A randomized study of telephonic care support in populations at risk for musculoskeletal preference-sensitive surgeries

BACKGROUND: The rate of elective surgeries varies dramatically by geography in the United States. For many of these surgeries, there is not clear evidence of their relative merits over alternate treatment choices and there are significant tradeoffs in short- and long-term risks and benefits of selecting one treatment option over another. Conditions and symptoms for which there is this lack of a single clear evidence-based treatment choice present great opportunities for patient and provider collaboration on decision making; back pain and joint osteoarthritis are two such ailments. A number of decision aids are in active use to encourage this shared decision-making process. Decision aids have been assessed in formal studies that demonstrate increases in patient knowledge, increases in patient-provider engagement, and reduction in surgery rates. These studies have not widely demonstrated the added benefit of health coaching in support of shared decision making nor have they commonly provided strong evidence of cost reductions. In order to add to this evidence base, we undertook a comparative study testing the relative impact on health utilization and costs of active outreach through interactive voice response technology to encourage health coaching in support of shared decision making in comparison to mailed outreach or no outreach. This study focused on individuals with back pain or joint pain. METHODS: We conducted four waves of stratified randomized comparisons for individuals with risk for back, hip, or knee surgery who did not have claims-based evidence of one or more of five chronic conditions and were eligible for population care management services within three large regional health plans in the United States. An interactive voice response (IVR) form of outreach that included the capability for individuals to directly connect with health coaches telephonically, known as AutoDialog®, was compared to a control (mailed outreach or natural levels of inbound calling depending on the study wave). In total, the study include 24,167 adults with commercial and Medicare Advantage private coverage at three health plans and at risk for lumbar back surgery, hip repair/replacement, or knee repair/replacement. RESULTS: Interactive voice response outreach led to 10.7 (P-value < .0001) times as many inbound calls within 30 days as the control. Over 180 days, the IVR group (“intervention”) had 67 percent (P-value < .0001) more health coach communications and agreed to be sent 3.2 (P-value < .0001) time as many DVD- and/or booklet-based decision aids. Targeted surgeries were reduced by 6.7 percent (P-value = .6039). Overall costs were lower by 4.9 percent (P-value = .055). Costs that were not related to maternity, cancer, trauma and substance abuse (“actionable costs”) were reduced by 6.5 percent (P-value = .0286). CONCLUSIONS: IVR with a transfer-to-health coach-option significantly increased levels of health coaching compared to mailed or no outreach and lead to significantly reduced actionable medical costs. Providing high levels of health coaching to individuals with these types of risks appears to have produced important levels of actionable medical cost reductions. We believe this impact resulted from more informed and engaged health care decision making.