Care Redesign

Engaging Stakeholders to Produce Sustainable Change in Surgical Practice

Case Study · December 12, 2018

To promote the use of minimally invasive gynecologic surgery, the UPMC Health System in Pittsburgh improved its decision-making process for hysterectomy by introducing an evidence-based decision support tool, or pathway, that actively involves both surgeon and patient. The initiative, designed to improve patient outcomes and satisfaction while containing costs, has led to sustainable change in surgical practice and physician behavior.

Key Takeaways

  1. Using an evidence-based systematic approach, it is possible to change physician behavior.

  2. Patient engagement is key to the successful integration of new clinical guidelines.

  3. Producing sustainable clinical change requires the engagement of all stakeholders, including physicians, administrators, and mid-level providers.

  4. This intervention — introducing a clinical decision pathway to encourage minimally invasive hysterectomies for noncancerous conditions — led to improved patient outcomes and value of care. In other words, costs went down while quality went up.

The Challenge

Hysterectomy, the surgical removal of the uterus, is the second most common surgery among women in the United States, after cesarean section. Profound changes are taking place in how this surgery is practiced, due to intense scrutiny of cost and quality metrics by provider employers, payers, and patients/consumers. Minimally invasive techniques such as laparoscopic and robotics approaches are gradually replacing open abdominal procedures for many conditions. Leading professional organizations recommend the use of minimally invasive approaches for benign indications over total (open) abdominal hysterectomy, which is associated with higher risks of complications, length of hospital stay, and costs.

Despite the benefits of minimally invasive surgery, evidence points to excessive use of open surgery for hysterectomy. Therefore, timely translation of best surgical practices into the operating room is vital, particularly for benign gynecologic disorders and symptoms such as heavy bleeding, pelvic pain, fibroids, and endometriosis, which can significantly impact a woman’s quality of life throughout her reproductive years and beyond.

Traditionally, gynecologic surgeons have passed on their craft to succeeding generations through apprenticeship, favoring more invasive surgical approaches. It is challenging to change physician, and especially surgeon, behavior in a sustained and purposeful way, even if new evidence, technology, or treatment options improve the quality of care and/or lower expenditures. Barriers include lack of provider awareness and acceptance of new clinical practice guidelines. While behavior change is a process, not an event, little is known about how to influence surgeon behavior.

In 2012, the UPMC Health System introduced an evidence-based hysterectomy decision-making algorithm for physicians treating patients with benign gynecologic conditions. It features the active involvement of both the surgeon and patient at all stages of the treatment process. Clinical pathways represent a shift from opinion-based practice to evidence-based practice.

Decision support tools have been shown to help providers and patients make informed decisions, especially where many options are available with various degrees of risks and benefits. Research suggests they may also increase patient involvement, help set realistic expectations of outcomes, and improve patient-provider communication. This case study describes how we changed the paradigm for hysterectomies by introducing measures affecting both surgeon and patient.

The Goal

To successfully develop, implement, and disseminate an evidence-based clinical pathway decision tool for noncancerous gynecologic conditions to reduce variation and uncertainty in the surgical decision-making process. We aimed to decrease abdominal hysterectomy rates, improve patient outcomes, and contain costs by increasing the use of minimally invasive hysterectomies (laparoscopic hysterectomy, vaginal hysterectomy, and robotic-assisted laparoscopic hysterecomy).

The Execution

Improving the consistency of decision-making by collaborating with physicians, and effectively analyzing the factors that influence decision-making, are critically important for enhancing the quality of care. Our practical approach includes concrete steps that health care systems can implement to influence physician behavior in a sustainable way, and in various settings, both locally and internationally.

The key processes for introducing evidence-based guidelines across UPMC institutions involved engaging stakeholders in developing and assessing the hysterectomypathway, ensuring provider and patient education, establishing incentives, and integrating the tool into the electronic medical record (EMR). Another goal was to prioritize patient involvement in treatment decisions and establish a patient-centered approach.

Summary of Comprehensive Approach to Physician Behavior and Practice Change

  Click To Enlarge.

Establish clinical pathway: The UPMC team thoroughly investigated both evidence in the literature and local practice patterns to develop standardized guidelines for physicians on hysterectomy approaches. To speed up the guidelines’ integration into medical practice, we involved department/division leadership in driving change, established a well-defined decision pathway, included mid-level providers (nurses and PAs) in its introduction, presented data in clinical conferences, and achieved consensus among physicians about the best ways to effect practice change.

The clinical pathway (algorithm) that emerged asks the physician a series of questions about the patient’s condition, such as symptoms, uterus size, and ability to undergo a minimally invasive procedure safely. It is important to note that this hysterectomy pathway focuses on the treatment of benign disease, with cancerous conditions potentially requiring different approaches.

Partial Hysterectomy Pathway User Interface from Provider Side of EMR - clinical pathway minimally invasive surgery shared decision support

  Click To Enlarge.

Physician engagement: Physicians were prospectively engaged in the clinical pathway development. A core group (including surgeons, anesthesiologists, mid-level providers, and administrators) convened to review and disseminate evidence-based literature, develop dashboards to compare physician performance, and present the project to different departments. Physicians also helped create the incentive structure for practices that follow the hysterectomy pathway.

Patient education: Patient education plays a key role in treatment success, but sharing information can be time-consuming for clinicians. We attribute the initiative’s success, in part, to online patient education materials that were made available to all patients considering a hysterectomy. These include the Emmi (videos) and Healthwise (printable booklets) systems. Paper-based materials posted on the UPMC website were also used in our research studies on pathway evaluation.

Provider education: Surgeons had the opportunity to train in minimally invasive techniques by observing and assisting established specialists. Further, the Volunteer Services Board of Magee-Womens Hospital of the UPMC Health System funded a standalone robotic trainer for surgeons to practice these skills. A recent evaluation of approaches for influencing physician behavior found that — consistent with our findings — active forms of continuing medical education (such as workshops and tailored interventions) are more effective for incorporating guidelines into general practice than passive methods, such as distributing printed materials.

Physician dashboard: Our health care system addressed practice variations by creating electronic physician dashboards that allow gynecologic surgeons to compare their clinical performance to other surgeons. The dashboard focused on metrics pertaining to quality of care, consistency, and reproducibility. Open hysterectomy rates, as well as quality and cost metrics, were presented in a blinded fashion, with surgeons inherently driven to not be outliers.

These dashboards played an important role in reducing open hysterectomy rates. They allowed us to engage physicians in a non-coercive, positive inquiry about their practice patterns. No punitive actions were taken against non-users. Pathway use is not required of physicians, but those who do not must justify their decision.

Sample Physician Dashboard - hysterectomy pathway clinical pathway minimally invasive surgery shared decision support

  Click To Enlarge.

Financial Incentives: The initial stage of clinical pathway integration included group financial incentives for participating providers. Supplemental pay (group bonus given to a whole practice with good pathway adherence) was later introduced for providers who performed above a particular threshold.

EMR Integration: Integrating the decision tool into the electronic medical record system was central to the initiative and to engaging patients and providers. It allowed for prospective measurement of pathway use and the proper application of pathway guidelines.

The Team

Our team consisted of physicians (anesthesiologists, oncologists, gynecologists, urogynecologists, etc.), mid-level providers (PAs, nurses), administrators, IT professionals (for dashboard development), and researchers.

Results

Participating surgeons gradually demonstrated change in their behaviors after the hysterectomy pathway’s implementation. For example:

  • The proportion of total abdominal hysterectomy procedures for noncancerous conditions fell from 27.8% in FY 2012 to 17% in FY 2014.
  • During fiscal year 2015, pathway adherence was 76%. As of 2018, adherence exceeds 85%.
  • Within 3 years of pathway use, surgical site infections had a 47% reduction.
  • Cost savings to the health system were about 40% per case if a minimally invasive technique was used instead of an open hysterectomy.

In addition, hysterectomy for benign conditions is often an elective procedure, and decisions about whether to have one, and which type, can be difficult. We believe the UPMC pathway is a powerful tool to minimize uncertainty in hysterectomy decision-making. It also allows for physicians to pause and evaluate their decisions at a time when the clinical course of action is still being determined.

Hurdles

  • Changing physician behavior is often challenging.
  • Lack of access to training in minimally invasive surgery for hysterectomy may pose a challenge to changing surgical routes.
  • Completing the hysterectomy pathway requires some additional time; anything that adds to a physician’s workload can be associated with resistance.
  • Shared evidence-based decision-making is a key factor for safe and effective health care, especially when more than one treatment option is available. However, it is well documented that not all physicians are equipped to enable effective shared decisions. With hysterectomies, patient attitudes can be influenced by such factors as insurance type, family tradition, and lack of awareness about alternative treatments. Surgeon choices may depend on the provider’s skill and the practice setting.

Next Steps

The future of gynecologic surgery may lie in improved development of decision support strategies like this pathway. Decision support tools are used in various clinical areas, but in hysterectomy they need to be better established and disseminated across health systems. Our future work will focus on examining patient-provider decision-making and strategies for attaining sustainable behavior change among physicians in gynecology and other fields. We plan to scale this work to other surgical disciplines (treating noncancerous conditions) such as general surgery, orthopedics, and plastic surgery.

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