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Healthcare fit and NPT


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This is the presentation Victor Montori (KER UNIT, Healthcare Delivery Research Program, Mayo Clinic) gave at the Normalization Process Theory symposium at King's Fund, London, UK on October 22, 2010.

Published in: Health & Medicine
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  • This is an excellent example of a professional taking a complex topic and designing slides that are easy to understand and don't take the focus away from the presentor. Very impressed with Slide 2: Disclosure. Dr. Montori is a very ethical physician and so it's helpful to see this information. Slide 9 Great graphic.
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Healthcare fit and NPT

  1. 1. 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
  2. 2. Disclosure Relevant Financial RelationshipsRelevant Financial Relationships NoneNone Off Label UsageOff Label Usage NoneNone
  3. 3. EBM x KT = ROI
  4. 4. 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
  5. 5. Rasmussen, J. N. et al. JAMA 2007;297:177- 186.
  6. 6. 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
  7. 7. 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
  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. Mayo Clinic Shared Decision Making Resource Center KER UNIT
  11. 11. Weymiller et al. Arch Intern Med 2007
  12. 12. 13
  13. 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.
  14. 14. 55 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
  15. 15. FIT Collaborate to co-create a program that fits better Intensify treatment
  16. 16. 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
  17. 17. 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
  18. 18. 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!
  19. 19. 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)
  20. 20. 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
  21. 21. 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
  22. 22. 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 NPT-based dimensions of treatment burden
  23. 23. 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
  24. 24. 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
  25. 25. Minimally disruptive healthcare Burden of treatment Coordination of care Comorbidity in clinical evidence and guidelines Prioritize from the patient’s perspective
  26. 26. LDL cholesterol HbA1c Bone mineral density Blood pressure Weight
  27. 27. Live longer Feel better Live unhindered by complications Minimally disruptive healthcare
  28. 28. 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.
  29. 29. Disobedience, the rarest and most courageous of the virtues, is seldom distinguished from neglect, the laziest and commonest of the vices George Bernard Shaw
  30. 30. FIT
  31. 31. @vmontori