Minimally disruptive medicine finds a home in Minneapolis…

Over the last few weeks it is exciting to see the concept of minimally disruptive medicine take off.  At the IHI meeting, Maureen Bisognano highlighted it as an example of fresh thinking about patient-centered care.  In Minnesota, Mark Linzer and his team at Hennepin County Medical Center are considering implementing an MDM clinic to help the myriad of patients with multiple chronic conditions, burdensome workloads and reduced capacity (mostly through poverty and its accompanying maladies).

Mark says:

I have been trumpeting the idea of an MDM (minimally disruptive medicine) clinic all day, from a morning meeting with the head of our EMR to a noon meeting with the director of our journal club and a leader in evidence-based medicine, and at an afternoon meeting with our health care reform work group where i spoke about MDM being the basis for the future of health care in our county (through an ACO).  This concept has truly affected us!  I believe i can find some willing partners for a pilot of an MDM clinic at Hennepin County Medical Center!  The idea of doing MDM as a way of using only technology or medication for which there is excellent evidence of benefit and in a way that is minimally disruptive of the patient’s lifestyle, is one that is fascinating all of us right now!

This is really awesome and the MDM team at Mayo is very excited about the potential for this partnership, a fantastic opportunity to test Minimally Disruptive Medicine as a philosophy of care for patients with multiple medical conditions.  Thanks Mark and a big ‘thank you’ to your team!

How negative studies can help with minimally disruptive medicine?

By Victor M. Montori, MD, MSc

Harlan Krumholz is a healthcare hero.  He has actively campaigned against the corruption of healthcare and has received attacks aimed at him personally and professionally.  He has formed a cadre of rigorous researchers in cardiovascular outcomes research who meet regularly. He is now the editor of the leading journal in this space.   He is an independent thinker, a productive researchers, and a supportive and loyal mentor to his peers and students.  The opportunity to express my admiration comes from the publication of Harlan’s op-ed in the Washington Post that directly relates to the topic of this blog.

For minimally disruptive medicine to take place, clinicians and patients need credible research evidence about what works, how much interventions are able to accomplish in terms of patient-important goals and outcomes, and what are the harms and costs to pay to get those benefits.  Both positive and negative trials (the latter referring to those who find conclusions of no difference between a new intervention and no intervention, placebo, or the standard of care) are essential to this mission.  However, negative trials are less likely to be published which furthers the notion that most of medicine’s treatments on average are effective.

Harlan’s Op-Ed makes a strong case for supporting, publishing, and celebrating negative trials.  And this is important for minimally disruptive medicine and to answer the question that patients ask: “is there something that we can stop doing?”  For many of my patients with diabetes taking pills this means that they can stop checking their blood sugars using finger sticks.  We know this from well conducted research showing marginal, if any, benefit.

Clinicians and patients in the US are enthusiastic tinkerers and are in the lookout for exciting new opportunities to improve their health.  As a result they are often attracted to new potentially effective therapies.  Publication of only positive trials contributes to sell those therapies; hiding of negative trials distorts the record, misleads clinicians and patients, and corrupts healthcare.

Thanks Harlan for raising this issue, and for all you do for patients.

Simplifying may not always be simple

A patient overwhelmed with the complexities of her program should prompt a simplification of her treatment. But what happens when simplifying, i.e. changing, has a new and steep learning curve and disrupts established routines? How should minimally disruptive medicine (MDM) deal with this problem.

A patient comes to see her diabetes doctor every 3 months at great burden to her (get a ride, company, time). When the MDM clinician seeks simplification of the follow up schedule with less intense schedule the patient feels abandoned. What is the role of e-health in this setting?

At a meeting of entrepreneurs in Minneapolis, MN I challenged them to consider patient disruption as a target for innovation and non disruption as a design criterion for new technologies for patients with chronic disease.

And the challenges of this new approach keep piling up…

Why patients with diabetes skip insulin doses?

While the study design cannot provide an in-depth picture (a qualitative analyses would), this Internet survey sought to identify correlates of why people would skip insulin doses (which a substantial proportion of patients reported doing: 57%; 20% reported skipping doses regularly).   Of note for our discussions in this blog is the prominence patients give to interference with daily activities.  This indicates patients directly indicating that a cause for nonadherence is the disruption to their lives caused by insulin use.

With very thin data to support this recommendation, many diabetologists are promoting the early use of insulin in patients with type 2 diabetes, the most common form of diabetes.  Since insulin use requires closer monitoring of blood sugars to manage the dose of insulin and avoid and manage low blood sugars, insulin-containing programs may be quite disruptive.  This paper adds that injecting the insulin can also be disruptive (in terms of effort and schedule I suspect given the correlation with more frequently prescribed injections) and embarrassing to some.

In my practice, I tried to address this with my patients, particularly those who need insulin to avoid symptoms of high blood sugars.  For these patients, I suggest the use of insulin pens and, when appropriate, insulin pumps.  However, the cost of these technologies has made them less accessible to my patients in these times of economic crises.  Thus, clinicians would have to review with patients their goals of care to determine whether, when, and how should insulin be used to manage their diabetes.  Calls for early use to protect the beta cell seem to ignore or at best place a lower value on avoiding or minimizing these challenges.

Lack of treatment fit also impacts smoking cessation tools

CNN reports on the death of the captain of the ship featured in the TV show “The Deadliest Catch” from complications of a stroke.  His son attributes his death to his bad habits, including smoking.  What caught my attention was the last statement by his son in this CNN quote:

“He did cut back on energy drinks, quite a bit from what he’d usually do,” Josh said, “but [doctors] have determined that smoking was the cause of this, and that was always his biggest habit. He had changed a lot of his habits but just could never kick the smoking. He started working with that electronic cigarette but, not used to it, he didn’t know how to charge it. He just kept smoking.”

The LA Times offers another glimpse of Minimally Disruptive Medicine and Diabetes

Jill Adams has written a very nice piece about the challenge before patients with type 2 diabetes seeking to decide how much they need to do to manage their disease and prevent complications.   The piece goes further and cites our group in seeking “good enough” diabetes control and mentions the work of being a patient.  Ms. Adams writes:

Montori notes that a good-enough blood sugar strategy would also ease the sheer time and energy it takes to manage diabetes. Treatment regimens — with frequent doses of pills or insulin, blood-sugar monitoring and doctor visits — are complicated and burdensome, particularly in patients who may be elderly and have other chronic conditions, such as high blood pressure and high cholesterol. One estimate of the time patients spend taking care of their condition, if they follow all the advice of their doctors, is 143 minutes per day. “That’s as much as a part-time job,” Montori says.

The link to the full article (LA Times, Oct 26 2009) is here

Burden of treatment – the path to poor treatment fidelity

Focusing on the patients’ experience of treatment may lead to a new understanding as to why some patients cannot, despite their willingness and knowledge, follow treatment recommendations.  Our team is exploring the aspects of treatments that may constitute treatment burden.  Do you have some ideas?

For instance, in the United States, patients may need to spend time on the phone, sending letters and faxes, and waiting for responses to obtain new medications, refill other ones, and deal with denials of coverage by their insurer.

Are there ways in which the healthcare professionals can help patients by providing adequate assistance and by modifying the regimen to minimize this form of treatment burden?  How would they know if they have been successful?  Who are the professionals best suited for this work?  Social workers, pharmacists, lifestyle coaches, nurses, and physicians working in teams alongside the patient and their caregivers?  Utopia?  No, we think this is reality just around the corner.  Can minimally disruptive medicine teams positively improve the value of healthcare delivery?  What are your thoughts?

One very astute opinion leader, Gary Oftedahl, is finding this compelling.  Read his blog here.  He notes:

If we in health care are unable to make simple changes in workflows or processes within our care delivery systems, how can we expect our patients to make often complex, and complicated changes, which disrupt a life-long pattern of activity?

What do you think?

Vulnerabilities – who is at risk of having their lives disrupted by medical care?Those

When discussing who is at risk of being burdened by treatments, we have come up with a list…we are wondering what other groups people can think of:

  • Individuals with limited familial or social support
  • Individuals with poor overall or health literacy
  • Individuals with many chronic conditions
  • Individuals with treatments that require constant attention, e.g., implanted devices that call attention to themselves throughout the day, pills that need to be taken several times per day
  • Individuals who travel far for healthcare
  • Individuals who have to wait for healthcare: to park, in line, at the office
  • Individuals who have tenuous health insurance who need to spend time arguing with insurance

Who else is in your list?