Minimally Disruptive Medicine

1. Minimally Disruptive Medicine Victor M. Montori, MD, MSc Professor of Medicine KER UNIT Mayo Clinic montori.victor@mayo.edu @vmontori

2. Disclosures • Relevant Financial Relationships • None • Off Label Usage • None

3. Encounter Research

4. Glasziou and Haynes ACP JC 2005

5. Key problem: Do not follow advice Wasted 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. Beliefs and adherence in diabetes Mann D et al. J Behav Med (2009) 32:278–284

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

10. Cumulative complexity model Burden of treatment Workload access use self-care Outcomes Capacity Burden of illness Shippee N et al JCE 2012

11. The work of being a chronic patient Sense-making work Organizing work and enrolling others Doing the work Reflection, monitoring, appraisal

12. The work of being a chronic patient People with more chronic conditions attend more visits, get more tests, and more medicines 2 hours/day spent on health-related activities Shippee D, In press Jowsey and Yem. BMC Public Health 2012 Of 83 worload discussions in 46 primary care visits (24 min): 70% left unaddressed Bohlen et al. Diabetes Care 2011

13. Barnett et al. Lancet 2012

14. Disease-specific guidelines and quality targets Multiple treatments | Monitoring tests Limited care prioritization Poor care coordination Life Burden of treatment Workload access use self-care Outcomes Capacity Burden of illness Shippee N et al JCE 2012

15. Workload Capacity Resilience Mental health Physical health Literacy Financial Social Environmental

16. Poor people accumulate comorbidity faster Barnett et al. Lancet 2012

17. Poor people accumulate mental comorbidity faster Barnett et al. Lancet 2012

18. Life Burden of treatment Workload access use self-care Outcomes Capacity Burden of illness Scarcity Shippee N et al JCE 2012

19. 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

20. On hospital discharge… Burden of treatment Workload access use self-care Outcomes Capacity Burden of illness Shippee N et al JCE 2012

21. Emerging approaches

22. RCTs of interventions to prevent readmissions 46 RCTs 1990-2013 18% (9-27%) reduction in risk of 30-day readmissions Leppin et al. In preparation

23. Subgroup Analyses

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. To fully play the role they play

26. http://minimallydisruptivemedicine.org montori.victor@mayo.edu | @vmontori