Healthcare fit and NPT

Focusing on work thanks to NPT: treatment fit and minimally disruptive medicine

Victor M. Montori, MD, MScProfessor of Medicine

Knowledge and Encounter Research UnitDivision of Endocrinology and Diabetes

Mayo Clinic

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EBM x KT = ROIEBM x KT = ROI

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

Rasmussen, J. N. et al. JAMA 2007;297:177-186.

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

Professional communication Patient

education Behavioral interventionsShared decision making

Pound et al. Soc Sci Med 2005

Encounter Research

Mayo Clinic Shared Decision Making Resource CenterKER UNIT

http://shareddecisions.mayoclinic.org

Weymiller et al. Arch Intern Med 2007

13

NPT in decision aid trials

• NPT orients analyses of factors that promote or inhibit the routinization of decision aids in practice:–Decision aids in diabetes trial–Translating comparative effectiveness into practice

trial–AMI Choice trial

• NPT orients analyses of factors that promote or inhibit the routinization of therapies in lives of patients.

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

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

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

115 workload discussions in 43 encounters with DM2 Duration: mean 24 min/visit

43(38%)

29(25%)

20(17%)23

(20%)

Access– Insurance, cost, pharmacy,

obtaining appt, transportation

Administration– Insulin, diet, exercise, many

doses/day

Effects– Intended/Unintended

Monitoring– Lab tests, self-monitoring

70% burden left unaddressed!

NPT and the work of patienthood

Sense-making work Organizing work and enrolling others

Doing the work Reflection, monitoring, appraisal

K. Gallacher and colleagues (Glasgow)

NPT-based dimensions of treatment burden

Organizing work and enrolling others

Doing the work Reflection, monitoring, appraisal

Learning about treatments and their

consequences

Gain an understanding of illness, tests, treatment, and when to seek help

Sense-making work

Doing the work Reflection, monitoring, appraisal

Engaging with others

Gaining support, advice, reassurance.

Organize transport, prescriptions

NPT-based dimensions of treatment burden

Sense-making work Organizing work and enrolling others

Reflection, monitoring, appraisal

Adhering to treatments and lifestyle changes

Attending appointments, taking medicines, enacting lifestyle

changesOvercoming barriers to access,

financesIntegrating treatment into social

circumstances

NPT-based dimensions of treatment burden

Sense-making work Organizing work and enrolling others

Doing the work

Monitoring the treatments

Altering management routine

Appraising treatments and medical advice

NPT-based dimensions of treatment burden

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

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

Live longerFeel better

Live unhindered by complications

Minimally disruptive healthcare

Long crazy story short for now, I just cracked a light beer, i plan to drink 4 tall boy light beers. What sort of drama can i expect with the meds im on? Please be kind with me, im trying real hard and its not easy. I fully know all about the fact im out of control with beer.

I would just like to know the facts from people who have drank on these meds.

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

montori.victor@mayo.edu

@vmontori

http://minimallydisruptivemedicine.org