Is how we are treating patients for chronic diseases (and pre-diseases) all wrong?

A look again at minimally disruptive healthcare. In June 2013 we wrote about a contrarian approach to treating chronic disease–and now the ‘pre-diseases’ which have been discovered, like Columbus with America, with all good and proactive intentions for the patient. There’s increasing pressure, and rigidity in applying, guidelines and quality standards which are both performance and financially based. Measure, measure, measure!! Prescribe, prescribe, prescribe!! Is your patient at goal? Yet we are losing the Battle of Real Results and improved health. Telehealth and telemedicine are being touted as ways to increase compliance, but do they complicate matters and add to–not reduce–the burden?

We return to the originator of this minimally disruptive approach to care, Victor Montori MD, an endocrinologist at Mayo Clinic, via a MedCityNews article by cardiologist John Mandrola MD and this video from a primary care conference, the NAPCRG annual meeting in New York. (At 45 minutes, you’ll want to save it for later).

Key points:

• Pills, procedures and quality guidelines are not working for the patient–or the physician/clinician. The latter are acutely aware that they are being too aggressive; a survey of 627 primary care clinicians indicated that 50 percent of their patients get too much care (15:13 in video).
• In order to make quality care work for the patient, the burden has to be reduced for both clinician and patient. How much work can we put on the patient before they throw up their hands and give up? What is the least amount to do?
• Quality guidelines need context to work in real life.
• Minimally disruptive care seeks to decrease the work of care while increasing the capacity of the patient to do the work.

A better strategy would be, in Dr Mandrola’s words, to:

1. Start by using the right language. Assess the burden of care and think about the patient’s capacity to do all that we prescribe.
2. Guideline writers must add context, otherwise guidelines will become irrelevant.
3. Use shared-decision making. If you have to treat 140 patients with a statin medication to prevent one heart attack (meaning 139 patients take the drug without benefit), it makes sense to incorporate the patient’s goals.
4. Think about deprescribing, not just in the elderly, but in relation to decreasing the work of healthcare.

When you are not winning the war, change the strategy. And for us in telehealth, telecare and telemedicine, what position will we take on the battlefield?

Related reading: Dr Mandrola hat-tipped one of this Editor’s favorites, Carolyn Thomas of the Heart Sisters blog. Her article on the parallels between judging illness and poverty is here. She also links to Dr Montori and his Mayo team’s site on Minimally Disruptive Medicine.