Challenges of patient-reported outcome assessment in hemophilia care—a state of the art review

INTRODUCTION

One of the recent advances in assessing outcomes of medical care is the inclusion of the patient perspective. The term patient-reported outcome (PRO) is used to reflect the patient perceptions of disease and its consequences as well as of treatment and health-care provision. The development of PRO measures has advanced rapidly, and implementation in clinical research and practice is now underway. From an evaluation perspective, recommendations for the choice of PRO measures and an appraisal of the potential benefits of PRO data collection within specific health conditions are needed.

METHODS

Hemophilia is a rare and clinically well-defined health condition with established and cost-intensive treatment strategies, in which PRO assessment is increasingly recognized as important. For this reason, measurement of PROs in hemophilia focusing on health-related quality of life (HRQoL) and patient preferences were reviewed to identify appropriate measures, to make recommendations for their choice, and to critically examine their impact in international hemophilia research and practice.

RESULTS

Using literature searches and expert discussion strategies, generic and targeted measures for HRQoL and patient preferences in adults and children with hemophilia were screened, and 20 were reviewed on the basis of their psychometric properties and international availability. Only a few of the 20 measures have been used in clinical settings or research related to persons with hemophilia.

CONCLUSION

Consequently, an increased use of these measures is recommended to understand patient views on disease and treatment and to judge the impact of PROs for improvements in health care.

[Backpain and haemophilia]

A literature research for back pain in hemophilia (1990-2007) revealed only five papers! They all had lumbar or sciatic pain due to hematoma. All symptoms responded to factor VIII replacement. A similar research for a normal population showed hundreds of papers with a lifetime prevalence of 80% for back pain. A survey of 49 patient with hemophilia showed similar results. 70% had experienced back pain before. The reported pain of 40 to 70 on a visual analog scale was significant. 40% reported that the back pain would be more limiting than the pain associated with hemophilia. The hemophilic patient has learned to cope! The treatment of back pain will be of growing importance for hemophilia centers while the typical complaints of hemophilic symptoms will decrease due to better treatment protocols.

Home treatment in haemophilia: clinical, social and economic advantages

Twenty-eight severely affected haemophiliacs were observed for 3 months under treatment as hospital out-patients and for the subsequent 9 months while treating themselves at home. Delay in receiving treatment and financial costs were both clearly reduced by home treatment, the patients recovered from individual bleeds more quickly and reported a greater sense of personal freedom and independence. The amount of treatment required did not materially change and no untoward effects were noted; the use of analgesics tended to be less.

Health-related quality of life in a cohort of adult patients with mild hemophilia A

OBJECTIVES

To compare the health-related quality of life among adult males affected with mild hemophilia A due to the same mutation (Val2016ala) to that of unaffected age and sex matched controls from the same general population.

METHODS

The Short-Form 36 (SF-36) and Health Assessment Questionnaire (HAQ) were used to measure health-related quality of life and physical function. Other measures included bleeding history, a measure of joint damage, body mass index, age, and viral infection status. Cross-sectional data were collected through research clinics and a retrospective chart audit over a two-year period.

RESULTS AND CONCLUSIONS

The study included 47 affected males and 33 controls. The affected males had a higher level of co-morbidity, prior bleeding, and existing joint damage than controls. With the exception of the social function and health transition scales, mean scores for each of the SF-36 domains were worse among affected males. Mean differences were more than a clinically important five points in five of eight domains, with the general health scale showing more than a 10-point difference. Despite the degree of difference noted, only two of the differences were statistically significant (general health and role emotional scales) because of the small sample size and considerable individual variation in SF-36 scale scores. Multiple regression analyses suggested existing joint damage and presence of heart disease as the strongest associates of lower physical health-related quality of life. Joint damage in turn was partly related to prior hemarthroses. Compared to the Canadian population, affected males had lower scores in six out of eight SF-36 domains as well as the physical component summary score. There were no significant differences found in the HAQ scores between the two groups. So-called mild hemophilia A was associated with a negative effect on physical health-related quality of life, contributed to by joint damage as a result of prior bleeding.

Identifying and overcoming barriers to prophylaxis in the management of haemophilia

Haemophilia is often characterized by acute haemarthrosis and synovitis arising from spontaneous bleeding episodes, particularly in the muscles and joints of the elbows, knees and ankles. Current treatment for patients with severe haemophilia involves coagulation factor concentrate (CFC) replacement therapy given on demand at the time of bleeding or through long-term prophylaxis aimed at preventing future bleeds and joint disease. Although prophylaxis has many advantages over on-demand therapy (particularly if started before age 2 and prior to any signs of joint disease), its practice varies widely even among developed countries because of several barriers. Such barriers include CFC costs and availability; patient perceptions, lifestyles and bleeding patterns; difficulties and complications arising from the use of intravenous access devices (IVADs); the development of inhibitors; and the lack of randomized clinical trials. These barriers can be overcome by tailoring treatment regimens according to individual patient bleeding patterns and CFC pharmacokinetic profiles, using IVADs selectively and judiciously, helping patients maintain normal weight and physical exercise and providing the families of patients with continuous support from healthcare providers.

Attitudes towards and beliefs about genetic testing in the haemophilia community: a qualitative study

Widespread genetic testing for haemophilia has recently been introduced in Victoria, Australia. While attitudes towards predictive testing have been studied in other conditions, such as cancer, there is limited knowledge about the attitudes of members of the haemophilia community towards predictive testing. This study aimed at exploring attitudes towards, and beliefs about, genetic testing amongst members of the haemophilia community in Victoria prior to the widespread introduction of testing. The study was qualitative and descriptive. In-depth face to face interviews were held with a sample of 39 individuals, including men with haemophilia, female carriers and family members. Data were analysed thematically using cross-case analysis techniques. There was considerable knowledge about the proposed introduction of widespread genetic testing. However, not everyone thought that testing was accessible or user friendly, and there was confusion about who needed to be tested. Most thought that testing was necessary for adolescent girls to determine carrier status to help prepare families for a child with haemophilia, rather than leading them to choose to terminate a pregnancy or not to have children. A minority of women stated that if there was a history of inhibitors in a family then a termination might be considered. The study revealed strong religious beliefs among those studied, which may have influenced attitudes and approaches towards testing. Further investigation is needed into how people with a possible haemophilia genotype negotiate decisions about their further identification, and how this knowledge is placed within cultural, religious and family contexts.

[The need for psychological help for haemophilic children and their families]

The aim of this paper is to present and discuss psychological care for children with haemophilia. The article identifies and indicates specific features of the psychosocial functioning of these patients, which need to be further investigated to gain a better understanding of the difficulties encountered by haemophiliacs and their families. Understanding these difficulties in the context of a child's experiences and those of its family is a vital element of professional psychological care and remains crucial in the process of treatment. Providing psychological care, as well as cooperation with a multidisciplinary group of specialists involved in the process of treatment, can enhance the quality of life for patients in Poland affected by haemophilia.

Living with haemophilia and von Willebrand's: a descriptive qualitative study

OBJECTIVE

The aim of this qualitative descriptive study was to describe the experience of living with bleeding disorders and to identify the associated salient issues from the perspectives of people living with haemophilia or von Willebrand's Disease (vWD).

METHODS

Nine members of The Haemophilia Society took part in a semi-structured interview. The interviews were tape recorded and transcribed and the results subjected to thematic content analysis.

RESULTS

Participants described the physical aspects of their condition, such as bleeding into joints, the implications of bleeds and development of co-morbid conditions (e.g. arthritis). Many felt that their bleeding disorder had impacted on their education, work, social activities and family life. Anxiety and depression were associated with daily management of symptoms, the unpredictable nature of bleeding disorders and concerns about the future. All participants had encountered a degree of stigmatisation related to their condition and felt that there was a public misconception about bleeding disorders. Many had experienced discrimination in educational and work settings. Some participants expressed a preference for seeking treatment from specialist services.

CONCLUSION

Living with haemophilia and vWD poses a number of daily and longer-term challenges not only for individuals, but also for their families. Further investigation of ways to support such individuals is warranted.

PRACTICE IMPLICATIONS

Greater awareness and understanding of the issues faced by people living with haemophilia and vWD is needed for the general public, employers, and healthcare staff, particularly those working in Accident and Emergency Departments.

Information and self-management needs of people living with bleeding disorders: a survey

The aim of the study was to conduct a survey of information and self-management needs among members of the UK Haemophilia Society (HS). Of 1082 members mailed, 307 took part in the survey, the mean age was 52.4 years (SD 14.8), 85% were male, 96% white and 66% were living with haemophilia A. 90% felt that there is a lack of understanding amongst the public regarding bleeding disorders, 76% felt that health professionals understood their health and information needs and 32% had experienced problems managing anxiety and or depression. Results suggest that there was a 'stigma' attached to having a bleeding disorder and almost half are very careful about informing others that they have a bleeding disorder. Self-efficacy was relatively high within the sample. Many respondents wanted to be kept informed about current research and the opportunity to participate in research. Women experienced a greater need for more information than men, particularly in the area of the 'medical management' and 'emotional' topics. Men appeared to need more information and or training on 'physical' aspects such as physiotherapy and joint replacement. The study provides an insight into the educational and self-management needs of those affected by bleeding disorders and highlights the importance of providing accessible information.

Psychological aspects and coping styles of parents with Haemophilic child undergoing a programme of counselling and psychological support

Parents of children affected by haemophilia must face, often without prior knowledge, the difficult challenge imposed by such a pathology. To satisfy the need of information, guideline and psychological support for a better quality of life, 30 parents with haemophiliac children have participated in a programme of counselling and psychological support. Such a programme has the aim of guiding the group trough a process of discovery, comparison and personal growth and stimulating adaptive processes of problem-solving and decision-making. The aim of this paper was to verify how the programme influenced coping strategies and other psychological constructs such as depression and anxiety. Subjects of this study were administered the following psychological tests: COPE (coping, orientation to problems experienced), BDI (beck depression inventory), STAI-Y form (state-trait anxiety inventory) at the beginning and at the end of the programme. The results show that by the end of the programme subjects are characterized by a greater use of problem-focused coping strategies, typical of individuals who think that the situation is susceptible to change, and a minor use of emotion-focused coping strategies, related to individuals who regard the situation as immutable. The use of avoidance -focused coping strategies seems to remain at the same level even if it was low. Also the other psychological aspects investigated, namely depression and anxiety, did receive a positive influence. The results show how significant such programme has been for parents.

Parents of children with haemophilia ? a transforming experience

Owing to the improvements in the management of haemophilia, children with severe haemophilia in the United Kingdom have very different experiences of their condition compared with many adults' early experiences of haemophilia. However, haemophilia can still have physical and social effects which can impact on the quality of life, not only for a child who has the condition, but also for their parents. The purpose of this study was to undertake a qualitative exploration of the impact of haemophilia on parents. The participants included 12 parents of children with severe haemophilia who took part in interviews or focus groups. Four major themes emerged from the data which were initial experiences, managing the condition, engaging with others and developing mastery. The findings highlighted the importance of evaluating parents' experiences. Parents are deeply affected by their child's condition and their lives are transformed by the experiences of living with a child with haemophilia. Parents' responses are influenced by how well the child manages the disorder and the difficulties they experience. Further studies are required in order to develop a more complete understanding of the impact of haemophilia on parent's lives.

Comparing two measures of quality of life for children with haemophilia: the CHO-KLAT and the Haemo-QoL

Disease-specific measures of quality of life (QoL) for children with haemophilia are now available for use in clinical studies [Haemophilia, 10, 2004, 9-16]. One of these measures, the Canadian Haemophilia Outcomes - Kids' Life Assessment Tool (CHO-KLAT), was developed in Canada with emphasis on the perspectives of children [Pediatr Blood Cancer, 47, 2006, 305-11; Haemophilia, 10, 2004, 34-43]. Another, the Haemo-QoL, was developed in Europe, with emphasis on the perspectives of clinicians [Haemophilia, 8, 2002, 47-54; Haemophilia, 10, 2004, 17-25]. While these two measures are unique and independent, researchers from both studies were collaboratively linked throughout development and testing. This study presents the results of a joint assessment of the two measures with respect to their strengths, limitations and unique contributions. The primary questions addressed were: 1 What is the relationship between the CHO-KLAT and the Haemo-QoL in terms of summary scores and item content? 2 What are the methodological strengths, limitations and unique contributions of each measure? We conducted a retrospective analysis of data from field testing of both measures. The analysis included a comparative assessment of the basic validity, reliability and items used in each measure. Overall, the CHO-KLAT and the Haemo-QoL are promising and valuable measures of QoL for children with haemophilia. Our analyses confirmed the basic psychometric properties of both tools, but identified some discrepancies between them. Additional data will allow for greater understanding of these discrepancies and lend clarity to how the tools should be used in clinical studies (separately or merged). The present recommendation is that the measures be run independently, but preferably concurrently in studies of children with haemophilia.

Participation in sports and physical activity of haemophilia patients

Modern therapy options offer haemophiliacs more and more possibilities for an active participation in sports. The purpose of the present study was to investigate the attitude of these patients towards sports, their participation in school and leisure time sports activities, and differences between juveniles and adults. We investigated 44 children and adolescents (aged from 4 to 16 years) and 27 adults (aged from 18 to 72 years) with haemophilia by means of a questionnaire. 79.6% of the juvenile patients participated always or almost always in school sports, while this percentage was significantly (P < 0.05) lower in the former school time of the adults (37%). Sports play an important or very important role in leisure time activities for 75% of the adolescent and 55.5% of the adult haemophiliacs (P < 0.05). Bleeding complications occurred in 17.6% of all patients; there was no correlation with any particular type of sports. There were only slight differences between both groups, regarding their motivation to participate in sports activities. The main reasons involved social aspects and having fun. The results show that the modern therapy of haemophilia probably leads to a more positive attitude towards sports and to a wider spectrum of practised sports. This, however, may be associated with an increasing potential of health risks, which require a high level of sports medical care.

Communicating about haemophilia within the family: the importance of context and of experience

This study examines communication within families affected by haemophilia, focusing especially on communication about carrier status. A qualitative study using semi-structured interviews with family members in the UK revealed recurrent patterns in communication strategies and styles. Participants drew a marked contrast between the nature of communication within the clinic and within the home. In families, it is notable that communication usually occurs within the context of concrete experience of the condition. Noticeable differences existed in families with obligate carriers when compared with families with non-obligate carrier daughters. In families with affected sons, daughters may have more experience of haemophilia and consequently more understanding of their possible carrier status than in families with an affected father. Families also typically make value judgements and comments on coping strategies when they communicate about the condition. Readiness to receive information is very variable, and depends upon factors such as personality and life stage. Information may seem to be successfully communicated but the recipient may sometimes actually comprehend much less, only understanding more fully later or when the information becomes directly relevant to them. Periodic checking of understanding of different family members, and the provision of written information, may be helpful.