minimally disruptive medicine victor m. montori, md, msc professor of medicine ker unit mayo clinic...

Minimally Disruptive MedicineVictor M. Montori, MD, MSc

Professor of MedicineKER UNIT

Mayo Clinic

montori.victor@mayo.edu @vmontori

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Encounter Research

Glasziou and Haynes ACP JC 2005

Key problem: Do not follow advice

Poor health despite cost and side effects

Complicated patient-clinician relationship

Wasted or misallocated healthcare resources: US$ 290b (100b in avoidable hospitalizations)

Cutler and Everett NEJM 2010 10.1056/NEJMp1002305

Mann D et al. J Behav Med (2009) 32:278–284

Need Low High Low High

Concerns High High Low Low

Beliefs and adherence in diabetes

Coercion thru threats of dire outcomes from poor control of the disorder are doubly

unethical: it does not work and high anxiety patients withdraw from care when threatened.

Haynes et al. JAMA 2002

Poor fidelity to treatments is the patient’s faultIntentional noncompliance

Beliefs about the disease and about the treatments

Pound et al. Soc Sci Med 2005

Professional communication Patient education

Behavioral interventionsShared decision making

55

DiabetesHypertension

High cholesterol

DepressionBad back

Can’t sleep

Obese

A1c 8.2%LDL high

HCTZBeta-blocker

MetforminGlipizide

Neuropathy

108 kg

Pain

Endocrinologist

Podiatrist

Dietitian

Dizzy

Take off workGet a ride

Take pills

Check sugars

Avoid salt, fats, carbs

Exercise

Check his feet

3 2 1Numbers don’t add up

Deadline is nowtake work home

perform!

Daughter back at home2 beautiful girls

Wasted!

mortgagedebt

insurance

Cumulative complexity model

Shippee N et al JCE 2012

Workload

Capacity

accessuseself-care

Outcomes

Burden of treatment

Burden of illness

The work of being a chronic patient

Sense-making work Organizing work and enrolling others

Doing the work Reflection, monitoring, appraisal

The work of being a chronic patient

People with more chronic conditions attend more visits, get more tests, and more medicines

2 hours/day spent on health-related activities

Jowsey and Yem. BMC Public Health 2012

Of 83 worload discussions in 46 primary care visits (24 min):

70% left unaddressedBohlen et al. Diabetes Care 2011

Shippee D, In press

Barnett et al. Lancet 2012

Shippee N et al JCE 2012

Workload

Capacity

accessuseself-care

Outcomes

Burden of illness

Disease-specific guidelines and quality targets

Multiple treatments | Monitoring tests

Limited care prioritization

Poor care coordination Life

Burden of treatment

Capacity

WorkloadResilienceMental healthPhysical healthLiteracyFinancialSocialEnvironmental

Poor people accumulate comorbidity faster

Barnett et al. Lancet 2012

Poor people accumulate mental comorbidity faster

Barnett et al. Lancet 2012

Shippee N et al JCE 2012

Workload

Capacity

accessuseself-care

Outcomes

Burden of illness

Life

Scarcity

Burden of treatment

Minimally disruptive healthcare

Health care delivery designed to reduce the burden of treatment on patients

while pursuing patient goals

May CR, Montori VM, Mair FS. BMJ 2009; 339:b2803

On hospital discharge…

Shippee N et al JCE 2012

Workload

Capacity

accessuseself-care

Outcomes

Burden of treatment

Burden of illness

Emerging approaches

RCTs of interventions to prevent readmissions

Leppin et al. In preparation

46 RCTs1990-2013

18% (9-27%) reduction in

risk of 30-day

readmissions

Subgroup Analyses

Minimally disruptive healthcare

Health care delivery designed to reduce the burden of treatment on patients

while pursuing patient goals

May CR, Montori VM, Mair FS. BMJ 2009; 339:b2803

To fully play the role they play

http://minimallydisruptivemedicine.org

montori.victor@mayo.edu | @vmontori