Hum. Reprod. Advance Access originally published online on March 27, 2008
Human Reproduction 2008 23(6):1242-1245; doi:10.1093/humrep/den094
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Coming soon to your clinic: high-quality ART
1 Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands 2 Centre for Quality of Care Research (WOK), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
3 Correspondence address. E-mail: i.vanempel{at}obgyn.umcn.nl
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Abstract |
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 Top Abstract IntroductionPatient-friendly ARTTerminology: from patient...Extension of the concept...Patient centrednessBalancing all six dimensionsConclusionsReferences |
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The concept of ‘patient-friendly’ medically assisted reproduction includes a robust set of clinical practice principles, to improve the quality of subfertility care. This concept is an important move away from the sole focus on effectiveness and high pregnancy rates in assisted reproduction technology (ART). Although the concept of ‘patient-friendly ART’ has several strong points, we feel it is incomplete. For achieving true high-quality ART, the concept should be extended to two more dimensions: timeliness and patient centredness. Moreover, we propose a change in the concept's name to the less ambiguous ‘high-quality ART’.
Key words: quality of care/subfertility/patient-centred care/patient-friendly IVF
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Introduction |
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TopAbstractIntroductionPatient-friendly ARTTerminology: from patient...Extension of the concept...Patient centrednessBalancing all six dimensionsConclusionsReferences |
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Pennings and Ombelet (2007)
started a debate about patient-friendly assisted reproduction technology (ART). We agree that there is still too much focus on treatment outcome in ART, but in our view, their concept of patient-friendly ART is not entirely complete. Therefore, we would like to add two extra dimensions to the concept. Furthermore, we think it is undesirable to use the term ‘patient friendly’ in combination with ART, and we will clarify why we prefer the more convenient term ‘high-quality ART’. |
Patient-friendly ART |
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TopAbstractIntroductionPatient-friendly ARTTerminology: from patient...Extension of the concept...Patient centrednessBalancing all six dimensionsConclusionsReferences |
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Pennings and Ombelet (2007)
have abandoned the current ART performance model, which focuses mainly on success rates such as pregnancy rates per treatment cycle. They proposed to improve subfertility care by introducing patient-friendly ART, an approach based on four principles: equity of access, cost-effectiveness, minimization of risks and minimization of emotional and physical burden. As an example of patient-friendly ART, they mention mild ovarian stimulation with single-embryo transfer (SET), which would provide important advantages such as fewer multiple-birth pregnancies, smaller physical burden and lower overall costs (Heijnen et al., 2007; Pennings and Ombelet, 2007). This robust set of clinical practice principles is of great value; patients would really benefit from the optimal mixture of these criteria in subfertility care. Moreover, like Pennings and Ombelet, we believe that high success rates are important. However, success rates give no information about the care process itself and little information about the opportunities for improvement (Min et al., 2004; Nelen et al., 2007). |
Terminology: from patient-friendly ART to high-quality ART |
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TopAbstractIntroductionPatient-friendly ARTTerminology: from patient...Extension of the concept...Patient centrednessBalancing all six dimensionsConclusionsReferences |
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Using the term patient friendly in relation to ART has considerable drawbacks. At first, ‘friendly’ care certainly sounds positive, irrespective of how this care actually takes place. Supposing that mild ovarian stimulation with SET is patient friendly, then this term implies that other treatment protocols, such as IVF with standard ovarian stimulation with double-embryo transfer, are unfriendly. Therefore, the term patient friendly is unsuitable for comparing the quality of different treatment strategies in ART in an objective way. In addition, this terminology is currently not applied consistently (Pelinck et al., 2002
; Basille et al., 2007; Heijnen et al., 2007) and could in theory be applied to any less invasive treatment strategy, such as natural-cycle ART (http://www.drmalpani.com/patient-friendly-ivf.htm).
Furthermore, ‘patient-friendly ART’ may have a false attractiveness, as undergoing ART is not pleasant at all. We should not forget that we are dealing with involuntary childlessness and its extensive and lengthy treatment with relatively low success rates. In other words, it is undesirable to describe the set of principles as patient friendly, since the patients still have to deal with a monthly uncertainty, and treatments characterized by a high drop-out rate, unpleasant ovum retrievals and great emotional burden (Verhaak et al., 2007).
Because of these disadvantages, we suggest the more convenient term ‘high-quality ART’. For patients, this term is less confusing as it implies well-considered specialized care, without suggesting attractiveness. In this way, patients are less likely to misjudge the characteristics of the care. For doctors, this term better reflects the concept aim and focuses more on quality and quality improvement (Nelen et al., 2007). Furthermore, usage of the term high quality will bring uniformity in terminology between countries as well as between the various medical specialties. Many large-scale and renowned healthcare institutions worldwide say ‘high-quality care’ when they mean that care is effective, safe, patient-centred, timely, efficient and accessible (Institute of Medicine, 2001; Bengoa et al., 2006; The Council of the European Union, 2006). This widespread usage indicates its universal acceptance. Nevertheless, we realize that certain unfavourable circumstances can make it hard for doctors to achieve high-quality ART in every patient, for example, in countries where reimbursement system are lacking, and in the case of high female age.
In brief, the term high-quality ART is less subjective than the term patient-friendly ART, and it fits better in the perception of quality of care that scientists and politicians have today.
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Extension of the concept from four to six dimensions |
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TopAbstractIntroductionPatient-friendly ARTTerminology: from patient...Extension of the concept...Patient centrednessBalancing all six dimensionsConclusionsReferences |
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Although the concept of patient-friendly ART has several strong points, we think it is incomplete and should be extended by two more dimensions. According to the World Health Organization and the Institute of Medicine, doctors should use a medical approach that covers all elements of high-quality care, to reach the best possible emotional and physical health for each patient (Institute of Medicine, 2001
; Bengoa et al., 2006). Pennings and Ombelet's concept of patient-friendly ART covers only four of the six dimensions of high-quality care (Table I): equity, safety, efficiency and effectiveness. The two missing dimensions are timeliness and patient centredness. Timeliness represents timely care, which means a reduction in waits and delays for both those receiving and providing care. There is room for improving timeliness in subfertility care; delays frequently occur due to, for example, inaccurate scheduling of appointments or repeating tests unnecessarily. Lack of timeliness can result in emotional distress and financial consequences for the patient (Leddy et al., 2003).
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Patient centredness |
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TopAbstractIntroductionPatient-friendly ARTTerminology: from patient...Extension of the concept...Patient centrednessBalancing all six dimensionsConclusionsReferences |
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The most important missing dimension of high-quality care in our opinion is patient centredness. Patient-centred care, or personalized care, is more than just being nice to the patients; it focuses on the patient's experience of illness and healthcare. Interestingly, there is no universally accepted and unambiguous definition of patient centredness. In the literature, patient centredness is often presented as a concept composed of several elements (Mead and Bower, 2000
; Stewart, 2001). Important elements of patient-centred care—also in subfertility care—are transparency and shared decision-making. Doctors should fully inform patients to enable them to make informed decisions when selecting a health plan, clinic or treatment of choice (Institute of Medicine, 2001; International Alliance of Patients’ Organizations, 2007). The Picker Institute introduced one of the most complete models of patient-centred care (Gerteis et al., 1993) in which they divide patient-centred care into eight components: respect for patients’ preferences; co-ordination of care; physical comfort; emotional support; transition and continuity; involvement of family and friends; access to care; and information, communication and education. All these components are mandatory for true patient centredness.
A patient-centred approach can be very fruitful, especially for chronic illnesses with great emotional impact, such as involuntary childlessness (Bauman et al., 2003). For instance, a patient-centred approach can improve emotional health, quality of life and doctor satisfaction. Furthermore, it can lessen the patient's burden and reduce anxiety (Anderson, 2002; Michie et al., 2003). There is even some evidence that patient-centred care is more efficient and results in fewer unnecessary referrals (Stewart, 2001).
The main significance of patient-centredness is that it moves the healthcare focus away from the disorder and towards the patient (Harkness, 2006). It is well-known that doctors and patients often differ in the aspects of care they consider important. Patients are more worried about psychological and social issues, whereas doctors are inclined to focus on the more technical and physical aspects of care and disease (Kernick et al., 1999). For example, subfertile couples feel that doctors give insufficient information about organizations that provide emotional support (Haagen et al., 2007). In order to reduce this doctor–patient gap, doctors should listen carefully to their patients’ needs and preferences and use the input to tailor their care (Coulter, 1999). For instance, ART treatment is rarely so straightforward that a single approach or protocol is universally applicable. The use of other treatment protocols as well enhances personalization and freedom of the patient's choice (Flisser et al., 2007). Our own experience has taught us that patients want information about alternatives to treatment, such as adoption and lifestyle changes (Haagen et al., 2007).
Fortunately, patient centredness in healthcare is now receiving more attention. Patient evaluation of subfertility care is being given more consideration as an important treatment outcome (Malin et al., 2001; Haagen et al., 2007). Patients and their families are better educated and informed about their health status than ever before, which changes the patient's role from passive to active and assertive (Jadad et al., 2003). Regrettably, Pennings and Ombelet's (2007) ‘patient friendly’ concept is more in line with the technical and physical ‘doctor approach’ outlined earlier, with only a small active role for the patient. Although they mention the importance of provision for shared decisions and patient information in their paper, they did not add patient centredness as an extra dimension to their concept. Therefore, their concept may look more paternalistic than they intended; patient experience needs to be more than just an afterthought (Edwards et al., 2004). Since patient discomfort in ART is still considerable, it is worth investing in ways to improve patient experience and emotional well-being in subfertility care (Verhaak et al., 2007). Striving for optimal patient-centred care is a perfect way to reach this goal.
There are many different starting points for patient-centred ART, and patient involvement depends on national wealth, culture and attitudes. Nevertheless, doctors should understand and apply patient-centred care. If patients and patient organizations work in partnership with subfertility specialists, care providers and policy-makers, high-quality ART can be achieved for both doctors and patients.
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Balancing all six dimensions |
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TopAbstractIntroductionPatient-friendly ARTTerminology: from patient...Extension of the concept...Patient centrednessBalancing all six dimensionsConclusionsReferences |
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In our proposed concept of ‘high-quality’ ART, we agree with Pennings and Ombelet that doctors should take all dimensions into account simultaneously. Patient centredness does not mean simply complying with all of the patient's requests. Meeting the patient's needs and preferences is valuable, but not at any price. For example, the initiation of ART for extremely obese women does not provide high quality, as their treatment is more expensive and less effective, and their potential pregnancies unsafe (Bhattacharya et al., 2007
; Maheshwari et al., 2007). They would be better helped by a personal coach for lifestyle change first. However, patients can hardly exert any influence on the safety, efficacy, timeliness and effectiveness of their care. These are the doctor's responsibilities. However, equity of access to ART also depends strongly on the availability of healthcare services and the way a country has arranged its reimbursement systems. In order to best answer your patients’ needs, first ask them what they really expect from you. Some patients are not in need of any treatment at all; knowing the cause of their problem can be sufficient. Therefore, more exploratory investigations about patients’ expectations and preferences of subfertility should be conducted to really meet patients’ needs. |
Conclusions |
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TopAbstractIntroductionPatient-friendly ARTTerminology: from patient...Extension of the concept...Patient centrednessBalancing all six dimensionsConclusionsReferences |
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This paper is a reaction to the debate about patient-friendly ART. Pennings and Ombelet (2007)
present a robust set of clinical practice principles to improve the quality of subfertility care. We agree that ART is still too much focused on treatment outcome. We propose a change in terminology, from ‘patient-friendly’ ART to the less ambiguous ‘high-quality’ ART. Furthermore, we add two more dimensions to their set of principles: timeliness and patient centredness. This would help achieve true high-quality ART.
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TopAbstractIntroductionPatient-friendly ARTTerminology: from patient...Extension of the concept...Patient centrednessBalancing all six dimensionsConclusionsReferences |
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Submitted on December 14, 2007; resubmitted on February 19, 2008; accepted on March 3, 2008.
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