Health status and health-related quality of life in a pediatric palliative care program

Socioeconomic Factors and Quality of Life Perceived by Parents and Children with Complex Chronic Conditions in Spain

Health-related quality of life of children with complex chronic conditions could be affected by sociodemographic factors. Most studies focus exclusively on the parents’ perceptions of quality of life. This study aimed to determine the health-related quality of life of these children, according to their parents and the children themselves. A cross-sectional study was developed on children aged over five years with complex chronic conditions. Health-related quality of life, educational attainment, and social status were evaluated. A total of 101 children were included with a mean age of 10.48 years, and 35.6% were female. The most frequent disease was oncological (28.7%). Children perceived a better health-related quality of life, compared to their parents’ assessment: median difference −8.4 (95%CI: −9.2 to −3.8). Moreover, differences were observed by socioeconomic factors. Parents and children with complex chronic conditions perceive differently the health-related quality of life. Social determinants associate with an uneven perceived quality of life.

Incorporating Mortality in Health Utility Measures

The creation of multiattribute health utility systems requires design choices that have profound effects on the utility model, many of which have been documented and studied in the literature. Here we describe one design choice that has, to the best of our knowledge, been unrecognized and therefore ignored. It can emerge in any multiattribute decision analysis in which one or more essential outcomes cannot be described in terms of the multiattribute space. In health applications, the state of being dead is such an outcome. When the remaining health is conceptualized as a multidimensional space, determining the utility of the state of being dead requires using the interval-scale properties of cardinal utility, combined with elicited utilities for the state of being dead and the all-worst state, to produce a utility function in which the state of being dead has a utility of 0 and full health has a utility of 1 (i.e., the quality-adjusted life-year scale). Although previously unrecognized, there are two approaches to accomplish that step, and they produce different results in almost all cases. As a corollary, the choice of approach determines the proportion of states rated as worse than dead by the system. For example, in the Health Utility Index 3 (HUI3), the method used classifies 78% of the 972,000 unique health states in the classification system as worse than dead, and that proportion increases to 85% when the HUI3 is recalculated using the alternative approach. Studies of populations with significant morbidity are the most likely to be sensitive to the design choice. Those who design utility measures should be aware that they are using a researcher degree of freedom when they decide how to scale the state of being dead.

Characterizing health state utilities associated with Duchenne muscular dystrophy: a systematic review

Background

Preferences for health states for Duchenne muscular dystrophy (DMD) are necessary to assess costs and benefits of novel therapies. Because DMD progression begins in childhood, the impact of DMD on health-related quality-of-life (HRQoL) affects preferences of both DMD patients and their families. The objective of this review was to synthesize published evidence for health state utility from the DMD patient and caregiver perspectives.

Methods

A systematic review was performed using MEDLINE and Embase, according to best practices. Data were extracted from studies reporting DMD patient or caregiver utilities; these included study and patient characteristics, health states considered, and utility estimates. Quality appraisal of studies was performed.

Results

From 888 abstracts, eight publications describing five studies were identified. DMD utility estimates were from preference-based measures presented stratified by ambulatory status, ventilation, and age. Patient (or patient–proxy) utility estimates ranged from 0.75 (early ambulatory DMD) to 0.05 (day-and-night ventilation). Caregiver utilities ranged from 0.87 (for caregivers of adults with DMD) to 0.71 (for caregivers of predominantly childhood patients). Both patient and caregiver utilities trended lower with higher disease severity. Variability in utilities was observed based on instrument, respondent type, and country. Utility estimates for health states within non-ambulatory DMD are under reported; nor were utilities for DMD-related health states such as scoliosis or preserved upper limb function identified.

Conclusion

Published health state utilities document the substantial HRQoL impacts of DMD, particularly with disease progression. Additional research in patient utilities for additional health states, particularly in non-ambulatory DMD patients, is warranted.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02355-x) contains supplementary material, which is available to authorized users.

Pediatric Palliative Care: A Five-Year Retrospective Chart Review Study

BACKGROUND

More children are living with serious illness. However, survival and complexity of illnesses have not been described.

OBJECTIVE

To describe types of illnesses, timing of referral, and time to death following referral to palliative care; to examine the associations between demographics and clinical characteristics and patient survival; and to examine whether average daily pain decreases after referral.

DESIGN

Retrospective chart review of all children ages 2-16 years referred to palliative care at one large children's hospital during the five-year study period from January 1, 2009, through December 31, 2013.

MEASUREMENTS

The primary outcome was patient survival and the main independent predictor was type of illness. Kaplan-Meier estimation was used to estimate patient survival time following referral, Cox proportional hazards regression was used to build predictive models based on gender, age, race, religion, and types of illnesses, and paired t-test compared the assessment of pain before and after referral.

RESULTS

The cohort consisted of 256 children. Survival experience did not differ significantly based on gender, age, race, or religion (p ≥ 0.05); however, survival did vary based on referring diagnosis (χ² = 40.3, df = 4, p < 0.001), particularly cancer. Forty-eight children with three days of pain assessments pre- and postreferral had significantly decreased pain postreferral (t(47) = 1.816, p < 0.05 one tailed), supporting our hypothesis.

DISCUSSION

Results provide important information on the complexity of disease processes for children referred to palliative care, types of illnesses referred, survival, and pain levels. Results reflect earlier referral to palliative care for most children and highlight the medical complexity especially for children with congenital and genetic diagnoses.

The under reporting of recruitment strategies in research with children with life-threatening illnesses: A systematic review

BACKGROUND

Researchers report difficulties in conducting research with children and young people with life-limiting conditions or life-threatening illnesses and their families. Recruitment is challenged by barriers including ethical, logistical and clinical considerations.

AIM

To explore how children and young people (aged 0-25 years) with life-limiting conditions or life-threatening illnesses and their families were identified, invited and consented to research published in the last 5 years.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, PsycINFO, Web of Science, Sciences Citation Index and SCOPUS were searched for original English language research published between 2009 and 2014, recruiting children and young people with life-limiting conditions or life-threatening illness and their families.

RESULTS

A total of 215 studies - 152 qualitative, 54 quantitative and 9 mixed methods - were included. Limited recruitment information but a range of strategies and difficulties were provided. The proportion of eligible participants from those screened could not be calculated in 80% of studies. Recruitment rates could not be calculated in 77%. A total of 31% of studies recruited less than 50% of eligible participants. Reasons given for non-invitation included missing clinical or contact data, or clinician judgements of participant unsuitability. Reasons for non-participation included lack of interest and participants' perceptions of potential burdens.

CONCLUSION

All stages of recruitment were under reported. Transparency in reporting of participant identification, invitation and consent is needed to enable researchers to understand research implications, bias risk and to whom results apply. Research is needed to explore why consenting participants decide to take part or not and their experiences of research recruitment.

Aspects and Intensity of Pediatric Palliative Case Management Provided by a Hospital-Based Case Management Team: A Comparative Study Between Children With Malignant and Nonmalignant Disease

OBJECTIVES

Anticipating case management is considered crucial in pediatric palliative care. In 2012, our children's university hospital initiated a specialized pediatric palliative care team (PPCT) to deliver inbound and outbound case management for children with life-shortening disease. The aim of this report is to gain insight in the first 9 months of this PPCT.

METHODS

Aspects of care during the first 9 months of the PPCT are presented, and comparison is made between patients with malignant disease (MD) and nonmalignant disease (NMD) in a retrospective study design. Insight in the aspects of care of all patients with a life-shortening disease was retrieved from web-based files and the hour registrations from the PPCT.

RESULTS

Forty-three children were supported by the PPCT during the first 9 months: 22 with MD with a median of 50 (1-267) days and 29 minutes (4-615) of case management per patient per day and 21 patients with NMD with a median of 79.5 (5-211) days and 16 minutes of case management per day (6-64). Our data show significantly more interprofessional contacts for patients with MD and more in-hospital contacts for patients with NMD. The median number of admission days per patient was 11 (0-22) for MD (44% for anticancer therapy) and 44 (0-303) for NMD (36% for infectious diseases).

SIGNIFICANCE OF RESULTS

This overview of aspects of pediatric palliative case management shows shorter but more intensive case management for MD in comparison with NMD. This insight in palliative case management guides the design of a PPCT.

Identifying domains of quality of life in children with cancer undergoing palliative care: A qualitative study with professionals

Objective:

The goal of pediatric palliative care (PPC) is to maintain the quality of life (QoL) of children whose lives are threatened. However, there are sparse scientific data on the domains of QoL in this particular context, and no measurement strategies are available. The present study aims to describe the domains of QoL in the context of PPC in oncology, according to the perceptions of professional caregivers.

Method:

Semistructured interviews were conducted with a random sample of 20 professional caregivers from the Division of Hematology/Oncology at Le Centre Hospitalier Universitaire Sainte-Justine (Montréal, Canada). The caregivers were asked about their perceptions about the QoL of the children they have cared for in this context. The data were analyzed using inductive thematic content analysis.

Results:

The analysis allowed us to identify seven domains of QoL: “physical comfort,” “alleviation of psychological suffering,” “fun and the present moment,” “sense of control,” “feeling valued and appreciated,” “feeling that life goes on,” and “meaningful social relationships.”

Significance of Results:

Caregivers recount the regard that should be accorded to maintaining well-being and a sense of fun, as well as fostering the child's abilities, taking account of the progression of the disease, and to fulfilling his or her needs, especially social ones. Our results also demonstrate that all domains were positively referred to by professional caregivers. The data from our study will lead to better assessment of QoL according to the trajectory of a child with advanced cancer while undergoing PPC.

A prospective study on the characteristics and subjects of pediatric palliative care case management provided by a hospital based palliative care team

Background

Case management is a subject of interest within pediatric palliative care. Detailed descriptions of the content of this type of case management are lacking. We aim to describe the contents of care provided, utilization of different disciplines, and times of usage of a pediatric palliative care case management program compared for patients with malignant disease (MD) and non-malignant disease (NMD).

Methods

A three-month prospective study, with questionnaires filled in by members of a pediatric palliative care team (PPCT) for each contact with parents.

Results

Four hundred fifty-five contacts took place with parents of 70 patients (27MD, 43NMD). Sixty-two percent of all contacts were with the specialized nurse. The child life specialists, psychologist and social worker were also regularly consulted, the chaplain was not consulted. Ninety-five percent of all contacts took place between 8 am and 6 pm during weekdays, a limited number between 6 pm and 9 pm. Twenty-five percent of all contacts were proactively initiated by the PPCT, 25 % were initiated by parents. In these care characteristics, no differences were seen for MD and NMD patients. Psychosocial topics were addressed most frequently. MD patients consulted the PPCT more often about school and NMD patients about socio-economic issues.

Conclusions

All different disciplines of the PPCT were regularly consulted, except for the chaplain. With an easy accessible team with a highly pro-active approach, availability from 8 am to 9 pm seems sufficient to accommodate patient’s and parent’s needs. More anticipation seems required for socio-economic topics. This insight in pediatric palliative case management can provide guidance in the development of a new PPCT.

Health-related quality of life in pediatric Chiari Type I malformation: the Chiari Health Index for Pediatrics

OBJECT The purpose of this study was to design and validate a patient-reported health-related quality of life (HRQOL) instrument for pediatric Chiari Type I malformation (CM-I), the Chiari Health Index for Pediatrics (CHIP). METHODS The CHIP has 45 items with 4 components making up 2 domain scores, physical (pain frequency, pain severity, nonpain symptoms) and psychosocial; physical and psychosocial scores are combined to create an overall HRQOL score. Increasing scores (0 to 1) represent increasing HRQOL. Fifty-five patients with CM-I (mean age 12 ± 4 years, 53% male) were enrolled and completed the CHIP and Health Utilities Index Mark 3 (HUI3). Twenty-five healthy controls (mean age 11.9 ± 4 years, 40% male) also completed the CHIP. CHIP scores were compared between these groups via the Mann-Whitney U-test. For CHIP discriminative function, subscore versus presence of CM-I was compared via receiver operating characteristic curve analysis. CHIP scores in the CM-I group were stratified by symptomatology (asymptomatic, headaches, and paresthesias) and compared via Kruskal-Wallis test with Mann-Whitney U-test with Bonferroni correction (p < 0.0167). CHIP was compared with HUI3 (Health Utilities Index Mark 3) via univariate and multivariate linear regression. RESULTS CHIP physical and psychosocial subscores were, respectively, 24% and 18% lower in CM-I patients than in controls (p < 0.001); the overall HRQOL score was 23% lower as well (p < 0.001). The area under the curve (AUC) for CHIP physical subscore versus presence of CM-I was 0.809. CHIP physical subscore varied significantly with symptomatology (p = 0.001) and HUI3 pain-related quality of life (R(2) = 0.311, p < 0.001). The AUC for CHIP psychosocial subscore versus presence of CM-I was 0.754. CHIP psychosocial subscore varied significantly with HUI3 cognitive- (R(2) = 0.324, p < 0.001) and emotion-related (R(2) = 0.155, p = 0.003) quality of life. The AUC for CHIP HRQOL versus presence of CM-I was 0.820. Overall CHIP HRQOL score varied significantly with symptomatology (p = 0.001) and HUI3 multiattribute composite HRQOL score (R(2) = 0.440, p < 0.001). CONCLUSIONS The CHIP is a patient-reported, CM-I-specific HRQOL instrument, with construct validity in assessing pain-, cognitive-, and emotion-related quality of life, as well as symptomatic features unique to CM-I. It holds promise as a discriminative HRQOL index in CM-I outcomes assessment.

Promoting an ethic of engagement in pediatric palliative care research

Background

This paper defends the ethical and empirical significance of direct engagement with terminally ill children and adolescents in PPC research on health-related quality of life. Clinical trials and other forms of health research have resulted in tremendous progress for improving clinical outcomes among children and adolescents diagnosed with a life-threatening illness. Less attention has been paid, however, to engaging this patient population directly in studies aimed at optimizing health-related quality of life in PPC. Though not restricted to care at the end of life, PPC—and by extension PPC research—is in part dependent on recognizing the social complexities of death and dying and where health-related quality of life is a fundamental element. To explore these complexities in depth requires partnership with terminally ill children and adolescents, and acknowledgement of their active social and moral agency in research.

Discussion

Principles of pediatric research ethics, theoretical tenets of the “new sociology of the child(hood),” and human rights codified in the United Nations Convention on the Rights of the Child (UNCRC) underpin the position that a more engagement-centered approach is needed in PPC research. The ethics, sociologies and human rights of engagement will each be discussed as they relate to research with terminally ill children and adolescents in PPC. Qualitative method(ologies) presented in this paper, such as deliberative stakeholder consultations and phenomenology of practice can serve as meaningful vehicles for achieving i) participation among terminally ill children and adolescents; ii) evidence-bases for PPC best practices; and iii) fulfillment of research ethics principles.

Conclusion

PPC research based on direct engagement with PPC patients better reflects their unique expertise and social epistemologies of terminal illness. Such an approach to research would strengthen both the ethical and methodological soundness of HRQoL inquiry in PPC.

A Review of the Development and Application of Generic Multi-Attribute Utility Instruments for Paediatric Populations

Multi-attribute utility instruments (MAUIs) are increasingly being used as a means of quantifying utility for the calculation of quality-adjusted life-years within the context of cost utility analysis. Traditionally, MAUIs have been developed and applied in adult populations. However, increasingly, researchers in health economics and other disciplines are recognising the importance of the measurement and valuation of health in both children and adolescents. Presently, there are nine generic MAUIs available internationally that have been used in paediatric populations: the Quality of Well-Being Scale (QWB), the Health Utility Index Mark 2 (HUI2), the HUI3, the Sixteen-dimensional measure of health-related quality of life (HRQoL) (16D), the Seventeen-dimensional measure of HRQoL (17D), the Assessment of Quality of Life 6-Dimension (AQoL-6D) Adolescent, the Child Health Utility 9D (CHU9D), the EQ-5D Youth version (EQ-5D-Y) and the Adolescent Health Utility Measure (AHUM). This paper critically reviews the development and application of the above nine MAUIs and discusses the specific challenges of health utility measurement in children and adolescents. Areas for further research relating to the development and application of generic MAUIs in paediatric populations are highlighted.

The impact of a palliative care team on residents' experiences and comfort levels with pediatric palliative care

BACKGROUND

8,600 children are eligible for palliative care services each day in the US, yet many pediatric residents and pediatricians do not feel comfortable providing palliative/end of life care.

OBJECTIVE

To evaluate the impact of a palliative care team (PCT) on pediatric and internal medicine/pediatric (IM/Peds) residents knowledge, comfort level and experience providing pediatric palliative care (PPC).

DESIGN

Electronic 32-item questionnaire.

SUBJECTS

Pediatric and IM/Peds residents at ACGME accredited programs during the 2011-2012 academic year.

MEASUREMENTS

Residents' PPC training, knowledge, comfort levels and experiences.

RESULTS

Nearly two-thirds of 294 respondents (63.6%; 95% CI: 58.2, 69.1) selected a description of PPC that describes palliative care as starting at the time of diagnosis regardless of treatment goals. Participants who reported the presence of a PCT at their institution selected this accurate description of PPC more often than those who did not report the presence of a PCT (72.3% vs. 53.3%; p<0.001, Fisher's Exact Test). Overall, 55.3% (95% CI: 49.2, 61.3) were comfortable providing PPC. Reporting the presence of a PCT was also associated with more comfort in providing PPC (p<0.01).

CONCLUSIONS

Reported presence of a PCT may be associated with greater resident comfort in providing PPC and a more accurate understanding of PPC. There remains ample opportunity to educate pediatric and IM/Peds residents in PPC.

Investigations of the pediatric hospice care in Taiwan: 2005 to 2010

BACKGROUND

The utilization of pediatric hospice care remains unclear in Taiwan.

METHODS

Data were analyzed from the claims of hospice admissions in patients aged 18 years or younger using the National Health Insurance Research Database from 2005 to 2010.

RESULTS

A total of 91 patients and 136 admissions were enrolled (male-female = 50:41; mean 11.6 years old). In all, 62 patients were admitted once, including 47 patients who died. All the patients had cancer, with brain cancer (40.7%) accounting the most . Among acute comorbidities, neurological complications (16.2%) were mostly accounted. Family physicians provided most (64.7%) of the hospice services. Hospice stay ≤3 days correlated positively with death in hospices (odds ratio = 2.922, 95% confidence interval = 1.268-6.730).

CONCLUSIONS

Pediatric hospice care revealed characteristics different from adults. Underlying late referrals were prevalent. There is space to promote the utilization of hospices for terminally ill pediatric patients.

Improving quality of life in hospitalized children

There are many ways to add to children's quality of life within the hospital environment. Inpatient settings offer both opportunities and challenges with respect to providing care to children with life-threatening illnesses. The barriers to pediatric palliative care (PPC) on hospital wards, as with those in other settings, frequently stem from misconceptions. However, some barriers are intensified by characteristics of acute inpatient centers. Yet some characteristics of the inpatient setting, including the availability of human resources and unique interventions, offer creative ways to ease distress and improve quality of life for children and their families.