Strategies to reduce patient dropout from art treatment

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“Understanding Infertility”: A CME Course in Reproductive Medicine
August 12-14th, 2011 New Delhi, India

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  • International Standardization Organization, began 1947.
  • Control of documents is basically keeping documents up-to-date through regular reviews and guaranteeing that the last version is the one in use.Control of records means keeping records identified, easily retrieved, safely stored (if paper, where, if electronic, backup), and determine retention time. Includes patient records, lab tests results, etc. Internal Audits are used to ensure that people are following the established quality system. In other words, is to check if procedures are being followed, if records are being filled in appropriately, and so on.A nonconformity is a failure to meet procedures, standards or practice guidelines, that needs a corrective action. A corrective action is taken after identifying the cause of the problem, and needs to prevent its recurrence.A preventive action is taken after analyzing the system and its objective is to eliminate possible causes of nonconformities.
  • Strategies to reduce patient dropout from art treatment

    1. 1. Strategies to Reduce Patient Dropout from ART Treatment<br />“Understanding Infertility” – New Delhi, India – August 2011<br />SandroEsteves, MD, PhD<br />Director, ANDROFERT<br />Center for Male Reproduction and Infertility<br />Campinas, BRAZIL<br />
    2. 2. Learning Objectives<br />A critical analysis of “quality” in IVF <br />Unravel IVF dropout <br />Numbers<br />Root causes<br />Dropout hotspots<br />Learn strategies to improve patient’s adherence to IVF treatment<br />
    3. 3. Is your IVF program good?<br />Pregnancy rates = Quality???????<br />50% is really better than 30% ?<br />Pregnancy rates<br />Esteves, 3<br />
    4. 4. Doctor Look Bad <br />PR = 30%<br />Doctor Look Good <br />PR = 50%<br /><ul><li>Established 1994
    5. 5. >1,000 babies born
    6. 6. Lots of credentials/experience
    7. 7. Several publications
    8. 8. All treatment options available
    9. 9. Individualized approach
    10. 10. Rare errors/patient complaints
    11. 11. Low multiple PR
    12. 12. Educational marketing
    13. 13. Established 2005
    14. 14. 100 babies born
    15. 15. Few credentials experience
    16. 16. No scientific publications
    17. 17. IVF first treatment line
    18. 18. No poor responders
    19. 19. Record of errors/patient complaints
    20. 20. High multiple PR
    21. 21. Advertise a lot </li></ul>Esteves, 4<br />
    22. 22. IVF Results<br />Esteves, 5<br />
    23. 23. So, what makes a high quality IVF Center?<br />Satisfied customers who return for treatment<br />Esteves, 6<br />
    24. 24. The dropout of patients undergoing IVF is huge!<br /> In a 2005 IVF study from the UK, per-cycle discontinuation rates ranged from 25-42% and increased with each subsequent cycle<br />Adapted from Rajkhowa et al. Reasons for discontinuation of IVF treatment: a questionnaire study. Hum Rep 2005;21:358-363<br />
    25. 25. Root Causes of Treatment Dropout<br />IVF events women find stressful7<br />Up to 65% of couples dropout from IVF without achieving pregnancy before they complete 3 cycles1-5<br />Reasons1,5,6<br />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.<br />Esteves, 8<br />
    26. 26. Root Causes of Treatment Dropout<br />Financial/cost issues are NOTprimary cause<br />High dropout rates in countries with national healthcare programs covering IVF<br />Domar AD. Fertil Steril 2004;81:271<br />
    27. 27. Strategies to reduce dropout <br />Make IVF more patient-friendly is the key issue<br />Esteves, 10<br />
    28. 28. Location<br /> Campinas, Sao Paulo, Brazil<br />Complexity<br />Category<br />Private Center<br />Foundation<br />Urologist/Andrologist Gynecologists, Anesthetists, Embriologists, Lab Technicians, Nurses, Psychologist, Pharmacist, Nutricionist, Acupuncturist, Administrative personnel<br />Staff<br />Workload<br />Our method<br />Tertiary Center for Male Reproduction<br />Stress reduction<br />Intensive nursing care<br />Education<br />Total quality management<br />1997<br />over 1,200 couples per year<br />Esteves, 11<br />
    29. 29. Reduce Patient Dropout from ART Lesson 1: Stress reduction<br />Some IVF difficulties<br />Understanding treatment steps/expectations<br />Several medications, documents, orientation<br />Excessive monitoring<br />Blood, ultrasound<br />Learning about injections<br />FSH/LH/hCG<br />Antagonist/agonist<br />OCP (pain, anesthesia)<br />Esteves, 12<br />
    30. 30. Reduce Patient Dropout from ART Lesson 1: Stress reduction<br />Medication Strategies<br />sc rFSH/rLH (pen devices)<br />Antagonist (vs agonist)<br />Combine meds (antag + rLH) <br />sc prefilled hCG<br />Vaginal progesterone 1x/day (vs IM)<br />Minimize blood tests <br />Esteves, 13<br />
    31. 31. Reduce Patient Dropout from ART Lesson 1: Stress reduction<br />PAIN<br />Anesthesia:<br /><ul><li> Egg retrieval
    32. 32. Sperm retrieval</li></ul>Esteves, 14<br />
    33. 33. Reduce Patient Dropout from ARTLesson 1: Stress reduction<br />Complementary Health Care Program<br />Integrated team of health professionals:<br /> - psychologist<br /> - nutritionist <br /> - acupuncturist<br />Weekly sessions<br />Goal: Reduce Stress<br />Rejane Ganzaroli<br />Psychologist, ANDROFERT<br />Esteves, 15<br />
    34. 34. Reduce Patient Dropout from ARTLesson 2: Intensive nursing care<br />Each patient assigned to a nurse (~20-25 couples per nurse)<br />Teaching (IVF steps, medication)<br />Individualized patient agenda<br />Medication plan<br />Schedule appointments<br />Hotline (24h/day; 7 days/week)<br />Follow-up:<br />Up to live birth (Registry report)<br />Return visit (non-pregnant) <br />More attention<br />less stressed,<br />happier patients<br />Esteves, 16<br />
    35. 35. Next employee: Nurse<br />A high quality IVF program has excellent nurses<br />Esteves, 17<br />
    36. 36. Reduce Patient Dropout from ARTLesson 3: Education<br />IVF education on site but preferable via Web<br />Esteves, 18<br />
    37. 37. ART Education<br />IVF education on site but preferable via Web<br />Material for download<br />Medication timetables<br />Consents<br />Procedure instructions<br />Medication instructions<br />Esteves, 19<br />
    38. 38. Reduce Patient Dropout from ARTLesson 3: Education<br />IVF education on site <br />but preferable via Web<br />Material for download<br />Medication timetables<br />Consents<br />Procedure instructions<br />IVF orientation<br />Goals:<br /> Patient visits<br /> Nursing time<br />Cost savings<br />IVF orientation guide<br />
    39. 39. ART Education<br />Video Medication Instructions<br />Cetrotide 02:31 <br />Learning how to administer injections via Web<br />Tutorial Videos on the Web<br />Available for download<br />Crinone 01:11 <br />Gonal 75 02:16 <br />Gonal Injector 02:39 <br />Luveris 02:15 <br />Ovidrel 00:55 <br />Synarel 01:08 <br />Subcutanea 01:57 <br />Esteves, 21<br />Intramuscular 01:56<br />
    40. 40. Reduce Patient Dropout from ART Lesson 4: Quality Management<br />How do you know you are doing a good job?<br />How do you measure your interventions/processes?<br />Are your patients satisfied?<br />Esteves, 22<br />
    41. 41. The IVF Clinic:a very complex organization<br />Esteves, 23<br />
    42. 42. Reduce Patient Dropout from ARTLesson 4: Quality Management<br />ISO 9001:2008<br />A well-organized workflow will guarantee good quality of work<br />Quality Management = Process management<br />Define what you want to do, how you want to do it, and how you can ensure it’s being done that way <br />Esteves, 24<br />
    43. 43. Reduce DropoutLesson 4: Quality Management<br />ISO 9001:2008:<br />requirements<br />Control of documents<br />Control of records<br />Internal Audits<br />Control of nonconformity and corrective action<br />Preventive action<br />Esteves, 25<br />
    44. 44. Reduce Patient Dropout from ARTLesson 4: Quality Management<br />The bigger the organization, the worse the customer focus<br /><ul><li>83% of the organizations assume that their customers are satisfied.
    45. 45. 90-96% of unhappy customers never lodge a complaint.</li></ul>Marketing for keeps, John Wiley, New York 1993<br />Esteves, 26<br />
    46. 46. Understanding our customers- Surveys <br />Esteves, 27<br />
    47. 47. Understanding our customers- Surveys <br />
    48. 48. Improve adherence to IVF Lesson 4: Quality Management<br />Total Quality Management<br />A high quality IVF program focuses on how the business is managed<br />Focus on patient<br />Improve communication<br />Continual improvement<br />Leadership<br />Esteves, 29<br />
    49. 49. Reduce Patient Dropout from ARTLesson 4: Quality Management<br />Leadership<br />Established unity of purpose and direction of the internal environment<br />Create an environment where people are fully involved in achieving the organization’s objectives<br />Fabiola Bento, MBA<br />Quality Manager <br />Esteves, 30<br />
    50. 50. Our method<br />Stress reduction<br />Intensive nursing care<br />Education<br />Total quality management<br />Source: Androfert, 1999-2009<br />Esteves, 31<br />
    51. 51. Reduce Patient Dropout from ART Practical Points<br />Quality in IVF involves technical issues and patient satisfaction<br />Dropout in IVF is mainly related to stress <br />Reducing stress will improve adherence and decrease dropout.<br />Make IVF patient-friendly is a key issue<br />
    52. 52. Reduce Patient Dropout from ART Practical Points<br />Infertile patients need education and support throughout the infertility journey<br />Invest in nurses and web-based educational tools<br />A quality system aid IVF Clinics to focus on the needs of the customer (patient): these includes medical, scientific and emotional needs.<br />

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