Patient Disobedience
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Patient disobedience Victor M. Montori, MD, MSc Knowledge and Encounter Research Unit Mayo Clinic
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Presented by Dr Victor Montory at McMaster Workshop, 2009
Transcript of Patient Disobedience
Patient disobedienceVictor M. Montori, MD, MSc
Knowledge and Encounter Research UnitMayo Clinic
Poor fidelity to the treatment program
Effective treatments
Increasing demands on patientswork | time | $$
Effective treatments
Increasing demands on patientswork | time | $$
Effective treatments
The need to collaborate to achieve goals of chronic care delivery
Poor health and expenditure
Poor health and expenditure
Waste or misallocation of healthcare resources
Poor health and expenditure
Complicated patient-clinician relationship
Waste or misallocation of healthcare resources
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communication
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision making
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
Poor fidelity to treatments is the patient’s faultIntentional noncompliance
Professional communicationPatient education
Shared decision makingReminders
Behavioral interventions
multiple chronic conditions
multiple chronic conditions
1 in 5 adults
multiple chronic conditions
1 in 5 adults
3 in 5 older adults
multiple chronic conditions
1 in 5 adults
3 in 5 older adults
multiple chronic conditions
1 in 5 adults
3 in 5 older adults
1 in 5 older adults 4+
multiple chronic conditions
1 in 5 adults
3 in 5 older adults
1 in 5 older adults 4+
80%
multiple chronic conditions
1 in 5 adults
3 in 5 older adults
1 in 5 older adults 4+
80%of Medicare expenditures
Evidence-based guidelines are disease-specific
Poor care coordination
Evidence-based guidelines are disease-specific
Increasingly complex regimensTreatments | Monitoring
Poor care coordination
Evidence-based guidelines are disease-specific
Increasingly complex regimensTreatments | Monitoring
Decreasing healthcare supportShift towards self-management
Poor care coordination
Evidence-based guidelines are disease-specific
Increasingly complex regimensTreatments | Monitoring
Decreasing healthcare supportShift towards self-management
Poor care coordination
Evidence-based guidelines are disease-specific
Increasing treatment burden
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
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
FITPatient is able to implement a program
that achieves patient goals
FIT
FIT
Collaborate to co-create a program that fits better
FIT
FIT
Intensify treatment
Poor treatment fidelity is in part structurally induced and is the result of cumulative burden of the practice
and organization of care
Encounter Research
Encounter Research
0
20
40
60
80
100
0 7 14 22 29 36
CP1313325B-1
%
Months since incident MI
StatinsBeta blockersACE-I/ARB
Shah et al. AHA Meeting Nov 2007
36901 Medicare Pts Kaiser/Commonwealth 2003
15,000 not taking prescribed pills
Why?10000 did not believe they needed them or disliked
side effects
USA Today, April 19, 2005
2673 adultsHarris/WSJ Poll 2007
27% did not fill a prescription
Why?52% MDs fear lawsuit41% MD make money
27% industry bias
WSJ March 15, 2007
36901 Medicare Pts Kaiser/Commonwealth 2003
15,000 not taking prescribed pills
Why?10000 did not believe they needed them or disliked
side effects
USA Today, April 19, 2005
FITPatient is able to implement a program
that achieves patient goals
55
55
Diabetes
55
DiabetesMetformin
55
DiabetesMetforminGlipizide
55
DiabetesMetforminGlipizideCheck sugars
55
Diabetes A1c 8.2%MetforminGlipizideCheck sugars
55
Diabetes
High cholesterolA1c 8.2%Metformin
GlipizideCheck sugars
55
Diabetes
High cholesterolA1c 8.2%LDL high
MetforminGlipizideCheck sugars
55
Diabetes
High cholesterolObese
A1c 8.2%LDL high
MetforminGlipizideCheck sugars
55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
MetforminGlipizideCheck sugars
55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
HCTZ
MetforminGlipizideCheck sugars
55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizideCheck sugars
55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyCheck sugars
55
DiabetesHypertension
High cholesterolObese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyTake pills
Check sugars
55
DiabetesHypertension
High cholesterol
Depression
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyTake pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyTake pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
DizzyTake pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
Pain
DizzyTake pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
DizzyTake pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
DizzyTake pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
DizzyTake pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
DizzyTake pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off work
Take pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off workGet a ride
Take pills
Check sugars
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off workGet a ride
Take pills
Check sugars
Avoid salt, fats, carbs
55
DiabetesHypertension
High cholesterol
DepressionBad back
Can’t sleep
Obese
A1c 8.2%LDL high
HCTZBeta-blocker
MetforminGlipizide
NeuropathyPain
Endocrinologist
Podiatrist
Dietitian
Dizzy
Take off workGet a ride
Take pills
Check sugars
Avoid salt, fats, carbs
Exercise
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
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
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 1
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 1Deadline is now
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 now
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 nowperform!
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!
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!insurance
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!
debtinsurance
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!
mortgagedebt
insurance
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 home
mortgagedebt
insurance
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
mortgagedebt
insurance
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
55
A1c<7%BP<130/80 mmHg
LDL<100
55 55
A1c<7%BP<130/80 mmHg
LDL<100
55 55
A1c<7%BP<130/80 mmHg
LDL<100
55
55 55
A1c<7%BP<130/80 mmHg
LDL<100
5545
55 55
A1c<7%BP<130/80 mmHg
LDL<100
5545 65
Disobedience, the rarest and most courageous of the virtues, is seldom
distinguished from neglect, the laziest and commonest of the vices
George Bernard Shaw
Minimally disruptive medicine
Effective care and service provision designed to reduce the burden of treatment on patients
Minimally disruptive medicine
Minimally disruptive medicine
Burden of treatment
Minimally disruptive medicine
Burden of treatment
Coordination of care
Minimally disruptive medicine
Burden of treatment
Coordination of care
Comorbidity in clinical
evidence and guidelines
Minimally disruptive medicine
Burden of treatment
Coordination of care
Comorbidity in clinical
evidence and guidelines
Prioritize from the patient’s perspective
HbA1c
HbA1cQuality of care
HbA1cQuality of care
Clinical inertia
HbA1cQuality of care
Clinical inertia
Report card
HbA1cQuality of care
Clinical inertia
Report card
Technical decisions
Live longerFeel better
Live unhindered by complications
The balance of desirable and undesirable effects of an intervention is dependent on
how people use it.
“The A1C Champions® program is one of the most innovative patient marketing initiatives that I’ve ever seen. It has been successfully utilized by the brand team to enhance the efforts of the brands and improve patients’ lives. This program is one of the biggest drivers for the brand team to break down barriers, educate patients and motivate them to take action.”
Angela Moskow – Associate Vice President, Marketing sanofi aventis
