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.