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Nguyen NAT, Auquier P, Beltran Anzola A, Harroche A, Castet S, Huguenin Y, Meunier S, Repesse Y, D'Oiron R, Rauch A, Desprez D, Spiegel A, Chamouni P, Schneider P, Baumstarck K, Boucekine M, Tabele C, Viprey M, Leroy T, Roques MA, Sannie T, Giraud N, Chambost H, Resseguier N. Determinants of adherence and consequences of the transition from adolescence to adulthood among young people with severe haemophilia (TRANSHEMO): A multicentric French national observational cross-sectional study based on the FranceCoag registry. Haemophilia 2023; 29:1202-1218. [PMID: 37572328 DOI: 10.1111/hae.14841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/25/2023] [Accepted: 07/31/2023] [Indexed: 08/14/2023]
Abstract
INTRODUCTION It is necessary to gain insights into adherence to healthcare in people with severe haemophilia (PwSH), especially during the transition from paediatric to adult care, which is an important phase in lives of young people with childhood chronic disease. This adherence can be considered as a marker of successful transition. OBJECTIVES The main objective of the quantitative phase of the TRANSHEMO project was to compare the adherence to healthcare between adolescents and young adults (YAs) with severe haemophilia. The secondary objective was to identify the determinants (facilitators and barriers) of this adherence and associations between these determinants. METHODS A multicentre, observational, cross-sectional study was conducted in 2017-2019 on PwSH aged between 14 and 17 years (adolescents) or between 20 and 29 years (YAs), included in the FranceCoag registry and having completed the questionnaires. The adherence to healthcare (treatment regimens and clinical follow-up) was compared between adolescents and YAs using the chi-squared test. The determinants of this adherence were analysed by structural equation modelling. RESULTS There were 277 participants, 107 adolescents, and 170 YAs. The rate of adolescents adhering to healthcare was 82.2%, while the rate of YAs was 61.2% (p < .001). The barriers to the adherence to healthcare were being YA, having repeated at least one school grade and presenting mental health concerns. CONCLUSION Adolescents had better adherence to healthcare than YAs. According to the determinants enlightened in this project, targeted supportive strategies and adapted therapeutic education programs can be developed for young PwSH to facilitate their adherence to healthcare.
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Affiliation(s)
- Ngoc Anh Thu Nguyen
- CEReSS/UR 3279 - Health Services and Quality of Life Research, Aix Marseille University, Marseille, France
- Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
| | - Pascal Auquier
- CEReSS/UR 3279 - Health Services and Quality of Life Research, Aix Marseille University, Marseille, France
- Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
- FranceCoag Network, Marseille, France
| | - Any Beltran Anzola
- CEReSS/UR 3279 - Health Services and Quality of Life Research, Aix Marseille University, Marseille, France
- Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
| | - Annie Harroche
- AP-HP, Haemophilia Treatment Centre, Hospital Necker, Paris, France
| | - Sabine Castet
- University Hospital of Bordeaux, Haemophilia Treatment Centre, Bordeaux, France
| | - Yoann Huguenin
- University Hospital of Bordeaux, Haemophilia Treatment Centre, Bordeaux, France
| | - Sandrine Meunier
- Hospices Civils de Lyon - Haemophilia Treatment Centre, Groupement Hospitalier Est, Bron, France
| | - Yohann Repesse
- University Hospital of Caen, Haemophilia Treatment Centre, Caen, France
| | - Roseline D'Oiron
- AP-HP, Haemophilia Treatment Centre, Hospital Bicêtre, Paris, France
| | - Antoine Rauch
- University Regional Hospital of Lille, Haemophilia Treatment Centre, Lille, France
| | - Dominique Desprez
- University Regional Hospital of Strasbourg, Haemophilia Treatment Centre, Strasbourg, France
| | - Alexandra Spiegel
- University Regional Hospital of Strasbourg, Pediatric Onco-Haematology Service, Strasbourg, France
| | - Pierre Chamouni
- University Hospital of Rouen, Haemophilia Treatment Centre, Rouen, France
| | - Pascale Schneider
- University Hospital of Rouen, Haemophilia Treatment Centre, Rouen, France
| | - Karine Baumstarck
- CEReSS/UR 3279 - Health Services and Quality of Life Research, Aix Marseille University, Marseille, France
- Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
- FranceCoag Network, Marseille, France
| | - Mohamed Boucekine
- CEReSS/UR 3279 - Health Services and Quality of Life Research, Aix Marseille University, Marseille, France
- Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
- FranceCoag Network, Marseille, France
| | - Clémence Tabele
- CEReSS/UR 3279 - Health Services and Quality of Life Research, Aix Marseille University, Marseille, France
- Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
- FranceCoag Network, Marseille, France
| | - Marie Viprey
- FranceCoag Network, Marseille, France
- Hospices Civils de Lyon, Health Data Department, Lyon, France
- Inserm, U1290 Unit, Research on Healthcare Performance RESHAPE, Claude Bernard Lyon 1 University, Lyon, France
| | - Tanguy Leroy
- Inserm, U1296 Unit, Radiation: Defense, Health and Environment, Lumière Lyon 2 University, Lyon, France
| | - Marie-Anaïs Roques
- Laboratory of Clinical Psychology, Psychopathology and Psychoanalysis, UR 3278, Aix-Marseille University, Aix-en-Provence, France
- AP-HM, Haemophilia Treatment Centre, Children Hospital La Timone, Marseille, France
| | - Thomas Sannie
- French Patients' Association for People with Haemophilia (AFH), Paris, France
| | - Nicolas Giraud
- French Patients' Association for People with Haemophilia (AFH), Paris, France
| | - Hervé Chambost
- FranceCoag Network, Marseille, France
- AP-HM, Haemophilia Treatment Centre, Children Hospital La Timone, Marseille, France
| | - Noémie Resseguier
- CEReSS/UR 3279 - Health Services and Quality of Life Research, Aix Marseille University, Marseille, France
- Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
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Liu Z, Feng J, Fang Y, Cheng Y, Li S. Barriers to prophylactic treatment among patients with haemophilia A in Shandong Province, China: a qualitative study. Orphanet J Rare Dis 2023; 18:226. [PMID: 37537616 PMCID: PMC10398971 DOI: 10.1186/s13023-023-02838-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 07/21/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Haemophilia A is a rare, hereditary haemorrhagic disease that manifests as induced spontaneous bleeding and leads to disability or premature death in severe cases. Prophylactic treatment is optimal for patients to prevent uncontrolled bleeding and reduce the severity of the injury. However, little is known about the use of prophylactic treatment among patients with haemophilia A in China, especially barriers that predispose them to low or non-adherence. In this study, we explore the barriers to the prophylactic treatment of patients with haemophilia A. METHOD We used personal interviews and focus groups to collect the data and analysed the data through thematic analysis. Purposive sampling was employed to recruit our participants. We continued recruiting participants until data saturation was reached from the thematic analysis. Ultimately, we obtained 37 participants, among whom 19 participated in personal interviews and 18 participated in focus groups (i.e., 3 focus groups with 6 participants each). RESULTS Three themes and nine subthemes were identified from the thematic analysis. Nine subthemes (i.e., perceived barriers) emerged from the analysis, which were further clustered into three themes: (1) poor primary health care, (2) inadequate financial support, and (3) a lack of patient-centred care. CONCLUSION The findings presented in this descriptive qualitative study offer a unique view of Chinese patients with haemophilia A and their barriers to prophylactic treatment. Our findings not only provide an in-depth understanding of barriers to prophylactic treatment encountered by Chinese patients with haemophilia A but also address the urgent need to strengthen primary care, provide adequate financial support, and establish patient-centred care for these suffering patients.
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Affiliation(s)
- Ziyu Liu
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China
- Centre for Health Preference Research, Shandong University, Jinan, 250012, China
| | - Junchao Feng
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China
- Centre for Health Preference Research, Shandong University, Jinan, 250012, China
| | - Yunhai Fang
- Shandong Blood Center, Shandong Haemophilia Treatment Center, Jinan, China
| | - Yan Cheng
- Shandong Blood Center, Shandong Haemophilia Treatment Center, Jinan, China
| | - Shunping Li
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China.
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China.
- Centre for Health Preference Research, Shandong University, Jinan, 250012, China.
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Clinical Predictors and Prediction Models for rFVIII-Fc Half Life in Real-World People with Severe Hemophilia A. J Clin Med 2023; 12:jcm12062207. [PMID: 36983209 PMCID: PMC10053229 DOI: 10.3390/jcm12062207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/27/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
The half life of recombinant factor VIII-Fc (rFVIII-Fc) for people with hemophilia A (PwHA) varies greatly. Understanding the factors influencing the variation and assessment of rFVIII-Fc half life is important for personalized treatment. Eighty-five severe-type PwHA with rFVIII-Fc treatment receiving an evaluation of half life by the Web-Accessible Population Pharmacokinetic (PK) Service—Hemophilia during 2019–2021 were retrospectively enrolled. The 50-patient PK profiles before 2021 were used for analysis and developing prediction models of half life, and the 35-patient PK profiles in 2021 were used for external validation. The patients in the development cohort were aged 8–64, with a median rFVIII-Fc half life of 20.75 h (range, 8.25–41.5 h). By multivariate linear regression analysis, we found two, four, and five predictors of rFVIII-Fc half life for the blood groups non-O, O patients, and overall patients, respectively, including VWF:Ag, BMI, VWF:activity/VWF:Ag ratio, body weight, O blood group, inhibitor history, HCV infection, and hematocrit. The three prediction equations of rFVIII-Fc half life (T) were respectively developed as T for non-O group patients = −0.81 + 0.63 × (BMI, kg/m2) + 6.07 × (baseline VWF:Ag, IU/mL), T for O group patients = −0.68 + 13.30 × (baseline VWF:Ag, IU/mL) + 0.27 × (BW, kg) − 1.17 × (BMI, kg/m2) + 16.02 × (VWF:activity/VWF:Ag ratio), and T for overall patients = −1.76 + 7.24 × (baseline VWF:Ag, IU/mL) − 3.84 × (Inhibitor history) + 2.99 × (HCV infection) − 2.83 × (O blood group) + 0.30 × (Hct, %), which explained 51.97%, 75.17%, and 66.38% of the half life variability, respectively. For external validation, there was a significant correlation between the predicted and observed half lives in the validation cohort. The median half life deviation was +1.53 h, +1.28 h, and +1.79 h for the equations of non-O group, O group, and overall group patients, respectively. In total, eight predictors influencing rFVIII-Fc half life were identified. Prediction equations of rFVIII-Fc half life were developed for the non-O and O blood groups and overall PwHA with a good degree of external validation. The equations could be applied to patients aged 8–64 without the need for PK blood sampling and clinically valuable for personalized therapy.
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Núñez R, Álvarez-Román MT, Bonanad S, González-Porras JR, De La Corte-Rodriguez H, Berrueco R, Jiménez-Yuste V. The Limitations and Unmet Needs of the Five Cornerstones to Guarantee Lifelong Optimization of Prophylaxis in Hemophilia Patients. TH OPEN 2022; 6:e365-e377. [DOI: 10.1055/s-0042-1757745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
AbstractProphylaxis to prevent bleeding is highly recommended for hemophilia patients. The development of new drugs and tools for modeling personalized prophylaxis provides the means for people with hemophilia to lead active lives with a quality of life comparable to that of nonhemophilic individuals. The choice of regimens must be made on a highly individual basis. Unfortunately, reference guides neither always concur in their recommendations nor provide directions to cover all possible scenarios. In this review, a group of experts identify the significant limitations and unmet needs of prophylaxis, taking advantage of their clinical experience in the disease, and supported by a rigorous literature update. To perform a more systematic and comprehensive search for gaps, the main cornerstones that influence decisions regarding prophylactic patterns were first identified.Bleeding phenotype, joint status, physical activity, pharmacokinetics/medication properties, and adherence to treatment were considered as the primary mainstays that should allow physicians guiding prophylaxis to secure the best outcomes. Several challenges identified within each of these topics require urgent attention and agreement. The scores to assess severity of bleeding are not reliable, and lead to no consensus definition of severe bleeding phenotype. The joint status is to be redefined in light of new, more efficient treatments with an agreement to establish one scale as the unique reference for joint health. Further discussion is needed to establish the appropriateness of high-intensity physical activities according to patient profiles, especially because sustaining trough factor levels within the safe range is not always warranted for long periods. Importantly, many physicians do not benefit from the advantages provided by the programs based on population pharmacokinetic models to guide individualized prophylaxis through more efficient and cost-saving strategies. Finally, ensuring correct adherence to long-term treatments may be time-consuming for practitioners, who often have to encourage patients and review complex questionnaires.In summary, we identify five cornerstones that influence prophylaxis and discuss the main conflicting concerns that challenge the proper long-term management of hemophilia. A consensus exercise is warranted to provide reliable guidelines and maximize benefit from recently developed tools that should notably improve patients' quality of life.
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Affiliation(s)
- Ramiro Núñez
- Hemophilia Unit, Hospital Universitario Virgen del Rocío, Sevilla, Andalucía, Spain
| | | | - Santiago Bonanad
- Haemostasis and Thrombosis Unit, Hospital Universitari i Politècnic La Fe, València, Spain
| | - José Ramón González-Porras
- Hematology Department, Hospital Universitario de Salamanca, Instituto Biosanitario de Salamanca (Ibsal), Salamanca, Spain
| | | | - Rubén Berrueco
- Pediatric Hematology Department, Hospital Sant Joan de Déu Barcelona, Esplugues de Llobregat, Barcelona, Spain
- Institut de Recerca, Pediàtrica Hospital Sant Joan de Déu de Barcelona (IRP-HSJD0), Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
| | - Víctor Jiménez-Yuste
- Department of Hematology and Hemotherapy, La Paz University Hospital-IdiPaz, Madrid, Spain
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Ballmann J, Ewers M. Nurse-led education of people with bleeding disorders and their caregivers: A scoping review. Haemophilia 2022; 28:e153-e163. [PMID: 35850204 DOI: 10.1111/hae.14629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/28/2022] [Accepted: 07/02/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION People with bleeding disorders (PwBd) and their caregivers face many challenges in developing viable self-management strategies for living with the condition. Nurse-led education can support them to overcome these challenges. However, it is often unclear what educational needs are addressed, how nurses educate PwBd and what didactic concepts they follow. AIM To gain deeper insights into nurse-led patient education in haemophilia care and provide a basis for a more systematic and evidence-based approach to this task. METHODS A scoping review methodology was used. A systematic search for relevant publications on this topic was conducted in various databases between November 2020 and April 2021. Data sets were analysed following the PRISMA-ScR-checklist and using content analysis. RESULTS Of 588 studies identified, 23 sources of evidence met the inclusion criteria. The educational needs of PwBd and their families are extensive, multifaceted, and variable but rarely assessed systematically. These needs were met at certain times throughout their lifetimes. Nurse-led education differed in content, duration, and modality, including interventions such as information, consultation and instruction. An improvement in treatment-oriented self-management and self-efficacy was the most reported outcome. The didactic concepts on which the educational interventions were based were rarely specified. CONCLUSIONS There is a lack of systematic approaches in assessing and addressing the educational needs of PwBd and their caregivers. High variability was found in the literature regarding nurse-led patient education in haemophilia care. This suggests that more research is needed on this topic - not least on the interventions' conceptual foundations and impact models.
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Affiliation(s)
- Julia Ballmann
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Health and Nursing Science, Berlin, Germany
| | - Michael Ewers
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Health and Nursing Science, Berlin, Germany
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Infusão endovenosa domiciliar: tecnologias educativas para o cuidado à pessoa com hemofilia. ACTA PAUL ENFERM 2022. [DOI: 10.37689/acta-ape/2022ao02902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Garrison LP, Pezalla E, Towse A, Yang H, Faust E, Wu EQ, Li N, Sawyer EK, Recht M. Hemophilia Gene Therapy Value Assessment: Methodological Challenges and Recommendations. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1628-1633. [PMID: 34711363 DOI: 10.1016/j.jval.2021.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 05/27/2023]
Abstract
Gene therapy for hemophilia is designed to produce health gains for patients over many years. Rewarding that value creation on the basis of a one-time treatment implies a large upfront cost. This cost can only be justified by long-term health benefits and being cost-effective compared with conventional treatments. Yet, uncertainties about the long-term benefits make it challenging to assess clinical and economic value of gene therapies at launch. We identify and discuss key methodological challenges in assessing the value of gene therapy for hemophilia, including the immaturity of evidence on the durability of benefits, lack of definition and valuation of cure for chronic diseases, absence of randomized controlled trials, limitations of traditional quality of life measures in hemophilia, approach for qualifying cost-savings compared with current treatments, and choice of perspective. The Institute for Clinical and Economic Review has developed a framework for assessing single or short-term therapies (ICER-SST) and has applied it in hemophilia. After reviewing this framework and its application, we recommend the following when assessing the value of hemophilia gene therapies: (1) leveraging expert clinical opinion to justify assumptions on the durability of benefits; (2) using external synthetic controls and lead-in, self-controlled trials to assess comparative effectiveness; (3) addressing limitations of traditional quality of life measures through the use of modified utility collection approaches; (4) adjusting cost offsets from gene therapies with caution; (5) considering outcome-based contracting to address uncertainties about prices and long-term outcomes; and (6) presenting societal and healthcare system perspectives in parallel.
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Affiliation(s)
- Louis P Garrison
- Department of Pharmacy, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA.
| | - Ed Pezalla
- Enlightenment Bioconsult, LLC, Wethersfield, CT, USA
| | | | | | | | - Eric Q Wu
- Analysis Group, Inc, Boston, MA, USA
| | | | | | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, NY, USA
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le Doré S, Grinda N, Ferré E, Roussel-Robert V, Frotscher B, Chamouni P, Meunier S, Bayart S, Dolimier E, Truong-Berthoz F, de Raucourt E. The Hemarthrosis-Simulating Knee Model: A Useful Tool for Individualized Education in Patients with Hemophilia (GEFACET Study). J Blood Med 2021; 12:133-138. [PMID: 33727876 PMCID: PMC7955736 DOI: 10.2147/jbm.s280032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/22/2021] [Indexed: 01/04/2023] Open
Abstract
Background Hemophilic arthropathy is a major complication in patients with severe hemophilia. A plastic knee model has been developed for the therapeutic education of patients to promote improved care management and self-treatment skills. The objective of this study was to evaluate the impact of this hemarthrosis-simulating artificial knee (HSAK) on patients’ knowledge of their disease and its treatment. Methods In this observational study, the impact of HSAK was assessed during individualized education in patients with severe/moderately severe hemophilia A or B at seven hemophilia treatment centers in France. Participants provided written informed consent and completed questionnaires to assess knowledge of their disease (score range: 0–7) and knowledge of their treatment (score range: 0–4). Questionnaires were completed before, immediately after and 6 months after HSAK use. The scores obtained before and after the use of the HSAK were compared. Results The participants comprised 32 children, 29 teenagers, and 31 adults. The mean (SD) disease knowledge score increased significantly in all age groups of patients from 4.5 (2.0) to 5.9 (1.5; p<0.001) immediately after the training and remained unchanged at 6 months. Mean (SD) treatment knowledge scores were unchanged, but Wilcoxon signed rank testing showed a significant increase after the training course that was maintained at 6 months in children and teenagers. Conclusion These findings suggest that an individualized training course can enhance the understanding of hemophilia in patients of all ages, especially in children and teenagers, and that the HSAK may assist in improving patients’ management of their disease.
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Affiliation(s)
- Sophie le Doré
- Haemophilia Treatment Centre, Hôpital Mignot, Versailles, France
| | - Nathalie Grinda
- Regional Hemophilia Centre, Hôpital de Bicêtre (AP-HP), Kremlin-Bicêtre, France
| | - Emmanuelle Ferré
- Haemophilia Treatment Centre, Hôpital Mignot, Versailles, France
| | | | - Birgit Frotscher
- Haemophilia Treatment Centre, Hôpital de Brabois, Vandoeuvre-Les-Nancy, France
| | - Pierre Chamouni
- Regional Hemophilia Treatment Centre, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Sandrine Meunier
- Hospices Civils de Lyon - Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Bron, France
| | - Sophie Bayart
- Haemophilia Treatment Centre, Hôpital Pontchaillou, Centre Hospitalier Universitaire de Rennes, Rennes, France
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Hoefnagels JW, Versloot O, Schrijvers LH, van der Net J, Leebeek FWG, Gouw SC, Fischer K. Sports participation is not associated with adherence to prophylaxis in Dutch patients with haemophilia. Haemophilia 2021; 27:e402-e405. [PMID: 33556987 DOI: 10.1111/hae.14244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 12/01/2022]
Affiliation(s)
| | - Olav Versloot
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Liesbeth H Schrijvers
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands.,Nursing Department, Utrecht University of Applied Sciences, Utrecht, The Netherlands
| | - Janjaap van der Net
- Center for Child Development, Exercise and Physical Literacy, University Children's Hospital, UMC Utrecht, Utrecht, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Samantha C Gouw
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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Cuesta-Barriuso R, Torres-Ortuño A, Nieto-Munuera J, López-Pina JA. Quality of Life, Perception of Disease and Coping Strategies in Patients with Hemophilia in Spain and El Salvador: A Comparative Study. Patient Prefer Adherence 2021; 15:1817-1825. [PMID: 34456562 PMCID: PMC8387734 DOI: 10.2147/ppa.s326434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/31/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Hemophilia is characterized by the development of joint bleeds that cause long-term joint damage (hemophilic arthropathy). Joint damage leads to disability and affects psychosocial aspects in patients with hemophilia. OBJECTIVE To compare the clinical situation, perception of disease and quality of life, and coping strategies in adult patients with hemophilia in El Salvador and Spain. METHODS In this comparative clinical study, 43 patients with hemophilia aged between 18 and 50 years old from Spain and El Salvador participated. After obtaining the patients' consent, they completed the Illness Perception Questionnaire-Revised (IPQ-R), Hemophilia-QoL and Inventory of Coping strategies questionnaires. Joint status was assessed using the Hemophilia Joint Health Score and based on a record of clinical and treatment data. RESULTS Hemophilia patients from Spain showed an improved perception of quality of life (p <0.05), although there were only differences in the self-criticism variable (p = 0.04) for coping strategies. Joint damage and age correlated (p <0.05) negatively with perception of disease, perceived quality of life and coping strategies in both populations. There were differences (p <0.05) between the two populations based on HIV and HCV coinfections in perception of disease and perceived quality of life. CONCLUSION Patients with hemophilia in El Salvador exhibit a poorer perception of disease and quality of life. Despite differences in access to treatment from one country to the other, there is no difference in coping with the disease. Older patients are better able to adapt to the disease.
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Affiliation(s)
- Rubén Cuesta-Barriuso
- Department of Physiotherapy, University of Murcia, Murcia, Spain
- Royal Victoria Eugenia Foundation, Madrid, Spain
- Correspondence: Rubén Cuesta-Barriuso Department of Physiotherapy, University of Murcia, Campus Espinardo, Murcia, 30200, SpainTel +34 868 887 286 Email
| | - Ana Torres-Ortuño
- Department of Psychiatry and Social Psychology, University of Murcia, Murcia, Spain
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ADHERENCE TO PROPHYLAXIS IN RELATION TO QUALITY OF LIFE AND ANXIETY LEVEL IN TURKISH PATIENTS WITH SEVERE HAEMOPHILIA A. INTERNATIONAL JOURNAL OF HEALTH SERVICES RESEARCH AND POLICY 2020. [DOI: 10.33457/ijhsrp.738665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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von Mackensen S, Schleicher C, Heine S, Graf N, Eichler H. Health-Related Quality of Life, Treatment Satisfaction and Adherence Outcomes of Haemophilia Patients Living in a German Rural Region. Hamostaseologie 2020; 40:631-641. [DOI: 10.1055/a-1141-1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractIn the context of the ‘Mobile Haemophilia Outpatient Care (MHOC)’ project we aimed to gather insights into the health-related quality of life (HRQoL), treatment satisfaction (TS) and adherence of persons with haemophilia (PWHs) who get treated at the Saarland University Hospital Haemophilia Treatment Centre (HTC). PWHs were visited at home at least twice (baseline, follow-up) by trained medical staff. Individual interviews were performed to measure patients' HRQoL and TS with validated questionnaires (Haem-A-QoL/Haemo-QoL and Hemo-SatA/Hemo-SatP). Socio-demographic and clinical data were collected. In total, 79 PWHs were enrolled; 56 adults with a mean age of 37.4 ± 16.4 years (17–78) and 23 children [mean age of 9.8 ± 4.2 years (3–16)]. In total, 62% were severely affected; 48.1% received prophylaxis. Patients reported good HRQoL (adults: 23.1 ± 17.1; kids: 24.3 ± 11.1). Patients (M = 11.2 ± 9.5) and parents (M = 14.3 ± 7.4) were very satisfied with their provided treatment. The majority of study participants were evaluated to have a good treatment adherence. After 1-year follow-up of the MHOC, a significant improvement in HRQoL was seen in adults (p < 0.033) and in proxy ratings of parents (p < 0.0001); TS remained high with no change by MHOC intervention. Patients reported good HRQoL and TS. Most of them were evaluated as having a good treatment adherence. After implementation of the MHOC, adult patients reported a better HRQoL. Such a mobile medical care service is considered beneficial for patients, especially with limited access to a HTC.
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Affiliation(s)
- Sylvia von Mackensen
- Department for Medical Psychology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Schleicher
- Institute of Clinical Haemostaseology and Transfusion Medicine, European Haemophilia Comprehensive Care Centre, Saarland University Hospital, Homburg, Saar, Germany
| | - Sabine Heine
- Department for Paediatric Oncology and Haematology, European Haemophilia Comprehensive Care Centre, Saarland University Hospital, Homburg, Saar, Germany
| | - Norbert Graf
- Department for Paediatric Oncology and Haematology, European Haemophilia Comprehensive Care Centre, Saarland University Hospital, Homburg, Saar, Germany
| | - Hermann Eichler
- Institute of Clinical Haemostaseology and Transfusion Medicine, European Haemophilia Comprehensive Care Centre, Saarland University Hospital, Homburg, Saar, Germany
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Tiede A, Bonanad S, Santamaria A, Goldmann G, Canaro M, Palomero A, Frade LJG, Eduardo Megias‐Vericat J, Martinez F, Garcia Candel F, Jimenez Yuste V, Sparber‐Sauer M, Halimeh S, Adolf D, Hukauf M, Reichmann J, Oldenburg J. Quality of electronic treatment records and adherence to prophylaxis in haemophilia and von Willebrand disease: Systematic assessments from an electronic diary. Haemophilia 2020; 26:999-1008. [DOI: 10.1111/hae.14178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/07/2020] [Accepted: 09/22/2020] [Indexed: 01/19/2023]
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Özceylan G. Evaluation of Patients’ Behavior with Bleeding Disorder in Preferring Primary Health Care Centre for Follow-Up and Treatment. EURASIAN JOURNAL OF FAMILY MEDICINE 2020. [DOI: 10.33880/ejfm.2020090309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim: The aim of this study is to examine the behaviors of patients who are members of the hemophilia association due to bleeding disorder, and due to health problems related to their diseases preferring primary health care institutions first, and to determine the reasons if they do not.
Methods: The study was a descriptive cross-sectional study. The universe of the study was composed of hemophilia patients who are members of the hemophilia association living in Tekirdağ province (n=48). In the study face to face questionnaire was applied. People were asked about their first medical institutions in their complaints about their illness. The patients were asked about their age, gender, working status, educational status, types of bleeding disorders, severity and history of diseases.
Results: Nobody preferred the primary health care institution for his complaints about bleeding disorder. Of the participants, 42.9% (n=18) stated that family physicians do not have sufficient information about this disease as the reason for not choosing primary health care institution.
Conclusion: The trust of patients with bleeding disorders to family physicians is not sufficient. Regardless of the severity, type and prophylactic drug use of their disease, they do not prefer primary health care institution for their follow-up and treatment.
Keywords: hemophilia, bleeding, family practice
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Butterfield JSS, Hege KM, Herzog RW, Kaczmarek R. A Molecular Revolution in the Treatment of Hemophilia. Mol Ther 2020; 28:997-1015. [PMID: 31843450 PMCID: PMC7132613 DOI: 10.1016/j.ymthe.2019.11.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/31/2019] [Accepted: 11/05/2019] [Indexed: 12/15/2022] Open
Abstract
For decades, the monogenetic bleeding disorders hemophilia A and B (coagulation factor VIII and IX deficiency) have been treated with systemic protein replacement therapy. Now, diverse molecular medicines, ranging from antibody to gene to RNA therapy, are transforming treatment. Traditional replacement therapy requires twice to thrice weekly intravenous infusions of factor. While extended half-life products may reduce the frequency of injections, patients continue to face a lifelong burden of the therapy, suboptimal protection from bleeding and joint damage, and potential development of neutralizing anti-drug antibodies (inhibitors) that require less efficacious bypassing agents and further reduce quality of life. Novel non-replacement and gene therapies aim to address these remaining issues. A recently approved factor VIII-mimetic antibody accomplishes hemostatic correction in patients both with and without inhibitors. Antibodies against tissue factor pathway inhibitor (TFPI) and antithrombin-specific small interfering RNA (siRNA) target natural anticoagulant pathways to rebalance hemostasis. Adeno-associated virus (AAV) gene therapy provides lasting clotting factor replacement and can also be used to induce immune tolerance. Multiple gene-editing techniques are under clinical or preclinical investigation. Here, we provide a comprehensive overview of these approaches, explain how they differ from standard therapies, and predict how the hemophilia treatment landscape will be reshaped.
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Affiliation(s)
| | - Kerry M Hege
- Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA
| | - Roland W Herzog
- Department of Pediatrics, University of Florida, Gainesville, FL, USA; Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA.
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA; Laboratory of Glycobiology, Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland.
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van Os S, Ryder N, Hart DP, Troop N. Adherence to prophylaxis in adolescents and young adults with severe haemophilia: a qualitative study with healthcare professionals. Health Psychol Behav Med 2020; 8:55-72. [PMID: 34040862 PMCID: PMC8114349 DOI: 10.1080/21642850.2020.1718501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 01/11/2020] [Indexed: 11/02/2022] Open
Abstract
Aim: to examine healthcare professionals' (HP) perceptions and experiences in relation to adherence to prophylactic treatment among young people living with haemophilia (YPH). Methods: All HPs in four haemophilia centres across England and Wales were invited to participate, and all HPs who agreed to take part (n = 6) were interviewed. Interviews were audio-recorded, transcribed and then analysed using Interpretative Phenomenological Analysis (IPA). Results: HPs estimate that generally young people with haemophilia keep to their treatment regimen well, although they also recognise that adherence may fluctuate with many patients going through shorter periods of non-adherence. The increasingly personalised or flexible approach to prophylaxis makes it harder to assess adherence. The main themes identified through IPA included (1) HPs' suggest that adherence fluctuates (2) Non-adherence is mainly driven by lifestyle and developmental, social and family factors, and (3) Education, HPs' sensitivity to individual needs, and psychological and peer support are key facilitators of good adherence. Conclusion: The increasingly flexible approach to prophylaxis requires a new way of thinking about, and assessment of, adherence. More personalised treatment regimen can be more complicated and may, therefore, lead to accidental non-adherence. The results of this study with HPs complement those of a previous qualitative study with patients but place greater emphasis on a broader perspective on understanding drivers of non-adherence as well as understanding strategies to improve adherence in the minority of patients who appear to struggle.
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Affiliation(s)
- S. van Os
- Psychology and Sport Sciences Department, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - N. Ryder
- Psychology and Sport Sciences Department, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - D. P. Hart
- The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK
- Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - N. Troop
- Psychology and Sport Sciences Department, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
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Torres-Ortuño A, Cuesta-Barriuso R, Nieto-Munuera J, Castiello-Munuera Á, Moreno-Moreno M, López-Pina JA. Haemo-Adhaesione: A New Measure of Adherence for Adolescent and Adult Patients with Haemophilia. Patient Prefer Adherence 2020; 14:455-465. [PMID: 32184574 PMCID: PMC7060779 DOI: 10.2147/ppa.s233601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 01/11/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To build a multidimensional questionnaire of adherence for a patient with hemophilia that includes not only clinical but also psychosocial aspects. PATIENTS AND METHODS One hundred and forty-six patients with haemophilia (A and B) were recruited from several Hemophilia Treatment Centers for this study. The recruitment was performed through a personal interview (20-25 mins for each patient). A literature review was carried out (different databases). In the first version (136 items), all items were subjected to an external judgment (experts in hemophilia) and also presented and discussed with a group of patients. It was made a study of content validity and homogeneity index and reliability coefficients of score were calculated with an alpha coefficient. Empirical validation was made with Pearson correlation. RESULTS The Haemo-Adhaesione scale was composed of 5 dimensions and 10 questions about basic haemophilia concepts. It was shown to be valid and reliable to assess adherence in the Spanish population. Its internal consistency was good in all dimensions. The Rasch model was used to confirm the multidimensional structure of the scale. Significant and negative correlations were observed with the VERITAS-Pro and VERITAS-PRN scale in all dimensions, and in the total score. CONCLUSIONS The Haemo-Adhaesione scale is a good measure of adherence for PWH. Its multidimensional structure favors the inclusion of the objective and subjective aspects implicit in its definition, as well as its dynamic nature. Patients with greater adherence are those who have more awareness of their disease, and as a result, they are more compliant with prescription and their self-care. It also discriminates between patients who follow one treatment or another.
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Affiliation(s)
- Ana Torres-Ortuño
- Department of Psychiatry and Social Psychology, Faculty of Medicine, University of Murcia, Murcia, Spain
- Association of Hemophilia, Murcia, Spain
- Correspondence: Ana Torres-Ortuño Department of Psychiatry and Social Psychology, Faculty of Medicine, University of Murcia, Campus de Espinardo s/n, 30100, SpainTel +34 868887170Fax +34 913508 Email
| | - Rubén Cuesta-Barriuso
- Department of Physiotherapy, School of Biomedical and Health Sciences, European University of Madrid, Madrid, Spain
- Royal Foundation Victoria Eugenia, Madrid, Spain
| | - Joaquín Nieto-Munuera
- Department of Psychiatry and Social Psychology, Faculty of Medicine, University of Murcia, Murcia, Spain
| | - Álvaro Castiello-Munuera
- Department of Psychiatry and Social Psychology, Faculty of Medicine, University of Murcia, Murcia, Spain
| | - Manuel Moreno-Moreno
- Association of Hemophilia, Murcia, Spain
- Royal Foundation Victoria Eugenia, Madrid, Spain
- Hematology and Hemotherapy Service, University Clinical Hospital Virgen de la Arrixaca, Murcia, Spain
| | - José Antonio López-Pina
- Department of Basic Psychology and Methodology, Faculty of Psychology, University of Murcia, Murcia, Spain
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Lambert C, Meité N, Sanogo I, Lobet S, Hermans C. Development and evaluation of appropriate, culturally adapted educational tools for Ivoirian patients with haemophilia, haemophilia carriers and their families. Haemophilia 2019; 25:838-844. [DOI: 10.1111/hae.13818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/21/2019] [Accepted: 06/14/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Catherine Lambert
- Haemostasis and Thrombosis Unit, Division of Hematology Cliniques Universitaires Saint‐Luc Brussels Belgium
| | - N’Dogomo Meité
- Division of Clinical Hematology Centre Hospitalier Universitaire de Yopougon Abidjan Côte d’Ivoire
| | - Ibrahima Sanogo
- Division of Clinical Hematology Centre Hospitalier Universitaire de Yopougon Abidjan Côte d’Ivoire
| | - Sébastien Lobet
- Haemostasis and Thrombosis Unit, Division of Hematology Cliniques Universitaires Saint‐Luc Brussels Belgium
- Division of Physical Medicine and Rehabilitation Cliniques universitaires Saint‐Luc Brussels Belgium
- Secteur des Sciences de la Santé, Institut de Recherche Expérimentale et Clinique, Neuromusculoskeletal Lab Université catholique de Louvain Brussels Belgium
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Hematology Cliniques Universitaires Saint‐Luc Brussels Belgium
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Lee Mortensen G, Strand AM, Almén L. Adherence to prophylactic haemophilic treatment in young patients transitioning to adult care: A qualitative review. Haemophilia 2019; 24:862-872. [PMID: 30485633 DOI: 10.1111/hae.13621] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 09/23/2018] [Indexed: 02/06/2023]
Abstract
Recombinant prophylactic treatment (PTX) has greatly improved morbidity, mortality and health-related quality of life (HRQoL) in patients with severe haemophilia. Yet, treatment adherence appears suboptimal in adolescents and young adults with haemophilia (YWH). Young patients experience major biopsychosocial changes challenging their adherence through the transition from parental to self-care, from paediatric to adult care. In clinical practice, a systematic approach to transition is rarely used and there is little evidence on best practices. This qualitative review was based on a systematic literature search including quantitative as well as qualitative research reports to examine all relevant factors influencing adherence to PTX in YWH. We aimed to gain comprehensive insight into main drivers and barriers to adherence by exploring them in the context of YWH's disease perceptions, characteristics, HRQoL and needs. The outcome is an overview of the latest published recommendations to support treatment adherence in YWH during the transition from family-oriented care to self-care and from paediatric to adult care. The literature suggests that adherence to PTX is best supported when individual patient needs and preferences are taken into consideration when planning treatment. Preserving normality is a main priority in young patients making it crucial to support patients from early childhood in considering PTX as enabling rather than hindering a normal social and physically active life. Education in self-management should include psychosocial support of patients as well as caregivers. This requires systematic transition planning including milestone assessments and ongoing multidisciplinary support until full self-management is secured.
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Myrin Westesson L, Wallengren C, Baghaei F, Sparud-Lundin C. Reaching Independence Through Forced Learning: Learning Processes and Illness Management in Parents of Children Affected by Hemophilia. QUALITATIVE HEALTH RESEARCH 2018; 28:2142-2154. [PMID: 30066606 DOI: 10.1177/1049732318789631] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Hemophilia is a complex condition to manage, especially for parents to newly diagnosed children. This grounded theory study explores parents' learning processes and illness management in daily life during the first year after the start of their child's treatment. Using a longitudinal qualitative design, eight parents of four children were interviewed repeatedly during 12 to 14 months. The core category, reaching independence through forced learning, reflected the parents' learning process and their experiences of the challenges during the first year after start of treatment. Incentives for learning were characterized by a longing to reach independence and regain control of one's life situation. The emerging key incentive for learning was a desire to become independent of health care professionals. Early home treatment reduced the impact of the illness, and by supporting parents in different ways during the learning process, health care professionals can promote the parents' trajectory toward independency.
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Affiliation(s)
| | - Catarina Wallengren
- 2 Institute of Health and Care Sciences, the Sahlgrenska Academy at University of Gothenburg, Sweden
- 3 Centre for Person-Centred Care (GPCC), University of Gothenburg, Sweden
| | | | - Carina Sparud-Lundin
- 2 Institute of Health and Care Sciences, the Sahlgrenska Academy at University of Gothenburg, Sweden
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21
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Attempting to remedy sub-optimal medication adherence in haemophilia: The rationale for repeated ultrasound visualisations of the patient's joint status. Blood Rev 2018; 33:106-116. [PMID: 30146094 DOI: 10.1016/j.blre.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 07/14/2018] [Accepted: 08/17/2018] [Indexed: 01/01/2023]
Abstract
Haemophilia is marked by joint bleeding (haemarthrosis) leading to cartilage damage (arthropathy). Lifelong prophylaxis-initiated after the first bleeding episode-leads to a dramatic decrease in arthropathy in haemophilia patients. However, adherence to continuous intravenous administrations of factor VIII (FVIII) or FIX products is challenging, and patients potentially suffer from breakthrough bleedings while on prophylaxis. Newer FVIII/FIX products with enhanced convenience attributes and/or easier infusion procedures are intended to improve adherence. However, pharmacokinetic data should be harmonised with information from individual attitudes and treatment needs, to tailor intravenous dosing and scheduling in patients who receive extended half-life products. Nor is there sound evidence as to how subcutaneous non-FVIII/FIX replacement approaches (concizumab; emicizumab; fitusiran) or single intravenous injections of adeno-associated viral vectors (when employing gene therapy) will revolutionize adherence in haemophilia. In rheumatoid arthritis, repeated ultrasound examination of a patient's major joints is a valuable tool to educate patients and parents to understand the disease and provide an objective framework for clinicians to acknowledge patient's adherence. Joint ultrasound examination in haemophilia significantly correlates with cartilage damage, effusion, and synovial hypertrophy evaluated by magnetic resonance imaging. Furthermore, in patients with haemophilia undergoing prophylaxis with an extended half-life product for a ≈ 2.8 year period, a significant continued improvement in joint health is detected at the physical examination. This provides the rationale for studies on repeated ultrasound examinations of joint status to attempt to remedy sub-optimal medication adherence and help identify which approach is most suited on which occasion and for which patient.
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Schleicher C, Heine S, Graf N, von Mackensen S, Eichler H. Feasibility and Results of a Mobile Haemophilia Outpatient Care Pilot Project. Hamostaseologie 2018; 38:129-140. [DOI: 10.1055/s-0038-1654721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Introduction Regular visits at haemophilia treatment centres (HTCs) in rural regions are often dependent on the access to a private car due to lack of or limited availability of public means. Therefore, a mobile haemophilia outpatient care (MHOC) concept providing home visits to haemophilia patients has been developed by the Saarland HTC, which is located in a rural German region.
Methods Haemophilia patients and their parents were home visited at least twice (baseline, follow-up) by trained medical staff. Socio-demographic and clinical data were collected and interviews were performed asking the patients and parents about their needs and expectations towards such a MHOC.
Results Seventy-nine patients were enrolled (56 adults, 23 children), 62.0% severely affected, 48.1% on prophylaxis, with a mean age of 37.4 ± 16.4 years (17–78) and 9.8 ± 4.2 years (3–16), respectively. Median travel distance to the HTC was 43.5 km (3–200). Note that 92.4% considered an intense binding to the HTC and a MHOC concept as ‘rather/very important’ (88.6%). They expected from a MHOC to provide consulting and educating activities, support in elderhood issues and treatment. For 35.4%, a MHOC could currently provide additional support, mainly due to patient's immobility and need of consultancy. They mainly used services in terms of consultancy in social–legal affairs and support in contacting authorities.
Conclusion The results of this study support the hypothesis that a MHOC concept is a needful supplement in haemophilia comprehensive care and will improve the challenging haemophilia treatment, especially for those with limited access to HTCs or with disabilities.
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Affiliation(s)
- Christian Schleicher
- Institute of Clinical Hemostaseology and Transfusion Medicine/European Hemophilia Comprehensive Care Center, Saarland University Hospital, Homburg/Saar, Germany
| | - Sabine Heine
- Department for Pediatric Oncology and Hematology/European Hemophilia Comprehensive Care Center, Saarland University Hospital, Homburg/Saar, Germany
| | - Norbert Graf
- Department for Pediatric Oncology and Hematology/European Hemophilia Comprehensive Care Center, Saarland University Hospital, Homburg/Saar, Germany
| | - Sylvia von Mackensen
- Department for Medical Psychology, University Medical Center Hamburg–Eppendorf, University of Hamburg, Hamburg, Germany
| | - Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine/European Hemophilia Comprehensive Care Center, Saarland University Hospital, Homburg/Saar, Germany
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Morfini M, Gherardini S. Pharmacokinetic-based prediction of real-life dosing of extended half-life clotting factor concentrates on hemophilia. Ther Adv Hematol 2018; 9:149-162. [PMID: 29899890 PMCID: PMC5992810 DOI: 10.1177/2040620718774258] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/09/2018] [Indexed: 01/12/2023] Open
Abstract
The improvement of clotting factor concentrates (CFCs) has undergone an impressive boost during the last six years. Since 2010, several new recombinant factor (rF)VIII/IX concentrates entered phase I/II/III clinical trials. The improvements are related to the culture of human embryonic kidney (HEK) cells, post-translational glycosylation, PEGylation, and co-expression of the fragment crystallizable (Fc) region of immunoglobulin (Ig)G1 or albumin genes in the manufacturing procedures. The extended half-life (EHL) CFCs allow an increase of the interval between bolus administrations during prophylaxis, a very important advantage for patients with difficulties in venous access. Although the inhibitor risk has not been fully established, phase III studies have provided standard prophylaxis protocols, which, compared with on-demand treatment, have achieved very low annualized bleeding rates (ABRs). The key pharmacokinetics (PK) parameter to tailor patient therapy is clearance, which is more reliable than the half-life of CFCs; the clearance considers the decay rate of the drug concentration-time profile, while the half-life considers only the half concentration of the drug at a given time. To tailor the prophylaxis of hemophilia patients in real-life, we propose two formulae (expressed in terms of the clearance, trough and dose interval between prophylaxis), respectively based on the one- and two-compartmental models (CMs), for the prediction of the optimal single dose of EHL CFCs. Once the data from the time decay of the CFCs are fitted by the one- or two-CMs after an individual PK analysis, such formulae provide to the treater the optimal trade-off among trough and time-intervals between boluses. In this way, a sufficiently long time-interval between bolus administration could be guaranteed for a wider class of patients, with a preassigned level of the trough. Finally, a PK approach using repeated dosing is discussed, and some examples with new EHL CFCs are shown.
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Affiliation(s)
| | - Stefano Gherardini
- Department of Physics and Astronomy, LENS, and
QSTAR, University of Florence, Sesto Fiorentino (Italy)
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24
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Na JH, Yoo KY, Kim JY, Park SK, Kim SK, Choi EJ. Educational Interventions to Enhance Adherence to Prophylactic Treatment in Korean Hemophilia Patients. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2018. [DOI: 10.15264/cpho.2018.25.1.38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Ji Hyun Na
- Department of Pediatrics, Daegu Catholic University School of Medicine, Daegu, Korea
| | | | - Ji Yoon Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Sang Kyu Park
- Department of Pediatrics, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soon Ki Kim
- Department of Pediatrics,Inha University College of Medicine, Incheon, Korea
| | - Eun Jin Choi
- Department of Pediatrics, Daegu Catholic University School of Medicine, Daegu, Korea
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Skinner MW, Chai-Adisaksopha C, Curtis R, Frick N, Nichol M, Noone D, O'Mahony B, Page D, Stonebraker JS, Iorio A. The Patient Reported Outcomes, Burdens and Experiences (PROBE) Project: development and evaluation of a questionnaire assessing patient reported outcomes in people with haemophilia. Pilot Feasibility Stud 2018; 4:58. [PMID: 29497561 PMCID: PMC5828307 DOI: 10.1186/s40814-018-0253-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 02/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background The interest of health care agencies, private payers and policy makers for patient-reported outcomes (PRO) is continuously increasing. There is a substantial need to improve capacity to collect and interpret relevant PRO data to support implementation of patient-centered research and optimal care in haemophilia. The Patient Reported Outcomes, Burdens and Experiences (PROBE) Project aims to develop a patient-led research network, to develop a standardized questionnaire to gather patient-reported outcomes and to perform a feasibility study of implementing the PROBE questionnaire. Methods A pilot questionnaire was developed using focus group methodology. Content and face validity were assessed by a pool of persons living with haemophilia (PWH) and content experts through interactive workshops. The PROBE questionnaire was translated with the forward-backward approach. PROBE recruited national haemophilia patient non-governmental organizations (NGOs) to administer the questionnaire to people with and without haemophilia. PROBE measured the time to complete the questionnaire and gathered feedback on its content and clarity; staff time and cost required to implement the questionnaire were also collected. Results The PROBE questionnaire is comprised of four major sections (demographic data, general health problems, haemophilia-related health problems and health-related quality of life using EQ-5D-5L and EQ-VAS). Seventeen NGOs participated in the pilot study of the PROBE Project, recruiting 656 participants. Of these, 71% completed the questionnaire within 15 min, and all participants completed within 30 min. The median total staff and volunteer time required for the NGOs to carry out the study within their country was 9 h (range 2 to 40 h). NGO costs ranged from $22.00 to $543.00 USD per country, with printing and postage being the most commonly reported expenditures. Conclusions The PROBE questionnaire assesses patient-important reported outcomes in PWH and control participants, with a demonstrated short completion time. PROBE proved the feasibility to engage diverse patient communities in the structured generation of real-world outcome research at all stages. Trial registration Trial registration: NCT02439710. Electronic supplementary material The online version of this article (10.1186/s40814-018-0253-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M W Skinner
- Institute for Policy Advancement Ltd, 1155 23rd Street NW #3A, Washington, DC 20037 USA
| | - C Chai-Adisaksopha
- 2Department of Medicine, McMaster University, Hamilton, Canada.,10Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - R Curtis
- Factor VIII Computing, Berkeley, USA
| | - N Frick
- 4National Hemophilia Foundation, New York, USA
| | - M Nichol
- 5Sol Price School of Public Policy, University of Southern California, Los Angeles, USA
| | - D Noone
- Irish Haemophilia Society, Dublin, Ireland
| | - B O'Mahony
- Irish Haemophilia Society, Dublin, Ireland.,7Trinity College Dublin, Dublin, Ireland
| | - D Page
- 8Canadian Hemophilia Society, Montreal, Canada
| | - J S Stonebraker
- 9Poole College of Management, North Carolina State University, Raleigh, USA
| | - A Iorio
- 2Department of Medicine, McMaster University, Hamilton, Canada.,10Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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Rangarajan S, Walsh L, Lester W, Perry D, Madan B, Laffan M, Yu H, Vettermann C, Pierce GF, Wong WY, Pasi KJ. AAV5-Factor VIII Gene Transfer in Severe Hemophilia A. N Engl J Med 2017; 377:2519-2530. [PMID: 29224506 DOI: 10.1056/nejmoa1708483] [Citation(s) in RCA: 467] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with hemophilia A rely on exogenous factor VIII to prevent bleeding in joints, soft tissue, and the central nervous system. Although successful gene transfer has been reported in patients with hemophilia B, the large size of the factor VIII coding region has precluded improved outcomes with gene therapy in patients with hemophilia A. METHODS We infused a single intravenous dose of a codon-optimized adeno-associated virus serotype 5 (AAV5) vector encoding a B-domain-deleted human factor VIII (AAV5-hFVIII-SQ) in nine men with severe hemophilia A. Participants were enrolled sequentially into one of three dose cohorts (low dose [one participant], intermediate dose [one participant], and high dose [seven participants]) and were followed through 52 weeks. RESULTS Factor VIII activity levels remained at 3 IU or less per deciliter in the recipients of the low or intermediate dose. In the high-dose cohort, the factor VIII activity level was more than 5 IU per deciliter between weeks 2 and 9 after gene transfer in all seven participants, and the level in six participants increased to a normal value (>50 IU per deciliter) that was maintained at 1 year after receipt of the dose. In the high-dose cohort, the median annualized bleeding rate among participants who had previously received prophylactic therapy decreased from 16 events before the study to 1 event after gene transfer, and factor VIII use for participant-reported bleeding ceased in all the participants in this cohort by week 22. The primary adverse event was an elevation in the serum alanine aminotransferase level to 1.5 times the upper limit of the normal range or less. Progression of preexisting chronic arthropathy in one participant was the only serious adverse event. No neutralizing antibodies to factor VIII were detected. CONCLUSIONS The infusion of AAV5-hFVIII-SQ was associated with the sustained normalization of factor VIII activity level over a period of 1 year in six of seven participants who received a high dose, with stabilization of hemostasis and a profound reduction in factor VIII use in all seven participants. In this small study, no safety events were noted, but no safety conclusions can be drawn. (Funded by BioMarin Pharmaceutical; ClinicalTrials.gov number, NCT02576795 ; EudraCT number, 2014-003880-38 .).
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Affiliation(s)
- Savita Rangarajan
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - Liron Walsh
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - Will Lester
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - David Perry
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - Bella Madan
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - Michael Laffan
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - Hua Yu
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - Christian Vettermann
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - Glenn F Pierce
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - Wing Y Wong
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
| | - K John Pasi
- From Hampshire Hospitals NHS Foundation Trust, Basingstoke (S.R.), University Hospitals Birmingham NHS Foundation Trust, Edgbaston (W.L.), Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge (D.P.), and the Centre for Haemostasis and Thrombosis, St. Thomas' Hospital (B.M.), Imperial College London and NIHR Clinical Research Facility at Imperial College Healthcare NHS Trust (M.L.), and Barts and the London School of Medicine and Dentistry (K.J.P.), London - all in the United Kingdom; and BioMarin Pharmaceutical, Novato (L.W., H.Y., C.V., W.Y.W.), and private consultant, La Jolla (G.F.P.) - both in California
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Bonanad S, Schulz M, Gordo A, Spurden D, Cicchetti M, Cappelleri JC, Tolley C, Staunton H, Brohan E. HaemoPREF: Further evaluation of patient perception and preference for treatment in a real world setting. Haemophilia 2017; 23:884-893. [PMID: 28925586 DOI: 10.1111/hae.13321] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Adherence to haemophilia A (HA) treatment may be influenced by patients' beliefs about their condition and treatment. Furthermore, difficulties administering treatment may lead to poor adherence. New treatment strategies aim to reduce the burden associated with administration and to improve patient perception of treatment, which, in turn, increase adherence levels. AIMS This study aimed to examine patient perception of HA treatment and related factors using patient-reported outcome (PRO) questionnaires and to confirm the psychometric properties of a recently developed questionnaire, the HaemoPREF. METHODS A non-interventional, cross-sectional, questionnaire study was conducted with adult HA patients in Spain (n=31), Germany (n=10) and Italy (n=48), who were using ReFacto AF with the FuseNGo administration device. Patients completed the HaemoPREF and other questionnaires measuring related constructs: treatment adherence, satisfaction and well-being, online at two time points. Correlational, regression and psychometric analyses were conducted. RESULTS PRO scores indicated that patients are satisfied with and adherent to their treatment. Multivariate regression of the HaemoPREF global score identified a number of significant predictors (P≤.05). The HaemoPREF Global Score had a moderate relationship with subscales on the related questionnaires (mean correlation=0.43; range=0.39-0.48). The HaemoPREF demonstrated good test-retest reliability (intraclass correlation coefficient=0.82), internal consistency reliability (Cronbach's alpha range=0.69-0.82) and convergent validity with measures of treatment satisfaction (Spearman correlation coefficient, r=.48) and well-being (r=.41). CONCLUSION The findings suggest that patients using ReFacto AF with FuseNGo were satisfied with and adherent to their treatment. The HaemoPREF can identify important concepts relating to patient treatment experience in HA.
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Affiliation(s)
- S Bonanad
- Haematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Schulz
- Pfizer Pharma GmbH, Berlin, Germany
| | - A Gordo
- Lab.Pfizer, Lda, Porto Salvo, Portugal
| | | | - M Cicchetti
- A Parexel Company, Execupharm, Groton, CT, USA
| | | | - C Tolley
- Adelphi Values, Bollington, Cheshire, UK
| | - H Staunton
- Adelphi Values, Bollington, Cheshire, UK
| | - E Brohan
- Adelphi Values, Bollington, Cheshire, UK
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