rima styra, md, med associate professor of psychiatry ... · powerpoint presentation author: rima...
TRANSCRIPT
Rima Styra, MD, Med
Associate Professor of Psychiatry
University Health Network
Toronto
Disclosures
Honoraria/Advisory Board
Pfizer, Lundbeck, BMS, Eli-Lilly
Objectives
Brief overview of two QoL studies
Identify the patient partnership at our hospital center
Explore next steps
German Aortic Valve Registry Results European Cardiology Society 2012
415 patients who survived 12 months after TAVI
Average age 81.9 ± 5.9 years; men 37.3%
Quality of life measures (EQ-5D) were done at baseline, 30 days and one year
Majority of improvement occurred by 30 days post-TAVI
Self-ratings of QoL mean: 44.7% ± 16.5 at baseline
62.9% ± 17.4 at 30 days
Usual activities and discomfort
Adjusted mean scores derived from longitudinal growth curve models for Kansas City
Cardiomyopathy Questionnaire (KCCQ) summary score (A), KCCQ subscales (B–E), the
Short-Form 12 (SF-12) physical (F) and mental (G) scores, and EuroQol-5D (EQ-5D) utilities
(H).
Hemal Gada et al. Circ Cardiovasc Qual Outcomes.
2015;8:338-346
Copyright © American Heart Association, Inc. All rights reserved.
Development of a Patient Partnership Patients are seen by the TAVI team with visits arranged over a single
day
Engagement often occurs not only with the patient but also with family members whom patients ask to be present
Majority of patients require assistance in transportation to the appointments and family members are the main resource
Our focus is broader than just cardiac
Information about the patient as an individual is obtained – usual daily activities, stresses, support, language barriers identified
Cognitive status is assessed
Chronic mental health symptoms are reviewed and it allows for clarification of medication use with the patient
Post-procedure concerns - one of the most common is care of spouse
Information and Expectations Information presented by the TAVI team
Information from friends – “trusted source”
‒ 93 yo male who decided to explore option after friend had it
done and “recommended it” ‒ 86 yo male – “I heard he’s so good you can live to be 200 years
old” ‒ Very common to see this in the retirement communities
Patients identifying that they have specifically chosen the
center
Some patients very knowledgeable – have researched extensively – watched TAVI videos on youtube
Information and Expectations Many patients because of age have rejected the concept of
open heart surgery Feel comfortable with the trans-femoral approach
Discussing the possibility of adverse events is appreciated
Family needs to respect the patient’s wishes
Patients and families need to be clear about TAVI outcomes
Dissonance between expectations and realistic outcomes
Expectations Overall – very realistic – “Improve the shortness of breath, feel less tired, walk a
bit further, a few more good years”
81 yo professor who continues to write, wants to get rid of “dizziness – spaced out feeling”
71 yo male finds himself having to do things “easier and smarter” – “any improvement would be appreciated”
Unrealistic expectations – disappointment
Patients with increased frailty and severe comorbidity issues
Confusion as to the etiology of their limitations
84 yo widowed female with severe COPD and on dialysis, uses a wheelchair, very limited activity for a number of years, expectations are to return to golfing and travelling
Expectations A step to the next procedure – “truly a lease on life”
82 yo male looking after his wife who has dementia and is blind, enjoys working on his farm and sells produce to supplement income, expectations post-TAVI are to proceed to knee replacement surgery
71 yo male – expectations – “more energy – to be put back on the renal transplant list once his cardiac function has been fixed “
Post-procedure contact Includes the hospital setting
Monitoring for delirium in a vulnerable population
Rates of delirium have improved with move towards minimal sedation
Patients with complications and who require longer length of stay often require support
Outpatient follow-up visit
Opportunity to discuss outcomes – more patient centered
Quality of life Quality of life –individual variation, stage of life
88 yo legally blind female, does her own groceries and is “careful crossing the street”, did not want to stay with her son even post-TAVI – TAVI allowed her to maintain her independence
85 yo male who runs his own company pre-TAVI and continues to do so post-TAVI – “just easier”
Satisfaction is high among patients ‒ “happy heart”, “a new man”, “can walk further”, “can breath”
Satisfaction is high among family members
‒ “I have my mother back” - “we can go for a walk and not stop
all the time” – “enjoys the grandchildren now”
Next steps in terms of QoL Clinical impression is that we need a different approach to
measuring QoL in these patients
Scales are based on a younger patient population in contrast to the older TAVI population which has not usually been addressed in clinical interventional studies
A need to develop QoL scales based on specific outcomes with input from TAVI patient
QoL results can then be better utilized to inform patients, clinicians and policy makers regarding outcomes and align expectations
Careful evaluation of patient factors will optimize patient-centered and value-based care
