Pain attitudes and pain outcomes among people with bleeding disorders: Results from community voices in research

INTRODUCTION

Among people with bleeding disorders (PwBD), pain is a major problem and pain treatments are often ineffective. Understanding of psychological factors involved in pain processing is limited. Maladaptive pain attitudes are associated with worse pain outcomes and adaptive pain attitudes are associated with better outcomes in high pain conditions, but relationships between pain attitudes and pain outcomes are so far unexplored among PwBD.

AIM

To investigate relationships between pain attitudes and pain outcomes among PwBD.

METHODS

Pain attitudes were measured with the Survey of Pain Attitudes, containing two adaptive scales (Control and Emotion) and five maladaptive scales (Disability, Harm, Medication, Solicitude, Medical Cure). Adults with bleeding disorders, who had pain, and were enrolled in Community Voices in Research were eligible. Participants (n = 72) completed an online survey. Cross sectional associations between pain attitudes and pain outcomes (pain and prescribed pain medication use) were investigated using logistic regression.

RESULTS

After adjustment for covariates, greater Control attitudes were associated with lower odds of more severe pain, and greater Disability, Harm, and Medication attitudes were all associated with higher odds of more severe pain and with higher odds of any prescribed pain medication use and opioid pain medication use.

CONCLUSIONS

We presented compelling evidence of relationships between pain attitudes and pain outcomes in PwBD, though corroboration is needed from other populations. Our findings suggest that modification of pain attitudes presents a possible avenue for interventions to improve pain outcomes and increase patient satisfaction with pain management.

Current and Emerging Approaches for Pain Management in Hemophilic Arthropathy

Introduction

Hemophilia is an inherited bleeding hematological disorder characterized by the partial or complete deficiency of clotting factor VIII or IX. Hemophilic arthropathy is the consequence of repeated joint bleeding (hemarthrosis) and its management is based on the prevention of acute bleeding through the administration of the deficient clotting factor concentrate or non-factor therapies. In addition, the management of acute and chronic pain is pivotal in hemophilic arthropathy in order to restore function and allow rehabilitation of the joint.

Methods

We conducted a qualitative review of the literature regarding current and emerging strategies for pain treatment in hemophilic arthropathy. This review considers systemic and local pharmacological and non-pharmacological interventions for acute and chronic pain management.

Results

In hemophilic arthropathy, pain management is based on analgesics such as paracetamol, which represents the first choice for acute and chronic pain in adults and children, in association with opioids for adults. Non-steroidal anti-inflammatory drugs inhibit platelet function, so that the currently preferred drugs are short courses of cyclooxygenase 2 inhibitors. Local treatment with intra-articular injections of corticosteroids is an option for refractory cases and physiotherapy has an important role after hemarthrosis and for the long-term management of chronic pain for both pediatric and adult patients.

Conclusions

The management of pain in hemophilia requires more standardization. Meanwhile, the safest drugs should be used at the lowest effective dosage and for periods as short as possible. For the non-pharmacological management of pain in these patients, a multidisciplinary team including hematologists, orthopedic surgeons, rheumatologists, and physiotherapists is warranted.

The role of the physiotherapist in the management of people with haemophilia: defining the new normal

Physiotherapists aim to maximise quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention and rehabilitation. Haemophilia care is witnessing a significant shift towards a new era of potentially life-changing treatments which offer a future of minimal or no bleeds for people with haemophilia. As such, physiotherapy intervention should be more proactive rather than reactive to treat and rehabilitate recurrent bleeding episodes. The role of the physiotherapist within the multidisciplinary team includes the differential diagnosis of musculoskeletal bleeding, supporting and encouraging higher levels of physical activity, rehabilitation to maximise physical potential and capabilities, assessment and treatment of non-bleed-related musculoskeletal issues, managing comorbidities and falls risk, and improving the longitudinal surveillance of musculoskeletal health. Encouraging and supporting people with haemophilia to become more active will improve wellbeing and improve health and health outcomes, and physical activity is becoming one of the most important outcomes for people with haemophilia. Recommendations on the best way to accurately capture these data are vital to ensure the full health benefits of new treatments for people with haemophilia are clear.

Effects of a non-pharmacological approach for chronic pain management in patients with haemophilia: efficacy of cognitive-behavioural therapy associated with physiotherapy

INTRODUCTION

More than half of adult patients with severe haemophilia (PWH) suffer pain daily, with chronic pain (CP) in more than 15% of cases, thereby reducing their quality of life (QoL). However, there are no evidence-based therapeutic guidelines for pain management.

AIM

To evaluate the effectiveness of a combined protocol based on psychology and physiotherapy in the improvement of CP self-efficacy in PWH with CP. Secondary outcomes are changes in QoL, emotional status, pain and kinesiophobia.

METHODS

In this prospective controlled trial study, recruited patients were allocated either to an experimental group (EG, n = 10) or to a control group (CG, n = 9). EG received interventions over four months: one cognitive-behavioural therapy (CBT) session per month and three home exercise sessions per week. Self-efficacy (Chronic Pain Self-Efficacy Scale), QoL (A36 Hemophilia-QoL), emotional status (Hospital Anxiety and Depression Scale and Rosenberg's Self-esteem Scale), pain (Visual Analogue Scale) and kinesiophobia (Tampa Scale for Kinesiophobia) were assessed at three time points (Week 0, Month 4 and Month 7). The intervention effects were determined with mixed 2-factor ANOVAs.

RESULTS

The EG showed a significant improvement (p < .05) in the control of symptoms and pain management scores on the Self-Efficacy Scale, QoL, self-esteem emotional status, pain and kinesiophobia. The intervention effects remained significant (p < .05) over time for pain management, QoL, pain and kinesiophobia.

CONCLUSION

The non-pharmacological treatment applied based on CBT and physiotherapy showed to be effective in improving CP self-efficacy, QoL and emotional status, while reducing pain and kinesiophobia in PWH with CP.

Budget impact analysis of Jivi (damoctocog alfa pegol, Bay 94-9027) in severe hemophilia A in Japan

OBJECTIVE

Hemophilia A (HA) is a genetic bleeding disorder characterized by a deficiency of clotting factor VIII (FVIII) requiring lifelong prophylactic treatment typically with conventional standard half-life recombinant FVIII (rFVIII). Lifelong prophylaxis impacts budget, patient adherence, and long-term outcomes. The consequent economic and treatment burden may be reduced by using novel extended half-life rFVIII. The objective of this analysis was to estimate the budget impact of introducing Jivi (damoctocog alfa pegol, BAY 94-9027), hereafter referred to as BAY 94-9027, as an on-demand and prophylactic treatment for severe HA from a Japanese payer's perspective.

METHODS

A global budget impact model was adapted to the Japanese setting using data obtained via a targeted literature review of Japanese sources. The model considered a five-year time horizon for a market without and with BAY 94-9027. Using annual per-patient costs, the total cost of on-demand and prophylactic treatment of adolescent and adult patients with severe HA (without inhibitors) were analyzed. The model used summary of product characteristics (SmPC) and clinical trial dosing, and unit costs from the National Health Insurance (NHI) drug price database. Comparators considered in the model comprised of currently available products in Japan. Projected BAY 94-9027 uptake ranged from 4% to 9% over the five years (2020-2024).

RESULTS

Introduction of BAY 94-9027 for the treatment of severe HA is estimated to decrease the overall budget by 1.5%, with a cost saving of approximately $67 million USD (¥7.4 billion JPY) over five years. Estimated cost savings associated with BAY 94-9027 ranged from $1.4 million USD (¥156 million JPY) in 2020 to $23 million USD (¥2.6 billion JPY) in 2024 for the Japanese healthcare system.

LIMITATIONS

There were limitations associated with the study. The Japanese guidelines consulted during the targeted literature review of national data sources in Japan were based on global data as reference sources. Also, studies reporting the bleeding rate, dosing guidelines, and economic burden in the Japanese population identified by the targeted literature review were limited hence global studies were used and may not have been representative of the Japanese population.

CONCLUSIONS

BAY 94-9027 can reduce total severe HA treatment costs, driven by lower annual rFVIII utilization, and a narrow weekly dosing range compared to competitor products in the Japanese market.

A new measure to assess pain in people with haemophilia: The Multidimensional Haemophilia Pain Questionnaire (MHPQ)

People with haemophilia (PWH) experience acute pain during joint bleeds and might develop chronic pain due to joint degeneration. However, there is a lack of standardized measures to comprehensively assess pain in PWH. This study aimed to develop a multidimensional questionnaire for haemophilia-related pain, the Multidimensional Haemophilia Pain Questionnaire (MHPQ), and to present initial validation data among adults.The questionnaire distinguishes between acute/chronic pain and queries about pain locations, duration, frequency, triggering factors, intensity, interference, strategies, specialists for pain management and satisfaction with treatment. An initial version was tested with 16 patients to ensure item comprehensibility and face validity. The final version was answered by 104 adults, with 82 (78.8%) reporting haemophilia-related pain in the previous year (mean age = 43.17; SD = 13.00). The non-response analysis revealed good item acceptability. Exploratory and confirmatory factor analysis (EFA/CFA), reliability (internal consistency, test-retest, inter-item and item-total correlations) and convergent validity were analysed for the intensity and interference dimensions of the questionnaire. A combined EFA with these two constructs supported a 2-factor structure distinguishing intensity (α = 0.88) from interference items (α = 0.91). CFA was tested for the interference dimension, demonstrating suitability for this sample. Item-total correlations were >0.30 on both dimensions and most inter-item correlations were <0.70. Test-retest reliability (n = 42) was good for intensity (r = 0.88) and interference (r = 0.73), and convergent validity was confirmed for most hypotheses (r>0.30).This questionnaire is a comprehensible tool, achieving a thorough assessment of relevant pain dimensions. The MHPQ can help guide treatment recommendations by highlighting relevant topics and contributing to more effective, integrated treatments.

Investigating the relationship between the HJHS and HAL in routine clinical practice: A retrospective review

INTRODUCTION

Comprehensive musculoskeletal assessment for monitoring joint health in haemophilia includes both physical assessment with Haemophilia Joint Health Score (HJHS) and assessment of self-reported function by Haemophilia Activities List (HAL).

METHODS

Correlation between physical assessment and joint function was undertaken between HJHS and HAL in patients with SHA and SHB who had both assessments at the same visit over a one-year period.

RESULTS

Data from 120 patients (96-SHA/24 = SHB) with a median age 33 years (range 19-73) were included. Median total HJHS was 19, increasing with age: 18-30 years-7, 31-50 years-25 and 51-73 years-44. Similarly, median total HAL score was 80 with decreased function associated with increasing age: 18-30 years-90.4, 31-59 years-71.7, 51-73 years-49.5. Median Total HJHS and HAL demonstrated strong correlation (r_s  = 0.66, P < 0.01). Moderate-to-strong correlations were seen across the entire age group between the HJHS LL and UL subtotals and corresponding limb HAL domains. Within age groups, correlations were less significant particularly for the upper UL domains in HAL and the UL HJHS score. The wide range of ROM in joints categorized as markedly affected (ie, ROM loss score = 3) highlights the potential ceiling effect of this domain score and its use in chronically damaged joints.

CONCLUSION

HJHS and HAL showed moderate-to-strong correlation with discrepancy in some individual patients. Prospective studies are required to better understand the clinical utility of both especially in severe joint disease where HAL may have a potential advantage.

Joint disease in haemophilia: Pathophysiology, pain and imaging

Haemarthroses cause major morbidity in patients with haemophilia. Blood has devastating effects on all joint components, resulting in synovitis, osteochondral degeneration and ultimately end-stage haemophilic arthropathy. Key players in this process are iron and inflammation. Preventing joint bleeds is of utmost importance to maintain joint health as targeted therapies directed against blood-induced inflammation and iron-mediated processes are lacking. Joint bleeds result in acute pain as well as chronic pain due to synovitis or arthropathy. Acute pain originates from nociceptors activated by tissue damage. In chronic inflammation, central and peripheral sensitization of nociceptors might occur resulting in chronic pain. This also triggers a series of brain disorders such as emotional fear, anxiety, mood depression and impairment of cognitive functions. Treatment of haemophilia-related pain not only consists of analgesics, but also of exercise, education and in selected cases antidepressants and anticonvulsants. For objective assessment of joint structural outcome and detecting earlier changes of haemophilic arthropathy, both ultrasound (US) and magnetic resonance (MR) imaging have shown valuable. Both can be considered equally able to reveal signs of disease activity. MR imaging is able to visualize haemosiderin deposition and is more comprehensive in depicting osteochondral changes. Disadvantages of MR imaging are the duration of the examination, evaluation of a single joint at a time, costs and may require sedation, and it may need intraarticular contrast injection to depict initial osteochondral changes with accuracy. As such, US is a more useful screening tool and can be used for repeated follow-up examinations.

Relations among Pain, Pain Beliefs, and Psychological Well-Being in Patients with Chronic Pain

BACKGROUND

Chronic pain influencing the quality of life and well-being of the patients are also affected by pain beliefs. Psychological well-being could make a person have positive pain beliefs and these could facilitate patients' coping skills. In the care of the patients with chronic pain, nursing interventions can improve patients' well-being.

AIMS

This study aimed to determine the relationship between pain, pain beliefs and psychological well-being in patients with chronic pain.

DESIGN

A cross-sectional and relational study.

SUBJECTS

This study was conducted with 86 patients with chronic joint pain.

METHODS

A convenience sample method was used in the research. Data were gathered using a Personel Information Form, The Pain Beliefs Questionnaire and Psychological Well-being Scale. Frequency, percentage, mean, standard deviation and correlation analysis were used for data assessment.

RESULTS

It was found that there was a statistically significant correlation between pain severity and organic pain beliefs, statistically significant negative correlation between frequency and severity of pain and psychological well-being, and statistically significant relationship between organic pain beliefs and the psychological well-being.

CONCLUSIONS

Organic pain beliefs and pain intensity affect the psychological well-being of the patients with chronic pain. To increase the psychological well-being level of patients with chronic pain, patients' informations, attitudes and beliefs about pain and pain control should be changed positively. Also, nursing care focused on improving well-being should be provided by nurses. Further studies should be carried out on other factors affecting the well-being of patients as well as pain and pain beliefs on larger samples.

Predictors of quality of life among adolescents and young adults with a bleeding disorder

BACKGROUND

Health-related quality of life (HRQoL) in adolescents and young adults with bleeding disorders is under-researched. We aimed to describe factors related to HRQoL in adolescents and young adults with hemophilia A or B or von Willebrand disease.

METHODS

A convenience sample of volunteers aged 13 to 25 years with hemophilia or von Willebrand disease completed a cross-sectional survey that assessed Physical (PCS) and Mental (MCS) Component Summary scores on the SF-36 questionnaire. Quantile regression models were used to assess factors associated with HRQoL.

RESULTS

Of 108 respondents, 79, 7, and 14% had hemophilia A, hemophilia B, and von Willebrand disease, respectively. Most had severe disease (71%), had never developed an inhibitor (65%), and were treated prophylactically (68%). Half of patients were aged 13 to 17 years and most were white (80%) and non-Hispanic (89%). Chronic pain was reported as moderate to severe by 31% of respondents. Median PCS and MCS were 81.3 and 75.5, respectively. Quantile regression showed that the median PCS for women (61% with von Willebrand disease) was 13.1 (95% CI: 2.4, 23.8; p = 0.02) points lower than men. Ever developing an inhibitor (vs never) was associated with a 13.1-point (95% CI: 4.7, 21.5; p < 0.01) PCS reduction. MCS was 10.0 points (95% CI: 0.7, 19.3; p = 0.04) higher for prophylactic infusers versus those using on-demand treatment. Compared with patients with no to mild chronic pain, those with moderate to severe chronic pain had 25.5-point (95% CI: 17.2, 33.8; p < 0.001) and 10.0-point (95% CI: 0.8, 19.2; p = 0.03) reductions in median PCS and MCS, respectively.

CONCLUSIONS

Efforts should be made to prevent and manage chronic pain, which was strongly related to physical and mental HRQoL, in adolescents and young adults with hemophilia and von Willebrand disease. Previous research suggests that better clotting factor adherence may be associated with less chronic pain.

Determining the health-related quality of life in individuals with haemophilia in developing economies: results from the Brazilian population

INTRODUCTION

Several studies show the negative impact of haemophilia in health-related quality of life (HRQOL). This issue is not well explored in developing countries.

OBJECTIVES

This cross-sectional study aimed to evaluate the HRQOL and its associated factors in patients with haemophilia A/B in Brazil. Data were collected by questionnaire and in medical records, including a Portuguese version of Haem-A-Qol.

RESULTS

Brazilian patients were invited to the study and 175 participants (147 haemophilics A and 28 haemophilics B) were included. The total score of the Haem-A-QoL had a median of 36.96 (range of 0-100), with worse performance in 'sport and leisure' and best on 'relationships' fields. HRQOL was worst among the older participants, the less educated, non-white, non-working, who were hospitalized in the last year, who did not have a single medical consultation and among those with the highest number of affected joints. Moreover, patients with hepatitis B had a significantly worse HRQOL in the domain 'sports and leisure', also observed in married patients. Otherwise, married individuals reported better HRQOL on 'dealing with the disease' domain. Patients with haemophilia B reported worse HRQOL in the domain 'self-perception'.

CONCLUSION

The results obtained could be helpful in guidance of haemophilia treatment which is determinant to improve HRQoL of the most vulnerable groups of patients. This work also reinforced the relevance of joint bleeds in all aspects of HRQoL in haemophilic patients. The use of prophylactic factor concentrates and multidisciplinary treatments could contribute to improve the quality of life in haemophilia.

Joining the patient on the path to customized prophylaxis: one hemophilia team explores the tools of engagement

BACKGROUND

The relationship between hemophilia team interventions and achievement of optimal clinical outcomes remains to be elucidated. The British Columbia Hemophilia Adult Team has previously reported results of a comprehensive approach to individualize prophylaxis that has resulted in substantially reduced bleeding rates. In order to facilitate knowledge exchange and potential replication, it was important to gain a thorough understanding of the team's approach.

METHODS

A focus group of the British Columbia Hemophilia Adult Team was conducted to identify specific roles and processes that might be contributing to the prophylaxis regimen outcomes in this clinic. The focus group consisted of two workshops; one to describe the individual and collective roles of the clinic team in providing clinical care and guiding patients toward individualized prophylaxis; and the other to describe the patient journey from initial contact through reaching a successful engagement with the clinic.

RESULTS

Analysis of the results revealed team roles and processes that underpinned a shared decision-making relationship with the patient with a particular focus on supporting the patient's autonomy. Within this relationship, team focus shifts away from "adherence" toward the process whereby patients design and implement prophylaxis regimens resulting in reduction or elimination of bleeding episodes.

LIMITATIONS

Using the current methodology, it is not possible to demonstrate a causal link between specific team processes and improved bleeding rates in patients.

CONCLUSION

Through the active support of patient autonomy in all aspects of decisions related to hemophilia management, the British Columbia Hemophilia Adult Team approach de-emphasizes "adherence" as the primary goal, and focuses on a prophylaxis plan that is customized by the patient and aligned with his priorities. Adoption of this comprehensive team approach facilitates shared goals between the patient and the team that may optimize treatment adherence, but more importantly, reduce bleeding rates.

Costs and utilization of treatment in patients with hemophilia

Background

Although hemophilia has a potentially high economic impact, there are no published estimates of healthcare costs for this disease in Portugal. The aim of this study was to evaluate costs of treatment and hospital utilization among patients with hemophilia A and B, with and without inhibitors, over a 3-year period in a Portuguese Comprehensive Care Hemophilia Centre. This is the first study on the financial impact of healthcare costs in patients with hemophilia in Portugal.

Methods

This retrospective, observational study identified patients diagnosed with hemophilia A and B using medical and pharmacy electronic medical records and data from Centro Hospitalar São João, between January 2011 and December 2013. Patients with inhibitors were all high responders (>5 Bethesda Units [BU]). Severity was classified as mild, moderate or severe based on clotting factor levels. Two main outcomes were measured: (1) cost associated with hospital pharmacy claims (clotting factor) and (2) number of hospital visits/hospitalization.

Results

A cohort of 103 patients were identified: 72 (69.9 %) with hemophilia A and 31 (30.1 %) with hemophilia B. Among these, five individuals were classified as patients with inhibitors (four with hemophilia A and one with hemophilia B). From the cohort of hemophilia A patients, 36 individuals (35.0 %) were identified as having severe disease; 20 (19.4 %) moderate; and 16 (15.5 %) mild. In the cohort of hemophilia B patients, 14 (13.6 %) were identified as having severe disease; 14 (13.6 %) moderate; and three (2.9 %) mild. The total mean aggregate cost per year (including clotting factor and hospital utilization) for patients with severe hemophilia B was €112,469, compared with €793 for mild hemophilia A. Clotting factor concentrate amounted for 90 % of total cost in severe cases and hospital utilization was also higher in these cases.

Conclusions

Hemophilia treatment is expensive, particularly for patients with severe disease and especially if they develop inhibitors to replacement clotting factors. In our study, severe hemophilia is associated with greater annual total costs in both types of hemophilia (A = €77,587 and B = € 112,469). Patients with inhibitors have costs 3.3 times higher than patients without inhibitors. Age was not associated with significantly greater total costs (clotting factor and hospital visits/hospitalizations).

Effects of a pain self-management intervention combining written and video elements on health-related quality of life among people with different levels of education

Combining written and video material could increase the impact of health education for people with less education, but more evidence is needed about the impact of combined materials in different formats, especially in the context of chronic pain self-management. This study tested the impact of combining written information about self-managing chronic joint pain, which used language at a high reading level, with a DVD containing narrative video material presented directly by patients, using language at a lower reading level. Physical and mental health-related quality of life (36-Item Short Form Health Survey) was measured among 107 men with hemophilia before and 6 months after being randomly assigned to receive an information booklet alone or the booklet plus the DVD. Analysis of covariance was used to compare health outcomes between randomized groups at follow-up, using the baseline measures as covariates, with stratified analyses for groups with different levels of education. The DVD significantly improved mental health-related quality of life among those with only high school education. Video material could therefore supplement written information to increase its impact on groups with less education, and combined interventions of this type could help to achieve health benefits for disadvantaged groups who are most in need of intervention.