Transcript How should we do it?

Supporting health outcomes,
patient-centred care and
innovation
Sandra Lauck PhD, RN
CADTH Symposium
April 11, 2016
Disclosure
Consultant for Edwards
Health Outcomes and PatientCentred Care?
Measuring health outcomes
“Changes in health status that occur as a result of a health
care intervention”
New treatment options:
A potential disconnect?
An example from the clinical world:
Integrating patient perspectives in
transcatheter aortic valve
implantation program evaluation
May Brown BSc, MPE, OBC, CM
Professor, UBC's School of Physical
Education and Recreation
Head coach, UBC Women’s Field Hockey
Team
Founder, Camp Deka BC
Commissioner, Vancouver Parks Board
(1973-76)
City Councillor, Vancouver (1977-87)
Member, BC Sports Hall of Fame
Order of British Columbia
Order of Canada
Devastating effects of heart valve disease
Survival
Percent
Onset of severe
symptoms
100
Latent Period (
80
Angina
Syncope
obstruction,
myocardial
overload)
60
Failure
0
40
2
4
Avg. survival
Years
6
20
0
Ross & Bruamwald, Circulation, 1968
Age
A “Heart Team Approach”
Can we do it?
Should we do
it?
Should we not
do it?
TAVI is not for everyone:
Treatment decision
Measuring success of TAVI?
May’s goals
What impact has your heart valve disease had on your life recently?
“I’ve been physically and socially active all my life. That’s what I live for.
I live alone but I have lots of friends ... I go to meetings, I go for a walk
in the woods… Now, I’m so tired, I can’t even go around the block. It’s
like I’m dying a bit more every day.”
What are you hoping to gain from having the procedure?
“I’ve had a great life. I’ve done a lot. But I feel like I still have more in
me. If I’m going to die, so be it. But to die like this… And if there’s any
hope I can get my health back to live better and to do what I want to
do… then that’s what I want. What I don’t want is to feel this tired, like
I can’t breathe… or lose my independence.”
What factors influence patients’ decision to
undergo the extensive assessment for TAVI?
“Falling off the cliff”
“Well, I used to be very active. I got a workshop in the basement,
and I was always making stuff. And for the last about four months
or so, I haven’t been down there to make anything … that’s a thing
of the past apparently” (P8, male, 92 years, lives independently
with his wife)
“I do get up in the morning… and I’m gasping for a little bit more
air… I haven’t given up. I’m still active mentally, but just not maybe
physically” (P4, male, 84 years, lives in remote area with his wife)
“Taking chances”
“Well the doctor and I had a chat, and he said, “Number 1 is do
nothing. Number 2 is open heart surgery. Number 3 is this
procedure (TAVI). Let’s consider the possibilities”. And I said, “Well, I
don’t want open heart surgery. At my age, it’s a pretty traumatic
thing. And what happens if I do nothing? He said, “well, eventually
you’ll die”. It’s just as simple as that… I’m hoping to get some of my
zip back” (P8, male, 92 years, lives independently with his wife)
“I’m just hoping that I can have a better quality of… call it existence,
where I can achieve what I could achieve before” (P4, male, 84
years, lives in remote area with his wife)
Measuring success of TAVI?
Clinician-Reported
Patient-Reported
• Mortality
• Symptoms?
• Myocardial infarction
• Activities of daily living?
• Stroke
• Social interactions?
• Bleeding complications
• Health-related quality of life?
• Acute kidney injury
• Well being?
• Vascular complications
• Satisfaction with care?
• Conduction disturbances
An evaluation model fit for patient-centred
care?
Sawatzky R.
An evaluation model fit for patient-centred
care?
Sawatzky R.
Sources of data for patient-centred
evaluation?
Patient
Experience
Patient-Centred
Performance
Indicators
Patient
Outcomes
Clinical
Outcomes
Access to care
Wait time
Medications at discharge
Ventilator-associated pneumonia
Infections
Hand hygiene
Surgical safety checklist
Mortality
Morbidity
Length of stay
Hospital readmission
Survival after TAVI in BC
Indications for TAVI in BC:
Likelihood to derive quantity
and quality of life benefit for > 2
years
Sources of data for patient-centred
evaluation?
Patient
Experience
PatientReported
Experiences
Ask the patient
Patient
Outcomes
PatientReported
Outcomes
“A miracle man”
“That operation he had, it made the world of difference to him. He
just had absolutely no energy for anything. His face was grey. He
wasn’t eating, hardly talking… The girls and I can hardly believe the
change. The neighbours around here think he’s a miracle man. It’s
all very, very positive. It made a great, great change in him”
(Spouse of P3, 1-month post TAVI)
“When they’re doing their work, you’re out cold, but when you
wake up you come right to. And I looked around and my hands
were pink, and my spirits were up, and it like turning on a light
switch” (P8, male, 92 years)
Less is better for TAVI patients
The next paradigm shift of TAVI
Can we do it?
How should
we do it?
Clinical
pathway
Anatomical
screening
Procedural
expertise
Procedural
expertise
Functional
screening
Anatomical
screening
Should we do
it?
Should we not
do it?
Functional
screening
RESERVE
STRESSORS
Multimodality
Multidisciplinary
but
Minimalist
Using existing technology, up to date knowledge (objective
anatomical and functional screening, procedural expertise) and a
standardized clinical pathway to facilitate NEXT DAY DISCHARGE
HOME and optimal outcomes
Changing the way we care for TAVI patients
Local
anaesthesia or
light sedation
Peripheral
intravenous
Changing the way we care for TAVI patients
Monitoring
Discharge
Planning
Reconditioning
Monitoring
Reconditioning
0–6 hours
6-12 hours
12-18 hours
18-24 hours
24-36 hours
Communication, Patient Teaching and Discharge Planning
Distribution of length of stay
(April 2012-October 2014; N=393)
23%
16%
33%
14%
11%
4%
Measuring a good outcome?
Thank you
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