Helping The Patient Navigate through Radical Cystectomy · Background • Invasive bladder cancer a...
Transcript of Helping The Patient Navigate through Radical Cystectomy · Background • Invasive bladder cancer a...
Helping The Patient Navigate through
Radical CystectomyJay B. Shah, MD
Assistant Professor
Director, Bladder Cancer Robotics Program
MDACC Department of Urology
@BladderCancerMD
Outline
• Lead in with connection from previous talk about patient involvement
• Intimately related to the concept of patient navigation is enhanced recovery
– We all want the patient to do better and to recover more smoothly
– This is what ERAS aims to do
– OSJ is the MDACC brand of ERAS
– Brief description of ERAS outcomes and OSJ outcomes
– Limitations: almost all outcomes focused on hospital-centric measures
– If we truly want to help navigate the patient, we must understand the patient experience
– To that end:• 1) MDASI to assess symptom burden – explain collection methodology and show results
• 2) Show outcomes based on enhanced recovery pathway
• 3) Development of a bladder cancer specific MDASI – top 5 symptoms to date
– Ultimate goal: better understand what the patients are experiencing so we can better
navigate them through the treacherous journey of bladder removal surgery
– Future: can we detect a “biomarker” that will predict poor recovery after RC?
– Tie in to Scott Gilbert talk on how exactly do we measure success?
Background
• Invasive bladder cancer a disease of the elderly
– Multiple medical conditions
– Cumulative smoke exposure
– Geriatric infirmity
– Immunosenescence
• Radical cystectomy is physiologically taxing for the patient
– 5-10 hours
– Significant fluid shifts
– Insensible losses with open surgery
– Positional challenges with robotic surgery
Shabsigh et al, 2009
Svatek et al, 2010
Outcomes with Traditional Care
• 5-10 liters of fluid received intra-op
• Possible ICU or extended recovery stay
• Passage of flatus > POD 4-5
• Typical stay ~10 days in US*
• ~50-70% complication rate (15% high-grade complications)
• ~25-30% hospital readmission rate
*15-20 days in Europe/Asia
Healthcare Cost and Utilization Project: www.hcupnet.ahrq.gov
Enhanced Recovery after Surgery
Intra-operative
Preoperative
@BladderCancerMDPost-operative
• Pruthi 2010 (UNC):– 11 ERAS elements on
pathway
– 80% DC POD 4-5
• Daneshmand 2014 (USC):– Most ERAS elements
– Alvimopan and neostigmine
– Subfascial catheters for pain control
– Routine IV hydration at home
• UK ERAS Programs
ExeterSouthampton
Smith J et al. BJUI 2014;114:375-383
Dutton TJ et al. BJUI 2014;113:719-725
Slide compliments of Scott Gilbert
Optimized Surgical Journey (OSJ)
Expectation counseling
Nutritional coaching
No bowel prep
No NPO p MN
Geriatric evaluation
Preemptive analgesia
Goal-directed fluid therapy
Minimal opioids
No urethral drain
Exparel
Minimal fluids
No opioids
No NGT
Immediate feeding
Early ambulation
Discharge POD3-4
OSJ versus Traditional Care
• All post-op milestones
achieved earlier
• 35% fewer
complications
• 8-fold reduction in
“Poor Recovery”
• Cost $8,237 less per
case ($2 – 2.5 M/year)
Shah JB et al, submitted
But what about the patient
experience?
• Patients don’t necessarily care about:
– Length of stay
– Hospital metrics
– Cost savings
• Lack of focus on patient-centered outcomes
– No measure of patient symptom burden
MDASI
• Paper survey
• Electronic capture
– Email from REDCap
– aVR (automated voice recording via telephone)
– Tablet app while inpatient
– (commercial enhanced recovery app on patient device)
Abdominal discomfort
Traditional
OSJ
Dry Mouth
traditional
OSJ
Sleep Disturbance
traditional
OSJ
Pain
Traditional
OSJ
Fatigue
Traditional
OSJ
Impairment of General Activity
Traditional
OSJ
Mood Disturbance
Traditional
OSJ
Impaired Relations with Others
Traditional
OSJ
Difficulty Walking
Traditional
OSJ
Impaired Enjoyment of Life
Traditional
OSJ
What are the patients telling us?
• OSJ better than traditional care in some ways:
– Less abdom discomfort, pain, difficulty walking
– Less impairment of gen activity
– Less mood disturbance & relationship impairment
– More enjoyment of life
• No better than traditional care in other ways:
– Fatigue, dry mouth, sleep disturbance
What now?
• Measurement of symptom burden allows:
– Identification of weak spots
– Opportunity to address those spots directly
• Can we integrate patient-reported outcomes
& hospital-centric outcomes?
– Is there a MDASI “biomarker” that can predict
poor recovery?
Next steps
• Correlate symptom burden with poor recovery
– PCORI grant under revision
• Develop a bladder cancer-specific MDASI
– Qualitative interviews completed
– Candidate items identified
– Validation to begin after expert panel review
Conclusion
• Enhancing recovery of RC patients is a
laudable goal
• Focus on hospital-centered outcomes is only
part of the goal
• Goal: better understand the patient
experience so we can better navigate them
through RC
Acknowledgements
• Dept of Urology
– Erika Wood, MPH
– Colin Dinney, MD
– Ashish Kamat, MD
– Neema Navai, MD
• Dept of Symptom Research
– Shelley Wang, PhD
– Quiling Shi, MD PhD
– Lori Williams, PhD