Assessing proxy reports: agreement between children with asthma and their caregivers on quality of life

Long-term durability between parent and child patient-reported outcomes in eosinophilic esophagitis

BACKGROUND

Because young children cannot self-report symptoms, there is a need for parent surrogate reports. Although early work suggested parent-child alignment for eosinophil esophagitis (EoE) patient-reported outcomes (PROs), the longitudinal alignment is unclear.

OBJECTIVE

We sought to assess the agreement and longitudinal stability of PROs between children with EoE and their parents.

METHODS

A total of 292 parent-child respondents completed 723 questionnaires over 5 years in an observational trial in the Consortium of Eosinophilic Gastrointestinal Disease Researchers. The change in and agreement between parent and child Pediatric Eosinophilic Esophagitis Symptom Score version 2 (PEESSv2.0) and Pediatric Quality of Life Eosinophilic Esophagitis Module (PedsQL-EoE) PROs over time were assessed using Pearson correlation and Bland-Altman analyses. Clinical factors influencing PROs and their agreement were evaluated using linear mixed models.

RESULTS

The cohort had a median disease duration equaling 3.7 years and was predominantly male (73.6%) and White (85.3%). Child and parent PEESSv2.0 response groups were identified and were stable over time. There was strong correlation between child and parent reports (PEESSv2.0, 0.83;PedsQL-EoE, 0.74), with minimal pairwise differences for symptoms. Longitudinally, parent-reported PedsQL-EoE scores were stable (P ≥ .32), whereas child-reported PedsQL-EoE scores improved (P = .026). A larger difference in parent and child PedsQL-EoE reports was associated with younger age (P < .001), and differences were driven by psychosocial PRO domains.

CONCLUSIONS

There is strong longitudinal alignment between child and parent reports using EoE PROs. These data provide evidence that parent report is a stable proxy for objective EoE symptoms in their children.

Development and content validation of a self-completed, electronic Pediatric Asthma Symptom Diary

BACKGROUND

Childhood asthma is an important unmet need. To date, patient-reported outcome measures (PROMs) for children with asthma have used a combination of caregiver or proxy-reported and self-reported measures. No comprehensive measure is available to assess the severity and impact of daytime and nighttime asthma symptoms and rescue medication use for self-completion by children aged 6-11 years. This study aimed to develop a novel, interactive, electronic Pediatric Asthma Symptom Diary (ePASD) measuring self-reported key symptom severity and proximal impacts of asthma in young children with varying reading ability and disease severity, consistent with US Food and Drug Administration (FDA) PRO guidance and the International Society for Health Economics and Outcomes Research (ISPOR) good research practices.

METHODS

A targeted literature review and clinician interviews were undertaken to characterize symptoms and impacts experienced by children with mild-to-severe asthma. Concept elicitation interviews (CEIs) were conducted with 44 children and their caregivers (30 US; 14 UK). Following item and digital application development, the ePASD was assessed for relevance, understanding, and interpretability through cognitive debriefing interviews (CDIs) with 21 US children. Face validity/translatability assessments were also performed.

RESULTS

Key measurement concepts included cough, wheeze, difficulty breathing, chest tightness/discomfort, nighttime awakening, and daytime activity limitations. Concept saturation was reached during CEIs for primary asthma-related daytime and nighttime symptoms and core impacts. Most CDI participants found the ePASD items clear, understandable, and comprehensive. Standardized training is anticipated to facilitate reliable child self-report.

CONCLUSION

The ePASD, a novel PROM for children aged 6-11 years with asthma, uses an innovative multimedia approach and has been developed in accordance with FDA PRO guidance and ISPOR good research practices, directly capturing the child's self-reported asthma symptoms, impacts on daily activities and nighttime awakening, and rescue medication use.

The effects of child anxiety and depression on concordance between parent-proxy and self-reported health-related quality of life for pediatric liver transplant patients

BACKGROUND

HRQOL is a key outcome following pediatric LT. Parent-proxy reports may substitute for patients unable to report their own HRQOL. This study compared parent-proxy and self-reported HRQOL in children who have undergone LT.

METHODS

Pediatric LT recipients between the ages of 8 and 18 years, and a parent, completed self and proxy versions of the PeLTQL questionnaire, PedsQL Generic and Transplant modules, and standardized measures of depression and anxiety.

RESULTS

Data from 129 parent-patient dyads were included. Median parent age was 44 years, and most (89%) were mothers. Median patient age was 2.5 years at LT and 13.6 years at the time of study participation. Parents had significantly lower scores than patients on PedsQL total generic (70.8 ± 18.5 and 74.3 ± 19.0, p = .01), PeLTQL coping and adjustment (63.0 ± 15.6 and 67.3 ± 16.2, p < .01), and social-emotional (66.3 ± 14.9 and 71.9 ± 15.6, p < .001) domains. Higher patient anxiety and depression were related to larger absolute differences between parent-proxy and self-reported scores on all HRQOL measures (all p < .05). In this disparity, parents reported higher HRQOL scores than their child as self-reported anxiety and depression scores increased.

CONCLUSIONS

Differences in concordance between parent-proxy and self-reported HRQOL scores can be more prominent when children have more symptoms of anxiety and depression. Children's mental health symptoms should be queried, if feasible, when interpreting differences in parent and child reports of HRQOL.

Focus on asthma 3: the psychosocial effects of asthma on the child and the family

This article is the third in a series on asthma. The first article explored global and UK trends in asthma and asthma care as they relate to children and young people, while the second article identified the adverse effects of air pollution on children, particularly those with asthma. This article explores the potentially significant psychosocial effects of asthma on the child and the family. A family-centred approach to care relies on healthcare professionals listening to and understanding families' health beliefs and narratives to target asthma education and aid self-efficacy, which can improve asthma control and quality of life.

Psychological and Socioeconomic Burdens Faced by Family Caregivers of Children With Asthma: An Integrative Review

INTRODUCTION

Asthma affects nearly 1 in every 12 children in the United States. Caring for a child with asthma poses significant challenges for the parent or caregiver. The purpose of this integrative review was to identify the psychological and socioeconomic burdens faced by family caregivers of children with asthma.

METHOD

An integrative review was conducted to review and appraise 80 studies.

RESULTS

Psychosocial burdens included decreased mental health, quality of life, sleep, family stress, educational deficits, cultural and health disparities, and health care communication challenges. Socioeconomic burdens included poor access to care, as well as work and financial challenges. Studies demonstrated a link between family caregiver health and child health outcomes. Facilitators included education and empowerment, social support, and use of technology.

DISCUSSION

As the family caregiver's health directly affects the asthmatic child's health, addressing the burdens of family caregivers should be a key consideration in pediatric asthma care.

Comparison between the health-related quality of life of children/adolescents with asthma and that of their caregivers: a systematic review and meta-analysis

OBJECTIVE

To evaluate the health-related quality of life (HRQoL) of children/adolescents with asthma and that of their caregivers, comparing the two.

METHODS

This was a systematic review and meta-analysis based on the criteria of Preferred Reporting Items for Systematic Reviews and Meta-Analyses, with a strategy of searching five health-related databases (MEDLINE/PubMed, EMBASE, ScienceDirect, SciELO, and LILACS). We included studies that evaluated the HRQoL of children/adolescents with asthma and that of their caregivers with the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire, respectively, using the total scores and the scores on the domains activity limitation, symptoms (children/adolescents only), and emotional function.

RESULTS

We identified 291 articles, and we evaluated 133 of those. A total of 33 articles, collectively including 4,101 subjects, were included in the meta-analysis. An analysis stratified by study design showed no differences between the HRQoL of the caregivers and that of the children/adolescents in the activity limitation domain and in the total score. However, the mean emotional function domain scores were significantly higher (better) among children/adolescents with asthma than among their caregivers in longitudinal studies-Δ = 0.82 (0.21-1.44)-and randomized clinical trials-Δ = 0.52 (0.29-0.79)-although not in cross-sectional studies-Δ = -0.20 (-0.03 to 0.43).

CONCLUSIONS

The total HRQoL scores proved to be similar between children/adolescents with asthma and their caregivers. However, the two groups differed in their perception of their emotional function, the caregivers scoring significantly lower than the children/adolescents in that domain.

Engaging patient partners in state-of-the-art allergy care: Finding balance when discussing risk

OBJECTIVE

To review risk communication in the context of shared decision making.

DATA SOURCES

Articles describing risk communication, shared decision making, and cost-effective healthcare delivery.

STUDY SELECTIONS

A narrative review detailing approaches to improve risk communication and shared decision making to optimize patient-centered cost-effective practice.

RESULTS

Risk communication must occur on a foundation of mutual trust and can be improved by keeping risk in perspective of everyday hazards, such as using pictograms when possible, providing numeric likelihoods of risks and benefits, and discussing absolute risks. Variability in patient-perceived quality of life for allergic and nonallergic health states may affect the health and economic outcomes of many allergy therapies. Shared decision making improves patient knowledge and risk perception, engagement, and adherence. Patient decision aids can be time-consuming to develop and validate, but their use is associated with a more accurate understanding of patient-oriented outcomes.

CONCLUSION

Communicating risk is complex, and validated patient decision aids using visual aids, presenting essential information, using knowledge checks, and incorporating values clarification can reduce decisional conflict and improve decisional self-efficacy.

Observational Study of Pediatric Inpatient Pain, Nausea/Vomiting and Anxiety

Background: The prevalence and severity of pain, nausea/vomiting, and anxiety (PNVA) among hospitalized children is not well established. We describe the prevalence and severity of PNVA among hospitalized patients from oncology, general pediatrics, and cardiology services in a tertiary care center. Methods: Patients were recruited on admission and enrolled if their caregiver consented, spoke English, and were anticipated to stay 2-30 days. Symptoms were measured weekdays using age-validated tools. PNVA symptoms were described and compared. Results: We enrolled 496 (49.4%) patients of 1005 admitted. Patients were predominantly Caucasian (57.9%) on their first admission (53.6%). The average (SD) age was 8.6 years (5.9) in oncology, 4.2 (5.3) in general pediatrics and 2.6 (4.0) in cardiology. 325 (65.6%) patients reported anxiety, 275 (55.4%) reported nausea and 256 (52.0%) reported pain. Mean (SD) severity out of 10 was 3.7 (2.5) for anxiety, 3.2 (2.1) for nausea and 3.0 (1.5) for pain. Prevalence of PNVA was no different between clinical programs, but pain (p = 0.008) and nausea (p = 0.006) severity were. PNVA symptom co-occurrence was positively correlated (p < 0.001). Conclusions: Anxiety was the most common and severe symptom for hospitalized children. Patients in oncology demonstrated the least severe pain and nausea with no difference in anxiety between services.

Changes in Quality of Life in Elementary School Children-The Health Oriented Pedagogical Project (HOPP)

BACKGROUND

Quality of life (QoL) studies may provide information of change in health status in the population. Few studies have followed up previous cross-sectional studies to investigate any change in the QoL status of healthy children. The aim of the current study is to compare QoL in children 6⁻12 years old in two large cross-sectional studies of healthy children completed a decade apart.

METHODS

In the current study children and parents from nine elementary schools (n = 2816) were included in a cross-sectional study investigating children's QoL. Using the Life Quality in Children and Adolescents (ILC), completed by both children and parents, the global QoL-score was estimated for 2297 children and 1639 parental reports. These results were compared to a similar study performed in 2004. The scores from both studies were divided into categories of below average, average and above average QoL. The percentage change of QoL between the two studies is presented.

RESULTS

Our results show that parents report that more children have below and above average QoL in 2015 compared to 2004. In contrast, more children scored in the average and above average QoL category in 2015 than in 2004.

CONCLUSION

Parents reported lower QoL and children higher QoL in 2015 compared to 2004.

Primary and Secondary Caregiver Reports of Quality of Life in Pediatric Asthma: Are They Comparable?

PURPOSE

This study aimed to compare primary and secondary caregiver QOL within families of children with asthma and determine the potential importance of including secondary caregiver QOL in clinical and research settings.

METHODS

Participants included 118 families of children with asthma that had primary and secondary caregivers. Families completed measures in a single research session. Caregivers reported on QOL, psychological functioning, and family burden; children completed a measure of QOL. Child lung function was determined from objective spirometry. Adherence to prescribed controller medication was measured for 6 weeks following the research visit.

RESULTS

Primary caregiver QOL was significantly lower than secondary caregiver QOL (Mean overall QOL of 5.85 versus 6.17, p < .05). Better medication adherence was associated with higher primary caregiver QOL (ρ = .22, p = .02); secondary caregiver QOL, not primary caregiver QOL, was positively associated with child QOL (ρ = .20, p = .03). Families with discrepant QOL scores between caregivers (difference in scores of at least .50) were characterized by more family burden and primary caregiver psychological symptoms.

CONCLUSIONS

Differences in QOL scores between caregivers may be a reflection of primary caregivers' greater investment in daily asthma management. In families reporting low burden and few psychological difficulties in the primary caregiver, QOL assessments from either caregiver may may be informative and representative of how parents are adapting to child asthma. In families experiencing high levels of burden or more primary caregiver psychological difficulties, QOL reports from secondary caregivers may not be as clinically meaningful.

Road to the Future: Priorities for Child Health Services Research

BACKGROUND

Prior health services research (HSR) agendas for children have been published, but major ones are now over 15 years old and do not reflect augmented understanding of the drivers and determinants of children's health; recent changes in the organization, financing, and delivery of health care; a growing emphasis on population health; and major demographic shifts in the population. A policy-relevant research agenda that integrates knowledge gained over the past 2 decades is essential to guide future child HSR (CHSR). We sought to develop and disseminate a robust, domestically focused, policy-oriented CHSR agenda.

METHODS

The new CHSR agenda was developed through a series of consultations with leaders in CHSR and related fields. After each round of consultation, the authors synthesized the previous experts' guidance to help inform subsequent discussions. The multistep process in generation of the agenda included identification of major policy-relevant research domains and specification of high-value research questions for each domain. Stakeholders represented in the discussions included those with expertise in child and family advocacy, adult health, population health, community development, racial and ethnic disparities, women's health, health economics, and government research funders and programs.

RESULTS

In total, 180 individuals were consulted in developing the research agenda. Six priority domains were identified for future research, including both enduring and emerging emphases: 1) framing children's health issues so that they are compelling to policy-makers; 2) addressing poverty and other social determinants of child health and wellbeing; 3) promoting equity in population health and health care; 4) preventing, diagnosing, and treating high priority health conditions in children; 5) strengthening performance of the health care system; and 6) enhancing the CHSR enterprise. Within these 6 domains, 40 specific topics were identified as the most pertinent for future research. Three overarching and crosscutting themes that affect research across the domains were also noted: the need for syntheses to build on the current, and sometimes extensive, evidence base to avoid duplication; the interrelated nature of the domains, which could lead to synergies in research; and the need for multidisciplinary collaborations in conducting research because research studies will look beyond the health sector.

CONCLUSIONS

The priorities presented in the agenda are policy-oriented and include a greater emphasis on how findings are framed and communicated to support action. We expect that the agenda will be useful for immediate uptake by investigators and research funders.

Mycoplasma pneumoniae and health outcomes in children with asthma

BACKGROUND

Acute infections with Mycoplasma pneumoniae (Mp) have been associated with worsening asthma in children. Mp can be present in the respiratory tract for extended periods; it is unknown whether the long-term persistence of Mp in the respiratory tract affects long-term asthma control.

OBJECTIVE

To determine the effect of Mp on asthma control.

METHODS

We enrolled 31 pediatric subjects 3 to 10 years of age with persistent asthma who completed up to 8 visits over a 24-month period. We detected Mp by antigen capture and polymerase chain reaction. Primary outcome measurements included symptom scores, quality of life, medication scores, oral corticosteroid use, health care usage, school absences, and exhaled breath condensate pH.

RESULTS

Low levels of Mp community-acquired respiratory distress syndrome toxin were detected in 20 subjects (64.5%) at enrollment. Subjects with Mp positivity at a given visit had a .579 probability of remaining Mp positive at the subsequent visit, whereas those with Mp negativity had a .348 probability of becoming Mp positive at the following visit. The incidence of Mp overall was higher in the spring and summer months. Overall, we found no significant relation between the detection of Mp and worse outcome measurements at the same visit or at subsequent visits.

CONCLUSION

The long-term persistence of Mp in the respiratory tract is common in children with asthma. However, the detection of Mp was not associated significantly with worse asthma symptoms, quality of life, health care usage, school absences, or exhaled breath condensate pH in this pediatric asthma cohort.

Childhood chronic conditions and health-related quality of life: Findings from a large population-based study

The objective of this study was to assess the impact of health-related quality of life (HRQOL) across prevalent chronic conditions, individually and comorbid, in school-aged children in the Netherlands. 5301 children aged 4-11 years from the Dutch Health Interview Survey were included. Parents completed questionnaires regarding child and parental characteristics. HRQOL of children was measured using the Child Health Questionnaire Parent Form 28 (CHQ-PF28). Independent-t tests were used to assess differences in the mean scores of the CHQ-PF28 summary scales and profile scales between children with a prevalent chronic condition (excluding or including children with multiple chronic conditions) and children without a chronic condition. Cohen's effect sizes (d) were calculated to assess the clinical significance of difference. The mean age of children was 7.55 (SD 2.30) years; 50.0% were boys. In children without any chronic condition, the mean score of physical summary scale (PhS) was 58.53 (SD 4.28) and mean score of the psychosocial summary scale (PsS) was 53.86 (SD 5.87). Generally, PhS and/or PsS scores in children with only one condition were lower (p<0.05) than for children without chronic conditions. When children with multiple conditions were included, mean scores of CHQ-PF28 summary and profile scales were generally lower than when they were excluded. The present study shows important information regarding the impact of prevalent chronic conditions on HRQOL in a representative population-based sample of school-aged children in the Netherlands. The information could be used for developing a more holistic approach to patient care and a surveillance framework for health promotion.

Mycoplasma pneumoniae CARDS toxin elicits a functional IgE response in Balb/c mice

Mycoplasma pneumoniae is strongly associated with new onset asthma and asthma exacerbations. Until recently, the molecular mechanisms utilized by M. pneumoniae to influence asthma symptoms were unknown. However, we recently reported that an ADP-ribosylating and vacuolating toxin called the Community Acquired Respiratory Distress Syndrome toxin, CARDS toxin, produced by M. pneumoniae was sufficient to promote allergic inflammation and asthma-like disease in mice. A mouse model of CARDS toxin exposure was used to evaluate total and CARDS-toxin specific serum IgE responses. Mast cell sensitization, challenge, and degranulation studies determined functionality of the CARDS toxin-specific IgE. In the current study, we report that a single mucosal exposure to CARDS toxin was sufficient to increase total serum IgE and CARDS toxin-specific IgE in mice. Mice given a second mucosal challenge of CARDS toxin responded with significant increases in total and CARDS toxin-specific IgE. CARDS toxin-specific IgE bound to an N-terminal peptide of CARDS toxin but not the C-terminal peptide. Likewise, full-length CARDS toxin and the N-terminal peptide induced mast cell degranulation. Altogether, these data demonstrate that exposure to CARDS toxin is sufficient to generate functional IgE in mice. M. pneumoniae and CARDS toxin are strongly associated with asthma exacerbations raising the possibility that the CARDS toxin-specific IgE-mast cell axis contributes to disease pathogenesis.

Symptoms in Children with Intermittent Exotropia and Their Impact on Health-Related Quality of Life

PURPOSE

In childhood intermittent XT, the frequency and type of symptoms have not been rigorously studied. We aimed to identify specific symptoms in children with intermittent XT, their frequency, and effects on health-related quality of life (HRQOL).

METHODS

35 children (5-13 years) with intermittent XT without previous surgery were enrolled in a prospective cohort study. Specific symptoms were identified from a previous study involving child and parent interviews and formulated as a 22-item symptom questionnaire. A frequency Likert-type rating scale was used and a response of "sometimes" or more was considered consistent with having the symptom. All 35 children, along with one parent for each child, also completed the patient-derived intermittent XT HRQOL questionnaire (IXTQ) with Child, Proxy, and Parent components. The frequency of symptoms was calculated, and the relationship between individual symptom question scores and Child, Proxy, and Parent HRQOL scores, was evaluated in multivariate linear regression analyses.

RESULTS

The mean number of specific symptoms was 7 (range 2 to 19). The most frequently reported were: rubbing the eye (29 [83%] of 35), problems with eyes in the sun, and the eyes feeling tired (each 22, 63%). Lower (worse) Child IXTQ HRQOL scores were associated with symptoms of difficulty focusing eyes (P=0.0007), double vision (P=0.007), eyes hurting (P=0.006), and problems with eyes in the sun (P=0.06). There were weak associations between Proxy IXTQ and Parent IXTQ scores and child symptoms. Overall, 7 symptom questions were associated with reduced HRQOL in multivariate models.

CONCLUSION

Children with intermittent XT frequently experience symptoms, some of which impact the child's HRQOL. Formal assessment of symptoms may aid understanding of the effects of intermittent XT on an individual child, and could use just the 7 symptom questions associated with reduced HRQOL.

Asthma Flare-up Diary for Young Children to monitor the severity of exacerbations

BACKGROUND

Few instruments exist to ascertain the severity of a preschool-aged child's asthma exacerbations managed at home.

OBJECTIVE

We sought to develop and validate a functional status instrument to assess asthma exacerbation severity in preschoolers.

METHODS

The parent-completed Asthma Flare-up Diary for Young Children (ADYC), which was developed systematically, comprises 17 items, each scored from 1 (best) to 7 (worst). The ADYC was completed daily from the onset of an upper respiratory tract infection (URTI) until asthma symptom resolution; the cumulative daily score was reported. The ADYC was examined for key psychometric properties in a randomized placebo-controlled trial of pre-emptive high-dose fluticasone in preschoolers with URTI-induced asthma.

RESULTS

In 121 children aged 2.7 ± 1.1 years (59.5% male), the ADYC's internal consistency (Cronbach α = .97), feasibility (97% completion), and test-retest reliability (r = 0.71; 95% CI, 0.59-0.80) were demonstrated. The ADYC was responsive to change between 2 consecutive days (Guyatt statistic = 0.77) with a minimal important difference of 0.22 (0.17-0.27). Of 871 episodes, the cumulative ADYC score was significantly higher during exacerbations than during URTIs (mean difference [MD], 7.6; 95% CI, 6.4-8.9) and for exacerbations with an acute-care visit (MD, 9.1; 95% CI, 7.6-10.7), systemic corticosteroids (MD, 10.1; 95% CI, 8.3-12.0), and hospitalization (MD, 6.8; 95% CI, 2.9-10.7) versus those without. In children receiving fluticasone, the ADYC score was significantly lower versus that in the placebo group (MD, 5.1; 95% CI, 1.8-8.3).

CONCLUSIONS

The 17-item ADYC proved feasible, responsive to day-to-day changes, and discriminative across exacerbations of different severities. In a trial testing effective therapy in preschoolers, it identified a significant reduction in asthma exacerbation severity.

An exploration of parent-child dyadic asthma management influences on quality of life

Most studies of childhood asthma management use data from a single family reporter and fail to capture the parent-child dyadic influences. In this descriptive exploratory study with 183 parent-child dyads, data were collected from both parents and children. Using structural equation modeling, the relationships of parents' and children's asthma knowledge, self-efficacy to manage asthma, and asthma management on the child's quality of life were examined. Direct significant relationships from knowledge to self-efficacy to asthma management were found for each member of the dyad. The associations between parents' and children's self-efficacy and asthma management were not statistically significant. Only the children's self-efficacy to manage asthma was significantly associated with children's asthma-related quality of life.

The Impact of Atopic Dermatitis on Quality of Life

Approximately 5-20% of children worldwide suffer from atopic dermatitis (AD), a kind of dermatitis characterized as an inflammatory, relapsing, noncontagious and itchy skin disorder. Children often develop AD during their first year of life. An increased rate of sensitization to both food and aeroallergens has been shown to coexist in patients with AD. Sensitization to well-known allergens such as cow's milk protein can occur on average in 50% of children with AD. In general, quality of life (QoL) is perceived as the quality of an individual's daily life, that is, an assessment of their well-being or lack thereof. QoL is a broad concept that includes such things as standard of living, community, and family life. Patients with skin diseases experience a wide range of symptoms ranging from trivial problems to major handicaps which affect their lives. The misery of living with AD cannot be overstated for it may have a profoundly negative effect on the health-related QoL of children and their families in many cases. Physicians taking care of children with AD should consult parents on how their child's illness has impacted their lifestyle and recommend professional intervention if deemed necessary.