Measuring the burden of treatment – a review

David Eton has led a team of researchers in summarizing existing tools to measure the burden of treatment. The paper was just published. Measuring burden of treatment is one of the cornerstones of minimally disruptive medicine. Making patients and clinicians aware of the burden of treatment might be helpful in moderating the intensity of treatment to ensure it matches without overwhelming the existing capacity of the patient and caregivers. Let us know what you think of this important review.

Minimally disruptive medicine – synonyms to inspire the road ahead.

The last few weeks have seen a surge in discussions in the press about minimally disruptive medicine. The Wall Street Journal had a piece as did the Star Tribune in Minnesota here. This press in turn has led to a number of people to reflect about healthcare and to contact our research team to test the model out.

Meanwhile two teams are working on measuring treatment burden, and two reviews are considering how the Cumulative Complexity Model can help understand the (in)efficacy of lifestyle modification interventions and readmission prevention interventions. Much to do everywhere to lift the burden off patients with multiple chronic conditions.

Importantly, I think, our group has been producing some synonyms that begin to draw in the mind’s canvas different paths toward Minimally Disruptive Medicine:

– Palliative care for those far from the end of life – focus on quality of life, function, symptoms, in achieving patient goals

– Geriatrics for the young – be parsimonious, mindful of comorbidity and limited capacity (the younger parallels with frailty and life expectancy)

– Goldilocks (not too much, not too little, just right) – it is not only about reducing healthcare, it is about optimizing the healthcare footprint making sure that under use of desirable interventions is addressed as well.

– Wellness for the sick – emphasize function to increase capacity as part of the strategy to reduce treatment burden.

– Lean consumption for patients – maximize the efficiency of the work of being a patient.

What other parallels can we draw? What else could we learn about these disciplines?

The quest to reduce the healthcare footprint on the lives of individuals and communities presses on. The response from the audience at the 2013 ICSI Colloquium in St Paul, MN was quite telling: clinicians wondering how to overcome the impotence they feel as they comply with guidelines, care processes, and public reporting that they feel makes them deviate from patient goals; patients echoing my call for patients to lead a revolution in healthcare. Indeed, a patient from Texas, who pertinently had the last word at that ICSI presentation, made an impassionate plea for change, for patient-centered care, for minimally disruptive medicine. She then proposed: Let Patients Lead.  This moved me and reminded me of a friend’s friend who in reviewing the concept said that he felt this should be renamed Maximally Generous Medicine. Another synonym to inspire our journey.

Short films about polypharmacy

Short films to discuss polypharmacy? Why not.  The entries to the First Short Film Festival about Polypharmacy and Health are here. These are great, instructive, fun, reflective, and artistic. Which one is your favorite?  Why? Simplifying treatments, drugectomies, physician-assisted noncompliance, medication therapeutic management – all of these reflect the need to reduce the burden of treatment imposed by complex, often unnecessary, and frequently unsafe medication programs.

Burden of treatment

One of the key aspects of minimally disruptive medicine is the need to become aware of the burden that our treatments cause on people’s lives. This concept, of burden of treatment, relates to the distress (including suffering, interruption, inconvenience) caused by treatment-associated demands for time, attention, and work.  We know very little about it, but our international team is working toward clarity in this area.

Some important studies have been recently published and I bring them here for your attention:

1: Eton DT, Ramalho de Oliveira D, Egginton JS, Ridgeway JL, Odell L, May CR, Montori VM. Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Relat Outcome Meas. 2012;3:39-49. doi: 10.2147/PROM.S34681. Epub 2012 Aug 24. PubMed PMID: 23185121; PubMed Central PMCID: PMC3506008.

2: Tran VT, Montori VM, Eton DT, Baruch D, Falissard B, Ravaud P. Development and description of measurement properties of an instrument to assess treatment burden among patients with multiple chronic conditions. BMC Med. 2012 Jul 4;10:68. doi: 10.1186/1741-7015-10-68. PubMed PMID: 22762722; PubMed Central PMCID: PMC3402984.

3: Jani B, Blane D, Browne S, Montori V, May C, Shippee N, Mair FS. Identifying treatment burden as an important concept for end of life care in those with advanced heart failure. Curr Opin Support Palliat Care. 2012 Nov 28. [Epub ahead of print] PubMed PMID: 23196381.

4: Shippee ND, Shah ND, May CR, Mair FS, Montori VM. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol. 2012 Oct;65(10):1041-51. doi: 10.1016/j.jclinepi.2012.05.005. Review. PubMed PMID: 22910536.

5: Gallacher K, May CR, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med. 2011 May-Jun;9(3):235-43. doi: 10.1370/afm.1249. PubMed PMID: 21555751; PubMed Central PMCID: PMC3090432.

6: Bohlen K, Scoville E, Shippee ND, May CR, Montori VM. Overwhelmed patients: a videographic analysis of how patients with type 2 diabetes and clinicians articulate and address treatment burden during clinical encounters. Diabetes Care. 2012 Jan;35(1):47-9. doi: 10.2337/dc11-1082. Epub 2011 Nov 18. PubMed PMID: 22100962; PubMed Central PMCID: PMC3241328.

The IHI and minimally disruptive medicine

I was pleased to learn recently that the podcast for the Institute for Healthcare Improvement called WIHI focused on Minimally Disruptive Medicine was among the top 10 most listened. My colleague Nilay Shah and I were invited to participate in this interesting and interactive forum and were delighted to learn, as is often the case, that the audience is quite to resonate with our diagnosis of the problem and contribute to a potential list of solutions. We ended up spending quite a bit of time discussing shared decision making as well, as part of the solution set.  The podcast and associated material is here.

Medicina minimamente impertinente

Here is the video of my presentation in Spanish about MDM at the National Meeting of Primary Care Pharmacists in Bilbao, Spain in October 2011.

Aqui esta el video de mi presentación en español sobre Medicina Minimamente Impertinente en el Congreso Nacional de Farmacéuticos de Atención Primaria en Bilbao, España en octubre 2011.

Fuente: Irekia – Gobierno Vasco

The evidence for minimally disruptive medicine grows…

Katie Gallacher and the MDM Team have just published a typology of treatment burden in this month’s issue of Annals of Family Medicine (   The group have identified core components of treatment burden as reported by individuals with chronic heart failure and state that although further exploration and patient endorsement are necessary, the findings lay the foundation for a new target for treatment and quality improvement efforts toward patient-centered care.   

Kurt Stange, Editor of Annals of Family Medicine, in this month’s editorial (, states that the group have identified factors that increase the burden on patients and agreed that the paper highlights targets for personalizing care.  The important role for MDM, which aims to ease the burden of polypharmacy, improve the organization of care, and increase accessibility and continuity, all of which are reported as key issues, is therefore clear.