Mdm ihi washington dc 2012
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Minimally Disruptive Medicine Victor M. Montori, MD, MSc Professor of Medicine Healthcare Delivery Research Program Center for Science of Healthcare Delivery KER UNIT Mayo Clinic
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This is my slideshow presentation for the IHI conference on primary care at Washington D
Transcript of Mdm ihi washington dc 2012
Minimally Disruptive Medicine
Victor M. Montori, MD, MScProfessor of Medicine
Healthcare Delivery Research ProgramCenter for Science of Healthcare Delivery
KER UNITMayo Clinic
DisclosuresDisclosures
Relevant Financial RelationshipsRelevant Financial RelationshipsNoneNone
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Objectives
Recognize that patient non-adherence can beinduced by the organization and the delivery of
care.
Enumerate the components of patient workand how patient work in relation to patient capacity
can worsen adherence and outcomes.
Identify the goals and components of minimallydisruptive medicine in the care
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
Encounter Research
http://shareddecisions.mayoclinic.org
Weymiller et al. Arch Intern Med 2007
Statin Choice
Osteoporosis Choice
Montori et al Am J Med 2011
13
Mullan et al Arch Intern Med 2009
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
FIT
Collaborate to co-create a program that fits better
Intensify treatment
A survey of 627 primary care physicians in the US 2011
Sirovich BE et al. Arch Intern Med 2011
Learned helplessness:malpractice,
performance measures, little time with patients
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
Epidemic of risk-defined diseases
Promotion of treatments
Mayo Clinic Data, 2010
The work of being a chronic patient
The work of being a chronic patient
Self-reported48 min / day incomplete
“not enough time”
Desirable (ADA)122 minutes/day
+ admin143 minutes/day
Russell LB et al. JFP 2005; 54: 52-56
83 workload discussions in 46 encounters with DM2 Duration: mean 24 min/visit
Administration28 (34%)
Monitor12 (14%)
Access
19 (23%)
AccessInsurance, cost, pharmacy,
obtaining appt, transportation
AdministrationInsulin, diet, exercise, many
doses/day
EffectsIntended/Unintended
MonitoringLab tests, self-monitoring
70% burden left unaddressed!
Effects24 (29%)
Bohlen et al. Diabetes Care 2011
The work of being a chronic patient
Sense-making work Organizing work and enrolling others
Doing the work Reflection, monitoring, appraisal
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
Cumulative complexity model
Shippee et al 2011
Workload
Capacity
accessuse
self-careOutcomes
Burden of treatment
Burden of illness
Capacity
Workload
PersonalMedical
FinancialSocial
Contextual
Minimally disruptive healthcare
Burden of treatment
Coordination of care
Comorbidity in clinical
evidence and guidelines
Prioritize from the patient’s perspective
Our team
The patient’s teamand…
Designer
Primary care MD
Admin
Dietician Project manager
Pharmacist
Care manager
Operations managerResearchers
Social worker
Each patient with multimorbidity is a “canary in the coal mine”
Minimally disruptive healthcare
Burden of treatment
Coordination of care
Comorbidity in clinical
evidence and guidelines
Prioritize from the patient’s perspective
LDL cholesterol
HbA1c
Bone mineral density
Blood pressure
Weight
Feel better
Live longer
Living independently, unhindered by complications
Minimally disruptive healthcare
Disobedience, the rarest and most courageous of the virtues, is seldom
distinguished from neglect, the laziest and commonest of the vices
George Bernard Shaw
FIT
http://kerunit.e-bm.orghttp://kercards.e-bm.infohttp://shareddecisions.mayoclinic.org
@vmontori
http://minimallydisruptivemedicine.org
