Differences between developed and developing countries in paediatric care in haemophilia

Patient-relevant health outcomes for hemophilia care: Development of an international standard outcomes set

BACKGROUND

Patient-relevant health outcomes for persons with hemophilia should be identified and prioritized to optimize and individualize care for persons with hemophilia. Therefore, an international group of persons with hemophilia and multidisciplinary health care providers set out to identify a globally applicable standard set of health outcomes relevant to all individuals with hemophilia.

METHODS

A systematic literature search was performed to identify possible health outcomes and risk adjustment variables. Persons with hemophilia and multidisciplinary health care providers were involved in an iterative nominal consensus process to select the most important health outcomes and risk adjustment variables for persons with hemophilia. Recommendations were made for outcome measurement instruments.

RESULTS

Persons with hemophilia were defined as all men and women with an X-linked inherited bleeding disorder caused by a deficiency of coagulation factor VIII or IX with plasma activity levels <40 IU/dL. We recommend collecting the following 10 health outcomes at least annually, if applicable: (i) cure, (ii) impact of disease on life expectancy, (iii) ability to engage in normal daily activities, (iv) severe bleeding episodes, (v) number of days lost from school or work, (vi) chronic pain, (vii) disease and treatment complications, (viii) sustainability of physical functioning, (ix) social functioning, and (x) mental health. Validated clinical as well as patient-reported outcome measurement instruments were endorsed. Demographic factors, baseline clinical factors, and treatment factors were identified as risk-adjustment variables.

CONCLUSION

A consensus-based international set of health outcomes relevant to all persons with hemophilia, and corresponding measurement instruments, was identified for use in clinical care to facilitate harmonized longitudinal monitoring and comparison of outcomes.

How to implement medical and patient associations in low-income countries: A proposition from the African French Alliance for the Treatment of Haemophilia (AFATH)

INTRODUCTION

There is a lack of joint recommendations by healthcare professionals (HCP) and patient organizations when a partnership between high and low-income countries in the field of haemophilia is planned.

AIM

To draft recommendations to clarify the methodology when a partnership between low- and high-income countries is planned with the objective of a long-term implication. This methodology is to be implemented for fulfilling both medical and associative aims.

METHODS

Based on the available literature, a first document was written, then diffused to AFATH (Alliance Franco-Africaine pour le Traitement de l'Hémophilie) members, and after a one-day meeting and further amendments, a second draft was approved by all members before submission for publication.

RESULTS

Based on 6 years experience, several recommendations regarding the joint and separate roles of patient association and HCP for a first mission in French-speaking sub-Saharan African countries have been established. The proposed methodology for establishing preliminary contacts, the first visit and the key points for diagnostic action, medical follow-up, patient education and advocacy strategy outlines a model of partnership between patients and HCP.

CONCLUSION

This paper written jointly by patients and physicians underlines the importance of reciprocal expert guidance and a partnership based on complementary inputs.

A challenging management of hemophilia B patient with inhibitors undergoing major orthopedic surgeries in a resource-constrained country

In this paper, we report a life-threatening condition and relate our experience in managing a hemophilia B patient who required three surgical procedures, highlighting the difficulties we encountered in our setting and propose some tangible.

Hemophilia gene therapy-New country initiatives

Gene therapy is an opportunity for haemophilia patients to receive a one-time treatment and have lasting factor levels for years or decades instead of dependence on repeated administration within short intervals and on sustained supply of drug. Great strides have been made in the development of gene therapy for haemophilia in the last decade. Adeno-associated virus (AAV) vector-mediated gene transfer in haemophilia A and B has entered the phase III trial stage. Gene transfer by lentiviral vector or gene editing technologies using factor VIII (FVIII) or IX (FIX) genes are now entering clinical evaluation. It is expected that the first FVIII and FIX gene therapy products will soon be approved and distributed in major markets. Global access to gene therapy is a critical goal. This review presents new and ongoing efforts towards this goal in countries other than North America and Europe. In Japan, researchers, regulators and funders have established a promising gene therapy development platform for multiple diseases including haemophilia. Decades of scientific and clinical research in haemophilia gene therapy in China have led to a recently registered clinical trial of AAV-mediated gene therapy for haemophilia B. Other countries are in earlier phases of building gene therapy programmes or participate in international trials. A phase 2 feasibility trial of AAV-mediated FIX gene therapy in low- and middle-income countries aims to demonstrate that gene therapy could become available in resource-constrained socio-economic settings. The different strategies for establishing gene therapy provide opportunities for closing the global gap in haemophilia care.

Exploring regional variations in the cross-cultural, international implementation of the Patient Reported Outcomes Burdens and Experience (PROBE) study

BACKGROUND

The Patient Reported Outcomes Burdens and Experience (PROBE) study has developed and validated the PROBE questionnaire for assessing patient-reported outcomes in people with haemophilia and participants without bleeding disorders.

OBJECTIVE

To explore the regional variations in the international implementation of the PROBE questionnaire.

METHODS

Data were collected from participants in four regions (Western Pacific, South America, North America and Europe). Participants were able to choose English or translated versions of the PROBE questionnaire into their first language. We used analysis of variance methods and multivariable regression to determine the relative contribution of the variance explained by region controlling for haemophilia diagnosis, age group and levels of educations. We also explored interactions between region and the other components.

RESULTS

We used 862 questionnaires from 14 countries. Mean age of participants was 40.03 years (standard deviation 13.89), and 73.67% were male. After adjusting, region contributed 0.44%-7.98% of the variance component in subitem scores and 0.26% in the PROBE score. Years of education contributed 0.34% in the PROBE score. Age and haemophilia diagnosis contributed 3.42% and 22.42% of the PROBE score.

CONCLUSIONS

The results demonstrate that the PROBE questionnaire is valid to implement for assessing health status among patients with haemophilia and participants without bleeding disorders across regions.

Clinical outcomes of arthroscopic synovectomy for adolescent or young adult patients with advanced haemophilic arthropathy

The aim of the present study was to assess the clinical outcomes of arthroscopic synovectomy in adolescent or young adult patients with advanced haemophilic arthropathy. From January 2009-January 2012, clinical data from 11 adolescent or young adult patients with advanced haemophilic arthropathy who were treated with arthroscopic synovectomy were retrospectively collected. The mean follow-up period was 71.91±5.28 months. The evaluated indicators included frequency of joint bleeding, range of motion (ROM), X-ray staging, hospital for special surgery (HSS) knee score and HSS pain scores. Joint bleeding frequency, pain degree and HSS scores significantly improved following arthroscopic synovectomy at the end of the follow up period. The ROM did not significantly improve. Among the 11 patients, radiographic stage remained unchanged in 9 cases whereas the remaining 2 cases progressed from stage IV to stage V. No patients required total knee arthroplasty through the end of the follow-up period. These findings suggested that arthroscopic synovectomy appears to an effective treatment option to decrease the frequency of bleeding and knee pain, improve knee function and delay knee joint arthroplasty to a certain extent for adolescent or young adult patients with advanced haemophilic knee arthropathy.

The role of patient and healthcare professionals in the era of new hemophilia treatments in developed and developing countries

Medical decisions in hemophilia care are primarily related to the type of factor replacement and treatment regimen. With the growing number of treatment options for patients with hemophilia, decision making is more complex and requires careful consideration of benefits, risks, and patient goals. Shared decision making and decision-aid tools facilitate patient and healthcare provider communication. In this review, the overall role of shared decision making in medicine is outlined, with special emphasis on models for practical implementation. Examples of shared decision making in hemophilia are outlined, and application to new therapeutics is discussed through a case-based approach.

Care models in the management of haemophilia: a systematic review

BACKGROUND

Haemophilia care is commonly provided via multidisciplinary specialized management. To date, there has been no systematic assessment of the impact of haemophilia care delivery models on patient-important outcomes.

OBJECTIVE

To conduct a systematic review of published studies assessing the effects of the integrated care model for persons with haemophilia (PWH).

SEARCH METHODS

We searched MEDLINE, EMBASE and CINAHL up to April 22, 2015, contacted experts in the field, and reviewed reference lists.

SELECTION CRITERIA

Randomized and non-randomized studies of PWH or carriers, focusing mainly on the assessment of care models on delivery.

DATA COLLECTION AND ANALYSIS

Two investigators independently screened title, abstract, and full text of retrieved articles for inclusion. Risk of bias and overall quality of evidence was assessed using Cochrane's ACROBAT-NRSI tool and GRADE respectively. Relative risks, mean differences, proportions, and means and their variability were calculated as appropriate.

RESULTS

27 non-randomized studies were included: eight comparative and 19 non-comparative studies. We found low- to very low-quality evidence that in comparison to other models of care, integrated care may reduce mortality, hospitalizations and emergency room visits, may lead to fewer missed days of school and work, and may increase knowledge seeking.

CONCLUSION

Our comprehensive review found low- to very low-quality evidence from a limited number of non-randomized studies assessing the impact of haemophilia care models on some patient-important outcomes. While the available evidence suggests that adoption of the integrated care model may provide benefit to PWH, further high-quality research in the field is needed.

Functional outcome of total knee arthroplasty in patients with haemophilia

INTRODUCTION

Haemophilic arthropathy (HA) is a debilitating complication of haemophilia which leads to TKA in severe cases.

AIM

We conducted a prospective study of the outcome of TKA in our haemophilia cohort to define the outcomes in this population and increase the cost effectiveness of the procedure in our developing country.

METHODS

We reviewed patients with haemophilia who underwent TKA between April 2010 and April 2014. Patients with at least 6 months of follow-up were included. Preoperative knee scores (KSS and WOMAC) and the scores of the quality of life were recorded. Radiographic indices were registered pre- and postoperatively. Any complications were recorded. The patients underwent TKA with medial parapatellar approach. We had a low threshold for quadriceps snip when exposure was difficult. As our routine we did not use suction drains postoperatively.

RESULTS

We included 83 patients (all males, 103 knees). The mean age of the patients was 35.8 years. The mean follow-up period was 45.1 months. Three patients (3.6%) had factor inhibitors. Twenty patients (24.1%) underwent bilateral simultaneous TKA. The mean admission time was 13.87 days. We had two cases of wound infection and one case of haematoma. None of our patients needed transfusion. All knee scores were significantly improved (P < 0.000).

CONCLUSION

Total knee replacement is an effective procedure in treatment of HA. Definition of standards of care for this procedure, which are tailored for resources of a developing country, can have major impact in improving outcomes while maximizing cost effectiveness of this surgery.