Healthcare fit and NPT

Focusing on work thanks to NPT: treatment fit and minimally disruptive medicine Victor M. Montori, MD, MSc Professor of Medicine Knowledge and Encounter Research Unit Division of Endocrinology and Diabetes Mayo Clinic

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EBM 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 Beliefs and adherence in diabetes Need Low High Low High Concerns High High Low Low

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 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

Encounter Research

Mayo Clinic Shared Decision Making Resource Center KER UNIT http://shareddecisions.mayoclinic.org

Weymiller et al. Arch Intern Med 2007

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.

Diabetes Hypertension High cholesterol Depression Bad back Can’t sleep Obese A1c 8.2% LDL high HCTZ Beta-blocker Metformin Glipizide Neuropathy 108 kg Pain Endocrinologist Podiatrist Dietitian Dizzy Take off work Get a ride Take pills Check sugars Avoid salt, fats, carbs Exercise Check his feet 3 2 1 Numbers don’t add up Deadline is now take work home perform ! Daughter back at home 2 beautiful girls Wasted! mortgage debt insurance 55

FIT Collaborate to co-create a program that fits better Intensify treatment

Increasingly complex regimens Treatments | Monitoring Decreasing healthcare support Shift 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 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

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

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 changes Overcoming barriers to access, finances Integrating treatment into social circumstances

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 longer Feel 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

http://kerunit.e-bm.org http://kercards.e-bm.info http://shareddecisions.mayoclinic.org [email_address] @vmontori http://minimallydisruptivemedicine.org

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Healthcare fit and NPT

by Victor Montori on Oct 23, 2010

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