Procrustes and Primary Care

Dee Mangin

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

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 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

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

Heart disease

Cancer

Proportion of total deaths

“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

• 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

Research evidence

Clinical state and circumstances

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 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.

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 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

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

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 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

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 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

Phronesis

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

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