How to improve patient´s adherence to ivf cycles

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"Serono Meeting for Assisted Reproductive Technology (SMART VI)", Cape Town, South Africa, April 2010

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  • July 2006 © Merck KGaA Darmstadt/Germany The purpose of this presentation is to talk about patient dropout. There are many “exit” points along the patient treatment path and throughout this presentation we will identify: Reasons why patients dropout of treatment Root causes of dropout, as we have been able to identify Identify particular stages of treatment, known as hotspots, that may see a higher rate of dropout Potential strategies to reduce patient dropout
  • First, let’s look at some rather remarkable observations related to the patient journey, specifically the different points along the treatment path where patients may drop out In one study, 45% of patients never even pursued medical treatment 1 Discounting those, of patients that did start therapy with clomiphene citrate, a total of 43% never moved on to inject able medications Half, or 20%, don’t ever get through one round of clomiphene citrate therapy and a little more than half, 23%, finished and never moved on to advanced treatment Based on the publication by Domar, of the patients who do make a consultation appointment with a Reproductive Endocrinologist, up to 40% never show up to the first appointment From there, another 60-65% of patients dropout before ever completing a cycle of treatment Numbers are: 100-45=55; 55x.0.43=31; 32-12=20 (target); dropout 12 (only 8 remain) References: Boivin J, et al. Hum Reprod 2007;6:1506 Data on file, ObGyn Research 2003, EMD Serono, Inc. Domar AD. Fertil Steril 2004;81:271
  • When a decision is made to refer the patient to the REI, communication between the REI and the ObGyn is critical Topics for discussion may include Answering patient’s questions prior to referral Deciding when to refer the patient Discussing when and how often the ObGyn would like updates on the patient’s progress Knowing when to refer patients back to the ObGyn, such as for surgery, D & C, pregnancy, etc Reference: Michael Alper, MD, Boston, IVF, Waltham, MA
  • July 2006 © Merck KGaA Darmstadt/Germany
  • July 2006 © Merck KGaA Darmstadt/Germany As this slide shows, there is a large number of patients that dropout after each cycle: starting with 25% in cycle #1 increasing to 33% in cycle # 2 40% in cycle #3 increasing to 42% after cycle #4
  • Patients that exhibit pretreatment anxiety may have a higher dropout rate than patients who do not exhibit pretreatment anxiety. This may or may not be related to the prognosis. The impact of stress was shown by Chen and colleagues They examined the prevalence of specific depressive and anxiety disorders in women before a new cycle of ART A psychiatric evaluation was performed on 112 consecutive patients 40.2% had a psychiatric disorder, ranging from major depression to anxiety disorders Only 3 of these patients had ever seen a psychiatrist before ART Reference: Chen TH, et al. Human Reprod 2004;10:2313
  • The second factor associated with treatment dropout is financial While this is important for many patients, it may not be the main cause As we saw in a previous slide dropout is still high, even in countries where treatment costs are covered as national benefit Reference: Domar AD. Fertil Steril 2004;81:271
  • July 2006 © Merck KGaA Darmstadt/Germany
  • July 2006 © Merck KGaA Darmstadt/Germany
  • International Standardization Organization, began 1947. July 2006 © Merck KGaA Darmstadt/Germany
  • 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. July 2006 © Merck KGaA Darmstadt/Germany
  • The key points of this presentation are: Infertility care involves time-limited and time-sensitive duration of treatment and management Infertile patients have unique and time-sensitive educational and emotional support needs Infertile patients require education and support throughout the infertility patient journey
  • The key points of this presentation are: Infertility care involves time-limited and time-sensitive duration of treatment and management Infertile patients have unique and time-sensitive educational and emotional support needs Infertile patients require education and support throughout the infertility patient journey
  • How to improve patient´s adherence to ivf cycles

    1. 1. SMART VI – Cape Town, South Africa – April 2010
    2. 2. Overview <ul><li>IVF dropout </li></ul><ul><ul><li>Numbers </li></ul></ul><ul><ul><li>Root causes </li></ul></ul><ul><ul><li>Dropout hotspots </li></ul></ul><ul><li>IVF quality: a critical analysis </li></ul><ul><li>Strategies to improve adherence </li></ul>
    3. 3. 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
    4. 4. Is your communication satisfactory? <ul><li>Communication </li></ul><ul><ul><li>Education (radio, TV, newspaper, magazines, Web, healthcare professionals, etc) </li></ul></ul><ul><ul><li>Referral physicians & Gyn: </li></ul></ul><ul><ul><ul><li>when to refer to IS </li></ul></ul></ul><ul><ul><ul><li>when/how often update </li></ul></ul></ul><ul><ul><ul><li>when to refer patients back: </li></ul></ul></ul><ul><ul><ul><ul><li>Surgery (laparoscopy) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pregnancy </li></ul></ul></ul></ul>Esteves,
    5. 5. Patient perspective in choosing an IVF Clinic <ul><li>Success rates </li></ul><ul><li>Quality of services provided </li></ul><ul><li>Localization </li></ul><ul><li>Experience and specialization </li></ul><ul><li>Costs </li></ul><ul><li>Counseling available </li></ul>Choosing an IVF Clinic Fertil Steril 2005
    6. 6. Is your IVF program good? <ul><li>Pregnancy rates = Quality??????? </li></ul><ul><li>50% is really better than 30% ? </li></ul>Esteves, Pregnancy rates
    7. 7. <ul><li>Established 2005 </li></ul><ul><li>100 babies born </li></ul><ul><li>Few credentials experience </li></ul><ul><li>No scientific publications </li></ul><ul><li>IVF first treatment line </li></ul><ul><li>No poor responders </li></ul><ul><li>Record of errors/patient complaints </li></ul><ul><li>High multiple PR </li></ul><ul><li>Advertise a lot </li></ul><ul><li>Established1994 </li></ul><ul><li>>1,000 babies born </li></ul><ul><li>Lots of credentials/experience </li></ul><ul><li>Several publications </li></ul><ul><li>All treatment options available </li></ul><ul><li>Individualized approach </li></ul><ul><li>Rare errors/patient complaints </li></ul><ul><li>Low multiple PR </li></ul><ul><li>Educational marketing </li></ul>Doctor Look Good PR = 50% Doctor Look Bad PR = 30% Esteves,
    8. 8. IVF Results Esteves,
    9. 9. So, what makes a high quality IVF Center? Esteves,
    10. 10. <ul><li>In a 2005 IVF study from the UK 8 , per-cycle discontinuation rates ranged from 25-42% and increased with each subsequent cycle </li></ul>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
    11. 11. 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%
    12. 12. <ul><li>Psychiatric assessment of 112 ART patients before starting IVF </li></ul><ul><li>40.2% had psychiatric disorder </li></ul><ul><li>Only 6.7% ever saw psychiatrist before ART </li></ul>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,
    13. 13. <ul><li>Financial/cost issues may not be primary cause </li></ul><ul><ul><li>High dropout rates in countries with national healthcare programs covering IVF </li></ul></ul>Root Causes of Treatment Dropout #2: Financial Domar AD. Fertil Steril 2004;81:271
    14. 14. Strategies to improve adherence? Make IVF more patient-friendly is the key issue Esteves,
    15. 15. Our method <ul><li>Stress reduction </li></ul><ul><li>Intensive nursing care </li></ul><ul><li>Education </li></ul><ul><li>Total quality management </li></ul>Esteves, Tertiary Center for Male Reproduction 1997 over 1,200 couples per year
    16. 16. Improve adherence to IVF Lesson 1: Stress reduction Esteves, <ul><li>Some IVF difficulties </li></ul><ul><li>Understanding treatment steps/expectations </li></ul><ul><li>Several medications, documents, orientation </li></ul><ul><li>Excessive monitoring </li></ul><ul><ul><li>Blood, ultrasound </li></ul></ul><ul><li>Learning about injections </li></ul><ul><ul><li>FSH/LH/hCG </li></ul></ul><ul><ul><li>Antagonist/agonist </li></ul></ul><ul><li>OCP (pain, anesthesia) </li></ul>
    17. 17. Improve adherence to IVF Lesson 1: Stress reduction Rejane Ganzaroli Psychologist, ANDROFERT Esteves, <ul><li>Complementary Health Care Program </li></ul><ul><li>Integrated team of health professionals: </li></ul><ul><ul><ul><li>- psychologist </li></ul></ul></ul><ul><ul><ul><li>- nutritionist </li></ul></ul></ul><ul><ul><ul><li>- acupuncturist </li></ul></ul></ul><ul><li>Weekly sessions </li></ul><ul><li>Goal: Reduce Stress </li></ul>
    18. 18. Improve adherence to IVF Lesson 1: Stress reduction Esteves, <ul><li>Medication Strategies </li></ul><ul><li>Typical Cycle (long protocol): </li></ul><ul><ul><ul><li>Daily SC GnRH-a: 21 </li></ul></ul></ul><ul><ul><ul><li>FSH/LH: 10-15 </li></ul></ul></ul><ul><ul><ul><li>hCG: 1 </li></ul></ul></ul><ul><ul><ul><li>Progesterone: 14 </li></ul></ul></ul><ul><ul><ul><li>Blood tests: 4-10 </li></ul></ul></ul><ul><li>Number of sticks: 36-60 </li></ul>
    19. 19. Improve adherence to IVF Lesson 1: Stress reduction Esteves, <ul><li>Medication Strategies </li></ul><ul><ul><ul><li>sc rFSH/rLH (pen devices) </li></ul></ul></ul><ul><ul><ul><li>Antagonist (vs agonist) </li></ul></ul></ul><ul><ul><ul><li>Combine meds (antag + rLH) </li></ul></ul></ul><ul><ul><ul><li>sc prefilled hCG </li></ul></ul></ul><ul><ul><ul><li>Vaginal progesterone 1x/day (vs IM) </li></ul></ul></ul><ul><ul><ul><li>Minimize blood tests </li></ul></ul></ul>
    20. 20. <ul><li>Anesthesia: </li></ul><ul><ul><li>Egg retrieval </li></ul></ul><ul><ul><li>Sperm retrieval </li></ul></ul>Improve adherence to IVF Lesson 1: Stress reduction Esteves,
    21. 21. Improve adherence to IVF Lesson 2: Intensive nursing care More attention less stressed, happier patients Esteves, <ul><li>Each patient assigned to a nurse (~20-25 couples per nurse) </li></ul><ul><li>Teaching (IVF steps, medication) </li></ul><ul><li>Individualized patient agenda </li></ul><ul><li>Medication plan </li></ul><ul><li>Schedule appointments </li></ul><ul><li>Hotline (24h/day; 7 days/week) </li></ul><ul><li>Follow-up: </li></ul><ul><ul><li>Up to live birth (Registry report) </li></ul></ul><ul><ul><li>Return visit (non-pregnant) </li></ul></ul>
    22. 22. Next employee: Nurse <ul><li>A high quality IVF program has excellent nurses </li></ul>Esteves,
    23. 23. Improve adherence to IVF Lesson 3: Education Esteves, IVF education on site but preferable via Web
    24. 24. Improve adherence to IVF Lesson 3: Education Esteves, <ul><li>IVF education on site but preferable via Web </li></ul><ul><li>Material for download </li></ul><ul><li>Medication timetables </li></ul><ul><li>Consents </li></ul><ul><li>Procedure instructions </li></ul><ul><li>Medication instructions </li></ul>
    25. 25. Improve adherence to IVF Lesson 3: Education IVF orientation guide <ul><li>IVF education on site </li></ul><ul><li>but preferable via Web </li></ul><ul><li>Material for download </li></ul><ul><li>Medication timetables </li></ul><ul><li>Consents </li></ul><ul><li>Procedure instructions </li></ul><ul><li>IVF orientation </li></ul><ul><li>Goals: </li></ul><ul><ul><li> Patient visits </li></ul></ul><ul><ul><li> Nursing time </li></ul></ul><ul><ul><li>Cost savings </li></ul></ul>
    26. 26. Improve adherence to IVF Lesson 3: Education Esteves, <ul><li>Learning how to administer injections via Web </li></ul><ul><li>Tutorial Videos on the Web </li></ul><ul><li>Available for download </li></ul>
    27. 27. The IVF Clinic: a very complex organization Esteves,
    28. 28. Improve adherence to IVF Lesson 4: Quality Management Esteves, <ul><li>Total Quality Management </li></ul><ul><li>A high quality IVF program focuses on how the business is managed </li></ul><ul><li>Focus on patient </li></ul><ul><li>Improve communication </li></ul><ul><li>Continual improvement </li></ul><ul><li>Leadership </li></ul>
    29. 29. Improve adherence to IVF Lesson 4: Quality Management Esteves, <ul><li>ISO 9001:2008 </li></ul><ul><li>A well-organized workflow will guarantee good quality of work </li></ul><ul><li>Quality Management = Process management </li></ul><ul><li>Define what you want to do , how you want to do it, and how you can ensure it’s being done that way </li></ul>
    30. 30. 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,
    31. 31. Improve adherence Lesson 4: Quality Management Esteves, <ul><li>ISO 9001:2008: </li></ul><ul><li>requirements </li></ul><ul><li>Control of documents </li></ul><ul><li>Control of records </li></ul><ul><li>Internal Audits </li></ul><ul><li>Control of nonconformity and corrective action </li></ul><ul><li>Preventive action </li></ul>
    32. 32. <ul><li>Corrective action </li></ul><ul><li>Preventive action </li></ul>Improve adherence to IVF Lesson 4: Quality Management Esteves,
    33. 33. <ul><li>The bigger the organization, the worse the customer focus </li></ul><ul><li>83% of the organizations assume that their customers are satisfied. </li></ul><ul><li>90-96% of unhappy customers never lodge a complaint. </li></ul>Marketing for keeps, John Wiley, New York 1993 Improve adherence to IVF Lesson 4: Quality Management Esteves,
    34. 34. Understanding our customers- Surveys Esteves,
    35. 35. Understanding our customers- Surveys
    36. 36. <ul><li>Communication is the Key: </li></ul><ul><li>Internal: </li></ul><ul><ul><li>Meetings </li></ul></ul><ul><li>External: </li></ul><ul><ul><li>Patients </li></ul></ul><ul><ul><li>Outside customers </li></ul></ul><ul><ul><li>Referring physicians </li></ul></ul>Improve adherence to IVF Lesson 4: Quality Management Esteves,
    37. 37. Leadership <ul><li>Established unity of purpose and direction of the internal environment </li></ul><ul><li>Create an environment where people are fully involved in achieving the organization’s objectives </li></ul>Improve adherence to IVF Lesson 4: Quality Management Esteves,
    38. 38. Our method <ul><li>Stress reduction </li></ul><ul><li>Intensive nursing care </li></ul><ul><li>Education </li></ul><ul><li>Total quality management </li></ul>Esteves, Source: Androfert, 1999-2009
    39. 39. <ul><li>Infertile pts. do not return for IVF treatment because IVF is stressful and complicated. </li></ul><ul><li>Reducing stress will improve adherence and reduce dropout . </li></ul><ul><li>Make IVF easier . </li></ul>
    40. 40. <ul><li>Infertile patients require education and support throughout the infertility patient journey. </li></ul><ul><ul><li>Invest in nurses and web-based educational tools. </li></ul></ul><ul><li>A quality system makes IVF Clinics focus on the needs of the customer (patient): these includes medical, scientific and emotional needs. </li></ul>

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