Living with scleroderma: patients’ perspectives, a phenomenological study

Multi-Method Approach in the Assessment of Alexithymia in Patients With Scleroderma: Use of Two Different Tools

Objective: Alexithymia is frequent in patients with some chronic dermatological conditions. The aim of the study was to measure the prevalence of alexithymia in patients with systemic sclerosis (SSc) using two different tools. Methods: Consecutive patients diagnosed with SSc were recruited at day hospital and hospitalization regimen. Alexithymia was measured using the self-administered questionnaire 20-item Toronto Alexithymia scale (TAS-20) and the semi-structured interview 24-item Toronto Structured Interview for Alexithymia (TSIA). Results: The study sample consisted of 67 female patients, aged from 29 to 82 years. According to TAS-20, 22.4% of patients were alexithymic and 17.9% were borderline alexithymic. Also, in our sample mean TAS-20 value was 48.9 and TSIA mean value was 20.3. Spearman's correlation coefficient between TAS-20 total score and TSIA total score was 0.603. A high correlation was observed between TAS total score and the "Affective Awareness" (AA) scale of the TSIA. TSIA total score significantly correlated with the "Difficulty describing feeling to others" (DDF) scale of the TAS-20. The highest correlation between scales of the two instruments was that between TAS-20 DDF and TSIA AA (r = 0.675). Conclusion: The prevalence of alexithymia in SSc patients was higher than in the general population, and similar to that of psoriasis patients. The measurements obtained using the TAS-20 and the TSIA were highly correlated. However, they also showed some diversities in the scales, indicating that they may measure different domains.

Poor maternal and foetal outcomes in women with systemic sclerosis: an interview-based study at a tertiary centre

Poor obstetric outcomes are described in rheumatic diseases (RDs) such as systemic sclerosis (SSc). We assessed the effect of the disease in Indian women and compared with those in developed countries and other RDs. Women with SSc (ACR/EULAR 2013 criteria) registered at a tertiary care centre (2010-2016) were interviewed by teleconsultation. Pregnancies occurring after disease onset were compared with those occurring prior to it. Maternal complications included antepartum hemorrhage, postpartum hemorrhage, spontaneous abortion, preterm rupture of membrane, oligohydramnios, infection, prolonged labour, and foetal complications including low birth weight (LBW), intrauterine death (IUD), preterm delivery, and neonatal infection. Results were expressed as median (Interquartile range). Of 200 SSc, 75 patients aged 31 (22-38) years and disease duration 41 (32-50) months were interviewed. Diffuse cutaneous SSc was the most common (42.56%). 127 conceptions before the onset of SSc were compared with 15 after. Among post-diagnosis, 9 (60%) were live births, 3 (20%) spontaneous abortions 1 (6.7%) induced abortion, 2 (13.3%) IUD. Of the live births, 4 (26.7%) were preterm and 3 (20%) were LBW. Pregnancies after disease onset had a higher rate of maternal (OR - 4.9) and foetal (OR - 9.9) complications compared to pregnancies before SSc. Compared to the Italian cohort, Indian SSc patients had a higher abortion rate (OR - 5.8), frequent lower section ceaserean section (OR - 9.4) and lower live births (OR - 0.05). More frequent caesarean deliveries (OR - 93), preterm deliveries (OR - 20) when compared with lupus and favourable maternal outcomes (OR - 0.15), higher preterm deliveries (OR - 9.6) in comparison with Takayasu arteritis were noted. SSc incurs a higher risk of poor maternal as well as the foetal outcome.

A specific method for qualitative medical research: the IPSE (Inductive Process to analyze the Structure of lived Experience) approach

BACKGROUND

This paper reports the construction and use of a specific method for qualitative medical research: The Inductive Process to Analyze the Structure of lived Experience (IPSE), an inductive and phenomenological approach designed to gain the closest access possible to the patients' experience and to produce concrete recommendations for improving care. This paper describes this innovative method.

METHODS

IPSE has five steps: 1) set up a research group, 2) ensure the originality of the research, 3) organize recruitment and sampling intended to optimize exemplarity, 4) collect data that enable entry into the subjects' experience, and 5) analyze the data. This final stage is composed of one individual descriptive phase, followed by two group phases: i) structure the experience, and ii) translate the findings into concrete proposals that make a difference in care.

RESULTS

This innovative method has provided original findings that have opened up new avenues of research and have important practical implications, including (1) the development of patient-reported outcomes, (2) clinical recommendations concerning assessment and treatment, (3) innovative ways to improve communication between patients and doctors, and (4) new insights for medical pedagogy.

CONCLUSIONS

IPSE is a qualitative method specifically developed for clinical medical research to reach concrete proposals, easily combined with quantitative research within a mixed-method study design and then directly integrated within evidence-based medicine.

How Systemic Sclerosis Affects Healthcare Use and Complication Rates after Total Hip Arthroplasty

OBJECTIVE

To assess whether outcomes after primary total hip arthroplasty (THA) differ in systemic sclerosis (SSc).

METHODS

We used the 1998-2014 US National Inpatient Sample. THA and SSc were identified using procedure and diagnostic codes, respectively. Multivariable-adjusted logistic regression analyses assessed the association of SSc with in-hospital complications (implant infection, revision, transfusion, mortality) post-THA and associated healthcare use (hospital charges, hospital stay, discharge to non-home setting), adjusting for age, sex, race, Deyo-Charlson comorbidity index, primary diagnosis for THA, household income, and insurance payer.

RESULTS

Of the 4,116,485 primary THA performed in the United States in 1998-2014, SSc patients made up 0.06% (n = 2672). In multivariable-adjusted analyses, compared to people without SSc, people with SSc had higher adjusted OR (95% CI) of the following post-primary THA: (1) non-home discharge, 1.25 (95% CI 1.03-1.50); (2) hospital stay > 3 days, 1.61 (95% CI 1.35-1.92); (3) transfusion, 1.54 (95% CI 1.28-1.84); and (4) in-hospital revision, 9.53 (95% CI 6.75-13.46). Differences in in-hospital mortality had a nonsignificant trend [2.19 (95% CI 0.99-4.86)]. There were no differences in total hospital charges or implant infection rates.

CONCLUSION

SSc was associated with a higher rate of in-hospital complications and healthcare use after primary THA. Future studies should examine whether pre- or postoperative interventions can reduce the risk of post-THA complications in people with SSc.

The patient experience of Raynaud's phenomenon in systemic sclerosis

RP is the most common manifestation of SSc and a major cause of disease-related morbidity. This review provides a detailed appraisal of the patient experience of SSc-RP and potential implications for disease classification, patient-reported outcome instrument development and SSc-RP clinical trial design. The review explores the clinical features of SSc-RP, the severity and burden of SSc-RP symptoms and the impact of SSc-RP on function, work and social participation, body image dissatisfaction and health-related quality of life in SSc. Where management of SSc-RP is concerned, the review focuses on the 'patient experience' of interventions for SSc-RP, examining geographic variation in clinical practice and potential barriers to the adoption of treatment recommendations concerning best-practice management of SSc-RP. Knowledge gaps are highlighted that could form the focus of future research. A more thorough understanding of the patient experience could support the development of novel reported outcome instruments for assessing SSc-RP.

Systemic sclerosis is associated with knee arthroplasty outcomes: a National US study

OBJECTIVE

To assess whether systemic sclerosis (SSc) is associated with total knee arthroplasty (TKA) outcomes.

METHODS

We used the 1998-2014 US National Inpatient Sample. We conducted multivariable-adjusted logistic regression analyses to examine the association of a diagnosis of SSc with post-TKA in-hospital complications (implant infection, revision, transfusion, mortality) and healthcare utilization (hospital charges, hospital stay, non-home vs. home discharge). Odds ratios (OR) and 95 % confidence intervals (CI) were calculated.

RESULTS

Our cohort included 8,123,388 people without SSc and 3894 people with SSc. In multivariable-adjusted analyses, compared to people without SSc, people with SSc had higher odds of transfusion, hospital stay > 3 days and non-home discharge with higher OR of 1.42 (95 % CI, 1.20, 1.69), 1.29 (95 % CI, 1.11, 1.49), and 1.29 (95 % CI, 1.11, 1.49), respectively. No differences were seen in revision, 0.68 (95 % CI, 0.10, 4.69) or hospital charges above the median, 1.01 (95 % CI, 0.70, 1.46). Differences in implant infection or mortality were not estimable, since none of the patients with SSc had implant infection or died. Sensitivity analyses that adjusted the main analysis additionally for hospital-level variables confirmed study findings with minimal or no attenuation of OR.

CONCLUSION

SSc was associated with higher risk of transfusion and increased healthcare utilization after TKA. Future studies should examine if interventions can address modifiable factors to further optimize these outcomes.Key Points• Systemic sclerosis was independently associated with higher healthcare utilization after TKA.• The adjusted odds of transfusion was higher in people with systemic sclerosis compared to those without systemic sclerosis who underwent TKA.

Patient perception of disease burden in diffuse cutaneous systemic sclerosis

Purpose:

Systemic sclerosis is a rare multi-organ autoimmune rheumatic disease, resulting in progressive fibrosis of the skin/internal organs. This study aimed to understand the impact of diffuse cutaneous systemic sclerosis symptoms and disease burden from the patient’s perspective.

Methods:

This was a mixed methodology, market research study involving ethnography, structured interviews, video diaries, and patient tasks. Patients had been diagnosed with diffuse cutaneous systemic sclerosis for ⩾ 6 months and were recruited via healthcare professionals or patient associations (France, Italy, the United Kingdom, and the United States). Patients filmed short (~15 min) daily video diaries about their lives over 7 days and participated in ethnographic sessions, patient tasks, and structured video interviews. In Germany and Spain, patients participated in 60-min telephone interviews.

Results:

Twenty-three patients (mean age: 54 years; 83% women; minimum disease duration: 6 months) participated in the study. Time to diagnosis was prolonged, as patients overlooked their symptoms and some healthcare professionals attributed symptoms to other causes. Patients rarely received additional information or support services at diagnosis. Importantly, although patients were aware of the seriousness of organ involvement, they reported that skin changes, pain, and fatigue impaired their ability to perform routine tasks. Patients had a high prescription treatment burden (mean: 10 tablets/day; up to >25 tablets/day) with additional non-prescription medication taken for other comorbidities. Treatment discontinuation was common due to side effects. Patients experienced diffuse cutaneous systemic sclerosis as a loss of independence and self-esteem. Moreover, patients tended to have small support networks, and emotional support services were not offered as standard care.

Conclusion:

Patients with diffuse cutaneous systemic sclerosis had high treatment and disease burdens, with skin changes, pain, and fatigue profoundly affecting their lives. There is an unmet need for patient information at the time of diagnosis and emotional support services throughout the patient’s journey with diffuse cutaneous systemic sclerosis. Based on the results of this study, we provide recommendations for improving diffuse cutaneous systemic sclerosis care.

Scleroderma patient perspectives on social support from close social relationships

Purpose: People with rare diseases must cope with many physical and psychological challenges; an endeavor that can be difficult to carry out without external support. The purpose of this study was to understand how patients with scleroderma perceive the social support they need and receive from close relationships to better manage their disease.Method: Four focus groups with patients (N = 19) were conducted. A semi-structured topic guide was used. Discussions were recorded and transcribed, and thematic analysis was performed.Results: Patients reported receiving emotional, informational, and instrumental support, with emotional support being a priority for them. Patients also referred to relational factors (i.e., communication style, active engagement, complementarity) that affected the social support received. More specifically, engaging in honest communication, carefully choosing sources of support, and having close relationships motivated to learn and get involved enhanced support. In contrast, patients who avoided interacting with others or speaking about scleroderma and close relationships with a lack understanding or involvement hindered support.Conclusions: Patients might benefit more from interventions aiming at coping with scleroderma as a collective. Findings from this study help better understand the unique experiences of scleroderma patients while receiving support from close relationships.Implications for RehabilitationPeople with scleroderma may benefit from receiving different types of support from their close social relationships, including emotional, informational, and instrumental support.Professionals working in the area of rehabilitation should encourage patients to identify close social relationships who have specialized knowledge and skills (e.g., comfort looking for resources and information on the Internet) to help them cope better with the challenges associated with scleroderma.As part of the proposed treatment, rehabilitation professionals should encourage patients to actively communicate their social support needs to close social relationships, as well as maintain an open and honest line of communication with them, which will improve their capacity to understand the patient and provide appropriate support.Rehabilitation professionals may support people with scleroderma by encouraging them to seek support from their close social relationships, but also by providing these close relationship with information and supportive services to learn new skills and better cope with their own distress.

Challenges and strategies for coping with scleroderma: implications for a scleroderma-specific self-management program

Purpose: The purpose of this study was to explore challenges faced by patients with systemic sclerosis, also called scleroderma, in coping with their disease and the strategies they used to face those challenges. Method: Five focus groups were held with scleroderma patients (4 groups, n = 34) and health care professionals who have experience treating scleroderma (1 group, n = 8). Participants' discussions were recorded, transcribed and analyzed using thematic analysis. Results: Participants reported challenges accessing information (e.g., knowledgeable specialists), dealing with negative emotions (e.g., stress due to misunderstandings with loved ones), and accessing resources (e.g., helpful products or devices). Strategies for overcoming challenges were also discussed (e.g., advocating for own needs). Conclusion: When faced with significant challenges while coping with scleroderma, patients develop strategies to manage better and improve their quality of life. To help them cope, patients would benefit from easier access to supportive interventions, including tailored scleroderma self-management programs. Although the challenges experienced by patients with scleroderma are unique, findings from this study might help better understand patients' perspectives regarding coping and disease management for other chronic diseases as well. Implications for Rehabilitation People living with rare diseases, including the rare autoimmune disease scleroderma, face unique challenges and often do not have access to disease-specific educational or other support resources. People with scleroderma report that they face challenges in accessing information, including knowledgeable healthcare providers; managing difficult social interactions and negative emotions; and accessing resources. Strategies employed by scleroderma patients to overcome these challenges include seeking connections to other people with scleroderma or scleroderma patient organizations, actively seeking out local resources, and learning to communicate and advocate more effectively. Rehabilitation professionals can support people with scleroderma by providing them with information on connecting with scleroderma patient organizations or by facilitating local patient support networks.

Reasons for attending support groups and organizational preferences: the European scleroderma support group members survey

PURPOSE

The objectives were to identify reasons why patients attend scleroderma support groups and to ascertain preferences for how meetings are best organized.

METHODS

The survey included 30-items on reasons for attending and nine items on organizational preferences. Patients were recruited through European patient organizations. Exploratory factor analysis was used to group reasons for attendance thematically.

RESULTS

About 213 scleroderma patients (192 women) completed the survey. A three-factor model best described reasons for attending [χ²(348) = 586.1, p < 0.001; Comparative Fit Index = 0.98; Tucker Lewis Index = 0.97; Root Mean Square Error of Approximation = 0.06] with themes that included: (1) obtaining interpersonal and social support, (2) learning about treatment and symptom management strategies, and (3) discussing other aspects of scleroderma. Among organizational preferences, respondents emphasized that meetings should include educational aspects and the opportunity to share information and support.

CONCLUSION

People with scleroderma attend support groups to give and obtain social support and for education about managing their disease and other aspects of living with scleroderma. Support groups should be structured to facilitate both educational and informational aspects and to provide opportunities for sharing and support between members. Implications for rehabilitation Local peer-led support groups are an important support and informational resource for patients living with scleroderma. People with scleroderma attend support groups in order to: (1) obtain interpersonal and social support, (2) learn about disease treatment and symptom management strategies, and (3) discuss other aspects of living with scleroderma outside of symptom management. Most support group members prefer groups with a trained facilitator, that include family members or loved ones in the groups, that include between 11and 20 members, that last between 1 and 2 h, and that meet once every 1-3 months. Rehabilitation professionals can support the formation and management of local support groups or can refer patients to national scleroderma patient organizations for information on support groups that they may be able to access.

Patients' views and needs about systemic sclerosis and its management: a qualitative interview study

Background

Systemic sclerosis (SSc) is a chronic connective-tissue disease responsible for reduced life expectancy, disability and a decreased quality of life. In order to optimize patients-physicians relationship and care strategy we aimed to survey views of patients on SSc and its management to reveal potential hurdles and improve health care strategies.

Methods

A qualitative study combined semi-structured interviews, focus groups, and a direct observation of an information session was performed between November 2008 and January 2009.

Results

Twenty-five patients with SSc were included. They encounter difficulties to have a clear representation of their disease. Physical, psychological, and social repercussions of SSc may lead to a psychological distress and different coping strategies, which widely differ among interviewed patients. Patients’ views on their therapeutic journey and the management of their disease highlighted strong expectations about patient-physician relationship. These expectations were numerous, complex and sometimes ambivalent. Patients expected physicians to be human and attentive but also involved in research in the field and to provide psychological and affective support to help them to accept the uncertainty of disease evolution and lack of curative treatment. They also expected more individualized management, improvements in diagnosis and follow-up organization, more efforts in education and information, comprehensive behaviors and support from working colleagues and relatives, and increased funding from the health care system.

Conclusions

Our results suggest that SSc management could be optimized, particularly with more attention to the patient–practitioner relationship. Patient profiles should be more precisely defined in terms of coping strategies and treatment preferences to propose more individualized options.

Patients' Perspectives and Experiences Living with Systemic Sclerosis: A Systematic Review and Thematic Synthesis of Qualitative Studies

OBJECTIVE

Systemic sclerosis (SSc) is a chronic, progressive autoimmune disease with major end-organ involvement. Much attention has been focused on the management of physical and clinical manifestations; however, the effect of the disease and treatment on the patient's identity, relationships, functioning, and mental well-being are less known. We aimed to describe the patients' perspectives and experiences of living with SSc.

METHODS

Electronic databases were searched to October 2014. Thematic synthesis was used to analyze the findings.

RESULTS

We included 26 studies involving 463 patients. Six key themes were identified: distressing appearance transformation (disturbing facial changes, stigmatizing sickness, unrecognizable self), palpable physical limitations (bodily restrictions, frustrating mind-body disconnect, pervasive fatigue, disabling pain), social impairment (breaking intimacy, struggling to fulfill family responsibilities, maintaining work, losing independence), navigating uncertainty (diagnostic ambiguity, medically fending for oneself, unpredictable course of illness), alone and misunderstood (fearful avoidance of fellow patients, invisible suffering), and gradual acceptance and relative optimism (adapting to change and accepting limitations, taking a positive spin, cautious hoping, empowering relationships, valuing medical support).

CONCLUSION

SSc is a rare and unpredictable illness that undermines patients' sense of certainty and control and impairs their self-image, identity, and daily functioning. Patient-centered care that encompasses strategies to promote self-esteem, resilience, and self-efficacy may help to improve treatment satisfaction and health and quality of life outcomes for patients with SSc.

Exploring Sources of Emotional Distress among People Living with Scleroderma: A Focus Group Study

Background

Systemic sclerosis, or scleroderma, is a chronic and rare connective tissue disease with negative physical and psychological implications. Sources of emotional distress and the impact they have on the lives of people with scleroderma are not well understood.

Objectives

To gain an in-depth understanding of the emotional experiences and sources of emotional distress for women and men living with scleroderma through focus group discussions.

Methods

Three semi-structured focus group discussions were conducted (two in English, one in French) with a total of 22 people with scleroderma recruited through the Scleroderma Society of Ontario in Hamilton, Ontario and a scleroderma clinic in Montreal, Canada. Interviews were recorded, transcribed, and then coded for emerging themes using thematic inductive analysis.

Results

Core themes representing sources of emotional distress were identified, including: (a) facing a new reality; (b) the daily struggle of living with scleroderma; (c) handling work, employment and general financial burden; (d) changing family roles; (e) social interactions; and (f) navigating the health care system. Collectively, these themes refer to the stressful journey of living with scleroderma including the obstacles faced and the emotional experiences beginning prior to receiving a diagnosis and continuing throughout the participants’ lives.

Conclusion

Scleroderma was portrayed as being an unpredictable and overwhelming disease, resulting in many individuals experiencing multiple sources of emotional distress. Interventions and supportive resources need to be developed to help individuals with scleroderma and people close to them manage and cope with the emotional aspects of the disease.

Impaired quality of life in systemic sclerosis and patient perception of the disease: A large international survey

OBJECTIVES

The purpose of this study was to assess health-related quality of life (HRQoL) and disease perception in a large, international group of patients with systemic sclerosis (SSc).

METHODS

We placed a standardized questionnaire on a website for patient access. Socio-demographic information, disease characteristics, and self-assessment questionnaires-the Short Form 36 (SF-36) and the Revised Illness Perception Questionnaire (IPQ-R)-were collected.

RESULTS

A total of 1902 patients from 60 countries were included. HRQoL appeared to be impaired in SSc, particularly for physical health (PCS, mean ± SD = 43.4 ± 23.4). SSc patients also had strong perceptions about the chronic nature and negative consequence of the disease, and experienced negative emotions due to SSc. Patients with diffuse cutaneous SSc had a poorer HRQoL than those with limited cutaneous SSc, for both physical (PCS, mean ± SD = 46.6 ± 23.7 vs. 39.8 ± 22.3; p < 0.0001) and mental components (MCS, mean ± SD = 53.8 ± 23.0 vs. 50.3 ± 23.2; p = 0.003). Late-stage SSc patients were more likely to perceive their disease chronic (p < 0.0001), less controllable (p = 0.03) and with more consequences (p = 0.008), but they had a better understanding of their disease and experienced fewer negative emotions. Raynaud's phenomenon and gastrointestinal complications were the organ involvements with the greatest impact on QoL, they were the two variables associated with the most negative perception of illness severity.

CONCLUSION

This study, performed on the largest group ever set up for this purpose, confirms the major impact on QoL and the negative perceptions of their disease expressed by SSc patients. However, the perception of this illness tended to improve with disease duration, suggesting that patients find effective coping strategies.