Comprehensive care in hemophilia

Rapid recognition and optimal management of hemophilia in the emergency department: A quality improvement project

Objectives

This study aimed to assess the effectiveness of a continuous quality improvement initiative at the University of Florida Health Physicians practice in reducing the time to administer factor replacement therapy (FRT) for hemophilia patients presenting with bleeding in the emergency department (ED).

Methods

The study, a quasi-experimental, interventional design, was conducted between January 2020 and January 2023. The intervention, implemented in September 2021, involved training ED physicians, creating a specialized medication order set within the electronic health record (EHR), and a rapid triage system. The effectiveness was measured by comparing the time from ED arrival to factor administration before and after the intervention and benchmarking it against the National Bleeding Disorders Foundation's Medical and Scientific Advisory Council (MASAC)-recommended 1-hour timeline for factor administration. An interrupted time series (ITS) analysis with a generalized least squares model assessed the intervention's impact.

Results

A total of 43 ED visits (22 pre-intervention and 21 post-intervention) were recorded. Post-intervention, the average time from ED arrival to factor administration decreased from 5.63 to 3.15 hours. There was no significant increase (27% vs. 29%) in the patients receiving factor within 1-hour of ED arrival. The ITS analysis predicted a 20-hour reduction in the average quarterly time to administer factor by the end of the study, an 84% decrease.

Conclusions

The quality improvement program decreased the time to administer FRT for patients with hemophilia in the ED. However, the majority of patients did not achieve the 1-hour MASAC-recommended timeline for factor administration after ED arrival.

Current Status and Challenges in Delivering Comprehensive Care for Patients with Hemophilia

The importance of comprehensive care as a treatment strategy for patients with hemophilia is recognized worldwide. Comprehensive care entails addressing full spectrum of medical and psychological aspects impacting both patients and their families. The primary objective of comprehensive care for individuals with hemophilia is to enable them to lead their daily lives just as anyone else would. To achieve this goal, it is necessary to have a positive and collaborative approach across various healthcare disciplines. This extends beyond clinical specialists, encompassing pediatricians, hematologists, orthopedic surgeons, dental and oral surgeons, gynecologists, nurses, physical therapists, clinical psychologists, and other professionals from diverse fields. This review article discusses the current status and challenges associated with comprehensive care for patients with hemophilia. We categorize these challenges as follows: hemophilic arthritis, rehabilitation, oral care, transitioning from pediatric to adult care, addressing carrier issues, and providing psychological care. There is still substantial work to be undertaken in addressing these hurdles and advancing the quality of comprehensive care for hemophilia patients.

Judicialization of coagulation factors in severe hemophilia: compliance with the care protocol and associated factors Judicialization and severe hemophilia

OBJECTIVE

This study aimed to analyze the compliance with the assistance protocol and factors associated with the judicialization of coagulation factors in severe hemophilia patients.

METHODS

A retrospective, cross-sectional study was conducted from June 2015 to May 2016 in adults with severe hemophilia in the Federal District, Brazil using data from their medical records and the Hemovida Web Coagulopathies System.

RESULTS

One-hundred and three patients from Federal District, the capital of Brazil, were included in the study. The mean age of the patients was 34.6±10.1. Ninety-three received prophylactic treatment (90.3%) and 53 received recombinant coagulation factors (51.7%). Judicialization occurred in 21 cases (20.4%), 13 of whom disagreed with the assistance protocol (12.6%). In the univariate analysis, an association was observed between reduced judicialization and treatment (4.8 vs. 47.6%; p<0.001) in the hemophilia treatment center and an increase that was associated with use of the recombinant coagulation factor in disagreement with the protocol (38.1 vs. 6.1%; p<0.001). In the multivariate analysis, the odds ratio for judicialization was 0.081 (95% confidence interval [CI] 0.010-0.055) for treatment at the hemophilia treatment center and 5.067 (95%CI 1.392-18.446) for the use of recombinant coagulation factor not in compliance with the protocol. More inhibitor development in judicialized patients (33.3 vs. 4.9%; p<0.001) was found.

CONCLUSIONS

The effectiveness of judicialization should be questioned, especially regarding coagulation factor prescriptions that are not in compliance with the protocol. The expense resulting from judicialization has not shown any benefit, and an even greater development of inhibitors during treatment in judicialized patients was found.

The Need for Comprehensive Care for Persons with Chronic Immune Thrombocytopenic Purpura

Chronic platelet disorders (CPD), including chronic immune thrombocytopenic purpura (cITP), thrombotic thrombocytopenic purpura (TTP) and platelet function disorders are among the most common bleeding disorders and are associated with morbidity and mortality. The clinical phenotype and complexity of cITP is much like that of hemophilia. In cITP and hemophilia, bleeding is problematic for many, complicating employability, insurability and overall quality-of-life (QoL). While myriad drug therapies are available for cITP and hemophilia, each are variable in their effectiveness, very few (except for clotting factor concentrates for hemophilia) alter the natural history of the disorder and sometimes contribute to specific morbidities and mortality. Like in hemophilia, the management of cITP is not solely based on access to effective treatment but also includes accurate diagnosis and comprehensive care by a multidisciplinary team of specialists trained in the management of bleeding disorders. The model of comprehensive care in Hemophilia Treatment Centers (HTCs) has been recognized as highly effective, improving life expectancy for persons with hemophilia. cITP, and other CPDs, are complex disorders requiring specialized care. However, an integrated care model with a systematic and reliable population-based surveillance program does not exist. Extending the Comprehensive Care model with all its related benefits to the community of persons with cITP is sorely needed. This review will focus on cITP as a prototype chronic platelet disorder that could benefit greatly from the Comprehensive Care model.

Pilot trial of semi-automated medical note writing using lexeme hypotheses

Clinicians write a billion free text notes per year. These notes are typically replete with errors of all types. No established automated method can extract data from this treasure trove. The practice of medicine therefore remains haphazard and chaotic, resulting in vast economic waste. The lexeme hypotheses are based on our analysis of how records are created. They enable a computer system to predict what issue a clinician will need to address next, based on the environment in which the clinician is working, and what responses the clinician has selected to date. The system uses a lexicon storing the issues (queries) and a range of responses to the issues. When the clinician selects a response, a text fragment is added to the output file. In the first phase of this work, the notes of 69 returning hemophilia patients were scrutinized, and the lexicon was expanded to 847 lexeme queries and 7995 responses to enable the construction of completed notes. The quality of lexeme-generated notes from 20 consecutive subjects was then compared to the clinicians' conventional clinic notes. The system generated grammatically correct notes. In comparison to the traditional clinic note, the lexeme-generated notes were more complete (88 % compared with 62 %), and had less typographical and grammatical errors (0.8 versus 3.5 errors per note). The system notes and traditional notes averaged about 800 words, but the traditional notes had a much wider distribution of lengths. The note-creation rate from marshalling the data to completion using the system averaged 80 wpm, twice as fast as the typical clinician can type. The lexeme method generates more complete, grammatical and organized notes faster than traditional methods. The notes are completely computerized at inception, and they incorporate prompts for clinicians to address otherwise overlooked items. This pilot justifies further exploration of this methodology.

Challenges facing community-dwelling adults with hemophilia: Implications for community-based adult education and nursing

Community-dwelling adults are members of society residing in community settings. Community-based adult education is designed for local residents and groups, to enable them to improve their quality of life within their community. Hemophilia is a bleeding disorder that can be inherited or acquired. World Hemophilia Day 2018 helped to raise awareness about the importance of sharing knowledge and the experience of hemophilia, as well as to improve access to care and treatment among people with this bleeding disorder. We used the documentary method of research, which has been adopted in recent review articles, to collect and analyze the findings of published literature on hemophilia. Our results showed that community-dwelling adults with hemophilia have concerns that merit the attention of government and non-governmental agencies. Some challenges faced by many community-dwelling adults with hemophilia include the cost of treatment and employment challenges. Herein, we discuss the implications for community-based health education and nursing with respect to patient care, adult education, nursing education, management, research, and policy. Finally, the authors note that sustainable efforts are needed in the provision of local, national and international leadership and educational resources to improve and sustain health care for community-dwelling adults with hemophilia.

Impact of the 340B Pharmacy Program on Services and Supports for Persons Served by Hemophilia Treatment Centers in the United States

Purpose Hemophilia Treatment Centers (HTCs) provide integrated and comprehensive services to individuals affected with rare bleeding disorders, such as hemophilia and Von Willebrand disease. Through the 340 Drug Pricing Program, HTCs may use pharmacy income to support clinical staff and patient services. The objective of this study was to describe the impact of the 340B program funding on services and support provided by HTCs to persons affected by rare bleeding disorders. Description Federally designated comprehensive HTCs with established 340B programs were invited to participate in a mailed survey in 2014. Participants were requested to report on 340B program-funded staff and services in the calendar year 2013. Assessment The 31 of 37 HTCs responding served over 10,000 individuals, or one-third of the national HTC patient population. The majority of responding HTCs reported that 340B program income supported over 90% of staff such as nurses, social workers, and physical therapists. Conclusion The results from this survey of 31 centers with established programs demonstrates the HTCs' reliance on 340B program support for vital comprehensive services, that are otherwise non-reimbursable, and highlights the importance of the 340B program in sustaining the high quality of care and in increasing access for a geographically dispersed, medically vulnerable population.

Management of Haemophilia in Developing Countries: Challenges and Options

There are significant challenges in managing haemophilia patients in developing countries. These challenges are (i) Lack of proper health care infrastructure and human resources suitable for haemophilia care (ii) Competing health care priorities of the government. (iii) Lack of penetrance of medical insurance in the population. (iv) Lesser visibility of the haemophilia patients in health care system (v) Low awareness across the medical profession, population and the policy makers about the condition (vi) Non availability of factor concentrates (vii) Inadequate utilization of knowledge for reducing factor concentrate use. (viii) Inadequate pain relief (ix) Challenges due to inhibitor developing (x) Viral hepatitis & (xi) Lack of research publications relevant to the country are some of the challenges faced by PWH for their management in developing country. The solutions are not easy but development of a strong patient organization with linkages with World Federation of Haemophilia is an important initial step. Following that internal and international twinning, use of internal sources, strong advocacy programme targeting government, doctors, opinion makers will solve many of the challenges in the time to come.

Global Emerging HEmophilia Panel (GEHEP): A Multinational Collaboration for Advancing Hemophilia Research and Treatment

GEHEP, established in 2009, is an independent, multi-institutional, international consortium of early career hematology specialists in the field of hemophilia and other inherited bleeding disorders. The main objective of the group, whose members practice at institutions in North America, Europe, and South Africa, is to advance hemophilia care by providing a forum for mentored collaborative research, developing programs for improving clinical care, and promoting academic career development of junior faculty. GEHEP members collect and document anonymized data on intra- and interinstitutional differences in patient populations, diagnosis, and treatment in the field of hemophilia and other bleeding disorders. To facilitate sharing of aggregated data among GEHEP members, a global protocol was developed and approved by most members' local institutional review board. Current GEHEP research initiatives are varied, encompassing work in pediatric and adult patients. GEHEP members have presented research at international meetings on the initiation of prophylaxis in children, use of immune tolerance induction in adults, and prevalence of acute coronary syndromes in older patients with hemophilia. The main goal of the continuing work of GEHEP is to advance the care of patients with hemophilia worldwide.