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Focusing on work thanks
to NPT: treatment fit and
minimally disruptive
medicine
Victor M. Montori, MD, MSc
Professor of Me...
Disclosure
Relevant Financial RelationshipsRelevant Financial Relationships
NoneNone
Off Label UsageOff Label Usage
NoneNo...
EBM x KT = ROI
Key problem:
Do not follow advice
Poor health despite cost and side effects
Complicated patient-clinician relationship
Was...
Rasmussen, J. N. et al. JAMA 2007;297:177-
186.
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 dia...
Coercion thru threats of dire outcomes
from poor control of the disorder are
doubly unethical: it does not work and high
a...
Poor fidelity to treatments is the patient’s fault
Intentional noncompliance
Beliefs about the disease
and about the treat...
Encounter Research
Mayo Clinic Shared Decision Making Resource Center
KER UNIT
http://shareddecisions.mayoclinic.org
Weymiller et al. Arch Intern Med 2007
13
NPT in decision aid trials
• NPT orients analyses of factors that promote
or inhibit the routinization of decision aids in...
55
Diabetes
Hypertension
High cholesterol
Depression
Bad back
Can’t sleep
Obese
A1c 8.2%
LDL high
HCTZ
Beta-blocker
Metfor...
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 car...
The work of being
a chronic patient
Self-reported
48 min / day
incomplete
“not enough time”
Desirable (ADA)
122 minutes/da...
115 workload discussions in 43 encounters with DM2
Duration: mean 24 min/visit
43
(38%)
29
(25%)
20
(17%)23
(20%)
 Access...
NPT and the work of patienthood
Sense-making work Organizing work and enrolling others
Doing the work Reflection, monitori...
NPT-based dimensions of treatment burden
Organizing work and enrolling others
Doing the work Reflection, monitoring, appra...
Sense-making work
Doing the work Reflection, monitoring, appraisal
Engaging with others
Gaining support, advice,
reassuran...
Sense-making work Organizing work and enrolling others
Reflection, monitoring, appraisal
Adhering to treatments and
lifest...
Sense-making work Organizing work and enrolling others
Doing the work
Monitoring the treatments
Altering management
routin...
Minimally disruptive healthcare
Health care delivery designed to reduce
the burden of treatment on patients
while pursuing...
Minimally disruptive healthcare
Burden of
treatment
Coordination
of care
Comorbidity
in clinical
evidence and
guidelines
P...
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 ca...
Disobedience, the rarest and most
courageous of the virtues, is seldom
distinguished from neglect, the laziest
and commone...
FIT
http://kerunit.e-bm.org
http://kercards.e-bm.info
http://shareddecisions.mayoclinic.org
montori.victor@mayo.edu
@vmontori
...
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.

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

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.

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