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


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.


A patient example…

Mayo Clinic Statin Choice Decision Aid:http://statindecisionaid.mayoclinic.org/


“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


The right thing for patients

What we are measuring?

Patient-centeredContext Dependent

Nuanced and Complex

Disease-centeredContext Independent

Simple and Systematized


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


To consider opportunities for innovating the primary care model to better fit complexity and uncertainty

Objective


The right thing for patients

Patient-centeredContext Dependent

Nuanced and Complex

More appropriate

targets

More appropriate measures

More appropriate

systems

DESTINATION

GUIDANCE

PERMISSION


DESTINATIONWhat are more appropriate targets?(person-centered and population-relevant end outcomes)


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.


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


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


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?


“Can you really do what I am asking you to do?”

Mair and May, BMJ, 2015


National Quality Forum. Patient Reported Outcomes in Performance Measurement, 2012

Where are these registries?


More appropriate targets?


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


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”


GUIDANCEWhat are more appropriate measures?(measures that incorporate context)


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?


NFL QB Passer Rating Total QBR

QB #1 26th 9th

QB #2 9th 26th

Measures that incorporate context are better measures of quality


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.


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?


Leppin, JAMA Int Med 2014


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”



PERMISSIONWhat are more appropriate systems?(systems that can accommodate complexity and nuance)


If the right thing to do for every patient in every situation was obvious…we could build care like we build cars.


But what if the right thing to do for every patient is not obvious?

What if it is complex and nuanced?



“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…


“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


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


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


Thank You!

[email protected]@aaronleppinmd

www.minimallydisruptivemedicine.org

Leppin NYP PC Final

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