Mdm ihi washington dc 2012

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This is my slideshow presentation for the IHI conference on primary care at Washington D

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  • 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
  • Mdm ihi washington dc 2012

    1. 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
    2. 2. DisclosuresRelevant Financial Relationships None Off Label Usage None
    3. 3. Objectives Recognize that patient non-adherence can be induced 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 minimally disruptive medicine in the care
    4. 4. Glasziou and Haynes ACP JC 2005
    5. 5. Key problem: Do not follow adviceWasted 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. 6. Beliefs and adherence in diabetesNeed Low High Low HighConcerns High High Low Low Mann D et al. J Behav Med (2009) 32:278–284
    7. 7. Coercion thru threats of dire outcomes from poor control of the disorder are doubly unethical: it does not work and high anxietypatients withdraw from care when threatened. Haynes et al. JAMA 2002
    8. 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
    9. 9. Encounter Research
    10. 10. http://shareddecisions.mayoclinic.org
    11. 11. Statin Choice Weymiller et al. Arch Intern Med 2007
    12. 12. Osteoporosis Choice Montori et al Am J Med 2011
    13. 13. 13Mullan et al Arch Intern Med 2009
    14. 14. 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! 55Daughter back at home Exercise Take pills Beta-blocker Depression Can’t sleep 2 beautiful girls Bad back Neuropathy Pain Check his feetPodiatrist
    15. 15. Collaborate to co-create a program that fits better FIT Intensify treatment
    16. 16. A survey of 627 primary care physicians in the US 2011Learned helplessness: malpractice,performance measures, little time with patients Sirovich BE et al. Arch Intern Med 2011
    17. 17. Epidemic of risk-defined diseases Promotion of treatmentsEvidence-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
    18. 18. Mayo Clinic Data, 2010
    19. 19. 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
    20. 20. 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
    21. 21. The work of being a chronic patient Sense-making work Organizing work and enrolling others Doing the work Reflection, monitoring, appraisal
    22. 22. Minimally disruptive healthcareHealth 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
    23. 23. Cumulative complexity model Burden of treatmentWorkload access use OutcomesCapacity self-care Burden of illness Shippee et al 2011
    24. 24. Workload Personal Medical Financial Capacity SocialContextual
    25. 25. Burden of Coordination treatment of care Minimally disruptive healthcareComorbidity in Prioritize from clinical the patient’sevidence and perspective guidelines
    26. 26. The patient’s team and… Our team Dietician Project Primary care MDCare manager Social worker managerDesigner Admin Pharmacist Researchers Operations manager
    27. 27. Each patient with multimorbidity is a “canary in the coal mine”
    28. 28. Burden of Coordination treatment of care Minimally disruptive healthcareComorbidity in Prioritize from clinical the patient’sevidence and perspective guidelines
    29. 29. LDL cholesterol HbA1cBone mineral density Blood pressure Weight
    30. 30. Minimally disruptive healthcare Feel better Live longer Living independently,unhindered by complications
    31. 31. Disobedience, the rarest and most courageous of the virtues, is seldomdistinguished from neglect, the laziest and commonest of the vices George Bernard Shaw
    32. 32. FIT
    33. 33. montori.victor@mayo.eduhttp://kerunit.e-bm.orghttp://kercards.e-bm.infohttp://shareddecisions.mayoclinic.org@vmontorihttp://minimallydisruptivemedicine.org

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