Youth-Therapist and Parent-Therapist Match and Mismatch on Internalizing and Externalizing Treatment Goals as Predictors of Treatment Engagement

Therapist-client cognitive match upon key constructs such as treatment goals is purported to be an important component of culturally competent care. For adolescent clients, treatment may involve both youths and their parents, suggesting the need to consider both youth-therapist and parent-therapist perspectives. This longitudinal study examined broadband youth-therapist and parent-therapist treatment goal matching and mismatching in relationship to treatment engagement in a culturally diverse sample of 245 outpatient mental health service-using youth. Although goal matching/mismatching did not uniformly predict treatment engagement as measured by a total score, youth-therapist internalizing goal matching predicted better youth engagement, and parent-therapist externalizing goal mismatch marginally predicted worse parent engagement. When selected post hoc analyses examined relationships to four individual engagement dimensions, youth-therapist internalizing goal matches positively predicted youth Client-therapist interaction, Communication/Openness, Client's perceived usefulness of therapy, and Collaboration with treatment, while parent-therapist externalizing goal mismatch negatively predicted parent Collaboration with treatment. Findings support the importance of cognitive match on treatment goals as well as the consideration of both parent and youth perspectives, matched and mismatched goals, internalizing and externalizing goals, and examining individual dimensions in addition to total scores of engagement.

A description of alopecia areata in European patients based on real-world survey data: physician-reported characterization of severity and associated treatment utilization

Alopecia areata (AA), an autoimmune disease -affecting the hair of the scalp, face, and/or body, can entail substantial psychological and physical burden for patients. There is currently no international agreement on how to treat AA and the approach may vary across countries. This study investigated the management of AA in clinical practice. Data from a point-in-time survey conducted in France, Germany, Italy, Spain, and the United Kingdom, between October 2021-June 2022, were analysed for adults with mild, moderate, and severe AA, based on physician assessment. Dermatologists were surveyed about factors used to assess disease severity, physician-reported treatment goals, and treatment patterns for AA, including the use of wigs. In total, 239 dermatologists reported on 2,083 patients. Physicians' severity assessment and treatment goals were predominantly driven by scalp hair loss. Topical and intralesional corticosteroids were the most prescribed treatments for mild and moderate AA. Conventional immunosuppressants, oral Janus kinase inhibitors, and topical immunotherapy use generally increased with AA severity and therapy line. Wig use was greatest for severe AA. The primary reasons for the last treatment change in the moderate and severe groups were worsening of condition, lack of initial efficacy, and loss of response, and for mild group were improvement in condition, lack of initial efficacy, and worsening of condition. Findings were generally similar across countries. This analysis provides insights into the management of AA in five European countries and confirms the need for more effective therapies, especially for patients with severe AA.

Australian consensus: Treatment goals for moderate to severe psoriasis in the era of targeted therapies - Adult patients

BACKGROUND

Over the last decade, the treatment landscape for moderate-severe psoriasis has rapidly evolved. The Australasian College of Dermatologists sought to review and update previously published treatment goals for moderate-severe psoriasis.

METHODS

A modified Delphi approach was used. Comprehensive literature review and guideline evaluation resulted in the development of statements and other questions to establish current clinical practices. Two rounds of anonymous voting were undertaken, with a collaborative meeting held in between to discuss areas of discordance. Overall, consensus was defined as achievement of ≥75% agreement in the range 7-9 on a 9-point scale (1 strongly disagree; 9 strongly agree).

RESULTS

Consensus was achieved on 26/29 statements in round 1 and a further 20 statements in round 2. There was strong agreement to expanding the classification/definition of psoriasis severity by including a choice of metrics, incorporating quality of life measures, and widening the scope of high-impact sites. Consensus was also reached on revised treatment response criteria, which were then incorporated into a new treatment algorithm. There was discordance with the current requirement to undertake a trial with established systemic agents before accessing targeted therapy.

CONCLUSION

The ability of new targeted treatment options to change the narrative in psoriasis patient care can only be properly realised if challenges to timely and equitable access are addressed. The proposed framework for the assessment, classification and management of moderate-severe psoriasis aligns with international recommendations. Its adoption into Australian clinical practice is hoped to improve treatment outcomes and patients' satisfaction with their care.

Understanding Treatment Preferences Among People Living with HIV in Australia: A Discrete Choice Experiment

Purpose

To better understand what is most important to people living with human immunodeficiency virus (PLWH) when choosing their treatment. We assessed how PLWH trade off the potential risks and benefits of oral and long acting injectable (LAI) treatments.

Participants and Methods

Firstly, in-depth interviews were conducted with 11 PLWH to develop a holistic understanding of experiences and determine attributes that contribute to treatment decision-making. Secondly, a discrete choice experiment (DCE) was used to understand the treatment preferences for PLWH with n = 99 PLWH aged 18 years or over with a diagnosis of human immunodeficiency virus (HIV) and who were currently using anti-retroviral therapy (ART). Study participants were presented with 12 scenarios and asked to select their preferred treatment among two hypothetical injectable treatment alternatives, "injection 1" and "injection 2" and their current oral ART treatment. The DCE data were modelled using a latent class model (LCM).

Results

The model revealed significant heterogeneity in preferences for treatment attributes among study participants. Two segments/classes of PLWH were identified. The first segment expressed a strong preference for their current oral treatment; the second segment showed strong preference for the injection treatment and for it to be administered in a GP clinic. Overall, out-of-pocket cost was the most important attribute for participants. One-third of PLWH were willing to switch to an LAI.

Conclusion

Not all PLWH valued the same treatment attributes equally. Overall, out-of-pocket costs for treatments were considered by respondents as the most determining factor in making treatment choices. Results have important implications for healthcare policy and will serve to better inform patients and stakeholders involved in the treatment decision-making process about the treatment preferences of PLWH. Clinicians are encouraged to consider shared decision-making to establish the treatment course that best aligns with PLWH's treatment goals.

Development of a Specific Variant of Patient Benefit Index (PBI) Assessing Patient Needs, Goals and Benefits in Rosacea Treatment

Introduction

Evaluation of patient-reported outcomes including health-related quality of life (HRQoL) and perceived benefits from treatment has become a fundamental component of medical decision-making. Standardized evaluation of treatment benefits in rosacea based on patient preferences is still lacking.

Objective

Development and validation of an instrument for recording patient-defined benefits in rosacea therapy based on the Patient Benefit Index (PBI) methodology.

Patients and Methods

In an open survey of n = 50 patients, potential benefits of therapy from the patient's perspective were examined. The generated item pool was combined with pre-existing PBI items for other skin conditions and reviewed by an expert panel of dermatologists, psychologists and patients. Items were condensed to n = 25 and converted into a Likert-scaled questionnaire. The validity and feasibility of the resulting Patient Benefit Index for rosacea (PBI-RO) were tested on individuals with rosacea recruited from a German rosacea patient organization.

Results

N = 446 patients with rosacea completed the PBI-RO. The internal consistencies measured by Cronbach's alpha were high (Patient Needs Questionnaire [PNQ] 0.94). Mean PBI-RO was 1.9 ± 1.2 (scale from 0 = no benefit to 4 = maximum benefit), 23.5% of the patients experienced a PBI-RO < 1 (no clinically relevant benefit). The PBI-RO correlated with HRQoL, health state, current extent of rosacea lesions and treatment satisfaction. The highest correlation was found between PBI-RO and satisfaction with previous treatment (r = -0.59, p < 0.001); correlation with the extent of rosacea lesions was low (r = 0.16, p < 0.001).

Conclusion

The PBI-RO shows satisfying internal consistency and construct validity. It offers the option of a patient-weighted evaluation of the therapeutic benefit of rosacea therapy and may add to more stringent goal orientation in therapy.

Low back pain management in routine clinical practice: what is important for the individual patient?

Chronic low back pain is a complex disorder influenced by biological, psychological, and social factors. Causes, personal circumstances and personal disease experiences are varied; patient care thus needs to be tailored to the individual. Supported by clinical study results and online patient survey data, the present paper explores factors which are important to the patient beyond pain relief and proposes topics to be raised in consultation to identify the most important treatment goals. Furthermore, the importance of communication, trust and empathy in the physician-patient relationship for effective pain management is addressed.

Treatment goals for rheumatoid arthritis: patient engagement and goal collection

Aim: We developed the Patient-Engaged Health Technology Assessment strategy for survey-based goal collection from patients to yield patient-important outcomes suitable for use in multi-criteria decision analysis. Methods: Rheumatoid arthritis patients were recruited from online patient networks for proof-of-concept testing of goal collection and prioritization using a survey. A Project Steering Committee and Expert Panel rated the feasibility of scaling to larger samples. Results: Survey respondents (n = 47) completed the goal collection exercise. Finding effective treatments was rated by respondents as the most important goal, and reducing stiffness was rated as the least important. Feedback from our steering committee and expert panel support the approach's feasibility for goal identification and ranking. Conclusion: Goals relevant for treatment evaluation can be identified and rated for importance by patients to permit wide input from patients with lived experience of disease.

Goals and Reasons for Entering Inpatient Withdrawal Treatment, and Perceptions of Help Received

OBJECTIVE

Abstinence has been the primary treatment goal for alcohol and other drug (AOD) users attending withdrawal treatment. However, other outcomes including harm reduction have also been identified. This observational study aimed to describe participants' goals and reasons for seeking inpatient withdrawal treatment and compare the needs of clients with comorbid mental health problems and those without.

METHODS

Participants completed questionnaires at intake and discharge. Questionnaires assessed reasons for entering withdrawal treatment, goals, comorbidity, and perceived help received.

RESULTS

The sample comprised 1746 participants (69.4% male). Participants endorsed diverse reasons for entering withdrawal treatment. The most and least endorsed reasons were "stop using" (97.9%) and "legal reasons" (43.1%). Comorbidity groups varied significantly in their endorsement of reasons for mental health, physical health, harm reduction, financial, and legal.

CONCLUSION

AOD users enter withdrawal treatment with a variety of reasons and goals including harm reduction. Variations in rates of endorsement highlight the importance of identifying individual needs dependent on mental health comorbidity.

The alliance in mental health care: conceptualization, evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

Treatment goals in IBD: A perspective from patients and their partners

Objective

To identify and compare treatment goals between IBD patients and partners, and how these change upon receiving information.

Methods

During a patient information day a self-made survey was distributed before and after a lecture about a physicians' view on treatments goals. Patients and partners were asked for their preferred treatment goals at 6 weeks and at 6 months and could choose between short-term goals (symptom free, improved functioning, better QOL, normal colonoscopy) and long-term goals (prevention of surgery, complications, flares and no steroids).

Results

Being "symptom-free" (55.9%) was the preferred goal. Patients with higher disease activity chose more short-term goals (p=0.03) at 6 weeks. Age, gender and education did not affect treatment goals. Partners chose more short-term goals (p=0.03) at 6 weeks. Post-lecture, answers shifter to normal colonoscopy (4.2% versus 18.0%, p=0.001), and a better QOL (21.2% vs 33.3%, p=0.039) as goal at 6-months.

Conclusions

Patients' 6-week treatment goals focused on being symptom-free and having a high QOL, especially those patients with high disease activity. Partners chose more short-term goals than patients at 6 weeks.

Innovation

General health information can be applied and translated into treatment goals. This may assist in remote shared goal setting and decision making.

Knowledge of HbA1c and LDL-C treatment goals, subjective level of disease-related information and information needs in patients with atherosclerotic cardiovascular disease

BACKGROUND/HYPOTHESIS

Risk factor control of diabetes mellitus (DM) and especially dyslipidemia remains unsatisfactory in patients with atherosclerotic cardiovascular disease (ASCVD). We aimed to analyze the knowledge of low-density lipoprotein cholesterol (LDL-C) and glycated hemoglobin (HbA1c) treatment goals, subjective level of information, and information needs in very high-risk patients with ASCVD.

METHODS

ASCVD patients (n = 210; 75 ± 9 years; 71.4% male; 89.5% coronary disease) with DM (96.7% type 2) completed a questionnaire assessing knowledge of HbA1c and LDL-C treatment goals and subjective level of information and information needs on disease-related topics of DM and ASCVD. Serum LDL-C and HbA1c were measured.

RESULTS

HbA1c goal (<7.0% in 60.6%) was attained more frequently than LDL-C goal (<70 mg/dl in 39.9%; p < .01). Significantly more participants named the correct goal for HbA1c compared to LDL-C (52.9% vs. 2.4%; p < .01). Subjective levels of information were higher and information needs were lower for DM than for ASCVD (p < .01 for all topics). No associations of knowledge of treatment goals and level of information with the attainment of treatment goals for HbA1c and LDL-C were found. However, in multivariate regression, higher levels of education were associated with knowledge of treatment goals (HbA1c: odds ratio [OR] 1.32, 95% confidence interval [CI] 1.01-1.72, p = .04; LDL-C: OR 2.32, 95% CI 1.07-5.03; p = .03).

CONCLUSION

In very high-risk patients with ASCVD, a deficit of knowledge of treatment goals to control dyslipidemia exists when compared to DM, patients felt significantly better informed for topics of DM than for ASCVD and display higher information needs for topics of ASCVD.

(Re)Appraising Remission in Ulcerative Colitis

As the therapeutic targets in ulcerative colitis (UC) shift from control of symptoms to mucosal healing and prevention of disease complications like disability, colectomy, and cancer, the definition of remission has evolved. The current definition of clinical remission is variable and is determined by the clinical context in which it is being used. This results in skepticism and uncertainty about the true meaning of the term "clinical remission." In this review, the authors reexamine the definition of clinical remission and propose a novel approach to define remission in UC.

Self-reported Treatment Goals in Chinese Patients with Inflammatory Bowel Disease During the Coronavirus Disease 2019 Pandemic

BACKGROUND

Inflammatory bowel disease is a chronic recurrent disease, and the treatment goals of inflammatory bowel disease are mainly based on doctors' perspective, but there are some differences between the doctor's perspective and the patient's perspective. The aim of this study is to understand the treatment goals and the related factors from the patients' perspective during the coronavirus disease 2019 pandemic.

METHODS

A total of 212 participants were recruited to fill out the questionnaires including clinical characteristics and treatment goals. Eleven treatment goals were measured by a Short-Form 34 questionnaire. Univariate and multivariate regression analyses were used to explore the related factors about these treatment goals.

RESULTS

A total of 212 inflammatory bowel disease patients were enrolled in this study. The most concerned treatment goal was the improvement of quality of life (mean score was 8.54), while mean score of ulcerative colitis patients and Crohn's disease patients was 9.10 and 8.45, respectively. We had also found some related factors such as the type of disease, the course of disease, the frequency of hematochezia, and defecation.

CONCLUSION

Our survey showed that inflammatory bowel disease patients pay more attention to the improvement of quality of life and few drugs during the coronavirus disease 2019 pandemic. There are some related factors such as the type of disease, the course of dis- ease, the frequency of hematochezia, and defecation. Our results help clinicians understand the patients' treatment goals, which can contribute to better management of inflammatory bowel disease patients.

In-home use of a hybrid closed loop achieves time-in-range targets in preschoolers and school children: Results from a randomized, controlled, crossover trial

AIM

To obtain additional information on the incremental differences between using a sensor-augmented pump (SAP) without automated insulin delivery (AID), using it with predictive low-glucose management (PLGM) or as hybrid closed loop (HCL), in preschool and school children.

METHODS

We conducted a monocentric, randomized, controlled, two-phase crossover study in 38 children aged 2-6 and 7-14 years. The primary endpoint was the percentage of time in range (TIR) of 70-180 mg/dl. Other continuous glucose sensor metrics, HbA1c, patient-related outcomes (DISABKIDS questionnaire, Fear of Hypoglycaemia Survey) and safety events were also assessed. Results from 2 weeks of SAP, 8 weeks of PLGM and 8 weeks of HCL were compared using a paired t-test or Wilcoxon signed-rank test.

RESULTS

Overall, we found a high rate of TIR target (>70%) achievement with HCL in preschool (88%) and school children (50%), with average times in Auto Mode of 93% and 87%, respectively. Preschool children achieved a mean TIR of 73% ± 6% (+8% vs. SAP, +6% vs. PLGM) and school children 69% ± 8% (+15% vs. SAP and + 14% vs. PLGM). Overall, HbA1c improved from 7.4% ± 0.9% to 6.9% ± 0.5% (P = .0002). Diabetes burden and worries and fear of hypoglycaemia remained at low levels, without significant changes versus PLGM. No events of severe hypoglycaemia or diabetic ketoacidosis occurred.

CONCLUSIONS

Preschool children profit from AID at least as much as those aged 7 years and older. To ensure safe use and prescribing modalities, regulatory approval is also required for young children.

Multinational evaluation of clinical decision-making in the treatment and management of mild-to-moderate ulcerative colitis

OBJECTIVES

To understand current thinking and clinical decision-making in the treatment and management of patients with mild-to-moderate ulcerative colitis (UC).

METHODS

This multinational, survey-based study was conducted in 2021. Two meetings were held, involving 11 IBD specialists, that used a series of questions and discussion to identify all factors possibly related to the management of UC. The importance of identified factors was assessed using an online questionnaire covering three scenarios - active disease, remission and patient empowerment. Each factor was scored on a scale of 0 (very-unimportant) to 100 (very-important) within each scenario, by a separate group of healthcare professionals working in IBD.

RESULTS

A total of 157 individual factors were identified by the 11 IBD specialists and scored in the three scenarios by 56 respondents (52; 93% specialist gastroenterologists) from Europe and North America (25; 45%), South America (19; 34%) and the Middle East, Asia and Australia (12; 21%). For all scenarios, factors related to educating patients regarding UC and its treatment and understanding of patient goals ranked highest, ahead of clinical considerations regarding disease activity and treatment history. Setting realistic short-term treatment targets was a key consideration. 5-ASA optimisation and use of faecal calprotectin monitoring were core strategies across the three scenarios tested. Support for patients during longer-term management of their disease, starting from initial flare, was an important recurring theme.

CONCLUSION

The current management approach for mild-to-moderate UC was found to be guided primarily by the patient's perspectives and goals, alongside assessment of their medical and disease history.

Identifying and Predicting the Goals and Concerns Prioritised by Individuals with Inflammatory Bowel Disease

BACKGROUND AND AIMS

In order to provide high-quality care, providers need to understand their patients' goals and concerns. This study aims to identify and predict the goals and concerns prioritised by patients with inflammatory bowel disease [IBD] in the outpatient setting.

METHODS

Mixed-methods analysis was performed to identify the types, frequencies, and predictors of IBD patients' goals and concerns using 4873 surveys collected over 2016-2019 at 25 gastroenterology clinics across the USA participating in the Crohn's & Colitis Foundation's IBD Qorus Learning Health System.

RESULTS

Patients with IBD most often prioritised goals and concerns related to symptoms/disease activity [50%] and clinical course/management [20%], whereas psychosocial/quality of life [12%] and medication [6%] concerns were less frequent. Females (odds ratio [OR] 22.1, 95% confidence interval [CI] 5.3-91.5) and patients in clinical remission [OR 2.2, 95% CI 1.2-4.1] were more likely to prioritise family planning. Patients >60 years old [OR 3.1, 95% CI 1.5-6.5] and patients with active disease [OR 3.2, 95% CI 1.4-7.6] were more often concerned about travelling. Smokers were more often concerned about nutrition [OR 4.2, 95% CI 1.9-9.2]. Surgery was more often a concern of patients with perianal Crohn's disease [OR 2.1, 95% CI 1.2-3.5], active disease [OR 1.9, 95% CI 1.1-3.4], and those with recent hospitalisations [OR 2.5, 95% CI 1.2-5.4].

CONCLUSIONS

IBD patients prioritised the remission of physical symptoms as treatment goals and they were less frequently concerned about medications and their side effects. Patients' demographics, IBD characteristics, and health care utilisation patterns can predict specific types of concerns/goals.

Benefit-risk trade-offs in treatment choice in advanced HER2 negative breast cancer: patient and oncologist perspectives

Objective: To evaluate which treatment attributes US patients and oncologists prioritize in HER2 negative advanced breast cancer (ABC). Methods: Preferences were assessed via a discrete choice experiment. Also, treatment goal statements were rated on an agreement scale. Results: Patients (n = 169) most valued improving overall survival (OS), followed by improving nausea and neuropathy. Oncologists (n = 117) most valued improving OS, followed by neuropathy and progression-free survival. Regarding treatment goals, oncologists (67%) perceived that patients are more focused on efficacy than quality of life; fewer patients (29%) agreed with this statement; 81% of oncologists and 51% of patients agreed that patients prefer oral treatment. Conclusion: Patients and oncologists were willing to accept increases in toxicities in exchange for efficacy improvements in HER2 negative ABC.

Patient-Defined Goals for Obstructive Sleep Apnea Treatment

Objectives

To characterize the treatment goals and values of adult patients with obstructive sleep apnea (OSA).

Study Design

Mixed methods design based on semistructured interviews followed by cross-sectional surveys.

Setting

Academic medical center and integrated managed care consortium.

Methods

Phase 1 involved qualitative analysis of focus groups and interviews to define treatment goal categories. Phase 2 included analysis of cross-sectional surveys on most important treatment goals from patients with OSA presenting to sleep surgery clinic. Positive airway pressure (PAP) use, Epworth Sleepiness Scale score, and apnea-hypopnea index were obtained to determine influences on goal choices.

Results

During focus groups and interviews, treatment goal themes identified included improving sleep quality, reducing daytime sleepiness, snoring sound reduction, and health risk reduction. In phase 2, 536 patients were surveyed, and they reported the primary treatment goals of health risk reduction (35%), sleep quality improvement (28%), daytime sleepiness improvement (21%), and snoring sound reduction (16%). The primary treatment goal was associated with age (P < .0001), excessive daytime sleepiness (Epworth Sleepiness Scale score >10, P < .0001), PAP use status (P < .0001), and OSA severity (apnea-hypopnea index, P < .0001). Severity of OSA was associated with increasing proportion of patients choosing health risk reduction as the main treatment goal (P < .05).

Conclusions

Adult OSA treatment goal choices vary with age, symptoms, PAP history, and OSA severity. Understanding patient-specific goals is the essential first step in the shared decision-making process when choosing surgical or nonsurgical treatments. Ultimately, goal-focused discussions ensure alignment of priorities and definitions of success between the patient and the provider.

Portuguese recommendations for the treatment of atopic dermatitis with biologic therapy and JAK inhibitors in adult patients

Atopic dermatitis is a highly prevalent chronic, immune-mediated inflammatory skin disease with a significant burden on patients, families and healthcare systems. This article presents recommendations developed by the Atopic Dermatitis Group of the Portuguese Society of Dermatology and Venereology addressing several clinical questions that arise in the management and care of moderate-to-severe atopic dermatitis with biologic agents and Janus kinase (JAK) inhibitors based on the available evidence. The recommendations were generated after a thorough evaluation of existing guidelines on the treatment of atopic dermatitis, publications concerning new biologics and JAK inhibitors not yet incorporated into existing guidelines, and expert-based recommendations. It also includes considerations on atopic dermatitis severity, indications for initiating biologic agents and JAK inhibitors, parameters to be considered in the treatment choice, in particular treatment goals, and recommendations for the use, screening and monitoring of these therapies.

Understanding the Treatment Preferences of People Living with Schizophrenia in Australia; A Patient Value Mapping Study

PURPOSE

To examine the treatment and long-term outcome preferences for people living with schizophrenia.

PATIENTS AND METHODS

Sixty-six Australian adults, living with schizophrenia completed a novel online survey with six sections: Demographic characteristics; Disease history; Quality-of-life; Patient support programmes; Discrete Choice Experiment, and Best-Worst Scaling exercise.

RESULTS

Participants indicated that they preferred to be involved in treatment decision with their doctor. A minority of participants reported having been previously involved in a patient support programme (28.8%) and only one in six participants had a National Disability Insurance Scheme (NDIS) package (16.7%) with over a third of participants indicating that they were ineligible (37.9%). Participants' average quality-of-life score was 60%.

CONCLUSION

Recent hospitalisation influenced the relative importance of treatment attributes, with effectiveness on hearing voices being the most important treatment attribute. The most important long-term goals were having a stable place to live, being independent, and physical health. People with schizophrenia care about their long-term functional recovery outcomes, rating symptom control and independence as their highest priority. They want to be part of the treatment conversation with their doctors. Therefore, psychiatrists are encouraged to use shared decision-making to establish the treatment course that best aligns with individuals' long-term goals.

Treatment goals and preferences of pediatric psoriasis patients, young adults, and parents

BACKGROUND

Treatment needs of young psoriasis patients and parents are not widely studied and could advance patient-centered care.

OBJECTIVE

To explore treatment goals and preferences of pediatric psoriasis patients, young adults, and parents.

METHODS

A web-based survey among Dutch psoriasis patients aged ≥6 to ≤30 years and parents included multiple-choice, open-ended, and 4-point Likert scale questions. Treatment goals and characteristic preferences of pediatric patients (≤17 years) were compared to young adults (≥18 years) and parents.

RESULTS

195 young patients (20.2 ± 6.3 years) and 45 parents were included. The most important treatment goals were 'preventing lesions', 'reducing lesions', 'no itch', and 'no lesions'. Regarding treatment characteristics, 'long-term safety', 'high effectiveness', and 'short-term safety' were most important. We found differences by age, gender, and current treatment. Pediatric patients rated 'not sticky', 'quick results', and 'no/few blood samples needed' higher than parents and/or young adults. Young adults rated 'feeling more confident' and 'better quality of sleep' higher than pediatric patients. Parents considered safety most important. Psychosocial goals were more important for women and patients on biologics.

CONCLUSION

Young psoriasis patients and parents mainly strive to clear lesions and itch with effective and safe treatment. However, revealed differences underline the relevance of addressing individual needs.

Definition of treatment goals in terms of clinician-reported disease severity and patient-reported outcomes in moderate-to-severe adult atopic dermatitis: a systematic review

BACKGROUND

Atopic dermatitis (AD) is a chronically relapsing skin disease. Although a definitive cure is not available, appropriate treatment can control the disease. The advent of biologic drugs has led to the need for a clear definition of the disease severity and treatment response. A standardized list of outcomes that defines clinician-reported disease severity and patients' reported severity are therefore essential. Solid criteria to define the response to treatment and treatment failure are lacking to date.

OBJECTIVE

This systematic review defines treatment goals in terms of clinician-reported disease severity and patient-reported outcomes, referring to the published moderate-to-severe AD clinical trials. The application of these goals in daily clinical practice will ensure a better selection of available treatment options, thus increasing patient quality of care.

MATERIALS AND METHODS

A systematic literature search was performed to identify the treatments goals of randomized controlled clinical trials (RCTs) on moderate-to-severe adult AD published between January 2000 and October 2020.

RESULTS

In total, 14 studies met the eligibility criteria. The most widely used tools in terms of clinician-reported disease severity were the Scoring of Atopic Dermatitis (SCORAD) followed by the Eczema Area Severity Score (EASI) and Investigator Global Assessment (IGA). For disease severity scales as efficacy outcome in RCTs, the greatest standardization and reproducibility was for improvement of at least 50% in EASI score and IGA score reduction of ≥2 grades from baseline. The most widely used tools from the patients' perspective were the Dermatology Life Quality Index (DLQI), Numeric Rate Scale (NRS)-itch and Patient Oriented Eczema Measure Score (POEM). In terms of patients' reported efficacy outcomes in RCTs, a numerical DLQI, NRS-itch and POEM score improvement of at least 4 points from baseline was reported.

CONCLUSIONS

This systematic review highlights the need for collaboration between experts in order to define and optimize treatment outcomes. Despite considerable progress in harmonizing outcome measures, promoted by the foundation of the Harmonizing Outcome Measures for Eczema (HOME) initiative in 2008, our results demonstrate that this endpoint is still an unmet need. Based on the literature data we propose a minimum treatment goal algorithm for use in daily clinical practice aimed at stimulating a discussion on how the care of AD patients could be further improved.

Patient needs and benefits of sublingual immunotherapy for grass pollen-induced allergic rhinitis: an observational study

Aim: Clinical efficacy of sublingual immunotherapy for grass pollen-induced allergic rhinitis (AR) needs to translate into patient benefit. Patients & methods: Patients received Oralair (Stallergenes, Antony, France) in real-life medical practice. Patient-relevant treatment benefits were measured with the AR-specific Patient Benefit Index. Subgroups were analyzed regarding distinct patient characteristics. Results: Data of 883 patients (children, adolescents, and adults) were analyzed. The highest-ranked patient needs referred to having less AR-symptoms, being able to go outdoors, and being free in the choice of leisure activities. Most patients (89.2-94.6%) attained at least minimally relevant benefit. All subgroups reported relevant benefits, with significantly higher scores in some subgroups. Conclusion: Treatment with Oralair was associated with considerable patient-relevant benefit in all age groups.

Consensus on treatment goals in hereditary angioedema: A global Delphi initiative

BACKGROUND

Hereditary angioedema (HAE) is a rare, life-threatening genetic disorder characterized by recurrent episodes of subcutaneous or submucosal angioedema. The ultimate goals of treatment for HAE remain ill-defined.

OBJECTIVES

The aim of this Delphi process was to define the goals of HAE treatment and to examine which factors should be considered when assessing disease control and normalization of the patient's life.

METHODS

The Delphi panel comprised 23 participants who were selected based on involvement with scientific research on HAE or coauthorship of the most recent update and revision of the World Allergy Organization/European Academy of Allergy and Clinical Immunology guideline on HAE. The process comprised 3 rounds of voting. The final round aimed to aggregate the opinions of the expert panel and to achieve consensus.

RESULTS

Two direct consensus questions were posed in round 2, based on the responses received in round 1, and the panel agreed that the goals of treatment are to achieve total control of the disease and to normalize the patient's life. For the third round of voting, 21 statements were considered, with the participants reaching consensus on 18. It is clear from the wide-ranging consensus statements that the burdens of disease and treatment should be considered when assessing disease control and normalization of patients' lives.

CONCLUSIONS

The ultimate goal for HAE treatment is to achieve no angioedema attacks. The availability of improved treatments and disease management over the last decade now makes complete control of HAE a realistic possibility for most patients.

Patients with Metastatic Lung Cancer and Oncologists' Views on Achievement of Treatment Goals and Making the Right Treatment Decision: A Prospective Multicenter Study

BACKGROUND

Previous studies have investigated patients' treatment goals before starting a treatment for metastatic lung cancer. Data on the evaluation of treatment goals are lacking.

AIM

To determine if patients with metastatic lung cancer and their oncologists perceive the treatment goals they defined at the start of systemic treatment as achieved after treatment and if in hindsight they believe it was the right decision to start systemic therapy.

DESIGN AND PARTICIPANTS

A prospective multicenter study in 6 hospitals across the Netherlands between 2016 and 2018. Following systemic treatment, 146 patients with metastatic lung cancer and 23 oncologists completed a questionnaire on the achievement of their treatment goals and whether they made the right treatment decision. Additional interviews with 15 patients and 5 oncologists were conducted.

RESULTS

According to patients and oncologists, treatment goals were achieved in 30% and 37% for 'quality of life,' 49% and 41% for 'life prolongation,' 26% and 44% for 'decrease in tumor size,' and 44% for 'cure', respectively. Most patients and oncologists, in hindsight, felt they had made the right decision to start treatment even if they had not achieved their goals (72% and 93%). This was related to the feeling that they had to do 'something.'

CONCLUSIONS

Before deciding on treatment, the treatment options, including their benefits and side effects, and the goals patients have should be discussed. It is key that these discussions include not only systemic treatment but also palliative care as effective options for doing 'something.'

Treatment Goals in Schizophrenia: A Real-World Survey of Patients, Psychiatrists, and Caregivers in the United States, with an Analysis of Current Treatment (Long-Acting Injectable vs Oral Antipsychotics) and Goal Selection

PURPOSE

To understand similarities and differences in patient treatment goals as selected by US psychiatrists, adult patients with schizophrenia, and their caregivers in a real-world setting in the United States, including stratification by current medication and age.

PATIENTS AND METHODS

Data were drawn from the Adelphi Schizophrenia Disease Specific Programme™, a point-in-time survey of psychiatrists and their consulting adult patients with schizophrenia, conducted from June to October 2019. Psychiatrists completed record forms for their next 8 consecutive outpatients and (where possible) 2 inpatients matching inclusion criteria. Participating psychiatrists, patients, and caregivers completed treatment goal questionnaires as part of the survey.

RESULTS

Psychiatrists (n = 124) provided data on 1204 patients with schizophrenia, including 1135 on drug treatment (207 inpatients [18%] and 928 outpatients [82%]); questionnaires were completed by 555 patients and 135 caregivers. Decrease in disease symptoms was identified as the most important patient treatment goal by patients (64%), psychiatrists (selecting for 63% of patients), and caregivers (selecting for 68% of patients). Patients, psychiatrists, and caregivers similarly rated the least important goals (less sexual problems and less weight gain). Patients indicated their current medication helped to reach their most important goals: decrease in disease symptoms (68%) and thinking more clearly (39%). Findings based on analysis of treatment goals by treatment and age were similar to overall trends.

CONCLUSION

These findings, including identification of a primary consensus goal of decrease in disease symptoms, may help with discussions between patients with schizophrenia, psychiatrists, and caregivers to inform effective management strategies and encourage shared decision-making.

Portuguese recommendations for the treatment of psoriasis with biologic therapy

Psoriasis is a highly prevalent chronic, inflammatory multisystem disease with a considerable impact on patients' quality of life and the healthcare system. This report presents the recommendations developed by the Portuguese Psoriasis Group of the Portuguese Society of Dermatology and Venereology that address several clinical questions arising during the management and care of psoriasis with biologic therapy, based on the available evidence. The recommendations were generated following thorough evaluation of existing guidelines on the treatment of psoriasis, publications concerning new biologic treatments that have not yet been considered in existing guidelines, as well as expert-based recommendations. Considerations regarding the severity of psoriasis, indications for initiating biologic therapy, parameters to be considered in treatment choice (in particular, treatment goals), as well as recommendations for using and monitoring therapy and screening programmes are also included.

Developing Consensus-Based Outcome Domains for Trials in Children and Adolescents With CKD: An International Delphi Survey

RATIONALE & OBJECTIVE

The inconsistency in outcomes reported and lack of patient-reported outcomes across trials in children with chronic kidney disease (CKD) limits shared decision making. As part of the Standardized Outcomes in Nephrology (SONG)-Kids initiative, we aimed to generate a consensus-based prioritized list of critically important outcomes to be reported in all trials in children with CKD.

STUDY DESIGN

An online 2-round Delphi survey in English, French, and Hindi languages.

SETTINGS & PARTICIPANTS

Patients (aged 8-21 years), caregivers/family, and health care professionals (HCPs) rated the importance of outcomes using a 9-point Likert scale (7-9 indicating critical importance) and completed a Best-Worst Scale.

ANALYTICAL APPROACH

We assessed the absolute and relative importance of outcomes. Comments were analyzed thematically.

RESULTS

557 participants (72 [13%] patients, 132 [24%] caregivers, and 353 [63%] HCPs) from 48 countries completed round 1 and 312 (56%) participants (28 [40%] patients, 64 [46%] caregivers, and 220 [56%] HCPs) completed round 2. Five outcomes were common in the top 10 for each group: mortality, kidney function, life participation, blood pressure, and infection. Caregivers and HCPs rated cardiovascular disease higher than patients. Patients gave lower ratings to all outcomes compared with caregivers/HCPs except they rated life participation (round 2 mean difference, 0.1), academic performance (0.1), mobility (0.4), and ability to travel (0.4) higher than caregivers and rated ability to travel (0.4) higher than HCPs. We identified 3 themes: alleviating disease and treatment burden, focusing on the whole child, and resolving fluctuating and conflicting goals.

LIMITATIONS

Most participants completed the survey in English.

CONCLUSIONS

Mortality, life participation, kidney function, and blood pressure were consistently highly prioritized by patients, caregivers, and HCPs. Patients gave higher priority to some lifestyle-related outcomes compared with caregivers/HCPs. Establishing critically important outcomes for all trials in children with CKD may improve consistent reporting of survival, kidney health, and clinical and life impact outcomes that are meaningful for decision making.

Patients' perceived lack of goal clarity in psychological treatments: Scale development and negative correlates

Goal setting in psychological treatments may have favourable effects on patients' motivation and treatment outcomes. Therefore, it seems important to detect when patients do not perceive clear treatment goals. The current study presents a questionnaire measuring patients' perceived lack of goal clarity. The cross‐sectional study consisted of 742 adult outpatients with diverse mental disorders. Patients completed the perceived lack of goal clarity questionnaire, and additional items measuring goal setting and evaluation, therapeutic alliance, symptom levels, patients' dependency on their treatment, and their expected and needed number of future treatment sessions. Exploratory factor analysis and reliability analyses resulted in a unidimensional and reliable questionnaire (nine items, α = .85). Additional findings showed that 23% of the treatments lacked initial goal setting according to the patients. Also, perceived lack of goal clarity was lower when treatment goals were established explicitly at the start of treatment, were formulated together with the therapist, and were discussed regularly during treatment, and treatment progress was monitored regularly. Moreover, patients reporting their goals as unclear also reported a poorer quality of the therapeutic alliance, higher symptom levels, increased need for future sessions, but also lower levels of care dependency. These findings underscore the importance of perceived goal clarity in psychological treatments, although the relation with actual goal setting remains uncertain.

Benefits of Art Therapy in People Diagnosed With Personality Disorders: A Quantitative Survey

Art therapy is widely used and effective in the treatment of patients diagnosed with Personality Disorders (PDs). Current psychotherapeutic approaches may benefit from this additional therapy to improve their efficacy. But what is the patient perspective upon this therapy? This study explored perceived benefits of art therapy for patients with PDs to let the valuable perspective of patients be taken into account. Using a quantitative survey study over 3 months (N = 528), GLM repeated measures and overall hierarchical regression analyses showed that the majority of the patients reported quite a lot of benefit from art therapy (mean 3.70 on a 5-point Likert scale), primarily in emotional and social functioning. The improvements are concentrated in specific target goals of which the five highest scoring goals affected were: expression of emotions, improved (more stable/positive) self-image, making own choices/autonomy, recognition of, insight in, and changing of personal patterns of feelings, behaviors and thoughts and dealing with own limitations and/or vulnerability. Patients made it clear that they perceived these target areas as having been affected by art therapy and said so at both moments in time, with a higher score after 3 months. The extent of the perceived benefits is highly dependent for patients on factors such as a non-judgmental attitude on the part of the therapist, feeling that they are taken seriously, being given sufficient freedom of expression but at the same time being offered sufficient structure and an adequate basis. Age, gender, and diagnosis cluster did not predict the magnitude of perceived benefits. Art therapy provides equal advantages to a broad target group, and so this form of therapy can be broadly indicated. The experienced benefits and the increase over time was primarily associated with the degree to which patients perceive that they can give meaningful expression to feelings in their artwork. This provides an indication for the extent of the benefits a person can experience and can also serve as a clear guiding principle for interventions by the art therapist.

Management of type 2 diabetes: consensus of diabetes organizations

Despite the advances in diabetes management, people with diabetes are not reaching their target glycemic goals. Healthcare professionals often fail to initiate, escalate, or de-intensify therapy when indicated. There are several organizations that provide guidance on the management of diabetes to assist the practitioner in achieving improved glycemic control, and this can cause confusion to the practitioner on which organizations' guidance to follow. Diabetes mellitus is associated with an elevated risk of cardiovascular disease, and there have been studies that suggest some antidiabetic medications increase cardiovascular risk and some reduce cardiovascular risk. Diabetes organizations recommend the individualization of treatment goals and choices of drug therapy that will be safe and effective. Healthcare professionals should be knowledgeable and equipped to decide on the best treatment regimen for each of their patients with type 2 diabetes (T2D) and be familiar with how to utilize the different organizations' philosophies in treating their patients.

What do elderly problem drinkers aim for? Choice of goal for treatment among elderly treatment-seeking alcohol-dependent patients

OBJECTIVE

The patient's free choice of treatment goals for alcohol use disorder (AUD) is predictive for treatment outcome. Presently there is limited knowledge of whether the age at onset of AUD influences the choice of goal for treatment. The present study investigates whether there are differences in choice of treatment goal between patients with very late onset alcohol use disorder (VLO AUD ≥ 60 years) and those having early or mid-age onset of AUD (EMO AUD < 60 years).

METHOD

Participants were 341 persons, voluntarily enrolled in the Elderly Study, who were seeking treatment for AUD in outpatient centres for alcohol treatment in Denmark. Data regarding thoughts about abstinence, alcohol use in the last 90 days, motivation for treatment and psychiatric diagnosis were collected via questionnaires. A logistics regression was used to analyse the data.

RESULTS

32.1% of the participants with VLO AUD chose temporary abstinence goals, compared to 18.2% of the patients with earlier-onset AUD (p = 0.024). Further, 10.7% of participants with VLO AUD chose total abstinence goals compared to 31.3% of participants with early or mid-age onset AUD (p = 0.002).

CONCLUSION

There are significant differences in choice of goal between participants with very late onset AUD and early or mid-age onset AUD. Individuals with very late onset alcohol use disorder tend to choose temporary abstinence over any other treatment goal whereas, in general, individuals with early onset alcohol use disorder choose permanent abstinence over other treatment goals.

Achievement of the National Psoriasis Foundation treatment targets with ixekizumab: Pooled analyses from 4 clinical studies

BACKGROUND

The National Psoriasis Foundation (NPF) published treatment targets for US patients with plaque psoriasis. However, data are lacking on how well existing therapies help achieve these goals.

OBJECTIVE

To examine the ability of an interleukin 17 inhibitor, ixekizumab, in achieving these treatment targets.

METHODS

Post hoc analysis was performed on pooled data from 4 phase III clinical trials assessing ixekizumab for plaque psoriasis: the UNCOVER-1, -2, and -3 trials and the IXORA-S trial. Treatment response was evaluated using the NPF-defined acceptable response (affected body surface area [BSA] of 3% or less or BSA improvement of 75% or higher at 12 weeks of treatment) and target response (BSA of 1% or less at 12 weeks and every 6 months thereafter).

RESULTS

In the UNCOVER trials (n = 2701), acceptable and target response rates at week 12 were 73.9% and 51.8% with ixekizumab 80 mg every 2 weeks, 35.7% and 14.9% with etanercept 50 mg, and 3.0% and 0.6% with placebo, respectively. In the IXORA-S trial (n = 302), acceptable and target response rates at week 12 were significantly higher with ixekizumab every 2 weeks versus ustekinumab (acceptable response 68.4% vs 38.6%, P < .0001; target response 50.7% vs 24.1%, P < .0001).

LIMITATIONS

Data were from controlled studies and may not reflect real-world practice.

CONCLUSION

The majority of patients treated with ixekizumab in 4 phase III clinical trials achieved NPF, patient-centered treatment targets.

Patient attitudes toward and goals for MDD treatment: a survey study

Background/Objectives: Major depressive disorder (MDD) is a highly prevalent disorder, frequently diagnosed and treated in a primary care setting; however, little information is available about the treatment decision-making process between MDD patients and their providers. A shared decision-making and goal attainment approach to establishing and tracking progress toward treatment goals that are meaningful to individual patients is explored in this survey study. In addition, information about patient perspectives on setting treatment goals, medication selection/switching, and engaging patients with their health care professionals was also collected and evaluated. Methods: A 50-question online survey was administered to members of the PatientsLikeMe community who indicated an MDD diagnosis and a switch in antidepressant medications within the past 2 years. Follow-up interviews were also conducted with a small subset of these participants. Results: Of the 200 participants who completed the survey, 42% reported currently having goals for MDD treatment. These goals were typically in the areas of physical health (62.7%), cognitive functioning (60.2%), and social aspects of life (57.8%). A majority of survey participants (61%) believed the goal attainment approach would be helpful to set and evaluate treatment goals. Conclusions: The data provide important insights into patient perspectives on the development of formal treatment plans and goals for MDD. In addition, the data also support the use of a patient-centric approach to shared decision-making by using a goal attainment scale to establish and track progress toward treatment goals that are meaningful to MDD patients in real-world clinical practice. The results of this study can be used to inform best practices in patient-clinician communication when developing an MDD treatment plan and goals.

Discrepancy between treatment goals documentation by oncologists and their understanding among cancer patients under active treatment with chemotherapy

OBJECTIVE/BACKGROUND

Discussion of treatment goals between oncologists and patients is challenging. Patients frequently misunderstand goals of therapy. There are several methods to document goals of chemotherapy, however, and are frequently not incorporated into patient charts.

METHODS/DESIGN

Cancer patients receiving their first cycle of chemotherapy were interviewed. Patients' recall of discussions with their oncologist regarding therapy intent was assessed and compared to documentation. An adjusted McNemar's test was utilised. A one-sample proportion test was used to evaluate whether the overall observed rate of discordance was significantly different from the proposed 33% rate; a rate posited as a threshold too high in the clinical sense.

RESULTS

Two hundred and seven eligible patients were interviewed. Oncologist identified treatment goals were not documented in 24.6% of cases and had to be excluded. There was not a significant difference in the directionality of discordance present. Inter-rater agreement between patient and oncologist was found to be adequate (κ = 0.64). The overall rate of discordance (17.29%) was found to be significantly less than the proposed acceptable level of 33% (p < 0.01). Upon univariable analysis, age, gender, marital and employment status were not found to be associated with discordance.

CONCLUSIONS

Discordance between treatment goals documentation and their understanding exists, indicating continued miscommunication between the patient and oncologist.

What areas of functioning are influenced by aquatic physiotherapy? Experiences of parents of children with cerebral palsy

OBJECTIVES

To explore the experiences regarding aquatic physiotherapy among parents of children with cerebral palsy and to identify a list of relevant intervention categories for aquatic physiotherapy treatments.

METHODS

We conducted semi-structured interviews and focus groups using the components of the International Classification of Functioning, Disability and Health (ICF) as a frame of reference to explore and code experiences regarding aquatic physiotherapy. A non-probabilistic purposive sampling strategy was used. Content analysis methods and ICF linking processes were used to analyze data.

RESULTS

From the parents' perspective (n = 34), both the Body Functions and Activities and Participation components were mainly influenced by aquatic physiotherapy. Also, parents described Environmental Factors acting as barriers affecting progress during therapy.

CONCLUSIONS

Parents identified a wide range of categories influenced by aquatic physiotherapy. Social and contextual aspects were highlighted, as well as a series of changes related to the illness as a result of treatment.

Achieving triple treatment goals in multi-ethnic Asian patients with type 2 diabetes mellitus in primary care

INTRODUCTION

Achieving optimal glycated hemoglobin (HbA1c), blood pressure (BP), and LDL-Cholesterol (LDL-C) in patients mitigates macro- and micro-vascular complications, which is the key treatment goal in managing type 2 diabetes mellitus (T2DM). This study aimed to determine the proportion of patients in an urban community with T2DM and the above modifiable conditions attaining triple vascular treatment goals based on current practice guidelines.

METHODS

A questionnaire was distributed to adult Asian patients with dyslipidemia at two primary care clinics (polyclinics) in northeastern Singapore. The demographic and clinical data for this sub-population with both T2DM and dyslipidemia were collated with laboratory and treatment information retrieved from their electronic health records. The combined data was then analyzed to determine the proportion of patients who attained triple treatment goals, and logistic regression analysis was used to identify factors associated with this outcome.

RESULTS

665 eligible patients [60.5% female, 30.5% Chinese, 35% Malays, and 34.4% Indians] with a mean age of 60.6 years were recruited. Of these patients, 71% achieved LDL-C ≤2.6 mmol/L, 70.4% had BP <l40/90 mmHg, and 40.9% attained HbAlc ≤7%. Overall, 22% achieved the triple treatment goals for glycemia, BP, and LDL-C control. The major determinants were the number of diabetic medications and intensity of statin therapy.

CONCLUSION

Eight in ten patients with T2DM failed to achieve concurrent glycemic, BP, and LDL-C treatment goals, subjecting them to risks of vascular complications. Primary healthcare professionals can mitigate these risks by optimizing therapeutic treatment to maximize glycemia, dyslipidemia, and BP control.

Quantifying the treatment goals of people recently diagnosed with schizophrenia using best-worst scaling

OBJECTIVE

This study seeks to quantify the treatment goals of people recently diagnosed with schizophrenia and explore their impact on treatment plan.

METHODS

People aged 18-35 years with a confirmed diagnosis of schizophrenia within the past 5 years were surveyed in the UK, Germany, and Italy. Treatment goals were assessed via a validated best-worst scaling instrument, where participants evaluated subsets of 13 possible treatment goals identified using a balanced incomplete block design. Participants identified the most and least important goals within each task. Data were also collected on current treatment and preference for daily oral versus long-acting injectable (LAI) treatment. Hierarchical Bayes was used to identify preference weights for the goals, and latent class analysis was used to identify segments of people with similar goals. The segments were compared with the current treatment and preference for oral versus LAI treatment.

RESULTS

Across 100 participants, the average age was 26 years, 75% were male and 50% were diagnosed within 2 years ago. Overall, preferences were most favorable for reduced disease symptoms, think clearly, reduced hospitalizations, reduced anxiety, and take care of self. A total of 61% preferred oral medication and 39% LAI. Two groups were identified with different treatment goals; 50% of participants emphasized clinical goals, including reduced disease symptoms (preference weight =19.7%), reduced hospitalizations (15.5%), and reduced anxiety (10.5%). The other 50% emphasized functional goals, including improved relationships with family/friends (11.4%), increased interest in work (10.6%), experiencing a fuller range of emotions (8.4%), and ability to socialize (7.5%). Those emphasizing functional goals were more likely to be on LAI (44% versus 26%; p=0.059) and preferred LAI (46% versus 32%; p=0.151).

CONCLUSIONS

People with recent-onset schizophrenia may focus more on clinical goals or functional goals, a discussion of which may help facilitate patient engagement.

Development of a stated-preference instrument to prioritize treatment goals in recent onset schizophrenia

OBJECTIVE

This study sought to evaluate a new stated-preference instrument to prioritize multiple treatment goals among people with recent onset schizophrenia.

METHODS

A draft survey instrument was developed to assess preferences for 13 key treatment goals that were identified based on the literature. The survey incorporates best-worst scaling (BWS), which shows repeated subsets comprising 4 of the 13 goals, and respondents identify which is most important and which is least important to them. Pre-test interviews were conducted in the UK, Italy, and Germany among people aged 18 to 35 diagnosed with schizophrenia within the past 5 years. Specifically, participants completed the instrument online in their native language, followed by a telephone interview to provide feedback on the clarity, relevance, and comprehensiveness of the survey. The interview data were analyzed to assess interpretation and content validity of the survey.

RESULTS

Fifteen participants (five per country) provided feedback (mean age = 31; 60% male). Feedback was comparable across countries and confirmed that the key treatment goals assessed were relevant and meaningful. Probing by interviewers ascertained that respondents interpreted the questions appropriately and identified the treatment goals that were most and least important to them. Based on the characterization of the goals, a conceptual model was developed illustrating hypothesized associations among them.

CONCLUSION

The results confirm that the BWS methodology and key treatment goals in this new instrument are appropriate for use in recent onset schizophrenia. These results will help guide measurement of patient-relevant endpoints in future studies.

Social work interventions in Sweden for patients newly diagnosed with type 1 or type 2 diabetes

We evaluated psychosocial work with patients in ordinary clinical practice who were newly diagnosed with type 1 or type 2 diabetes and experienced psychosocial problems at disease onset. We examined types of psychosocial problems, causes of these problems, psychosocial interventions, extent of achievement of psychosocial treatment goals, and whether the patients felt they benefited from the treatment. Eighty-nine working-age (18-65-year-old) Swedish adults newly diagnosed with diabetes were included. Each was interviewed and responded to questionnaires at the beginning and end of the study period. Thirty-four (38%) received psychosocial treatment as needed over 2 years. A psychosocial treatment plan with a defined goal was developed for each. Interventions included counseling, problem-focused support, social information, and advice. The treatment process was documented. Eighteen patients had type 1, and 16 had type 2 diabetes. One-third had emotional problems directly caused by receiving a diagnosis. Several of them had crisis reactions. The rest had problems primarily caused by their life situations. Those with psychosocial problems caused by receiving a diagnosis achieved treatment goals more frequently than the others. Distinguishing the cause of the psychosocial problems of newly diagnosed patients may help ensure that social work resources in health care are used as effectively as possible.

Engagement in Advance Care Planning and Surrogates' Knowledge of Patients' Treatment Goals

OBJECTIVES

A key objective of advance care planning (ACP) is improving surrogates' knowledge of patients' treatment goals. Little is known about whether ACP outside of a trial accomplishes this. The objective was to examine patient and surrogate reports of ACP engagement and associations with surrogate knowledge of goals.

DESIGN

Cohort study SETTING: Primary care in a Veterans Affairs Medical Center.

PARTICIPANTS

350 community-dwelling veterans age ≥55 years and the individual they would choose to make medical decisions on their behalf, interviewed separately.

MEASUREMENTS

Treatment goals were assessed by veterans' ratings of 3 health states: severe physical disability, cognitive disability, and pain, as an acceptable or unacceptable result of treatment for severe illness. Surrogates had knowledge if they correctly predicted all 3 responses. Veterans and surrogates were asked about living will and health care proxy completion and communication about life-sustaining treatment and quality versus quantity of life (QOL).

RESULTS

Over 40% of dyads agreed that the veteran had not completed a living will or health care proxy and that there was no QOL communication. For each activity, sizeable proportions (18-34%) disagreed about participation. In dyads who agreed QOL communication had occurred, 30% of surrogates had knowledge, compared to 21% in dyads who agreed communication had not occurred and 15% in dyads who disagreed (P = .01). This relationship persisted in multivariable analysis. Agreement about other ACP activities was not associated with knowledge.

CONCLUSION

Disagreement about ACP participation was common. Agreement about communication regarding QOL was modestly associated with surrogate knowledge of treatment goals. Eliciting surrogates' perspectives is critical to ACP. Even dyads who agree about participation may need additional support for successful engagement.

Current evidence supporting mucosal healing and deep remission as important treatment goals for inflammatory bowel disease

Mucosal healing (MH) is now considered as a major treatment goal in clinical trials and clinical practice for patients with inflammatory bowel disease (IBD). MH is associated with sustained clinical remission, steroid-free remission, and reduced rates of hospitalization and surgery. There is a well-known disconnect between clinical symptoms and mucosal lesions that is more pronounced in CD. More stringent therapeutic goals have been discussed recently such as deep remission defined as clinical remission associated with MH. Recent international guidelines from the IOIBD recommended deep remission as a treatment goal in clinical practice. However there is no validated definition of deep remission in IBD. Also, the efficacy of available drugs to induce and maintain deep remission in IBD is poorly known. Finally, whether deep remission is the best way to modify the course of IBD and whether it should be achieved before considering drug de-escalation have to be formally evaluated in upcoming disease-modification trials.

Can we improve service efficiency in CAMHS using the CAPA approach without reducing treatment effectiveness?

Health-care systems are under increasing pressure to deliver more care with similar or even less resources and there is concern that this may be achieved at the cost of reduced clinical effectiveness. In Child and Adolescent Mental Health Services (CAMHS), the Choice and Partnership Approach (CAPA) has been widely adopted as a way of increasing the efficient use of limited service resources. Some evaluations have reported increased patient flow and reduced waiting times, but it remains unknown whether such changes have been achieved at a cost of clinical effectiveness. This article describes a pragmatic multi-method evaluation of a CAMHS service reporting service outcomes (client satisfaction, waiting times, and patient flow) and clinical outcomes (clinician-rated clinical outcomes and goals achieved by families). Results showed improved service outcomes (high levels of client satisfaction and reduced waiting times) and an increase in patient flow (49 cases increased to 72 cases over an equivalent time period). Clinical outcomes showed no reduction in effectiveness and a significant improvement against the agreed goals of the intervention. The evaluation suggested that a well-structured goal-focused patient flow system may improve services by increasing patient flow while maintaining high satisfaction levels, without negatively impacting clinical effectiveness.

On the transition from a nurse-led hypertension clinic to hypertension control in primary care: identifying barriers to and factors acting against continuous hypertension control

Many hypertensive patients are not treated to target and hence do not benefit fully from the blood pressure-related improvements in cardiovascular health. Hypertensive patients who had primarily been treated to a target goal in a nurse-led hypertension clinic were re-examined to evaluate whether their target goal blood pressure was maintained after their discharge from the hypertension clinic for further control in primary care, and to evaluate potential barriers to and factors acting against continuous hypertension control. The median observation time was 3.6 years (range 3 months to 7.9 years). Only 45.2% of the patients were well controlled at the time of re-examination. No patient-related factors (age, body mass index, gender, attitudes towards medication) predicted the outcome. Two factors were significant in the reduction in continuous hypertension control: the cooperation between the patient and health personnel and the shared commitment towards the target goal were discontinued; and many patients did not make control visits to the general practitioner's office. In conclusion, maintained strict control of hypertension requires both continued close collaboration between the patient and health personnel, with an emphasis on treatment goals, and systematic control visits.

Canagliflozin Treatment in Patients with Type 2 Diabetes Mellitus

Current guidelines for treatment of type 2 diabetes mellitus (T2DM) indicate a patient-centered approach that should go beyond glycemic control. Of the many antihyperglycemic agents available for treatment of T2DM, sodium-glucose cotransporter 2 (SGLT2) inhibitors offer the advantages of reduced glycated hemoglobin (A1C), body weight (BW), and systolic blood pressure (SBP) and are associated with a low risk of hypoglycemia when used either as monotherapy or with other agents not typically associated with increased risk of hypoglycemia. Collaborative, multidisciplinary teams are best suited to provide care to patients with diabetes, and clinical pharmacists can enhance the care provided by these teams. This review aims to provide insight into the mode of action, pharmacology, potential drug-drug interactions, clinical benefits, and safety considerations associated with use of the SGLT2 inhibitor canagliflozin in patients with T2DM and to provide information to enhance clinical pharmacists' understanding of canagliflozin.

Understanding the purpose of treatment and expectations in patients with inoperable lung cancer treated with palliative chemotherapy

AIM OF THE STUDY

Informing cancer patients about various types of treatment and their adverse effects and communicating negative information is an important element of diagnostic and therapeutic procedures. Understanding the purpose of treatment and expectations, and socio-demographic factors in patients undergoing palliative chemotherapy because of lung cancer.

MATERIAL AND METHODS

The study included 100 patients with lung cancer at the age of 40-80 years (mean 63.1) in the Oncology Center in Bydgoszcz in 2013-2014. The diagnostic survey method with the author's questionnaire was used.

RESULTS

Forty-one percent of patients were convinced that the purpose of chemotherapy is to cure the disease. Both inhabitants of small towns (population below 50 thousand) and large villages (p = 0.09) were similarly convinced about the effectiveness of chemotherapy. Seventy-three percent of inhabitants of small towns and 79% of country dwellers (p = 0.005) thought that chemotherapy is aimed at improving the quality of life. Patients with very good economic conditions responded that chemotherapy is designed to improve the quality of life more often than those with good and bad economic conditions, 90%, 88% and 60%, respectively (p = 0.001). With the increase in population the number of people who claimed that palliative chemotherapy prolongs their life increased, 71%, 77% and 90%, respectively (p = 0.03).

CONCLUSIONS

The knowledge of patients with lung cancer about palliative chemotherapy is insufficient. Almost half of them do not understand the purpose of treatment and hope that chemotherapy will cure them of the disease. Most patients know that the aim of chemotherapy is to alleviate symptoms and improve quality of life and prolong their life. Half of the patients want to obtain information on treatment and half of them about life expectancy. Almost half of the patients feel stress and anxiety towards chemotherapy. Most patients do not use the help of a psychologist and do not feel such a need.

An evolution in switching therapy for psoriasis patients who fail to meet treatment goals

Switching psoriasis treatment is a common, accepted practice that is used to improve disease management and improve patient outcomes (e.g., when patients are experiencing suboptimal efficacy and/or tolerability with a given therapy). Historically, switching treatment was often performed to limit patients’ cumulative exposure to conventional systemic agents (e.g., methotrexate, cyclosporine) with the goal of reducing end‐organ toxicity. However, the practice of switching treatments has evolved in recent years with the availability of highly effective and tolerable biologic agents. In current practice, near‐complete skin clearance with minimal side effects should be a realistic treatment goal for most patients with moderate‐to‐severe psoriasis, and consideration for switching therapies has shifted to become more focused on achieving maximum possible skin clearance, enhanced quality of life, and improved patient satisfaction. This review provides a discussion of recent guidance on switching psoriasis therapies, including initial considerations for when switching therapy may be advisable and challenges associated with switching therapy, along with an overview of published clinical studies evaluating outcomes associated with switching therapy. The goal of this review is to empower dermatologists to optimally manage their patients’ psoriasis by providing the tools needed to develop rational strategies for switching treatments based on the pharmacologic characteristics of available treatments and each patient's clinical needs and treatment preferences.

Crohn's disease in adolescence: presentation and treatment

Crohn's disease is a chronic inflammatory bowel condition that affects more than 115,000 people in the UK. This article focuses on Crohn's disease in adolescents. Management of the condition in this group should address adolescent-specific characteristics and treatment goals. Key elements include optimising growth, pubertal development and social functioning, including education. The condition can affect an individual's mental and emotional wellbeing significantly, as well as their physical health. As adolescence is a time of great change, the additional burden of a chronic illness can prove difficult to manage. The authors provide information on the presentation of Crohn's disease in adolescence and insights into the particular issues encountered by this group.