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

jbshah@mdanderson.org

@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

Jay B. Shah, MD

MD Anderson Cancer Center

jbshah@mdanderson.org

@BladderCancerMD

Thank you!