Leppin NYP PC Final
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Transcript of Leppin NYP PC Final
©2014 MFMER | slide-1
Measuring Complex Things in Simple WaysAn introduction to minimally disruptive medicine
Aaron Leppin, MD
Knowledge and Evaluation Research UnitDivision of Health Care and Policy ResearchMayo Clinic
©2014 MFMER | slide-2
Disclosures
• I can’t drive a stick shift• I think everything tastes better with miracle whip• This is the nicest hotel I have ever stayed in
Otherwise, none.
©2014 MFMER | slide-3
A patient example…
Mayo Clinic Statin Choice Decision Aid:http://statindecisionaid.mayoclinic.org/
©2014 MFMER | slide-4
“we have to do it…..it’s going to hurt our quality numbers…..
but it’s the right thing for patients”
Chief Quality OfficerMid-sized Health System
What we measure
An indicator of quality
©2014 MFMER | slide-5
The right thing for patients
What we are measuring?
Patient-centeredContext Dependent
Nuanced and Complex
Disease-centeredContext Independent
Simple and Systematized
©2014 MFMER | slide-6
Doing the right thing for patients is neither simple nor obvious.
We prefer to measure things that are simple and obvious.
If doing the right thing for patients is the best indicator of quality, innovations are needed that help us measure complex
things in simple ways.
Key propositions
©2014 MFMER | slide-7
To consider opportunities for innovating the primary care model to better fit complexity and uncertainty
Objective
©2014 MFMER | slide-8
The right thing for patients
Patient-centeredContext Dependent
Nuanced and Complex
More appropriate
targets
More appropriate measures
More appropriate
systems
DESTINATION
GUIDANCE
PERMISSION
©2014 MFMER | slide-9
DESTINATIONWhat are more appropriate targets?(person-centered and population-relevant end outcomes)
©2014 MFMER | slide-10
Disease-centered targets assume that the right thing for diseases is also the
right thing for patients. This may ignore patient context and may promote health
care fragmentation.
©2014 MFMER | slide-11
Rather than dictating a one-size-fits all approach to care,
clinical practice guidelines are able to…[make]
recommendations...relevant to the individual patient
encounter…. However, the current state of CPG
development has yet to meet this potential
©2014 MFMER | slide-12
Is it not ironic that patient-centered medical homes are encouraged to use disease registries?1
1Cusack et al, Practice-Based Population Health: Information Technology to Support Proactive Primary Care. AHRQ Publication No. 10-0092-EF
©2014 MFMER | slide-13
What is the single most efficacious treatment for a patient with depression?
What is the single most efficacious treatment for a patient with arthritis?
What is the single most efficacious treatment for a patient with diabetes?
What is the single most efficacious treatment for a patient with cancer?
What is the single most efficacious treatment for a patient with depression, arthritis, diabetes, and cancer who also
lives alone and is on a fixed income?
How do you answer these questions?
©2014 MFMER | slide-14
“Can you really do what I am asking you to do?”
Mair and May, BMJ, 2015
©2014 MFMER | slide-15
National Quality Forum. Patient Reported Outcomes in Performance Measurement, 2012
Where are these registries?
©2014 MFMER | slide-16
More appropriate targets?
©2014 MFMER | slide-17
Life expectancyWell-being
Overweight and obesityAddictive behavior
Unintended pregnancyHealthy communitiesPreventive services
Care access
Patient safety
Evidence-based care
Care match with patient goals
Personal spending burden
Population spending burden
Individual engagement
Community engagement
©2014 MFMER | slide-18
Moving past a one-size-fits all approach to care requires incorporation of patient context
Developing measures of patient context could provide guidance so that
“what we measure” is also “the right thing for patients”
©2014 MFMER | slide-19
GUIDANCEWhat are more appropriate measures?(measures that incorporate context)
©2014 MFMER | slide-20
A quarterback leads the League in total passing yards and in touchdowns thrown.
Is he the best quarterback in the League?
Is he a quality quarterback?
©2014 MFMER | slide-21
NFL QB Passer Rating Total QBR
QB #1 26th 9th
QB #2 9th 26th
Measures that incorporate context are better measures of quality
©2014 MFMER | slide-22
1May, BMJ 2009; 2Leppin, Healthcare 2015
2Models of healthcare delivery often promote patient-centered ideas or concepts without providing specific
instruction on how to implement them… The MDM Care Model describes a theoretical relationship between
testable constructs that affect care.
©2014 MFMER | slide-23
Workload Capacity
Exercise Routine
4 Kids
Labs
Self-Monitoring
Church Activities
Grocery Shopping
Extra Work Shifts
Medications
Bank Account
Reliable Caregiver
Broken Car
Unsafe Neighborhood
Arthritic Knee
Diabetic Neuropathy
Resilient Qualities
PATIENT CONTEXT?
©2014 MFMER | slide-24
Leppin, JAMA Int Med 2014
©2014 MFMER | slide-25
Leppin, JAMA Internal Medicine, 2014
The most effective interventions used a “consistent and complex strategy that
emphasized the assessment and addressing of factors related to patient
context and capacity for self-care”
©2014 MFMER | slide-26
©2014 MFMER | slide-27
PERMISSIONWhat are more appropriate systems?(systems that can accommodate complexity and nuance)
©2014 MFMER | slide-28
If the right thing to do for every patient in every situation was obvious…we could build care like we build cars.
©2014 MFMER | slide-29
But what if the right thing to do for every patient is not obvious?
What if it is complex and nuanced?
©2014 MFMER | slide-30
©2014 MFMER | slide-31
“Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism
lacks the evidence base needed by policy makers and planners to support service redesign…We need
practice-based evidence to fill this gap… recognizing generalist practice as a ‘complex intervention’
(intervening in a complex system)…”1
1Reeve, et. al. BMC Family Practice 2013
perhaps what generalism lacks is specificity and boundaries…
©2014 MFMER | slide-32
“In Jazz, improvisation isn’t a matter of just making any ol’ thing up…There’s no right or wrong, just some choices that are better than others.”
Wynton Marsalis
©2014 MFMER | slide-33
Right Care?
Can this be a chord progression, a key, and a
rhythm for guiding quality?
Right-sizes Patient Workload
Enhances Patient Capacity
Pursues Patient Goals
©2014 MFMER | slide-34
Strategies for adapting primary care to make sense of its own complexity
1. Targets and measures that show us what the right care is
2. Flexible models that permit the right care
3. Both
©2014 MFMER | slide-35
Thank You!
[email protected]@aaronleppinmd
www.minimallydisruptivemedicine.org