patient disobedience
DESCRIPTION
Presented by Dr Victor Montory at McMaster Workshop, 2009TRANSCRIPT
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Patient disobedienceVictor M. Montori, MD, MSc
Knowledge and Encounter Research UnitMayo Clinic
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Poor fidelity to the treatment program
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Effective treatments
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Increasing demands on patientswork | time | $$
Effective treatments
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Increasing demands on patientswork | time | $$
Effective treatments
The need to collaborate to achieve goals of chronic care delivery
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Poor health and expenditure
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Poor health and expenditure
Waste or misallocation of healthcare resources
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Poor health and expenditure
Complicated patient-clinician relationship
Waste or misallocation of healthcare resources
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Poor fidelity to treatments is the patient’s faultIntentional noncompliance
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Poor fidelity to treatments is the patient’s faultIntentional noncompliance
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Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communication
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Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
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Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision making
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Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
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Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
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Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
![Page 19: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/19.jpg)
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
![Page 20: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/20.jpg)
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
![Page 21: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/21.jpg)
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
![Page 22: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/22.jpg)
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multiple chronic conditions
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multiple chronic conditions
1 in 5 adults
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multiple chronic conditions
1 in 5 adults
3 in 5 older adults
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multiple chronic conditions
1 in 5 adults
3 in 5 older adults
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multiple chronic conditions
1 in 5 adults
3 in 5 older adults
1 in 5 older adults 4+
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multiple chronic conditions
1 in 5 adults
3 in 5 older adults
1 in 5 older adults 4+
80%
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multiple chronic conditions
1 in 5 adults
3 in 5 older adults
1 in 5 older adults 4+
80%of Medicare expenditures
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Evidence-based guidelines are disease-specific
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Poor care coordination
Evidence-based guidelines are disease-specific
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Increasingly complex regimensTreatments | Monitoring
Poor care coordination
Evidence-based guidelines are disease-specific
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Increasingly complex regimensTreatments | Monitoring
Decreasing healthcare supportShift towards self-management
Poor care coordination
Evidence-based guidelines are disease-specific
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Increasingly complex regimensTreatments | Monitoring
Decreasing healthcare supportShift towards self-management
Poor care coordination
Evidence-based guidelines are disease-specific
Increasing treatment burden
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Increasingly complex regimensTreatments | Monitoring
Decreasing healthcare supportShift towards self-management
Poor care coordination
Evidence-based guidelines are disease-specific
Increasing treatment burden
Failure to cope
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Increasingly complex regimensTreatments | Monitoring
Decreasing healthcare supportShift towards self-management
Poor care coordination
Evidence-based guidelines are disease-specific
Increasing treatment burden
Failure to cope
Poor fidelity to the treatment program
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FITPatient is able to implement a program
that achieves patient goals
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FIT
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FIT
Collaborate to co-create a program that fits better
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FIT
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FIT
Intensify treatment
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Poor treatment fidelity is in part structurally induced and is the result of cumulative burden of the practice
and organization of care
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Encounter Research
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Encounter Research
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0
20
40
60
80
100
0 7 14 22 29 36
CP1313325B-1
%
Months since incident MI
StatinsBeta blockersACE-I/ARB
Shah et al. AHA Meeting Nov 2007
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36901 Medicare Pts Kaiser/Commonwealth 2003
15,000 not taking prescribed pills
Why?10000 did not believe they needed them or disliked
side effects
USA Today, April 19, 2005
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2673 adultsHarris/WSJ Poll 2007
27% did not fill a prescription
Why?52% MDs fear lawsuit41% MD make money
27% industry bias
WSJ March 15, 2007
36901 Medicare Pts Kaiser/Commonwealth 2003
15,000 not taking prescribed pills
Why?10000 did not believe they needed them or disliked
side effects
USA Today, April 19, 2005
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FITPatient is able to implement a program
that achieves patient goals
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55
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55
Diabetes
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55
DiabetesMetformin
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55
DiabetesMetforminGlipizide
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55
DiabetesMetforminGlipizideCheck sugars
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55
Diabetes A1c 8.2%MetforminGlipizideCheck sugars
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55
Diabetes
High cholesterolA1c 8.2%Metformin
GlipizideCheck sugars
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55
Diabetes
High cholesterolA1c 8.2%LDL high
MetforminGlipizideCheck sugars
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55
Diabetes
High cholesterolObese
A1c 8.2%LDL high
MetforminGlipizideCheck sugars
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55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
MetforminGlipizideCheck sugars
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55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
HCTZ
MetforminGlipizideCheck sugars
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55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizideCheck sugars
![Page 64: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/64.jpg)
55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyCheck sugars
![Page 65: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/65.jpg)
55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyTake pills
Check sugars
![Page 66: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/66.jpg)
55
DiabetesHypertension
High cholesterol
Depression
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyTake pills
Check sugars
![Page 67: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/67.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyTake pills
Check sugars
![Page 68: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/68.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyTake pills
Check sugars
![Page 69: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/69.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
Pain
DizzyTake pills
Check sugars
![Page 70: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/70.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
DizzyTake pills
Check sugars
![Page 71: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/71.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
DizzyTake pills
Check sugars
![Page 72: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/72.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
DizzyTake pills
Check sugars
![Page 73: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/73.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
DizzyTake pills
Check sugars
![Page 74: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/74.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off work
Take pills
Check sugars
![Page 75: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/75.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off workGet a ride
Take pills
Check sugars
![Page 76: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/76.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off workGet a ride
Take pills
Check sugars
Avoid salt, fats, carbs
![Page 77: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/77.jpg)
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off workGet a ride
Take pills
Check sugars
Avoid salt, fats, carbs
Exercise
![Page 78: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/78.jpg)
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
![Page 79: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/79.jpg)
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
![Page 80: Patient Disobedience](https://reader031.vdocuments.mx/reader031/viewer/2022020112/568c46911a28ab19138b4dc3/html5/thumbnails/80.jpg)
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 1
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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 1Deadline is now
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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 now
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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 nowperform!
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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!
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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!insurance
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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!
debtinsurance
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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!
mortgagedebt
insurance
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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 home
mortgagedebt
insurance
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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
mortgagedebt
insurance
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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
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55
A1c<7%BP<130/80 mmHg
LDL<100
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55 55
A1c<7%BP<130/80 mmHg
LDL<100
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55 55
A1c<7%BP<130/80 mmHg
LDL<100
55
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55 55
A1c<7%BP<130/80 mmHg
LDL<100
5545
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55 55
A1c<7%BP<130/80 mmHg
LDL<100
5545 65
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Disobedience, the rarest and most courageous of the virtues, is seldom
distinguished from neglect, the laziest and commonest of the vices
George Bernard Shaw
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Minimally disruptive medicine
Effective care and service provision designed to reduce the burden of treatment on patients
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Minimally disruptive medicine
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Minimally disruptive medicine
Burden of treatment
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Minimally disruptive medicine
Burden of treatment
Coordination of care
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Minimally disruptive medicine
Burden of treatment
Coordination of care
Comorbidity in clinical
evidence and guidelines
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Minimally disruptive medicine
Burden of treatment
Coordination of care
Comorbidity in clinical
evidence and guidelines
Prioritize from the patient’s perspective
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HbA1c
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HbA1cQuality of care
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HbA1cQuality of care
Clinical inertia
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HbA1cQuality of care
Clinical inertia
Report card
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HbA1cQuality of care
Clinical inertia
Report card
Technical decisions
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Live longerFeel better
Live unhindered by complications
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The balance of desirable and undesirable effects of an intervention is dependent on
how people use it.
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“The A1C Champions® program is one of the most innovative patient marketing initiatives that I’ve ever seen. It has been successfully utilized by the brand team to enhance the efforts of the brands and improve patients’ lives. This program is one of the biggest drivers for the brand team to break down barriers, educate patients and motivate them to take action.”
Angela Moskow – Associate Vice President, Marketing sanofi aventis
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