Procrustes and Primary Care
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Transcript of Procrustes and Primary Care
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Procrustes and Primary Care
Dee Mangin
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Effective Care
Recognition of the patients needsConsideration by professional and patient of the
best that medical science has to offer Context a relationship that will maximise the
therapeutic effect of using or not using treatments
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Dr. Cabot employed new diagnostic techniques in his practice with patients, techniques that were sometimes ignored by his patients
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Evidence based medicine
risks becoming
Scientific - bureaucratic medicine
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Unmet need
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Unrecognized Erectile Dysfunction
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“The occasion when in the intimacy of the consulting room or sick room, a person seeks the advice of a doctor,
whom she trusts. This is a consultation and all else in the practice of medicine
derives from it.”
Sir James Spence
The Consultation
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Real populations
In primary care 40% of new presentations never fit criteria for any known diagnosis
In primary care 40% of patients have multiple comorbid conditions
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Infectious diseases
Heart disease
Cancer
Proportion of total deaths
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“hypertensive DISEASES, ischemic heartDISEASES, rheumatic fever, pulmonary heart DISEASE and DISEASES of the pulmonary circulation, other
forms of heart DISEASE cerebrovascular DISEASES or stroke, DISEASES of veins, lymphaticvessels,
and lymph nodes, OTHER AND UNSPECIFIED DISORDERS OF THE CIRCULATORY
SYSTEM, AND congenital MALFORMATIONS, or birth
defects of the circulatory system.”
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14
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drew blood from his body forced him to vomit violently gave him a strong laxative shaved his head applied blistering agents to his scalp put special plasters made from pigeon droppings onto the
sole of his feet fed him gallstones from the bladder of a goat made him drink 40 drops of extract from a dead man's skull
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Hypothetical >70 year old woman
– COPD– Type 2 diabetes– Hypertension– Osteoarthritis– Osteoporosis
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• 19 doses of 12 different medications• Taken at five times during the day• 14 non pharmacological activities• 10 different possibilities for significant
medicine interactions either with other medicines or other diseases
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Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing ever happened
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Intermediate indicators as quality targets
Adding torcetrapib to atorvastatin
↓ LDL cholesterol
Higher death rate in treatment arm
HRT ↓ LDL cholesterol
Higher death rate in treatment arm
Adding ezitimbe to simvastatin
↓ LDL cholesterol
No change in death rate
Rosiglitazone for diabetes
Better glucose control
Higher rate of heart attacks and deaths in treatment arm
Tighter glucose control Lower HbA1C Higher death rate in treatment arm
Lower glucose control target
Better kidney function
More hypoglycemic episodes in treatment arm
Adding an ACE blocker to and ACE inhibitor
Lower blood pressure
Higher adverse events with no change in CV events in treatment arm
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Machado de Assis
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Research evidence
Clinical state and circumstances
Patients’ preferences and actions
Improved health outcomes
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Patient priorities
“Life itself is not the most important thing in life. Some cling to it as a miser to his money and to as little purpose. Some risk it for a song, a hope, a cause, for wind in their hair.”
Sir Theodore Fox
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Professionals relying on epidemiological knowledge to guide their enquiries about
unmet needs in older patients may find that the needs that they identify are not perceived as unmet, or even meetable, by their patients
Drennan V et al Fam. Pract. 24:454-460, 2007
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What characterizes illness is itsvariability, not its average
manifestations. Virtually all of theconclusions of randomized controlledclinical trials are based on the averageresponse. Variability, which underliesthe genesis and progression of illness,the role of risk factors, and the impactof interventions, goes unrecognized.
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Not Doing Well?
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Not Doing, Well
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The Art of Not Doing, Well
“It is an art of no little importance to administer medicines properly: but, it is an art of much
greater and more difficult acquisition to know when to suspend or altogether to omit them.”
Philippe Pinel Treatise on Insanity
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Technological brinkmanship and the therapeutic imperative
Daniel Callahan
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Discriminatory Prescribing
“It is an art of no little importance to administer medicines properly: but, it is an art of much
greater and more difficult acquisition to know when to suspend or altogether to omit them.”
Philippe Pinel Treatise on Insanity
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Discontinuation
BP lowering35 - 40% remained normotensiveBain K et al. JAGS. 2008; 56: 1946-52
199 ‘disabled’ patients in residential careStopped 332 medicines (mean 2.8 / patient)Garfinkel D Israel Medical Association Journal 2007: 9:430-4
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Overall mortality and morbidity indicators
P - Value Control
Group
StudyGroup
71 119 Total no.
0.001 32 (45%) 25 (21%) Death /yr
0.002
21 (30%) 14 (11.8%) Referrals to
acute care /yr
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Arch Intern Med. 2010;170(18):1648-1654
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• 311 medications in 64 patients (58%) of drugs discontinued
• 4/5 didn’t have to be restarted• 80% reported a global improvement in health• No adverse events from the discontinuations
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Effective Care
Recognition of the patients needsConsideration by professional and patient of the
best that medical science has to offer Context a relationship that will maximise the
therapeutic effect of using or not using treatments
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The evidence is strong that no matter how technically correct a medical transaction might be, patients do not get better at the same rate, if they did not feel
that their needs were heard and understood over the course of their medical encounters.18, 160-167
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Effective Care
Recognition of the patients needsConsideration by professional and patient of the
best that medical science has to offer Context a relationship that will maximise the
therapeutic effect of using or not using treatments
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Phronesis
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Relationship-Centered Care Model: 3D+Combined horizontal and vertical integration within the framework of
relationship-centered primary care over time
HHHH
PRIMARY CARE TEAM
TIM
E
SECONDARY & TERTIARY CARE
PATIENT
FAMILY DOCTOR
FIGURE 5
HORIZONTAL BANDS =PERSON-FOCUSSED HORIZONTAL, INTEGRATION
VERTICAL DISEASE-FOCUSSED ELEMENTS FROM FIGURE 4 ARENOW INTER-WOVEN, INTEGRATED AND CONTEXTUALIZED
DIAB
ETES
NEU
ROCA
RDIO
VASC
ULA
R
YELLOW = RELATIONSHIP OVER TIME
Monk T, Mangin D, Stange K, Starfield B
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Better primary care gives better health outcomes
Source: Starfield B. www.pitt.edu/~super1/lecture/lec8841/index.htm
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Fit for Purpose
• Primary care that meets primary care standards
• Secondary care that meets secondary care standards
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Critical Structural Features
• Accessibility • Mechanisms of continuity of care• Range of services available in primary care
.
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The evidence-based primary care functions that achieve this are
• First contact for new needs/problems• Person (not disease) focused care (recognition
of people’s health problems)• The range of services provided in primary care• Coordination (of treatment and needs
recognition over time)
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Theseus
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urpose