healthcare fit and npt
DESCRIPTION
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.TRANSCRIPT
Focusing on work thanks to NPT: treatment fit and minimally disruptive medicine
Victor M. Montori, MD, MScProfessor of Medicine
Knowledge and Encounter Research UnitDivision of Endocrinology and Diabetes
Mayo Clinic
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EBM x KT = ROIEBM x KT = ROI
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
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 diabetes
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
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Beliefs about the disease and about the treatments
Professional communication Patient
education Behavioral interventionsShared decision making
Pound et al. Soc Sci Med 2005
Encounter Research
Mayo Clinic Shared Decision Making Resource CenterKER 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 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.
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
Neuropathy
108 kg
Pain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off workGet a ride
Take pills
Check sugars
Avoid salt, fats, carbs
Exercise
Check his feet
3 2 1Numbers don’t add up
Deadline is nowtake work home
perform!
Daughter back at home2 beautiful girls
Wasted!
mortgagedebt
insurance
FIT
Collaborate to co-create a program that fits better
Intensify treatment
Increasingly complex regimensTreatments | Monitoring
Decreasing healthcare supportShift towards self-management
Poor care coordination
Evidence-based guidelines are disease-specific
Increasing treatment burden
Failure to cope
Poor fidelity to the treatment program
The work of being a chronic patient
The work of being a chronic patient
Self-reported48 min / day incomplete
“not enough time”
Desirable (ADA)122 minutes/day
+ admin143 minutes/day
Russell LB et al. JFP 2005; 54: 52-56
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!
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)
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
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
Sense-making work Organizing work and enrolling others
Reflection, monitoring, appraisal
Adhering to treatments and lifestyle changes
Attending appointments, taking medicines, enacting lifestyle
changesOvercoming barriers to access,
financesIntegrating treatment into social
circumstances
NPT-based dimensions of treatment burden
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
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
Minimally disruptive healthcare
Burden of treatment
Coordination of care
Comorbidity in clinical
evidence and guidelines
Prioritize from the patient’s
perspective
LDL cholesterol
HbA1c
Bone mineral density
Blood pressure
Weight
Live longerFeel 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 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.
Disobedience, the rarest and most courageous of the virtues, is seldom
distinguished from neglect, the laziest and commonest of the vices
George Bernard Shaw
FIT
http://kerunit.e-bm.orghttp://kercards.e-bm.infohttp://shareddecisions.mayoclinic.org
@vmontori
http://minimallydisruptivemedicine.org