Intravitreal Dexamethasone as a Rescue for Anti-Vascular Endothelial Growth Factor Therapy in Neovascular Age-Related Macular Degeneration with Persistent Disease Activity and High Treatment Demand

Purpose: To assess the impact of switching to, or adding, an intravitreal dexamethasone implant (Dex; Ozurdex®) in anti-vascular endothelial growth factor (VEGF) therapy on disease stability and treatment intervals in eyes with neovascular age-related macular degeneration (nAMD) and persistent disease activity and high treatment demand. Methods: This retrospective noncomparative multicenter longitudinal case series included pseudophakic eyes with nAMD and persistent retinal fluid despite regular anti-VEGF therapy (ranibizumab or aflibercept) that received at least 1 intravitreal Dex implant. Visual acuity, central retinal thickness (CRT), and intraocular pressure were recorded before, and after, the addition of Dex to anti-VEGF therapy. Results: Sixteen eyes of 16 patients met the inclusion criteria of persistent fluid despite anti-VEGF therapy, under treatment intervals of ≤7 weeks in 14 instances. Patients were 80.9 ± 7.4 years old and had received 25.5 ± 17.4 anti-VEGF injections before Dex over a period of 36.4 ± 21.9 months before switching. The treatment interval increased from 5.5 ± 3.2 weeks between the last anti-VEGF and first Dex injection to 11.7 ± 7.3 weeks thereafter (P = 0.022). CRT remained stable (385.3 ± 152.1, 383.9 ± 129.7, and 458.3 ± 155.2 μm before switching as well as 12 and 24 months after switching; P = 0.78 and P = 0.36, respectively). An insignificant mean short-term early increase in visual acuity was not sustained over time. Conclusions: The addition of Dex resulted in a relevant and sustained increase in treatment intervals, whereas CRT and visual acuity remained stable in these difficult-to-treat eyes. It may be discussed whether inflammation or other steroid-responsive factors play a significant role in cases of nAMD with nonsatisfactory responses to anti-VEGF.

Negotiating treatment and managing expectations in chronic kidney disease: A qualitative study in Argentina

OBJECTIVES

To describe how patients with CKD negotiated assigned responsibilities in the management of their disease, resulting in potential relational nonadherence.

METHODS

Qualitative study performed in two healthcare facilities in Buenos Aires, Argentina, including 50 patients and 14 healthcare providers. We conducted semistructured interviews which were analysed using a frame of reference with concepts of Burden of Treatment and Cognitive Authority theories.

FINDINGS

Adherence to treatment defined "good patients". Patients needed to negotiate starting treatment, its modality and dialysis schedule, although most patients felt they did not participate in the decision process and that providers did not acknowledge implications of these decisions on their routine. Some patients skipped dialysis if concerns were not attended. Regularly, patients negotiated frequency of visits, doses, dietary restrictions and redefined relationships with their support networks, sometimes with devasting effects. As a result of overwhelming uncertainty some patients refused enrolling into a transplant program. When the frequency of complications increased, patients considered abandoning dialysis.

CONCLUSION

When patients perceived demands were excessive or conflicting, they entered into negotiations. Relationally induced nonadherence may arise when professionals do not or cannot enter into negotiations over patients' beliefs or knowledge about what is possible for them to do.

Becoming Experts in Their Own Treatment: Child and Caregiver Engagement With Burn Scar Treatments

Children who experience a severe burn injury not only require acute medical care but may also need ongoing rehabilitation. To mitigate the potential long-term consequences of scarring and the impact of scarring on their everyday lives, children may be expected to use a variety of time-consuming and multi-component non-invasive scar treatments (such as pressure garments and silicone gels). These treatments may pose unique challenges for children and their caregivers. With limited research previously addressing how Australian children navigate the use of scar treatments at home, this study aimed to develop a grounded theory of children and their caregivers' engagement with non-invasive burn scar treatments. Using a constructivist grounded theory approach, interviews were completed with 20 caregivers and 7 children, and a theory of children and their caregivers becoming experts in the use of non-invasive burn scar treatments was developed. Through persistence and flexibility, they continued to develop expertise. Engaging with scar treatments was an evolving process over time for children with burns and their caregivers. Theoretical categories identified included 'making it work', 'finding the balance' and 'seeking reassurance' and highlighted the remarkable strengths and adaptability of children and their caregivers. Through trial and error, children and their caregivers developed their own unique strategies for engaging with scar treatments. These insightful results may inform the development of interventions to support children and their caregivers' day-to-day engagement with non-invasive burn scar treatments and guide health professionals recommending these treatments.

Treatment Burden Discussion in Clinical Encounters: Priorities of COPD Patients, Carers and Physicians

Purpose

Many people with chronic obstructive pulmonary disease (COPD) feel overburdened with the treatment and management of their illness. Although research has begun to shed light on how COPD patients experience treatment burden, most of what we know is limited to personal experiences of patients. The aim of this study is to identify and prioritise areas of treatment burden that should be discussed during the clinical encounter from the perspectives of COPD patients, carers, and respiratory physicians.

Patients and Methods

Data were collected from participants using the nominal group technique. Five nominal group sessions were conducted in total (n = 31); three sessions with patients (n = 18), one with carers (n = 7) and another with respiratory physicians (pulmonologists or chest physicians) (n = 6). Each session was recorded and analyzed using thematic analysis.

Results

Going beyond understanding patients’ and carers’ experiences of treatment burden, this study offers a practical viewpoint of what should be discussed in a clinical encounter. Each group of participants contextualized treatment burden issues for discussion from their own perspectives. There was strong agreement, however, across the groups that difficulties accessing healthcare, lack of education and information, and worry about COPD treatment and prognosis were the most important treatment burden priorities for discussion.

Conclusion

Understanding and creating opportunities to discuss these issues in a clinical encounter is important in not only reducing treatment burden but also improving health outcomes and quality of life for COPD patients and their carers.

Qualitative interviews results from heart failure survey respondents on the interaction between symptoms and burden of self-care work

AIMS AND OBJECTIVES

Following a cross-sectional survey, a sub-sample of participants was interviewed to explore the interaction between symptoms and burden of treatment.

BACKGROUND

Burden of treatment considers both the work associated with illness and treatment, including self-care work, as well as the individuals' capabilities and resources to engage in that work. The recent survey revealed the existence of a complex interaction.

DESIGN

Qualitative abductive analysis of semi-structured interviews.

METHODS

Adults with heart failure who participated in the survey were purposely sampled and invited to participate in semi-structured interviews. Location and mode of interview varied by participant choice. Excerpts from the verbatim transcripts were assessed for interactions between symptoms and burden of treatment, and when identified these were characterised and explained. We followed COREQ checklist for reporting. The patient research ambassador group was involved from research design to dissemination.

RESULTS

Participants (n = 32) consistently discussed how symptoms altered their capability to engage in self-care work. As symptom intensity increased the difficultly of their self-care work increased. A number of intervening factors appeared to influence the relationship between symptoms and burden of treatment. Intervening factors included illness pathology, illness identity, the value of the tasks attempted and available support structures. These factors may change how symptoms and burden of treatment are perceived; a model was constructed to explain and summarise these interactions.

CONCLUSIONS

The interaction between symptoms and burden of treatment is complex. Intervening factors-illness identity and pathology, task value and performance, and available support structures-appear to exert a strong influence on the interaction between symptoms and burden of treatment.

RELEVANCE TO CLINICAL PRACTICE

These intervening factors present clinicians and researchers with opportunities to develop interventions that might reduce burden of treatment and improve symptoms and quality of life.

CLINICAL TRIAL REGISTRATION

SYMPACT was registered with ISRCTN registry: ISRCTN11011943.

Impact of Routines and Rituals on Burden of Treatment, Patient Training, Cognitive Load, and Anxiety in Self-Injected Biologic Therapy

BACKGROUND

Self-injection of biologics is a mainstay of chronic disease treatment, yet the process of self-injection often causes persistent apprehension and anxiety, distinct from needle phobia. While literature alludes to the role that routines and rituals play in self-injection, there is no comprehensive study on the routines and rituals self-injectors employ, nor of the process by which they are discovered and ingrained.

METHODS

We conducted a mixed-method, observational pilot ethnography study of 27 patients with plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis with and without prior biologic self-injection experience. Patients submitted self-made videos, photos, and projective exercises of an actual biologic self-injection and completed validated instruments to assess burden of treatment. Videos and photos containing routine and ritual elements were thematically categorized based on functional and emotional benefit, and analyzed for differences based on current biologic, dosing frequency, time on current biologic, and burden of treatment measures.

RESULTS

During patients' initial at-home injections, training gaps became apparent, leading to a process of experimentation aimed at reducing pain/anxiety, increasing confidence, and building a consistent injection process. Routines were present in 27/27 (100%) patients and anchored the time, place, and process for injection, and incorporated approved use steps for the injection device. Ritual elements served as emotional coping strategies for patients and were present in 21/27 (77.8%) of patients.

CONCLUSION

Our findings suggest that providing patients device training using adult learning principles, teaching routines and rituals concurrently, and providing at-home opportunities for practice with a device trainer may be useful strategies to reduce anxiety, avoid unnecessary experimentation, and improve adherence to injection therapy. While further studies are needed to generalize our findings, we posit that routine and ritual elements can be incorporated into existing patient-clinician interactions or novel digital interventions through mobile medical applications, smart training devices, and connected injection ecosystems.

"His first word was 'cream'." The burden of treatment in pediatric atopic dermatitis-A mixed methods study

The burden of treatment (BOT) is the workload of health care experienced by patients with chronic conditions and consequences on well-being. This study aimed to assess the BOT of atopic dermatitis (AD) on children and caregivers using mixed methods. The quantitative component of this mixed methods study involved the Treatment Burden Questionnaire. The qualitative component involved interviews with parents of children with moderate-severe AD. The questionnaire was completed by 168 parents; 32.1% had mild AD, 39.9% had moderate AD, and 28% had severe AD. The average burden score was 3.5 (out of 10). Average burden scores were low in mild AD (1.0 out of 10) and were proportionally higher in moderate (3.9 out of 10) and severe (5.8 out of 10) AD (p < 0.001). Increased frequency of therapy had increased perceived burden. In moderate-severe AD, oral therapy was rated as less burdensome than topical therapies. Semi-structured interviews were conducted with 15 parents of children with moderate-severe AD. Thematic analysis grouped experiences into health care burden, treatment burden, and financial burden. Insights from health care burden analysis included "mixed messages," "treatment futility," and "expectant resolution." Insights from treatment burden included treatment routine, schooling impact, and "topical-sparing" with systemic treatment. Factors of financial burden included topical treatments, clothing, and health care visits. Moderate-severe AD is associated with high BOT, particularly related to topical therapies, which may be reduced by systemic treatment. All physicians treating children with AD should avoid potentially damaging communication regarding mixed messages, treatment futility, and expectant resolution.

The lived experience of a novel disruptive therapy in a group of men and boys with haemophilia A with inhibitors: Emi & Me

BACKGROUND

People with haemophilia A and inhibitors (PwHi) suffer more orthopaedic complications, bleeding and pain than those without inhibitors. The advent of emicizumab as a prophylactic treatment has led to a reduction in bleed frequency and a significant improvement in overall quality of life. No research to date has examined the nature of this improvement on treated individuals and their families.

AIMS

The Emi & Me study aims to capture the real-life experience of using emicizumab for PwHi and their families.

METHODS

Participants were recruited through treatment centres, social media and by word of mouth. Each participant and a family member, if available, took part in a semistructured qualitative interview. All interviews were recorded, transcribed verbatim and analysed thematically. All elements of the study were reviewed by local statutory authorities and informed consent was sought from all participants.

RESULTS

Fifteen PwHi, mean age 27.2 years (range 8-63 years), most with a family member, participated in a single qualitative interview online (n = 13), by telephone (n = 1) or in person (n = 1). Mean time on emicizumab was 2.26 years (range 1-5 years). Six major themes emerged: bleeds; pain; treatment burden; control; freedom (for both PwHi and family members) and missed potential. Emicizumab prophylaxis has delivered significant improvements in the lives of the participants. Despite these improvements, some participants felt that their pre-existing physical disabilities and the lack of physiotherapy provision had prevented them achieving similar improvements in their functional ability.

CONCLUSION

This study shows that in reducing bleeds, pain and treatment burden, emicizumab had given PwHi greater control over their condition, allowing a sense of freedom they had not experienced with factor VIII or bypassing agent prophylaxis. However, for emicizumab to be truly effective, there is a need to ensure the continued availability and accessibility of robust multidisciplinary support services. Without this, it is unlikely that PwHi will realize the life-changing potential offered either by emicizumab or any other novel treatment approach.

PATIENT OR PUBLIC CONTRIBUTION

A patient participant (who did not wish to be included as an author of the paper) was involved in the design of the study protocol and interview guide.

The Experiences of Treatment Burden in People with Parkinson's Disease and Their Caregivers: A Systematic Review of Qualitative Studies

BackgroundHigh treatment burden is associated with poor adherence, wasted resources, poor quality of life and poor health outcomes. Identifying factors that impact treatment burden in Parkinson's disease can offer insights into strategies to mitigate them.ObjectiveTo explore the experiences of treatment burden among people with Parkinson's disease (PwP) and their caregivers.MethodsA systematic review of studies published from year 2006 was conducted. Qualitative and mixed-method studies with a qualitative component that relate to usual care in Parkinson's disease were included. Quantitative studies and grey literature were excluded. Data synthesis was conducted using framework synthesis.Results1757 articles were screened, and 39 articles included. Understanding treatment burden in PwP and caregivers was not the primary aim in any of the included studies. The main issues of treatment burden in Parkinson's disease are: 1) work and challenges of taking medication; 2) healthcare provider obstacles including lack of patient-centered care, poor patient-provider relationships, lack of care coordination, inflexible organizational structures, lack of access to services and issues in care home or hospital settings; and 3) learning about health and challenges with information provision. The treatment burden led to physical and mental exhaustion of self-care and limitations on the role and social activities of PwP and caregivers.Conclusion:There are potential strategies to improve the treatment burden in Parkinson's disease at an individual level such as patient-centered approach to care, and at system level by improving access and care coordination between services. Future research is needed to determine the modifiable factors of treatment burden in Parkinson's disease.

The role of growth hormone device optimization in patient-reported outcomes: real-world evidence from South Korea

BACKGROUND

Growth hormone (GH) treatment preference and adherence are affected by delivery device convenience, injection-site pain, confidence in correct dose administration, and device satisfaction. This survey investigated if switching device to NordiFlex® improved treatment experience in pediatric patients in South Korea.

DESIGN AND METHODS

Patients aged 4-≤18 years were surveyed. Participants were NordiFlex® users who previously used NordiLet®/other devices. Participants compared preference, self-reported adherence, satisfaction, perceived ease of use, and device subjective benefits (across four domains: ease of use, self-efficacy, minimal disruption of daily life, positive feelings about injections) of NordiFlex® vs. previous device.

RESULTS

Ninety-four patients were enrolled, of which 91.5% previously used NordiLet®. Significantly more patients preferred, and were more satisfied with NordiFlex® vs. previous device; mean score: 0.65 (95% confidence interval [CI]:0.41;0.88) and 0.61 (95% CI:0.36;0.85), respectively. Participants reported greater perceived ease of use (0.49 [95% CI:0.26;0.72]) and fewer missed injections (0.20 [95% CI:0.06;0.34], with NordiFlex® vs. previous device. Bivariate analysis showed significant associations between preference for NordiFlex® and higher scores on self-efficacy, ease of use, minimal disruption of daily life, and positive feelings about injection (all p < 0.001).

CONCLUSION

These results suggest that improvements in device features could be associated with improved treatment experience.

'Like a fish on dry land': an explorative qualitative study into severe asthma and the impact of biologicals on patients' everyday life

RESULTS

Findings show how our respondents experience a high burden of disease (breathlessness, fatigue, exacerbations, loss of family, friends and employment) and treatment (oral corticosteroids' side-effects, dependency, life-style changes). Treatment with biologicals is relatively new for respondents. They mention to be cautious in their embrace of biologicals and in expressing hope for the future. Respondents who react to treatment with biologicals experience relief of both the burden of disease and treatment. They aim to regain their social life and societal participation, a contrast to those for whom biologicals prove ineffective. Biologicals' burden of treatment is experienced as low and minor side-effects are mentioned by three respondents. Respondents appear relatively unconcerned about the lack of knowledge concerning the long-term effects of biologicals.Conclusions: Effective treatment with biologicals is generally experienced as a cautiously optimistic next step in a much longer and complex process of living with severe asthma. The practical lessons we draw point to managing patients' expectations and the need to pay attention to patients not eligible for treatment with biologicals.

Specific Measures of Quality of Life in Patients with Multimorbidity in Primary Healthcare: A Systematic Review on Patient-Reported Outcome Measures' Adequacy of Measurement

Purpose

The aim of this study is to search systematically for Patient Reported Outcome Measures (PROMs) used among patients with multimorbidity. Furthermore, the aim is to evaluate the adequacy and validity of the PROMs identified.

Design and setting

This systematic review follows the PRISMA guidelines. To assess the adequacy and validity of the identified PROMs the COSMIN Risk of Bias Checklist is used, more specifically a validation of the development, content validity, structural validity, and internal consistency of the PROMs.

Results

Four PROMs were identified in the primary search, and one was found from references. The sixth PROM was published after the primary search. None of the identified PROMs were aimed specifically at measuring the quality of life in patients with multimorbidity. According to the checklist, the development process and content validity were rated “adequate” in only one measure and “invalid”/“doubtful”/“inadequate” in the rest of the measures. The structural validity of the measures was rated “adequate” in four measures and “very good” in one. Regarding the internal consistency, two measures were rated doubtful and three “very good”. None of the six PROMs reported analyses about invariant measurement. The COSMIN Risk of Bias Checklist proved easy to use; however, there are some concerns in the rating of bias, that are discussed further.

Conclusion

All six PROMs developed for patients with multimorbidity identified possessed inadequacy in their measurement properties. Therefore, the aim for the future is to develop a valid and adequate measure of the quality of life among patients with multimorbidity.

Temporary Stoppages and Burden of Treatment in Patients With Cancer

OBJECTIVES

To examine the effect of burden of treatment and multimorbidity on the relationship between baseline characteristics and oral oncolytic agent (OOA) temporary stoppages.

SAMPLE & SETTING

272 patients newly prescribed OOAs at six National Cancer Institute-designated comprehensive cancer centers.

METHODS & VARIABLES

Patients were randomly assigned to an adherence and symptom management group or a usual care/control group. Temporary OOA stoppages, symptom interference, OOA regimen complexity, and multimorbidities were explored. Data were collected at four-week intervals for 12 weeks.

RESULTS

Burden of treatment variables and multimorbidity had no significant effect on OOA temporary stoppages. Women and those prescribed kinase inhibitors were significantly more likely to experience a temporary stoppage.

IMPLICATIONS FOR NURSING

Oncology nurses are in a crucial position to educate patients on self-management of OOAs and symptoms. Nurses should be aware of patients who may be more susceptible to severe symptoms, including those with multimorbidities. Future research is needed to better understand OOA stoppages and factors associated with preventing stoppages.

What You Cannot See Can Still Kill You: On the Use of Latent Constructs

Nursing research relies heavily on the use of latent constructs to describe and understand phenomena that cannot be measured through direct observation. In statistical models, variables representing these constructs, often operationalized and represented as scores on self-report measures, stand in as symbolic representations of real forces having an impact on patients' experiences of living and dying. In this sense, latent constructs represent real phenomena that cannot always be seen directly.

Multi-morbidity: A patient perspective on navigating the health care system and everyday life

OBJECTIVE

The importance of everyday life when managing the burden of treatment is rarely studied. This article explores the burden of treatment among people with multi-morbidity by investigating the tension between everyday life and the health care system.

METHOD

This was an ethnographic study using individual interviews and participant-observations. An inductive analytical approach was applied, moving from observations and results to broader generalisations.

RESULTS

People with multi-morbidity experience dilemmas related to their individual priorities in everyday life and the management of their treatment burdens. Dilemmas were identified within three domains: family and social life; work life; agendas and set goals in appointments with health professionals. Individual resources and priorities in everyday life play a dominant role in resolving dilemmas and navigating the tension between everyday life and the health care system.

DISCUSSION

People with multi-morbidity are seldom supported by health professionals in resolving the dilemmas they must face. This study suggests an increased focus on patient-centredness and argues in favour of planning health care through cooperation between health professionals and people with multi-morbidity in a way that integrates both health and everyday life priorities.

"Experiences of the burden of treatment"-Patient reports of facilitated subcutaneous immunoglobulin treatment in adults with immunodeficiency

AIMS AND OBJECTIVES

To evaluate patient-reported experiences of facilitated subcutaneous immunoglobulin treatment in adults with primary or secondary immunodeficiency.

BACKGROUND

Decreased levels of circulating antibodies (humoral immunodeficiency) are often associated with higher infection rates which cause problems in daily living, for example, symptoms of severe and recurrent bacterial infections that may cause chronic lung diseases. For some diagnoses, treatment with immunoglobulin becomes critical and lifelong. The acceptability of administration forms is important to achieve adherence to treatment and to increase quality of life for these patients.

DESIGN

Convergent mixed-method approach.

METHODS

A structured telephone interview with nine questions evaluated on a score scale about treatment experience, satisfaction and ancillary supplies was used, followed by open-ended questions for each item.

RESULTS

Prohibiting factors were revealed, exemplified by problems due to technical issues and ancillary supply issues. Promoting factors were shown by high a satisfaction according to the score-scale when combining treatment with daily life as well as increased well-being. Facilitated subcutaneous immunoglobulin treatment led to fewer treatment sessions, with a time-saving aspect also described by high scores in the item concerning longer treatment interval.

CONCLUSIONS

The opportunity to be given the best possible treatment plan adjusted for each patient's situation is central. Healthcare professionals should discuss the different aspects that can promote and inhibit the outcomes of treatment.

RELEVANCE TO CLINICAL PRACTICE

The results can help professionals to understand different factors that may impinge on the patients' everyday life when they are forced into a lifelong treatment regimen. This knowledge is also important for nurses who have a responsibility to promote health concerning patients with long-term conditions in general.

Burden of treatment in the face of childhood cancer: A quantitative study using medical records of deceased children

Lived experiences of childhood cancer patients and their families have been described as interrupted and as a loss of normal life. Apart from symptoms due to the cancer disease, families continuously experience burden of treatment. Since coping capacities are unique to each individual, we captured variables that offer objective measures of treatment burden, with a particular focus on the disruptive effects of treatment on families' lives. Our sample was comprised by 193 children that died of cancer. Medical records were extracted retrospectively. Quantitative data were statistically analysed with respect to variables related to treatment burden. Deceased children with cancer and their families faced a significant burden of treatment. Results revealed that deceased leukaemia patients had a higher number of inpatient stays, spent more time in the hospital both during their illness and during the last month of their life, and were more likely to die in the hospital when compared to deceased patients with CNS neoplasms and with other diagnoses. Our findings highlight the disruptive effects of treatment that are likely to have a great impact on families' daily life, that go beyond exclusively focusing on side effects, and that needs to be taken into account by the treating staff.

What Is the Burden of Immunoglobulin Replacement Therapy in Adult Patients With Primary Immunodeficiencies? A Systematic Review

Background

Primary immunodeficiency disorders (PIDs) are a group of heterogeneous rare disorders, whereby the immune system is missing or not functioning adequately. For patients requiring treatment, the most common option is immunoglobulin replacement therapy (Ig). Treatment of PIDs is simultaneously associated with both improvements in health-related quality of life (HRQoL) and increased treatment burden.

Objectives

This review sought to review studies investigating the burden of Ig treatment, synthesize evidence in relation to administration routes (subcutaneous or intravenous) and instruments used, as well as make recommendations for clinical and research applications in this area for patients aged 16 years and older.

Methods

We searched Medline, EMBASE, and The Cochrane Library. Sifting of titles was performed by two reviewers, and the assessment of full-text articles by three. From a database which contained 3,770 unique results, 67 full texts were reviewed. Eventually, 17 studies were found to meet the inclusion criteria, and included in this review. Due to data heterogeneity, a narrative, descriptive synthesis of the evidence was undertaken.

Results

Most studies were carried out in the USA/North America, used a prospective observational design and involved patients with common variable immune deficiency. Four studies measured the burden of receiving IVIg therapy and 13 measured SCIg therapy. A wide range of measures, primarily designed to measure aspects of treatment satisfaction (e.g., life quality index or a slightly modified version) and HRQoL (e.g., The Short Form-36) had been used.

Conclusion

Lack of a parallel control group in most studies meant that changes in outcomes could be due to factors other than changes in the treatment regimen. However, overall, PID patients appeared to report little Ig treatment burden and were satisfied with either modality. However, patient preference appeared to be the delivery of the Ig treatment in the patient's home and SCIg was preferred after switching from IVIg therapy. Individual differences appeared to affect treatment preference and therefore understanding the decision support needs of PID patients facing IG treatment choices would be valuable. Using a questionnaire specifically designed to measure the burden of Ig treatment from the patient's perspective is recommended in future research.

Patients' perspectives on how to decrease the burden of treatment: a qualitative study of HIV care in sub-Saharan Africa

Objective

Patients living with HIV infection (PLWH) in sub-Saharan Africa face an important burden of treatment related to everything they do to take care of their health: doctor visits, tests, regular refills, travels, and so on. In this study, we involved PLWH in proposing ideas on how to decrease their burden of treatment and assessed to what extent these propositions could be implemented in care.

Methods

Adult PLWH recruited in three HIV care centres in Côte d’Ivoire participated in qualitative interviews starting with ‘What do you believe are the most important things to change in your care to improve your burden of treatment?’ Two independent investigators conducted a thematic analysis to identify and classify patients' propositions to decrease their burden of treatment. A group of experts involving patients, health professionals, hospital leaders and policymakers evaluated each patient proposition to assess its feasibility.

Results

Between February and April 2017, 326 participants shared 748 ideas to decrease their burden of treatment. These ideas were grouped into 59 unique patient propositions to improve their personal care and the organisation of their hospital or clinic and/or the health system. Experts considered that 27 (46%), 19 (32%) and 13 (22%) of patients' propositions were easy, moderate and difficult, respectively, to implement. A total of 118 (36%) participants offered at least one proposition considered easily implementable by our experts.

Conclusion

Asking PLWH in sub-Saharan Africa about how their care could be improved led to identifying meaningful propositions. According to experts, half of the ideas identified could be implemented easily at low cost for minimally disruptive HIV care.

Making sense of self-care practices at the intersection of severe mental illness and physical health-An Australian study

The poor physical health of people who experience severe mental illness (SMI) is an important public health issue that has been acknowledged, yet not properly addressed. People who live with SMI perform a myriad of complex tasks in order to take care of their physical health, while receiving unpredictable levels of support and assistance from health professionals. In this qualitative study, we aimed to uncover the kinds of work people with SMI do in order to look after their physical health. In a metropolitan area in Queensland, Australia, 32 people with lived experience of SMI participated in semi-structured, face-to-face interviews. Data were digitally recorded, transcribed verbatim and open coded. They were then themed using a constant comparative process. We found that people with SMI were engaged in a "rhythm of life with illness" that consisted of relatively short, acute and chaotic cycles of mental and physical illness, accompanied by much longer mental and physical illness recovery cycles. Participants engaged in three specific types of health-related work to manage these cycles: discovery work (and the associated role of the health professional); sense-making work to meaningfully interpret health and illness; and embedding work to become engaged self-managers of illness and producers of health. We discuss how varying levels of support from health professionals impact consumers' self-management of their physical and mental health; how health professionals influence consumers' experience of treatment burden; and implications for practice.

Experiences of long-term life-limiting conditions among patients and carers: what can we learn from a meta-review of systematic reviews of qualitative studies of chronic heart failure, chronic obstructive pulmonary disease and chronic kidney disease?

OBJECTIVES

To summarise and synthesise published qualitative studies to characterise factors that shape patient and caregiver experiences of chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD).

DESIGN

Meta-review of qualitative systematic reviews and metasyntheses. Papers analysed using content analysis.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science were searched from January 2000 to April 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews and qualitative metasyntheses where the participants were patients, caregivers and which described experiences of care for CHF, COPD and CKD in primary and secondary care who were aged ≥18 years.

RESULTS

Searches identified 5420 articles, 53 of which met inclusion criteria. Reviews showed that patients' and caregivers' help seeking and decision-making were shaped by their degree of structural advantage (socioeconomic status, spatial location, health service quality); their degree of interactional advantage (cognitive advantage, affective state and interaction quality) and their degree of structural resilience (adaptation to adversity, competence in managing care and caregiver response to demands).

CONCLUSIONS

To the best of our knowledge, this is the first synthesis of qualitative systematic reviews in the field. An important outcome of this overview is an emphasis on what patients and caregivers value and on attributes of healthcare systems, relationships and practices that affect the distressing effects and consequences of pathophysiological deterioration in CHF, COPD and CKD. Interventions that seek to empower individual patients may have limited effectiveness for those who are most affected by the combined weight of structural, relational and practical disadvantage identified in this overview. We identify potential targets for interventions that could address these disadvantages.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42014014547.

The compliance and burden of treatment with the epinephrine auto-injector in food-allergic adolescents

BACKGROUND

Food-allergic patients at high risk of potential fatal anaphylaxis should carry an epinephrine auto-injector (EAI) at all times. This treatment may be perceived as burdensome and this may affect compliance and health-related quality of life (HRQL). The aims of the study were (1) to determine the burden of treatment (BoT) of an EAI, (2) to examine the relationship between this burden and compliance, and (3) to analyze which factors contribute to the BoT of the EAI as perceived by food-allergic adolescents and their parents.

METHODS

Dutch food-allergic adolescents prescribed an EAI, and their parents completed a questionnaire package (n = 55). Relationships between BoT and HRQL, illness severity and perception, and anxiety measures were investigated.

RESULTS

Food-allergic adolescents and their parents were (extremely) positive about the EAI (54.5%; 72.7%, respectively) (=low BoT). The BoT measure showed a significantly greater burden in food-allergic adolescents prescribed an EAI who reported not carrying the EAI at all times than adolescents who reported they did. The BoT scores of both adolescents and their parents were not associated with HRQL, illness severity and perception, or trait anxiety.

CONCLUSIONS

The majority of food-allergic adolescents and their parents were positive about the EAI (=low BoT). However, the BoT was significantly associated with self-reported compliance with carrying the EAI. The BoT was higher in food-allergic adolescents prescribed an EAI who reported not carrying the EAI at all times. The BoT measure seems to be a useful tool to study compliance with carrying an EAI. The BoT of an EAI is not associated with HRQL. The BoT measures a distinct concept related to compliance behavior.

Taxonomy of the burden of treatment: a multi-country web-based qualitative study of patients with chronic conditions

BACKGROUND

Management strategies for patients with chronic conditions are becoming increasingly complex, which may result in a burden of treatment for patients. To develop a Minimally Disruptive Medicine designed to reduce the burden of treatment, clinicians need to understand which healthcare tasks and aggravating factors may be responsible for this burden. The objective of the present study was to describe and classify the components of the burden of treatment for patients with chronic conditions from the patient's perspective.

METHODS

We performed a multi-country qualitative study using an online survey and a purposive sampling strategy to select English-, French-, and Spanish-speaking participants with different chronic conditions. Participants were recruited by physicians, patients' associations, advertisement on social media, and 'snowballing'. The answers were analyzed by i) manual content analysis with a grounded theory approach, coded by two researchers, and ii) automatic textual analysis by Reinert's method.

RESULTS

Between 2013 and 2014, 1,053 participants from 34 different countries completed the online survey using 408,625 words. Results from both analyses were synthesized in a taxonomy of the burden of treatment, which described i) the tasks imposed on patients by their diseases and by their healthcare system (e.g., medication management, lifestyle changes, follow-up, etc.); ii) the structural (e.g., access to healthcare resources, coordination between care providers), personal, situational, and financial factors that aggravated the burden of treatment; and iii) patient-reported consequences of the burden (e.g., poor adherence to treatments, financial burden, impact on professional, family, and social life, etc.). Our findings may not be applicable to patients with chronic conditions who differ from those who responded to our survey.

CONCLUSIONS

Our taxonomy of the burden of treatment, provided by patients with chronic conditions from different countries and settings, supports the development of tools to ascertain the burden of treatment and highlights potential targets for interventions to minimize it.

Making sense of technology adoption in healthcare: meso-level considerations

It has been clear for some time that the development of telecare faces significant problems. Large scale studies and clinical trials seem to suggest that the cost and clinical effectiveness of telecare systems is doubtful, and the claim that these systems empower or enable service users often seems greatly overstated. The question that stems from this is, can these problems be overcome? Greenhalgh et al. have critiqued the construction of telecare as a generalised technological solution to problems of the delivery of care and have offered a new framework for defining quality in telecare and telehealth. They outline a set of principles that focus on user-centredness, co-creation, integration, and evaluation. This is a valuable approach, and is part of a much wider transformation of the way in which policy and practice researchers conceptualise healthcare delivery as a problem of performativity. Recognising that this is an important shift, in this paper I argue that we also need to keep in mind the meso-level factors that structure new technology applications in practice. Please see the related article: http://dx.doi.org/10.1186/s12916-015-0279-6.