Dr. Victor Montori: "On careful and kind care for our complex patients"

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This document discusses the complex care needs of patients with multiple chronic conditions. It notes that such patients often have high treatment burdens from multiple medications and self-care needs that can exceed their capacity. Guidelines and care are often focused on single diseases and do not consider patient context. The document calls for a focus on balancing patient workload from treatment with their capacity through strategies like prioritizing care, deprescribing unnecessary treatments, coaching, and connecting patients to community resources.

Healthcare

On careful and kind care
for our complex patients
Victor M. Montori, MD, MSc
@vmontori

Multiple chronic conditions
On dialysis
Lives with son and his family
Does not speak English
Bland diet
Contact by phone

What is best for me?
What is best for my family?
Is our care the answer?

Disclosure Statement
I do not have financial
relationships to disclose.

Violence
Pollution
Chronic
stress
Multi
morbidity
Loneliness
Obesity
Poverty
Alienation
Age, sex, genes

Comorbidities are common
Dumbreck et al. BMJ 2015;350:h949

Richardson and Doster J Clin Epidemiol 2014
Do the other conditions and their management impact…
Baseline risk
Vulnerability
Responsiveness
Antidepressant
+
antihyperglycemic
Diabetes
+
HTN
+
Hyperlipidemia
Neuropathy
+
Antihypertensive
+
Anticonvulsant

Drug-disease
interactions rare, but for
chronic kidney disease.
Drug-drug interactions
are common, and ~20%
serious
Dumbreck et al. BMJ 2015;350:h949
Expected interactions
between guidelines

Observational
RCT RC
RCTRCT
RCT
RCT
Observational

Increasingly complex regimens
Limited to no prioritization
Poor care coordination
Evidence-based guidelines
Care pathways
Quality measures
Specialist care
are
disease focused and context blind
Overwhelmed patients and families

The work of being a patient
Sense-making work Organizing work and enrolling others
Doing the work Reflection, monitoring, appraisal
Gallacher et al. Annals Fam Med 2012

New work
Prepare for the consultation
Watch educational video
Bring questions; be ready for new ones
Record and review the visit
Review the medical record
Communicate via portal and transmit data
Self-measure, self-monitor, self-manage
Manage appointments, prescriptions, bills
Keep family and important others informed
Take care of significant other
Advocate for self and others

Prevalence of Treament Burden
Clinicians ask for too much,
the work is too hard, and it
gets delayed or not get done.
More common in low SES and
sicker patients who were more
likely to delegate.
Wolff JL, Byd CM. JGIM 2015 30: 1497-504
Nationally representative survey of 2040 >65 Americans

Capacity
WorkloadPurpose
Resilience
Literacy
Bandwidth
Health
Financial
Social
Environmental

Workload-capacity imbalance?
Workload Capacity
Life
Treatment burden
Sick
Personal
Socio-economical
Functional

Mullan et al Arch Intern Med 2009
KER UNIT | Mayo Clinic Video / Web
What aspect of your next diabetes
medicine would you like to discuss first?

Summary of Mayo experience
Age: 40-92 (avg 65)
Primary care, ED, hospital, specialty care
74-90% clinicians want to use tools again
Adds ~3 minutes to consultation
58% fidelity without training
Effects on SDM are similar in vulnerable populations
Variable effect on clinical outcomes, cost
Wyatt et al. Implement Sci 2014; 9: 26
Coylewright et al CCQO 2014, 7: 360-7

Workload-capacity imbalance?
Capacity
Treatment burden
Prioritize (SDM)
De-prescribe
Coaching
Self management training
Palliative care
Mental health
Physical and occupational therapy
Financial and resource security services
Community and governmental resources

25 yrs and 42 RCTs
30-day readmission
Interventions supporting capacity
30% more effective
Leppin A et al. JAMA Intern Med 2014
Shippee N et al JCE 2012

Accountability
Imbalance of
workload : capacity
Burden of illness
Burden of treatment
Adapted from NQF: MCC Measurement Framework 2012
Satisfaction with and
ease of access,
continuity, transitions
Physical and mental health
Role function
Disease control

The challenge
What are we doing for our care to be the best for
this patient and her family?
Careful
with patients’ workload
Kind
with patients’ capacity

Dr. Victor Montori: "On careful and kind care for our complex patients"

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