1. 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
3. Objectives
Recognize that patient non-adherence can be
induced by the organization and the delivery of
care.
Enumerate the components of patient work
and how patient work in relation to patient capacity
can worsen adherence and outcomes.
Identify the goals and components of minimally
disruptive medicine in the care
5. Key problem:
Do not follow advice
Wasted or misallocated healthcare resources:
US$ 290b (100b in avoidable hospitalizations)
Poor health despite cost and side effects
Complicated patient-clinician relationship
Cutler and Everett NEJM 2010 10.1056/NEJMp1002305
6. Beliefs and adherence in diabetes
Need Low High Low High
Concerns High High Low Low
Mann D et al. J Behav Med (2009) 32:278–284
7. 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
8. Poor fidelity to treatments is the patient’s fault
Intentional noncompliance
Beliefs about the disease
and about the treatments
Professional communication
Patient education
Behavioral interventions
Shared decision making
Pound et al. Soc Sci Med 2005
15. 321 Get a ride
Numbers don’t add up
Deadline is now Dietitian Take off work
take work home Obese 108 kg Endocrinologist
perform! High cholesterol
Avoid salt, fats, carbs LDL high
insurance Metformin A1c 8.2%
mortgage Diabetes GlipizideCheck sugars
debt
Hypertension HCTZDizzy
Wasted! 55
Daughter back at home Exercise
Take pills Beta-blocker
Depression Can’t sleep
2 beautiful girls Bad back Neuropathy
Pain Check his feetPodiatrist
17. A survey of 627 primary care
physicians in the US 2011
Learned helplessness:
malpractice,
performance measures,
little time with patients
Sirovich BE et al. Arch Intern Med 2011
18. Epidemic of risk-defined diseases
Promotion of treatments
Evidence-based guidelines are disease-specific
Poor care coordination
Increasingly complex regimens
Treatments | Monitoring
Decreasing healthcare support
Shift towards self-management
Increasing treatment burden
Failure to cope
Poor fidelity to the treatment program
20. The work of being
a chronic patient
Self-reported
48 min / day
incomplete
“not enough time”
Desirable (ADA)
122 minutes/day
+ admin
143 minutes/day
Russell LB et al. JFP 2005; 54: 52-56
21. 83 workload discussions in 46 encounters with DM2
Duration: mean 24 min/visit
Access
Insurance, cost, pharmacy,
obtaining appt, transportation
Administration
28 (34%)
Effects Administration
24 (29%) Insulin, diet, exercise, many
doses/day
Effects
Access Monitor Intended/Unintended
19 (23%) 12 (14%) Monitoring
Lab tests, self-monitoring
70% burden left unaddressed!
Bohlen et al. Diabetes Care 2011
22. The work of being a chronic patient
Sense-making work Organizing work and enrolling others
Doing the work Reflection, monitoring, appraisal
23. 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
24. Cumulative complexity model
Burden of treatment
Workload access
use Outcomes
Capacity self-care
Burden of illness
Shippee et al 2011
26. Burden of Coordination
treatment of care
Minimally disruptive healthcare
Comorbidity in
Prioritize from
clinical
the patient’s
evidence and
perspective
guidelines
27. The patient’s team
and…
Our team
Dietician Project
Primary care MD
Care manager Social worker manager
Designer
Admin
Pharmacist
Researchers Operations manager
29. Burden of Coordination
treatment of care
Minimally disruptive healthcare
Comorbidity in
Prioritize from
clinical
the patient’s
evidence and
perspective
guidelines
30. LDL cholesterol
HbA1c
Bone mineral density
Blood pressure
Weight
32. Disobedience, the rarest and most
courageous of the virtues, is seldom
distinguished from neglect, the laziest and
commonest of the vices
George Bernard Shaw
Some areas of “ disagreement ” Biggest concern = the calcuator uses femoral neck T-score, so if your patient ’ s hips are good, but their spine is bad, this underestimates their risk for spine fractures. But overall hip BMD is a better predictor of overall fracture risk
POint out that efforts to improve the outcomes in one disease lead to carve outs that end up fracturing the care of the chronic patient. Acknowledge patient experitse
POint out that efforts to improve the outcomes in one disease lead to carve outs that end up fracturing the care of the chronic patient. Acknowledge patient experitse Discontinuation