Transcript It is an art of no little importance to administer medicines

Procrustes and Primary Care
Dee Mangin
Effective Care
Recognition of the patients needs
Consideration 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
Dr. Cabot employed new
diagnostic techniques in
his practice with
patients, techniques that
were sometimes ignored
by his patients
Evidence based medicine
risks becoming
Scientific - bureaucratic
medicine
Unmet need
Unrecognized Erectile Dysfunction
The Consultation
“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
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
Infectious diseases
Proportion of
total deaths
Heart disease
Cancer
“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.”
14
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
Hypothetical >70 year old woman
– COPD
– Type 2 diabetes
– Hypertension
– Osteoarthritis
– Osteoporosis
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•
•
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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
Men occasionally stumble over the truth,
but most of them pick themselves up and
hurry off as if nothing ever happened
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
Machado de Assis
Clinical state and circumstances
Research
evidence
Patients’
preferences
and actions
Improved health outcomes
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
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
What characterizes illness is its
variability, not its average
manifestations. Virtually all of the
conclusions of randomized controlled
clinical trials are based on the average
response. Variability, which underlies
the genesis and progression of illness,
the role of risk factors, and the impact
of interventions, goes unrecognized.
Not Doing Well?
Not Doing, Well
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
Technological brinkmanship and the
therapeutic imperative
Daniel Callahan
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
Discontinuation
BP lowering
35 - 40% remained normotensive
Bain K et al. JAGS. 2008; 56: 1946-52
199 ‘disabled’ patients in residential care
Stopped 332 medicines (mean 2.8 / patient)
Garfinkel D Israel Medical Association Journal 2007: 9:430-4
Overall mortality and morbidity indicators
Study
Group
Control
Group
P - Value
Total no.
119
71
Death /yr
25 )21%(
32 )45%(
0.001
Referrals to
acute care /yr
14 )11.8%(
21 )30%(
0.002
Arch Intern Med. 2010;170(18):1648-1654
• 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
Effective Care
Recognition of the patients needs
Consideration 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
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
Effective Care
Recognition of the patients needs
Consideration 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
Phronesis
Relationship-Centered Care Model: 3D+
Combined horizontal and vertical integration within the framework of
relationship-centered primary care over time
PRIMARY
CARE TEAM
PATIENT
FAMILY DOCTOR
FIGURE 5
Monk T, Mangin D, Stange K, Starfield B
YELLOW =
RELATIONSHIP
OVER TIME
HORIZONTAL BANDS =
PERSON-FOCUSSED
HORIZONTAL,
INTEGRATION
TIME
VERTICAL DISEASEFOCUSSED ELEMENTS
FROM FIGURE 4 ARE
NOW INTER-WOVEN,
INTEGRATED AND
CONTEXTUALIZED
HH
HH
CARDIOVASCULAR
NEURO
DIABETES
SECONDARY &
TERTIARY CARE
Better primary care gives better health outcomes
Source: Starfield B. www.pitt.edu/~super1/lecture/lec8841/index.htm
Fit for Purpose
• Primary care that meets primary care
standards
• Secondary care that meets secondary care
standards
Critical Structural Features
• Accessibility
• Mechanisms of continuity of care
• Range of services available in primary care
.
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)
Theseus
urpose