Strategies to reduce patient dropout from art treatment

Strategies to Reduce Patient Dropout from ART Treatment
“Understanding Infertility” – New Delhi, India – August 2011
SandroEsteves, MD, PhD
Director, ANDROFERT
Center for Male Reproduction and Infertility
Campinas, BRAZIL

Learning Objectives
A critical analysis of “quality” in IVF
Unravel IVF dropout
Numbers
Root causes
Dropout hotspots
Learn strategies to improve patient’s adherence to IVF treatment

Is your IVF program good?
Pregnancy rates = Quality???????
50% is really better than 30% ?
Pregnancy rates
Esteves, 3

Doctor Look Bad
PR = 30%
Doctor Look Good
PR = 50%
Established 1994
>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
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
Esteves, 4

IVF Results
Esteves, 5

So, what makes a high quality IVF Center?
Satisfied customers who return for treatment
Esteves, 6

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

Root Causes of Treatment Dropout
IVF events women find stressful7
Up to 65% of couples dropout from IVF without achieving pregnancy before they complete 3 cycles1-5
Reasons1,5,6
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.
Esteves, 8

Root Causes of Treatment Dropout
Financial/cost issues are NOTprimary cause
High dropout rates in countries with national healthcare programs covering IVF
Domar AD. Fertil Steril 2004;81:271

Strategies to reduce dropout
Make IVF more patient-friendly is the key issue
Esteves, 10

Location
Campinas, Sao Paulo, Brazil
Complexity
Category
Private Center
Foundation
Urologist/Andrologist Gynecologists, Anesthetists, Embriologists, Lab Technicians, Nurses, Psychologist, Pharmacist, Nutricionist, Acupuncturist, Administrative personnel
Staff
Workload
Our method
Tertiary Center for Male Reproduction
Stress reduction
Intensive nursing care
Education
Total quality management
1997
over 1,200 couples per year
Esteves, 11

Reduce Patient Dropout from ART Lesson 1: Stress reduction
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)
Esteves, 12

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
Esteves, 13

PAIN
Anesthesia:
Egg retrieval
Sperm retrieval
Esteves, 14

Reduce Patient Dropout from ARTLesson 1: Stress reduction
Complementary Health Care Program
Integrated team of health professionals:
- psychologist
- nutritionist
- acupuncturist
Weekly sessions
Goal: Reduce Stress
Rejane Ganzaroli
Psychologist, ANDROFERT
Esteves, 15

Reduce Patient Dropout from ARTLesson 2: Intensive nursing care
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)
More attention
less stressed,
happier patients
Esteves, 16

Next employee: Nurse
A high quality IVF program has excellent nurses
Esteves, 17

Reduce Patient Dropout from ARTLesson 3: Education
IVF education on site but preferable via Web
Esteves, 18

ART Education
IVF education on site but preferable via Web
Material for download
Medication timetables
Consents
Procedure instructions
Medication instructions
Esteves, 19

Reduce Patient Dropout from ARTLesson 3: Education
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
IVF orientation guide

ART Education
Video Medication Instructions
Cetrotide 02:31
Learning how to administer injections via Web
Tutorial Videos on the Web
Available for download
Crinone 01:11
Gonal 75 02:16
Gonal Injector 02:39
Luveris 02:15
Ovidrel 00:55
Synarel 01:08
Subcutanea 01:57
Esteves, 21
Intramuscular 01:56

Reduce Patient Dropout from ART Lesson 4: Quality Management
How do you know you are doing a good job?
How do you measure your interventions/processes?
Are your patients satisfied?
Esteves, 22

The IVF Clinic:a very complex organization
Esteves, 23

Reduce Patient Dropout from ARTLesson 4: Quality Management
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
Esteves, 24

Reduce DropoutLesson 4: Quality Management
ISO 9001:2008:
requirements
Control of documents
Control of records
Internal Audits
Control of nonconformity and corrective action
Preventive action
Esteves, 25

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
Esteves, 26

Understanding our customers- Surveys
Esteves, 27

Understanding our customers- Surveys

Improve adherence to IVF Lesson 4: Quality Management
Total Quality Management
A high quality IVF program focuses on how the business is managed
Focus on patient
Improve communication
Continual improvement
Leadership
Esteves, 29

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
Fabiola Bento, MBA
Quality Manager
Esteves, 30

Our method
Stress reduction
Intensive nursing care
Education
Total quality management
Source: Androfert, 1999-2009
Esteves, 31

Reduce Patient Dropout from ART Practical Points
Quality in IVF involves technical issues and patient satisfaction
Dropout in IVF is mainly related to stress
Reducing stress will improve adherence and decrease dropout.
Make IVF patient-friendly is a key issue

Reduce Patient Dropout from ART Practical Points
Infertile patients need education and support throughout the infertility journey
Invest in nurses and web-based educational tools
A quality system aid IVF Clinics to focus on the needs of the customer (patient): these includes medical, scientific and emotional needs.

Strategies to reduce patient dropout from art treatment

by Sandro Esteves on Aug 10, 2011

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