Supporting health outcomes, patient-centred care and innovationSandra Lauck PhD, RNCADTH Symposium April 11, 2016

Disclosure

Consultant for Edwards

Health Outcomes and Patient-Centred Care?

Measuring health outcomes

“Changes in health status that occur as a result of a health care intervention”

Can we do it?

Should we do it? Patients’

perspectives

Cost to society

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 TeamFounder, Camp Deka BCCommissioner, Vancouver Parks Board (1973-76)City Councillor, Vancouver (1977-87)Member, BC Sports Hall of FameOrder of British Columbia Order of Canada

Devastating effects of heart valve disease

0

20

40

60

80

100

Age

SurvivalPercent

Onset of severe symptoms

6420Avg. survivalYears

AnginaSyncope

Failure

Latent Period ( obstruction, myocardial overload)

Ross & Bruamwald, Circulation, 1968

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?

• Mortality• Myocardial infarction• Stroke• Bleeding complications• Acute kidney injury• Vascular complications• Conduction disturbances

Clinician-Reported Patient-Reported

• Symptoms?• Activities of daily living?• Social interactions?• Health-related quality of life? • Well being? • Satisfaction with care?

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 Outcomes

Patient-Centred Performance

Indicators

Access to careWait time Medications at dischargeVentilator-associated pneumoniaInfectionsHand hygieneSurgical safety checklist

Clinical Outcomes

MortalityMorbidityLength of stayHospital readmission

Indications for TAVI in BC:Likelihood to derive quantity and quality of life benefit for > 2 years

Survival after TAVI in BC

Sources of data for patient-centred evaluation?

Patient Experience

Patient Outcomes

Patient-Reported

Experiences

Ask the patientPatient-

Reported 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

Procedural expertise

Functional screening

Anatomical screening

Clinical pathway

Procedural expertise

Functional screening

Anatomical screening

Can we do it?

Should we do it?

Should we not do it?

How should we do it?

RESERVE STRESSORS

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

MultimodalityMultidisciplinarybutMinimalist

Changing the way we care for TAVI patients

Local anaesthesia or light sedation

Peripheral intravenous

Changing the way we care for TAVI patients

Monitoring Reconditioning Discharge Planning

0–6 hours 12-18 hours 24-36 hours18-24 hours6-12 hours

Monitoring

Reconditioning

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 youslauck@providencehealth.bc.ca