing campaign in all clinics that included patient-oriented brochures and posters, as well as academic detailing for clinic physicians and staff.  Highest DESI distribution rates were seen in clinics that had highly engaged physician and staff champions raising the visibility of the programs.

Conclusion: Distribution of DESIs in primary care clinics part of a large, community-based, multi-specialty group was variable and highly dependent on distribution strategy as well as physician and staff enthusiasm.  Successful strategies include recruiting physician and staff champions, engaging all members of the medical team, and increasing program visibility with social marketing and frequent contact with clinics to increase visibility, awareness, and adjust workflows.