Sandro Esteves, MD, PhD
Director, ANDROFERTCenter for Male Reproduction and Infertility
Campinas, BRAZIL
Strategies to Reduce Patient Dropout from ART Treatment
“Understanding Infertility” – New Delhi, India – August 2011
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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???????
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50% is really better than 30% ?
Pre
gn
ancy
rat
es
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
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
Doctor Look Good
PR = 50%
Doctor Look Bad
PR = 30%
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IVF Results
ET ≤2 80% 60% 35%Multiples 22% 48% 44%
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So, what makes a high quality IVF Center?
Satisfied customers who return for treatment
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In a 2005 IVF study from the UK, per-cycle discontinuation rates ranged from 25-42% and increased with each subsequent cycle
25%
33%40% 42%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
1 2 3 >=4
cycle number
% not pregnant and d/c Tx
n=246 n=183 n=184 n=119
Adapted from Rajkhowa et al. Reasons for discontinuation of IVF treatment: a questionnaire study. Hum Rep 2005;21:358-363
The dropout of patients undergoing IVF is huge!
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 cycles1-5
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%
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.
Reasons1,5,6
IVF events women find stressful7
Root Causes of Treatment Dropout
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Financial/cost issues are NOT primary cause
— High dropout rates in countries with national healthcare programs covering IVF
Domar AD. Fertil Steril 2004;81:271
Root Causes of Treatment Dropout
Strategies to reduce dropout
Make IVF more patient-friendly is the
key issue
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Our method
1. Stress reduction
2. Intensive nursing care
3. Education
4. Total quality management
Location
Complexity
Foundation
Staff
Workload
Campinas, Sao Paulo, Brazil
Urologist/Andrologist Gynecologists, Anesthetists, Embriologists, Lab Technicians, Nurses, Psychologist, Pharmacist, Nutricionist, Acupuncturist, Administrative personnel
Category Private Center
Tertiary Center for Male Reproduction
1997
over 1,200 couples per yearEsteves, 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)
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Reduce Patient Dropout from ART Lesson 1: Stress reduction
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
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Anesthesia:• Egg retrieval• Sperm retrieval
Reduce Patient Dropout from ART Lesson 1: Stress reduction
PAIN
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Complementary Health Care Program
Integrated team of health professionals:
- psychologist
- nutritionist
- acupuncturist Weekly sessions
Goal: Reduce Stress
Reduce Patient Dropout from ARTLesson 1: Stress reduction
Rejane GanzaroliPsychologist, ANDROFERT
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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
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Next employee: Nurse
A high quality IVF program has excellent nurses
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IVF education on site but preferable via Web
Reduce Patient Dropout from ARTLesson 3: Education
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IVF education on site but preferable via
Web
Material for download
Medication timetables
Consents
Procedure instructions
Medication instructions
ART Education
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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
Reduce Patient Dropout from ARTLesson 3: Education
IVF orientation guide
Learning how to administer injections
via Web
Tutorial Videos on the Web
Available for download
ART Education
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Gonal Injector 02:39
Cetrotide 02:31
Crinone 01:11
Gonal 75 02:16
Luveris 02:15
Ovidrel 00:55
Synarel 01:08
Subcutanea 01:57
Intramuscular 01:56
Video Medication Instructions
How do you know you are doing a good job?
How do you measure your interventions/processes?
Are your patients satisfied?
Reduce Patient Dropout from ART Lesson 4: Quality Management
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The IVF Clinic:a very complex organization
CEO
Clinic Director
Urology/Andrology
Microsurgery
Gynecology
Endoscopy
Nursing sectionComplementary health services
Psychology service
Nutrition service
Acupuncture
Anesthesia Ultrasound
Administrative Director
General services
Biomedicineengineer
Maintenance
Computersection
Data entry
Website &Intranet
Administrativeassistant
Secretaries
Legal dept.
Lab Director
Supervisor Lab
Andrology Lab
Cryopreservation Lab
IVF Lab
Scientific Director
Research Training
Associated services
EndocrineLaboratory
Genetics Laundry Sterilization Hospital Pathology Immunology
Radiology
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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
Reduce Patient Dropout from ARTLesson 4: Quality Management
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ISO 9001:2008:
requirements
1. Control of documents
2. Control of records
3. Internal Audits
4. Control of nonconformity and corrective action
5. Preventive action
Reduce DropoutLesson 4: Quality
Management
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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
Reduce Patient Dropout from ARTLesson 4: Quality Management
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Understanding our customers- Surveys
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Understanding our customers- Surveys
Total Quality Management
A high quality IVF program focuses on how the business is managed
1. Focus on patient
2. Improve communication
3. Continual improvement
4. Leadership
Improve adherence to IVF Lesson 4: Quality Management
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Leadership
1. Established unity of purpose and direction of the internal environment
2. Create an environment where people are fully involved in achieving the organization’s objectives
Reduce Patient Dropout from ARTLesson 4: Quality Management
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Fabiola Bento, MBAQuality Manager
Our method
1. Stress reduction
2. Intensive nursing care
3. Education
4. Total quality management
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Source: Androfert, 1999-2009
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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
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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.