How to improve patient´s adherence to ivf cycles

SMART VI – Cape Town, South Africa – April 2010

Overview
IVF dropout
Numbers
Root causes
Dropout hotspots
IVF quality: a critical analysis
Strategies to improve adherence

The Infertility Patient Journey 1 Boivin J, et al. Hum Reprod 2007;6:1506; 2 Data on file, ObGyn Research 2003, EMD Serono, Inc. 3 Domar AD. Fertil Steril 2004;81:271 Esteves, Having Difficulty Conceiving Treated by ObGyn Treated by Infertility Specialist 20% discontinued treatment before finishing clomiphene citrate (CC) 2 23% finished CC therapy and then discontinued treatment 2 25-40% who came to IS for initial consult did not initiate treatment 2 60-65% who started treatment dropped out before completing treatment 3 45% of infertile couples never sought medical treatment 1

Is your communication satisfactory?
Communication
Education (radio, TV, newspaper, magazines, Web, healthcare professionals, etc)
Referral physicians & Gyn:
when to refer to IS
when/how often update
when to refer patients back:
Surgery (laparoscopy)
Pregnancy
Esteves,

Patient perspective in choosing an IVF Clinic
Success rates
Quality of services provided
Localization
Experience and specialization
Costs
Counseling available
Choosing an IVF Clinic Fertil Steril 2005

Is your IVF program good?
Pregnancy rates = Quality???????
50% is really better than 30% ?
Esteves, Pregnancy rates

Established 2005
100 babies born
Few credentials experience
No scientific publications
IVF first treatment line
No poor responders
Record of errors/patient complaints
High multiple PR
Advertise a lot
Established1994
>1,000 babies born
Lots of credentials/experience
Several publications
All treatment options available
Individualized approach
Rare errors/patient complaints
Low multiple PR
Educational marketing
Doctor Look Good PR = 50% Doctor Look Bad PR = 30% Esteves,

IVF Results Esteves,

So, what makes a high quality IVF Center? Esteves,

In a 2005 IVF study from the UK 8 , per-cycle discontinuation rates ranged from 25-42% and increased with each subsequent cycle
The dropout of patients undergoing IVF is huge! 8 Adapted from Rajkhowa et al. Reasons for discontinuation of IVF treatment: a questionnaire study. Hum Rep 2005;21:358-363

1. Olivius K t al, Fertil Steril 2004;81:258; 2. Land JA et al, Fertil Steril 1997; 68:278; 3. Schroder AK, et al, RBM Online 2004; 5:600; 4. Osmanangaoglu K et al, Hum Reprod 2002; 17:2655; 5. Rajkhowa M et al, Hum Reprod 2006; 21:358; 6. Brandes M et al, Hum Reprod 2009; 24:3127; 7. Hammarberg K et al, Hum Reprod 2001; 16:374. Reasons 1,5,6 IVF events women find stressful 7 Root Causes of Treatment Dropout Esteves, Psychological burden 49%-26% Prognosis 40%-23% Cost of treatment 23%-0% Relationship/divorce 15%-9% Physical burden 7-6% Up to 65% of couples dropout from IVF without achieving pregnancy before they complete 3 cycles 1-5 Pregnancy loss 94% Unsuccessful cycle 87% Waiting after ET 81% Waiting to find out how many eggs fertilized 68% Result of pregnancy scan 47% Oocyte retrieval 52% Embryo transfer 29% Injections 29% Physical pain 20% Blood tests 14%

Psychiatric assessment of 112 ART patients before starting IVF
40.2% had psychiatric disorder
Only 6.7% ever saw psychiatrist before ART
Psychological distress as a potential predictive indicator Chen TH, et al: Human Reprod 2004;10:2313 % of patients Root Causes of dropout #1: Stress Esteves,

Financial/cost issues may not be primary cause
High dropout rates in countries with national healthcare programs covering IVF
Root Causes of Treatment Dropout #2: Financial Domar AD. Fertil Steril 2004;81:271

Strategies to improve adherence? Make IVF more patient-friendly is the key issue Esteves,

Our method
Stress reduction
Intensive nursing care
Education
Total quality management
Esteves, Tertiary Center for Male Reproduction 1997 over 1,200 couples per year

Improve adherence to IVF Lesson 1: Stress reduction Esteves,
Some IVF difficulties
Understanding treatment steps/expectations
Several medications, documents, orientation
Excessive monitoring
Blood, ultrasound
Learning about injections
FSH/LH/hCG
Antagonist/agonist
OCP (pain, anesthesia)

Improve adherence to IVF Lesson 1: Stress reduction Rejane Ganzaroli Psychologist, ANDROFERT Esteves,
Complementary Health Care Program
Integrated team of health professionals:
- psychologist
- nutritionist
- acupuncturist
Weekly sessions
Goal: Reduce Stress

Medication Strategies
Typical Cycle (long protocol):
Daily SC GnRH-a: 21
FSH/LH: 10-15
hCG: 1
Progesterone: 14
Blood tests: 4-10
Number of sticks: 36-60

Medication Strategies
sc rFSH/rLH (pen devices)
Antagonist (vs agonist)
Combine meds (antag + rLH)
sc prefilled hCG
Vaginal progesterone 1x/day (vs IM)
Minimize blood tests

Anesthesia:
Egg retrieval
Sperm retrieval

Improve adherence to IVF Lesson 2: Intensive nursing care More attention less stressed, happier patients Esteves,
Each patient assigned to a nurse (~20-25 couples per nurse)
Teaching (IVF steps, medication)
Individualized patient agenda
Medication plan
Schedule appointments
Hotline (24h/day; 7 days/week)
Follow-up:
Up to live birth (Registry report)
Return visit (non-pregnant)

Next employee: Nurse
A high quality IVF program has excellent nurses
Esteves,

Improve adherence to IVF Lesson 3: Education Esteves, IVF education on site but preferable via Web

Improve adherence to IVF Lesson 3: Education Esteves,
IVF education on site but preferable via Web
Material for download
Medication timetables
Consents
Procedure instructions
Medication instructions

Improve adherence to IVF Lesson 3: Education IVF orientation guide
IVF education on site
but preferable via Web
Material for download
Medication timetables
Consents
Procedure instructions
IVF orientation
Goals:
 Patient visits
 Nursing time
Cost savings

Improve adherence to IVF Lesson 3: Education Esteves,
Learning how to administer injections via Web
Tutorial Videos on the Web
Available for download

The IVF Clinic: a very complex organization Esteves,

Improve adherence to IVF Lesson 4: Quality Management Esteves,
Total Quality Management
A high quality IVF program focuses on how the business is managed
Focus on patient
Improve communication
Continual improvement
Leadership

ISO 9001:2008
A well-organized workflow will guarantee good quality of work
Quality Management = Process management
Define what you want to do , how you want to do it, and how you can ensure it’s being done that way

How do you know you are doing a good job? How do you measure your interventions/processes? Are your patients satisfied? Improve adherence to IVF Lesson 4: Quality Management Esteves,

Improve adherence Lesson 4: Quality Management Esteves,
ISO 9001:2008:
requirements
Control of documents
Control of records
Internal Audits
Control of nonconformity and corrective action
Preventive action

Corrective action
Preventive action

The bigger the organization, the worse the customer focus
83% of the organizations assume that their customers are satisfied.
90-96% of unhappy customers never lodge a complaint.
Marketing for keeps, John Wiley, New York 1993 Improve adherence to IVF Lesson 4: Quality Management Esteves,

Understanding our customers- Surveys Esteves,

Understanding our customers- Surveys

Communication is the Key:
Internal:
Meetings
External:
Patients
Outside customers
Referring physicians

Leadership
Established unity of purpose and direction of the internal environment
Create an environment where people are fully involved in achieving the organization’s objectives

Our method
Stress reduction
Intensive nursing care
Education
Total quality management
Esteves, Source: Androfert, 1999-2009

Infertile pts. do not return for IVF treatment because IVF is stressful and complicated.
Reducing stress will improve adherence and reduce dropout .
Make IVF easier .

Infertile patients require education and support throughout the infertility patient journey.
Invest in nurses and web-based educational tools.
A quality system makes IVF Clinics focus on the needs of the customer (patient): these includes medical, scientific and emotional needs.

How to improve patient´s adherence to ivf cycles

by Sandro Esteves on Apr 06, 2011

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How to improve patient´s adherence to ivf cycles — Presentation Transcript