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 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 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

6. Mann D et al. J Behav Med (2009) 32:278–284 NeedLowHighLowHigh ConcernsHigh Low Beliefs and adherence in diabetes

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 Pound et al. Soc Sci Med 2005 Professional communication Patient education Behavioral interventions Shared decision making

9. 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

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

11. The work of being a chronic patient Sense-making workOrganizing 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 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 Shippee D, In press

13. Barnett et al. Lancet 2012

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

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

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 Want NeedCan

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

21. Emerging approaches

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

23. Subgroup Analyses

24. Coding Strategy Leppin et al. In preparation

25. 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 Want NeedCan

26. To fully play the role they play

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