minimally disruptive medicine victor m. montori, md, msc professor of medicine ker unit mayo clinic...
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Minimally Disruptive MedicineVictor M. Montori, MD, MSc
Professor of MedicineKER UNIT
Mayo Clinic
[email protected] @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
