Supporting health outcomes, patient-centred care and innovation. Sandra Lauck PhD, RN CADTH Symposium April 11, 2016
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1 Supporting health outcomes, patient-centred care and innovation Sandra Lauck PhD, RN CADTH Symposium April 11, 2016
2 Disclosure Consultant for Edwards
3 Health Outcomes and Patient- Centred Care?
4 Measuring health outcomes Changes in health status that occur as a result of a health care intervention
5
6 New treatment options: A potential disconnect?
7 An example from the clinical world: Integrating patient perspectives in transcatheter aortic valve implantation program evaluation
8
9 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 ( ) City Councillor, Vancouver ( ) Member, BC Sports Hall of Fame Order of British Columbia Order of Canada
10 Devastating effects of heart valve disease Survival Percent Latent Period ( obstruction, myocardial overload) Onset of severe symptoms Avg. survival Years Angina Syncope Failure 6 0 Age Ross & Bruamwald, Circulation, 1968
11 A Heart Team Approach Can we do it? Should we do it? Should we not do it?
12 TAVI is not for everyone: Treatment decision
13 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.
14 What factors influence patients decision to undergo the extensive assessment for TAVI?
15 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)
16 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)
17 Measuring success of TAVI? Clinician-Reported Mortality Myocardial infarction Stroke Bleeding complications Acute kidney injury Vascular complications Conduction disturbances Patient-Reported Symptoms? Activities of daily living? Social interactions? Health-related quality of life? Well being? Satisfaction with care?
18 An evaluation model fit for patient-centred care? Sawatzky R.
19 An evaluation model fit for patient-centred care? Sawatzky R.
20 Sources of data for patient-centred evaluation? Patient Experience Patient-Centred Performance Indicators Access to care Wait time Medications at discharge Ventilator-associated pneumonia Infections Hand hygiene Surgical safety checklist Patient Outcomes Clinical Outcomes Mortality Morbidity Length of stay Hospital readmission
21 Survival after TAVI in BC Indications for TAVI in BC: Likelihood to derive quantity and quality of life benefit for > 2 years
22 Sources of data for patient-centred evaluation? Patient Experience Patient Outcomes Patient- Reported Experiences Patient- Reported Outcomes Ask the patient
23 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)
24 Less is better for TAVI patients
25 The next paradigm shift of TAVI Can we do it? How should we do it? Anatomical screening Functional screening Should we do it? Should we not do it? Procedural expertise Clinical pathway Anatomical screening Procedural expertise Functional screening
26 RESERVE STRESSORS
27
28 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
29 Changing the way we care for TAVI patients Local anaesthesia or light sedation Peripheral intravenous
30 Changing the way we care for TAVI patients Monitoring Reconditioning Discharge Planning Monitoring Reconditioning 0 6 hours 6-12 hours hours hours hours Communication, Patient Teaching and Discharge Planning
31
32 Distribution of length of stay (April 2012-October 2014; N=393) 23% 16% 33% 14% 11% 4%
33 Measuring a good outcome?
34
35 Thank you
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