This document discusses differences in type 2 diabetes outcomes and the role of the clinical encounter. It notes that differences in race, income, or healthcare access alone cannot explain differences in life expectancy for those with diabetes. The clinical encounter is often limited in translating evidence into practice, with large variation in practice and low patient adherence and satisfaction. Shared decision making, where patients and clinicians exchange information and deliberate together, can help address these issues compared to paternalistic or informed decision making approaches. Decision aids can improve knowledge, participation and adherence when used in clinical encounters for conditions like diabetes.

1. The clinical encounter
Differences and disparities in type 2 diabetes
Victor M. Montori, MD, MSc
Professor of Medicine
Knowledge and Encounter Research Unit
Mayo Clinic

2. Disclosure
Relevant Financial Relationships
None
Off Label Usage
None

3. Our journey
• Diabetes
• Differences in diabetes outcomes
• The role of the clinical encounter
• The role of context

4. Type 2 diabetes
Carbohydrate dysregulation that causes
symptoms attributable to high glucose levels in
the blood and urine and, in the long run, is
associated with loss of vision, pain and loss of
sensation, autonomic dysfunction, kidney failure,
susceptibility to infections, poor wound healing,
cardiovascular events, and loss of limbs, all
complications associated with large economic
costs as well as major loss of quality and
duration of life.

5. Shaw JE et al. Diabetes Research and Clin Pract 2009 (In press)

6. Diabetes
Health determinants
Health care
Health behaviors
Socioeconomic factors
Physical environment

7. Diabetes definition
Symptoms
Glycosuria
Hyperglycemia
GTT
Tolbutamide test
Fasting BG > 140
Fasting BG > 126
HbA1c > 6.5%

8. Diabetes definition

9. America 1/2
America 7/8
Race, income, or basic health-care
access and utilization alone cannot
explain differences in life expectancy

10. Suggested reading
Murray CJL et al. Eight Americas:
Investigating Mortality Disparities across
Races, Counties, and Race-Counties in
the United States. PLoS Medicine 3(9):
e260

11. National Center for Health Statistics, CDC 2008
For 2010, diabetes will be responsible for 1 in every 6 deaths of
any cause in North America.
Roglic G, Unwin N. Diabetes Research Clin Prac (In press)

12. Schillinger, D. et al. JAMA 2002;288:475-482.

13. Before drug treatment,
no differences in A1c
On drug treatment,
significant differences in
A1c appear across race/
ethnicity.
Predictors:
Race/ethnicity
Diabetes duration
Lack of insurance
Complex regimen
Heisler, M. et al. Arch Intern Med 2007;167:1853-1860.
Poor adherence

14. Ho, P. M. et al. Arch Intern Med 2006;166:1836-1841.
Rasmussen, J. N. et al. JAMA 2007;297:177-186.

16. Key problem:
Do not follow advice

17. Key problem:
Do not follow advice

18. Key problem:
Do not follow advice
Wasted or misallocated healthcare
resources: US$ 290b

19. Key problem:
Do not follow advice
Wasted or misallocated healthcare
resources: US$ 290b
Poor health despite cost and side effects

20. Key problem:
Do not follow advice
Wasted or misallocated healthcare
resources: US$ 290b
Poor health despite cost and side effects
Complicated patient-clinician relationship

21. Adherence
Osterberg. NEJM. 353(5) 2005; 487-497.

22. Suggested reading
Osterberg L, Blaschke T. Adherence to Medications.
N Engl J Med 2005; 353(5); 487-497.

23. Poor fidelity to treatment
Intentional
Structural

24. Disease Beliefs %
Disease or Medication Belief OR 95% CI
Have diabetes only when sugar is high 12
Can feel when sugar is high 54 Have diabetes only when sugar high 7.4 2.0 - 27.2
Will not always have diabetes 11
Doctor will cure diabetes 29 Not need to take meds when sugar is 3.5 0.9 – 13.7
normal
Treatment Beliefs
Worried about side-effects 3.3 1.3 – 8.7
Don’t need to take medicine when sugar is normal 23
High sugar only when > 200 mg/dL 56 Low confidence in controlling diabetes 2.8 1.1 – 7.1
Low sugar is < 110 30
Medicines are hard to take 14.0 4.4 – 44.6
Have heard of HgA1C 37
80 78
60
% Nonadherent
40 36
25
20 17
0
Skeptical Ambivalent Indifferent Accepting
Mann D et al.

25. Evidence-based Medicine

26. Evidence-based Medicine
The conscientious and judicious use of
current best evidence from clinical care
research in making health care decisions

27. The better the research, the more confident the
decision
Evidence alone is never sufficient to make a
clinical decision

29. Woman with terminal cancer and chronic pain has come to
terms with her condition, has issues in order, said her
goodbyes. She wishes to receive palliative care. She develops
pneumococcal pneumonia.

30. Woman with terminal cancer and chronic pain has come to
terms with her condition, has issues in order, said her
goodbyes. She wishes to receive palliative care. She develops
pneumococcal pneumonia.
85 year old man severely demented, incontinent, and mute,
without friends or family and in apparent discomfort. He
develops pneumococcal pneumonia

31. Woman with terminal cancer and chronic pain has come to
terms with her condition, has issues in order, said her
goodbyes. She wishes to receive palliative care. She develops
pneumococcal pneumonia.
85 year old man severely demented, incontinent, and mute,
without friends or family and in apparent discomfort. He
develops pneumococcal pneumonia
30 year old mother of two and otherwise healthy develops
pneumococcal pneumonia.

32. Patients with atrial fibrillation at risk of stroke
In 2 years:
Without treatment,100 patients will suffer:
12 strokes (six major, six minor)
3 serious GI bleeds
With warfarin, 100 patients will suffer:
4 strokes (8 fewer strokes, 4 major, 4 minor)
x serious GI bleeds

33. Devereaux PJ et al. BMJ 2001;323:1218

34. Is this real?
530 Canada MDs
3120 patients with a-fib + warfarin bleed (IC, GI)
90 days 90-365 days
1 afib patient at
1 afib patient at
high risk of
high risk of stroke
stroke

35. Likelihood of warfarin prescription
Days relative to bleed Odds ratio (95% CI)
90 d prior 1.00
0-90 d post 0.79 (0.62-1.00)
91-180 d post 0.60 (0.46-0.69)
181-270 d post 0.61 (0.46-0.81)
271-360 d post 0.72 (0.54-0.97)
1.0
Less warfarin after bleeding

36. Values + Preferences
Patients’ perspectives, beliefs,
expectations, and goals for health and life.
Underlying processes used in considering
the benefits, harms, costs, and
inconveniences patients will experience with
each management option and the resulting
preferences for each option.

37. Encounter Research

38. Paternalistic

39. Paternalistic
Clinician offers minimal information about the options

40. Paternalistic
Clinician offers minimal information about the options
Clinician deliberates about relative merits of the options

41. Paternalistic
Clinician offers minimal information about the options
Clinician deliberates about relative merits of the options
Clinician makes decisions without patient input

42. Paternalistic
Clinician offers minimal information about the options
Clinician deliberates about relative merits of the options
Clinician makes decisions without patient input
NOT CONSISTENT WITH EBM!!!

43. Clinician as perfect
Clinicians must assess patients values and
preferences
Clinicians, acting on their understanding of the
patient’s best interest, make a recommendation

44. Informed
Patient receives information about options
Patient deliberates and makes decision with minimal
clinician input

45. Shared decision-making
Patients and clinicians exchange information about
options
They both share information about their V+P
They deliberate together
Reach decision by consensus

46. Decision making models
Clinician-as-perfect Shared decision-
Approaches Parental Informed
agent making
Direction and amount of
information flow about Clinician Patient Clinician Patient Clinician Patient Clinician Patient
options
Direction of information
flow about values and Clinician Patient Clinician Patient Clinician Patient Clinician Patient
preferences
Deliberation Clinician Clinician Clinician, Patient Patient
Decider Clinician Clinician Clinician, Patient Patient
No when decision is not
Consistent with EBM
purely technical and Yes Yes Yes
principles
there are options
Modified from Charles C et al

47. Text
Lobke van Aar

51. Qu
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52. Qu
BP ali
ty
LD < 12 Go
A1 L < 0/8
Mi c < 70 0
cro 6.5
alb %
Jackevicious et al. JAMA 2002 um

53. The clinical encounter

54. The clinical encounter
our art is not that crafty
our science not that rigorous

55. The clinical encounter
our art is not that crafty
our science not that rigorous
Limited translation of evidence into practice
Large variation in practice
Low patient satisfaction
Poor patient adherence
Low physician satisfaction

56. 36901 Medicare Pts Kaiser/
Commonwealth 2003
15000 not taking
prescribed pills
Why?
10000 did not believe they
needed them
or
disliked side effects
USA Today, April 19, 2005

57. 2673 adults
36901 Medicare Pts Kaiser/
Harris/WSJ Poll
Commonwealth 2003
2007
15000 not taking
prescribed pills 27% did not fill a prescription
Why? Why?
10000 did not believe they 52% MDs fear lawsuit
needed them 41% MD make money
or 44% meet patient demands
disliked side effects 25% make fast decisions
27% industry bias
USA Today, April 19, 2005 WSJ March 15, 2007

58. Wiser Choices Program
at Mayo Clinic’s KER UNIT
Clinical encounter
Patient important outcomes
Success of the decision aid
Knowledge transfer
Creates a conversation
FIT

60. Wiser Choices Program
at Mayo Clinic’s KER UNIT
http://kercards.e-bm.info

62. The Statin Choice decision aid:
Acceptable to patients (OR 2.8)
Improved knowledge (2.4/9)
Improved risk estimation (OR 22)
Decreased decisional conflict (11/100)
Improved total trust (OR 2.6)
Improved action (70% fewer Rx in low risk patients)
Short-term adherence (OR 3.4)
Weymiller et al. Arch Intern Med 2007

67. Montori VM et al. Publication in preparation

68. Montori VM et al. Publication in preparation

69. Montori VM et al. Publication in preparation

70. The Osteoporosis Choice decision aid:
Just as acceptable as usual care
>75% MDs found helpful (+ 1 min to consultation)
Improved knowledge (1.8/9)
Improved risk estimation (~RR 2)
No change in decisional conflict or trust
Increased patient participation in choice (9%)
Same rate of Rx (~50%) in low and high risk patients
Significant improvement in % pts >80% adh to meds
Montori VM et al. Publication in preparation

71. Glucose control in type 2 diabetes
No clear evidence for a goal HbA1c
Comparative effectiveness data of safety
9 types of agents (+ lifestyle modification)
Many attributes per agent

73. Diabetes medication choice cards
Breslin M et al. Pa.ent Educa.on and Counseling 2008

75. Knowledge
Conversation 6 mo
Adherence
Decision aid Decision
HbA1c
Satisfaction
Choice
DM2 patients seen in primary
care
n= 46 patients
Adams, Austin, Baldwin Primary Care, 21 clinicians
Baldwin Family Medicine, Kasson,
Kenyon, NE Clinic, NW Clinic and
Olmsted Medical Center
R Allocation concealment / blinding to hypothesis / ITT
1889 assessed
1754 not eligible
50 refused n= 39 patients
85 patients enrolled 19 Clinicians
Knowledge
Conversation 6 mo
Usual care Decision Adherence
Satisfaction HbA1c
Choice

76. Satisfaction, conflict, and knowledge
Outcome Decision aid Usual care Adjusted mean
Median (range) Median (range) difference (95% CI)
Amount of info 7 (4‐7) 7 (4‐7) ‐0.01 (‐0.3, 0.3)
Clarity of info 6 (3‐7) 6 (4‐7) ‐0.01 (‐0.4, 0.4)
Helpfulness of info 6 (4‐7) 6 (4‐7) 0.4 (0.04, 0.7)
Recommend to 7 (2‐7) 7 (1‐7) 0.4 (‐0.3, 1.1)
others
Want for other 7 (1‐7) 6 (1‐7) 0.3 (‐0.4, 1.1)
decisions
Decisional conflict 7.8 (0‐100) 14.1 (0‐50) ‐0.9 (‐5.4, 3.6)
General knowledge 5 (0‐6) 4 (0‐6) 0.8 (0.1, 1.4)
Specific knowledge 2 (0‐4) 2 (0‐3) 0.5 (0, 0.9)

77. Patient involvement
Outcome Decision aid Usual care Adjusted mean
Median (range) Median (range) difference (95% CI)
OPTION score (video) 49 (23‐83) 23 (13‐56) 22 (13, 31)

78. Most frequently picked first (33%)
Most commonly picked overall (63%)

79. Choice
MedicaMon decision Decision aid (n=48) Usual care (n=37)
Added new meds 16 (33%) 8 (22%)
Start meWormin, SU, exena.de 14 (29%) 4 (11%)
Start glitazones or insulin 2 (4%) 3 (8%)
Other 0 1

80. Clinicians voice
• Of the 21 clinicians who used the DA:
–84% helpful
–90% would use again if available
• “It helped focus the discussion”
• “ Buy in was better”
• “I was surprised patient was willing to be more
aggressive”
• “Seemed like there were no surprises in the next
steps”

81. At 6-months
Outcome Decision aid Usual care Comparison DA vs. UC
(95% CI)
Self‐reported health status, 3 (1‐5) 3 (2‐5) AMD: ‐0.03 (‐0.4, 0.4)
median (range)
Did not miss a dose in last week 31 (76%) 25 (81%) OR: 0.74 (0.2, 2.3)
Persistence: No. days covered 180 (0‐180) 180 (180‐180) AMD: ‐12 (‐21, ‐2.7)
Adherence: % days covered 98 (0‐100) 100 (74‐100) AMD: ‐9 (‐14, ‐4)
A1c at 6‐months, median 7.1 (5.8‐10.7) 7.0 (5.9‐10.8) AMD: ‐0.01 (‐0.5, 0.5)
(range)
Decrease in A1c, median (range) 0.1 (‐3, 2.0) 0.5 (‐3.3, 2.0) AMD: 0.01 (‐0.5, 0.5)
Mullan RJ et al. Arch Intern Med 2009

82. Do they work?
Systematic review of 55 RCTs of 30 DAs (of 523)
Compared to usual care, decision aids:
Increased pat involvement: RR 1.7 (95%CI 1.3, 2.0)
Improved patient knowledge: 15% (95% CI 12, 19)
Reduced decisional conflict by 9.3/100 (95% CI 6, 13)
Reduced proportion undecided: RR 0.5 (95% 0.3, 0.8)
No difference in satisfaction, health outcomes
No consistent effect on costs, and on decisions
O’Connor et al. Cochrane review

83. When no tools exist?
Here are the options
This is not a technical decision
No wrong choice, including doing nothing
Happy to help you implement any of these

84. Triage of decision encounters
Tough decisions
True choice
Time
Tools
Training
Typicality
Take-part

85. Suggested reading
Gigerenzer G, et al. Helping doctors and patients to
make sense of health statistics. Psychol Sci Public
Interest. 2007;8:53–96. doi: 10.1111/j.
1539-6053.2008.00033.x.
Montori VM, Gafni A, Charles C. A shared treatment
decision-making approach between patients with
chronic conditions and their clinicians: the case of
diabetes. Health Expectations 2006; 9: 25-36.
Edwards A and Elwyn G. Shared decision making in
healthcare. Second Edition. Oxford Press 2009.

86. Poor fidelity to treatments is the patient’s fault
Intentional noncompliance

87. Poor fidelity to treatments is the patient’s fault
Intentional noncompliance
Reminders / technologies

88. Poor fidelity to treatments is the patient’s fault
Intentional noncompliance
Reminders / technologies
Behavioral interventions

89. Poor fidelity to treatments is the patient’s fault
Intentional noncompliance
Reminders / technologies
Behavioral interventions
Professional communication

90. Poor fidelity to treatments is the patient’s fault
Intentional noncompliance
Reminders / technologies
Behavioral interventions
Professional communication
Patient education

91. Poor fidelity to treatments is the patient’s fault
Intentional noncompliance
Reminders / technologies
Behavioral interventions
Professional communication
Patient education
Shared decision making

92. Poor fidelity to treatments is the patient’s fault
Intentional noncompliance
Reminders / technologies
Behavioral interventions
Professional communication
Patient education
Shared decision making
kercards.e-bm.info

93. 55

94. Diabetes
55

95. Metformin
Diabetes
55

96. Metformin
Diabetes Glipizide
55

97. Metformin
Diabetes Glipizide
55
Hypertension

98. Metformin
Diabetes Glipizide
55
Hypertension HCTZ

99. Metformin
Diabetes Glipizide
55
Hypertension HCTZ
Beta-blocker

100. Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker

101. High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker

102. High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression

103. High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression
Bad back

104. High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression
Bad back Neuropathy

105. Obese High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression
Bad back Neuropathy

106. Endocrinologist
Obese High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression
Bad back Neuropathy

107. Endocrinologist
Obese High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression
Bad back Neuropathy
Podiatrist

108. Dietitian
Endocrinologist
Obese High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression
Bad back Neuropathy
Podiatrist

109. DietitianTake off work
Endocrinologist
Obese High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression
Bad back Neuropathy
Podiatrist

110. Get a ride
DietitianTake off work
Endocrinologist
Obese High cholesterol
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression
Bad back Neuropathy
Podiatrist

111. Get a ride
DietitianTake off work
Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
Depression
Bad back Neuropathy
Podiatrist

112. Get a ride
DietitianTake off work
Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
ExerciseDepression
Bad back Neuropathy
Podiatrist

113. Get a ride
DietitianTake off work
Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs
Metformin
Diabetes Glipizide
55
Hypertension HCTZ Dizzy
Beta-blocker
ExerciseDepression
Bad back Neuropathy
Podiatrist
Check his feet

114. Get a ride
DietitianTake off work
Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs
Metformin
Diabetes Glipizide
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepression
Bad back Neuropathy
Podiatrist
Check his feet

115. Get a ride
DietitianTake off work
Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs
Metformin
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepression
Bad back Neuropathy
Podiatrist
Check his feet

116. Get a ride
DietitianTake off work
Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepression
Bad back Neuropathy
Podiatrist
Check his feet

117. Get a ride
DietitianTake off work
Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs LDL high
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepression
Bad back Neuropathy
Check his feetPodiatrist

118. Get a ride
DietitianTake off work
108 kg Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs LDL high
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepression
Bad back Neuropathy
Check his feetPodiatrist

119. Get a ride
DietitianTake off work
108 kg Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs LDL high
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepression
Bad back Neuropathy
Pain Check his feetPodiatrist

120. Get a ride
DietitianTake off work
108 kg Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs LDL high
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepressionCan’t sleep
Bad back Neuropathy
Pain Check his feetPodiatrist

121. 321 Get a ride
DietitianTake off work
108 kg Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs LDL high
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepressionCan’t sleep
Bad back Neuropathy
Pain Check his feetPodiatrist

122. 321 Get a ride
Deadline is now DietitianTake off work
108 kg Endocrinologist
Obese High cholesterol
Avoid salt, fats, carbs LDL high
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepressionCan’t sleep
Bad back Neuropathy
Pain Check his feetPodiatrist

123. 321 Get a ride
Deadline is now DietitianTake off work
108 kg Endocrinologist
Obese High cholesterol
perform! Avoid salt, fats, carbs LDL high
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepressionCan’t sleep
Bad back Neuropathy
Pain Check his feetPodiatrist

124. 321 Get a ride
Deadline is now DietitianTake off work
108 kg Endocrinologist
take work home Obese High cholesterol
perform! Avoid salt, fats, carbs LDL high
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepressionCan’t sleep
Bad back Neuropathy
Pain Check his feetPodiatrist

125. 321 Get a ride
Numbers don’t add up
Deadline is now DietitianTake off work
108 kg Endocrinologist
take work home Obese High cholesterol
perform! Avoid salt, fats, carbs LDL high
Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepressionCan’t sleep
Bad back Neuropathy
Pain Podiatrist
Check his feet

126. 321 Get a ride
Numbers don’t add up
Deadline is now DietitianTake off work
108 kg Endocrinologist
take work home Obese High cholesterol
perform! Avoid salt, fats, carbs LDL high
insurance Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepressionCan’t sleep
Bad back Neuropathy
Pain Check his feetPodiatrist

127. 321 Get a ride
Numbers don’t add up
Deadline is now DietitianTake off work
108 kg Endocrinologist
take work home Obese High cholesterol
perform! Avoid salt, fats, carbs LDL high
insurance Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
debt
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepressionCan’t sleep
Bad back Neuropathy
Pain Check his feetPodiatrist

128. 321 Get a ride
Numbers don’t add up
Deadline is now DietitianTake off work
108 kg Endocrinologist
take work home Obese High cholesterol
perform! Avoid salt, fats, carbs LDL high
insurance
mortgage Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
debt
Hypertension HCTZ Dizzy
55
Take pills Beta-blocker
ExerciseDepressionCan’t sleep
Bad back Neuropathy
Pain Check his feetPodiatrist

129. 321 Get a ride
Numbers don’t add up
Deadline is now DietitianTake off work
108 kg Endocrinologist
take work home Obese High cholesterol
perform! Avoid salt, fats, carbs LDL high
insurance
mortgage Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
debt
Hypertension HCTZ Dizzy
55
Daughter back at home Exercise
Take pills Beta-blocker
DepressionCan’t sleep
Bad back Neuropathy
Pain Check his feetPodiatrist

130. 321 Get a ride
Numbers don’t add up
Deadline is now DietitianTake off work
108 kg Endocrinologist
take work home Obese High cholesterol
perform! Avoid salt, fats, carbs LDL high
insurance
mortgage Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
debt
Hypertension HCTZ Dizzy
55
Daughter back at home Exercise
Take pills Beta-blocker
DepressionCan’t sleep
2 beautiful girls Bad back Neuropathy
Pain Check his feetPodiatrist

131. 321 Get a ride
Numbers don’t add up
Deadline is now DietitianTake off work
108 kg Endocrinologist
take work home Obese High cholesterol
perform! Avoid salt, fats, carbs LDL high
insurance
mortgage Metformin A1c 8.2%
Diabetes GlipizideCheck sugars
debt
Hypertension HCTZ Dizzy
Wasted! 55
Daughter back at home Exercise
Take pills Beta-blocker
DepressionCan’t sleep
2 beautiful girls Bad back Neuropathy
Pain Check his feetPodiatrist

132. FIT

133. Collaborate to co-create a program that fits better
FIT

134. FIT

135. FIT
Intensify treatment

137. Evidence-based guidelines are disease-specific

138. Evidence-based guidelines are disease-specific
Poor care coordination

139. Evidence-based guidelines are disease-specific
Poor care coordination
Increasingly complex regimens
Treatments | Monitoring

140. Evidence-based guidelines are disease-specific
Poor care coordination
Increasingly complex regimens
Treatments | Monitoring
Decreasing healthcare support
Shift towards self-management

141. Evidence-based guidelines are disease-specific
Poor care coordination
Increasingly complex regimens
Treatments | Monitoring
Decreasing healthcare support
Shift towards self-management
Increasing treatment burden

142. 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

143. 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

144. Mojtabai and Olfson, Health Affairs, Vol 22, Issue 4, 220-229

145. Gibson et al. Am J Manag Care. 2006;12:509-517

146. McWilliams, J. M. et al. JAMA 2007;298:2886-2894.

148. 100
80
60
%
40
Statins
20 Beta blockers
ACE-I/ARB
0
0 7 14 22 29 36
Months since incident MI
Shah et al. Am J Med 2009

149. 70%
cardiologists think it is unethical
to offer these medications as choices
Ting et al.

153. 55
A1c<7%
BP<130/80 mmHg
LDL<100

154. 55 55
A1c<7%
BP<130/80 mmHg
LDL<100

155. 55 55 55
A1c<7%
BP<130/80 mmHg
LDL<100

156. 45 55 55 55
A1c<7%
BP<130/80 mmHg
LDL<100

157. 45 55 55 55 65
A1c<7%
BP<130/80 mmHg
LDL<100

158. FIT

160. 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.

161. Disobedience, the rarest and most
courageous of the virtues, is seldom
distinguished from neglect, the laziest and
commonest of the vices
George Bernard Shaw

163. Health care delivery designed to reduce the
burden of treatment on patients
while pursuing patient goals

164. Minimally disruptive medicine

165. Burden of
treatment
Minimally disruptive medicine

166. Burden of Coordination of
treatment care
Minimally disruptive medicine

167. Burden of Coordination of
treatment care
Minimally disruptive medicine
Comorbidity in
clinical
evidence and
guidelines

168. Burden of Coordination of
treatment care
Minimally disruptive medicine
Comorbidity in
Prioritize from
clinical
the patient’s
evidence and
perspective
guidelines

169. LDL cholesterol
HbA1c
Bone mineral density
Blood pressure
Weight

170. Live longer
Feel better
Live unhindered by complications

171. Suggested reading
May CR, Montori VM, Mair FS. We need
minimally disruptive medicine. BMJ
2009; 339: 485-7
Bodenheimer T. A 63-year-old man with
multiple cardiovascular risk factors and
poor adherence to treatment plans.
JAMA 2007; 298: 2048-2055.

172. Socio-economic factors have strong influence on
differences and disparities in diabetes incidence and
outcomes.
A modifiable risk factor for these differences is poor
treatment fidelity from volitional and structural causes.
More work is needed to make healthcare equitable and
effective.

173. FIT

174. word in your hand project - tudiabetes.com

175. word in your hand project - tudiabetes.com

176. montori.victor@mayo.edu
http://kerunit.e-bm.org
http://kercards.e-bm.info
@vmontori
http://minimallydisruptivemedicine.org