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Kiel – In the innovation fund project “Making SDM a Reality”, a concept for shared decision making (SDM) was developed at the University Hospital Schleswig-Holstein (UKSH), Kiel Campus, and rolled out throughout the hospital.

The Innovation Committee funded the project with 13.6 million euros between October 2017 and September 2021. In February 2023, it recommended that it be transferred to standard care.

In conversation with the German Medical Journal Study director Friedemann Geiger explains what effect the project had on patient care at the UKSH and on the costs of care and whether it has now become part of standard care.

5 questions for Friedemann Geiger, Head of the National Competence­Center SDM at UKSH, Campus Kiel

Professor Geiger, what was your project “Making SDM a Reality” about?
With shared decision making, doctors work with patients to find the therapy that best suits them and their life context. This structured conversation technique can be easily learned through our compact training courses.

To support this, we provide patients with online decision aids that describe the various treatment options. Better information increases patients’ health literacy and also their satisfaction with the treatment.

All of these factors together mean that patients are more willing to implement a therapy as discussed. In addition, they are more likely to be able to be committed to the therapy.

What is your assessment of the project?
Positive in every respect. We have managed to make SDM the standard for medical decision-making in an entire hospital – despite the pandemic. This is unique in the world.

We achieved positive results for all endpoints: Patient participation increased significantly, as did health literacy. As a result, the quality of care increased compared to other hospitals in the country – while costs fell: for every euro invested in SDM in Kiel, the health insurance companies saved seven euros.

How did you measure the increase in the quality of care?
We formed a control group for our patients from the data set of the Techniker Krankenkasse with so-called twins: patients who are comparable to ours in terms of age, gender, diagnosis and severity of the disease, but who were treated in a different hospital.

The follow-up period was twelve months, allowing us to compare the care before and after the introduction of SDM in Kiel with standard care elsewhere at the same time points.

Patients in Kiel who received SDM had significantly fewer complications that led to emergency admissions than those in the control group. The reduced costs for health insurance companies are partly due to the lower number of emergency admissions.

On the other hand, we also used fewer resources than the control group, for example fewer imaging procedures were performed. And fewer hospitalizations were necessary. Even if the last two advantages were not significant, they still improve cost efficiency when taken together.

Incidentally, our results coincide with those of colleagues in the USA: from a working group led by David Veroff from Boston. We replicated their study design and analysis methodology 1:1. They were also able to show that patients and doctors with SDM are more likely to not undergo surgery or to choose the more conservative option: for example, physiotherapy instead of disc surgery – with the same or better treatment results.

Such a reduction in overtreatment also naturally reduces costs. We are currently conducting such analyses using our data. The data examined so far also indicate a trend in favor of less intensive and therefore usually more cost-effective interventions.

How have the findings from your project so far been part of patient care in German­country?
At the UKSH on the Kiel campus, we currently treat 130,000 cases with SDM every year, and the number is rising. Our clinics offer continuous SDM training for medical and nursing staff and are audited annually to renew the Share-to-Care certificate. This allows them to signal to both patients and professionals on the job market that patient-centeredness is a top priority at the UKSH.

Outside of the UKSH, the Kiel model is currently being introduced in six Bavarian university hospitals, as well as in the Helios Klinikum Schleswig and the Malteser St. Franziskus Hospital in Flensburg. The university hospitals in Hamburg and Aachen will follow. The methodology is also being adapted in Spain, Denmark and Norway. However, one important step is still missing in order to be able to implement SDM across the board.

In Kiel, health insurance companies promote the model by paying an additional fee for every patient who is treated in a clinic with a Share-to-Care certificate. This is also economically worthwhile because they save more money per patient than they invest. This means we can continue to train new colleagues and update the decision-making aids.

In Kiel, SDM has thus been implemented sustainably. For the rest of the country, however, the financing of SDM is not yet guaranteed, although the Federal Joint Committee, the German Medical Association and the Government Commission for Hospitals have recommended its transfer to standard care.

That is why it is now up to the legislator. It could make the Kiel model available to all other hospitals by amending the Hospital Remuneration Act. This is exactly what the health insurance companies want because of the advantages of SDM.

Alternatively, the reserve budget provided for in the hospital reform could be increased in all hospitals with a Share-to-Care certificate. This is what the government commission has proposed. Both ways work. It just has to happen. From then on, SDM will spread all by itself in Germany: we already have 200 hospitals on the waiting list that are ready to adopt the Kiel model.

In your opinion, how great is the influence of the Innovation Fund on improving the supply­quality in Germany?
The potential is huge. My foreign colleagues are looking longingly to Germany, where the Innovation Fund makes it possible to test new care models on a large scale and where a mechanism for transferring them to standard care is at least outlined. This gives us an empirically sound basis for argumentation that cannot be argued away. But our example shows that in the end it is up to politicians to complete the process. © fos/aerzteblatt.de