Caregiver Burden of Spinal Muscular Atrophy: A Systematic Review

Understanding the health-related quality of life impacts of caring for children and adolescents with rare progressive life-limiting conditions: key challenges and future research priorities

The inclusion of health-related quality of life (HRQoL) impacts on informal carers in health technology assessments (HTAs) is lacking due, primarily, to a deficiency in evidence and methodological issues on how informal carer HRQoL is captured and incorporated into economic models. These issues are magnified in areas of significant burden, such as caring for children and adolescents with rare, progressive, life-limiting conditions. In this commentary we outline key challenges in measuring, and incorporating in HTA submissions, informal carer HRQoL data in rare, progressive, paediatric, life-limiting conditions and identify future research priorities in this space. We argue that: (i) a generic model of carer HRQoL is likely inadequate to characterise the HRQoL impacts in this population; (ii) the underlying evidence-base is underdeveloped, including understanding commonalities across conditions, impact beyond the primary carer, and differences over time; and (iii) methodological challenges in modelling informal carer HRQoL in cost-effectiveness analysis are inhibiting progress. A research agenda is proposed that addresses these challenges by focusing first on in-depth qualitative research to develop an appropriate, content valid 'disease-group-specific' model for understanding informal carer HRQoL in rare, progressive, paediatric, life-limiting conditions. This model can be used to inform the appropriate measurement of carer HRQoL in this population, which, alongside methodological research on addressing modelling challenges, can help to facilitate the recommended inclusion of informal carer HRQoL data in HTA submissions for children and adolescents living with rare, progressive, life-limiting conditions.

Patient and caregiver spinal muscular atrophy treatment attribute preferences in Latin America

BACKGROUND

Spinal muscular atrophy (SMA) is a rare, progressive neuromuscular disease associated with a significant burden of illness to both patients and caregivers; however, there is little evidence available regarding how patients and caregivers evaluate potential treatment benefit-risk profiles. As access to SMA disease-modifying therapies increases, it is imperative to understand which treatment attributes drive treatment choices.

OBJECTIVE

To identify which treatment attributes drive treatment choices in adults with SMA and caregivers of children with SMA across nine countries in Latin America.

METHODS

A discrete choice experiment (DCE) survey was developed for market research using data collected via qualitative interviews and consultations with medical experts. Adults with Type 2/3 SMA and caregivers of children with Types 1-3 SMA were recruited by patient advisory groups and physician referrals. Respondents completed a 30-min, online survey that collected patient demographics, disease-specific information, and quality of life data (via the EQ-5D-5L), and included the DCE, in which respondents were asked to choose between 14 sets of hypothetical treatment profiles. Data were pooled for analysis, as the country-level sample sizes were small. Raw data were aggregated in Microsoft Excel. Statistical testing was performed using data tables and SPSS (as appropriate). Demographic data were summarized descriptively.

RESULTS

A total of 143 respondents (45 adults with SMA and 98 caregivers) completed the online survey. Most respondents were from Argentina (35.0%) or Brazil (19.6%). Breathing function outcome was the most important treatment attribute for caregivers, while adults with SMA placed greater importance on motor function outcome. Both adults with SMA and caregivers placed the greatest importance on improvements in function compared with worse or stable outcomes.

CONCLUSIONS

Understanding treatment attribute preferences at a regional level will improve shared medical decision-making for individuals with SMA.

Quality of Life, Caregiver Burden, and Symptoms of Depression and Anxiety in Parents of Children with Spinal Muscular Atrophy: A Comparison with Healthy Controls

Background: Spinal muscular atrophy (SMA) is a disease that leads to muscle weakness and significantly affects the lives of both patients and caregivers. This study aims to compare quality of life, caregiver burden, symptoms of depression and anxiety, life satisfaction, and mental well-being between parents of children with SMA and those of healthy children. Methods: This cross-sectional study included parents of children under 18 years old, both healthy and diagnosed with SMA. The participants completed the WHOQOL-BREF, Zarit Caregiver Burden Scale (ZCBS), Hospital Anxiety and Depression Scale (HADS), Satisfaction with Life Scale (SWLS), and the Flourishing Scale (FS). In addition, the relationships among these measures were analyzed. Results: Our study showed that the parents of children with SMA had significantly higher scores across all subscales of the WHOQOL-BREF (p = 0.004, p = 0.009, p = 0.007, p < 0.001) and the HADS depression subscale (p = 0.005). However, no significant differences were found between the groups in terms of the ZCBS, the HADS anxiety subscale (p = 0.802), SWLS (p = 0.251), or FS (p = 0.929) scores. Additionally, the ZCBS and HADS anxiety scores were significantly higher among parents of children with SMA type 1 compared to those with type 3 (p = 0.010 and p = 0.037, respectively). Lastly, a moderate positive correlation was found between the ZCBS and the HADS anxiety subscales (r = 0.632, p < 0.001). Conclusions: This study highlights the decline in quality of life and increased depression symptoms among parents of children with SMA, suggesting the need for psychiatric evaluation and additional support for those caregivers.

Informal caregivers' attitudes towards care robots: a mixed methods systematic review

BACKGROUND

Care Robots (CR) is capable of performing a multitude of caregiving tasks, demonstrating potential in addressing the aging crisis. However, the implementation of CR faces challenges, and user attitudes are vital for implementation of CR. Informal caregivers (IC), who are the primary providers of care and bear the heavy burden of caregiving, are seldom studied in terms of their attitudes toward CR.

OBJECTIVE

To systematically review the ICs' attitudes towards CR.

METHODS

The PubMed, Embase, Web of Science, Cochrane Library, CINAHL, and IEEE Xplore were searched from inception to September 2024. Studies related to ICs' attitudes towards CR were included. This review followed the methodology for mixed-methods reviews outlined by the Joanna Briggs Institute (JBI) and employed a convergent integrated approach for this study.

RESULTS

34 studies were included, including six quantitative studies, eighteen qualitative studies and ten mixed methods studies. Following thematic analysis and synthesis, four broad analytic themes were identified for concept of CR, expectations of CR, facilitators and barriers to use CR, and ethical concerns of CR.

CONCLUSIONS

ICs generally accepted the use of CR, but they also reported some concerns about using CR for implement. In order to support the safe, equitable, and people-oriented implementation of CR in the long-term care system, we propose consider the ICs' attitudes to optimize CR, offer more technical support to IC, and find a way to balance the conflict of use right between IC and their care recipients in the use of CR.

Rehabilitation practices for childhood spinal muscular atrophy

PURPOSE

Spinal muscular atrophy (SMA) is a neuromuscular condition characterized by muscle weakness and impaired motor function. The introduction of disease modifying treatments, such as gene therapy, have significantly improved prognosis. Children with SMA now have the potential for active rehabilitation, but limited evidence exists to guide rehabilitation professionals and families. Our objective was to explore and describe how rehabilitation therapists are approaching this changing landscape, including the challenges and opportunities.

METHODS

We conducted a qualitative study using a demographic survey and three focus groups with 10 occupational and physical therapists from across Canada. Participants shared their experiences navigating the changing landscape of SMA rehabilitation.

RESULTS

Reflexive thematic analysis was used to analyze the transcripts and generate four main themes: (1) Managing Expectations; (2) New Possibilities; (3) Centering the Child; (4) Navigating a Changing Landscape.

CONCLUSION

This study highlighted challenges and benefits in providing rehabilitation amidst the changing SMA landscape. Updated practice guidelines and effective knowledge dissemination are needed to guide therapists, alongside prioritization of psychosocial support for families and children coping with high expectations. What we learned about therapists' experiences may help inform others on how to adapt rehabilitation when disease modifying treatment options become available for other conditions.

Global Economic Burden of Spinal Muscular Atrophy: A Systematic Literature Review

Spinal muscular atrophy (SMA) is a rare inherited neuromuscular disease classified into four main subtypes and characterized by severe muscle weakness and loss of motor function. Its high mortality rates, high treatment costs, and lengthy care requirements place a heavy burden on patients, caregivers, and the healthcare system. This study aims to explore the economic burden of SMA subtypes by analyzing costs, healthcare resource use, and loss of productivity for patients and their caregivers. We conducted a systematic literature review, searching for studies published since 2010 via Medline, Embase, Google Scholar, and gray literature databases. We extracted data concerning costs, healthcare resources, and productivity losses among SMA subtypes. The quality of the included studies was assessed using the Newcastle-Ottawa Scale and the Quality of Health Economic Studies tools. We retrieved 55 studies from 32 countries with economic data variation due to the study design, location, and SMA subtype. The weighted average annual cost for an SMA patient was US$109,906 with the highest costs observed in type 1 patients, who incurred direct medical costs without disease-modifying treatments of US$187,88. The non-medical costs accounted for US$109,379 per patient, along with frequent hospitalizations and high caregiver productivity losses, requiring 2,947 hours of caregiving annually. The direct and indirect costs of SMA are substantial. The necessity for standardized approaches to evaluate and analyze the economic impact across various SMA subtypes is highlighted by the heterogeneity of the data. In order to control the financial burden of SMA, governments and healthcare systems can benefit from these insights to develop policies aimed at improving financial sustainability and patient support.

International Precision Child Health Partnership (IPCHiP): an initiative to accelerate discovery and improve outcomes in rare pediatric disease

Advances in genomic technologies have revolutionized the diagnosis of rare genetic diseases, leading to the emergence of precision therapies. However, there remains significant effort ahead to ensure the promise of precision medicine translates to improved outcomes. Here, we discuss the challenges in advancing precision child health and highlight how international collaborations such as the International Precision Child Health Partnership, which embed research into clinical care, can maximize benefits for children globally.

The Socio-Economic Burden of Spinal Muscular Atrophy: A Cost-of-Illness Study in Bulgaria

Background/Objectives: The objective of our study was to quantify the annual costs, from a societal perspective, encompassing direct health care costs, direct non-health care costs, and labor productivity losses associated with spinal muscular atrophy (SMA) patients in Bulgaria and their caregivers. Methods: We applied a prevalence-based, bottom-up costing methodology to assess the socio-economic burden of SMA from a societal perspective. We evaluated and summed up all costs for health services (diagnosis, treatment, follow-up, and rehabilitation), educational and social services, and formal and informal care in the community, as well as indirect costs due to the loss of productivity and work capacity of the SMA patients' caregivers. Results: Nine parents of SMA patients provided consent and completed the study's questionnaire. Two children had SMA type III, and seven had SMA type II. The median annual socio-economic burden per SMA patient was EUR 254,968.80. The high direct costs, primarily driven by drug expenses, and the substantial indirect costs resulting from the loss of productivity among informal caregivers were the primary causes. We found no utilization of social care and educational services. Conclusions: We emphasize the need for careful consideration of long-term outcomes, real-world data collection, and performance-based reimbursement. An ideal scenario could achieve these objectives in synergy. A second layer of policy actions and measures must address the unmet needs of SMA patients and their families using a holistic approach. The indirect costs associated with SMA, particularly the productivity loss of informal caregivers, underscore the need for comprehensive support programs.

Absenteeism and presenteeism among caregivers of chronic diseases: A systematic review and meta-analysis

INTRODUCTION

Productivity-adjusted life-year (PALY) is a relatively new measure for quantifying the impact of disease on productivity. This study aims to systematically review the productivity factors such as absenteeism and presenteeism among informal caregivers of patients with a wide range of chronic health conditions to inform the PALY quantifications.

METHOD

A literature search across MEDLINE, Embase, EconLIT, PsychInfo, and CINAHL identified 3578 studies from which a final 23 studies were included in the analysis. To explore the pooled estimate of caregiver absenteeism/presenteeism across diseases and possible drivers, a meta-analysis and meta-regression were conducted using studies where relevant data was available.

RESULT

The pooled proportion for absenteeism, presenteeism, and work productivity loss (WPL) was 14% (95% Confidence Interval [CI]:9-19%; I2 = 96.3%), 32% (95% CI:22-42%; I2 = 98.0%) and 44% (95% CI:35-53%; I2 = 95.4%) respectively with a high a level of heterogeneity. Factors such as the disease type, and disease severity can influence the caregivers' work productivity.

CONCLUSION

The data derived in this study will enable the derivation of productivity indices to estimate PALY among caregivers. Future studies can explore the work productivity impact among caregivers of patients with other chronic conditions where they have a significant role but are unexplored, and severity-wise studies in conditions such as stroke and dementia to understand the caregivers' societal productivity impact.

Sleep quality and daytime sleepiness amongst family caregivers of children with Spinal Muscular Atrophy

BACKGROUND

While there are limited studies focusing on sleep quality of family caregivers of children with Spinal Muscular Atrophy (SMA), there are no studies on daytime sleepiness in SMA.

AIMS

This study aimed a) to compare the sleep quality and daytime sleepiness between caregivers of children with SMA and those of healthy peers and b) to investigate the sleep quality and daytime sleepiness of family caregivers of children with different types of SMA.

METHODS AND PROCEDURES

This study included 30 family caregivers of children with SMA (SMA Type 1:12, SMA Type 2:10, and SMA Type 3:8) and 31 family caregivers of healthy peers. Sleep quality and daytime sleepiness of family caregivers were evaluated using the Pittsburg Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (EPS), consecutively.

OUTCOMES AND RESULTS

Demographic characteristics of children with SMA and healthy peers were similar (p > 0.05). The mean ages of family caregivers of children with SMA and healthy peers were 36.07 ± 5.84 and 35.26 ± 5.02 years, respectively (p = 0.6). The PSQI scores of family caregivers of children with SMA (7.50 ± 3.90 points) were lower than those of healthy peers (4.09 ± 1.97 points) (p < 0.001). There was no difference in PSQI scores between SMA types (p = 0.8). Also, no difference was found between SMA types and between SMA and healthy peers in terms of EPS (p > 0.05).

CONCLUSIONS AND IMPLICATIONS

Family caregivers of children with SMA had poor sleep quality but similar daytime sleepiness compared with those of healthy peers. Among SMA types, family caregivers had similar sleep quality and daytime sleepiness. It was demonstrated that the sleep quality of family caregivers should be taken into consideration in the disease management of SMA.

Non-Invasive Spinal Cord Stimulation for Motor Rehabilitation of Patients with Spinal Muscular Atrophy Treated with Orphan Drugs

Spinal muscular atrophy (SMA) is an orphan disease characterized by the progressive degeneration of spinal alpha motor neurons. In recent years, nusinersen and several other drugs have been approved for the treatment of this disease. Transcutaneous spinal cord stimulation (tSCS) modulates spinal neuronal networks, resulting in changes in locomotion and posture in patients with severe spinal cord injury and stroke. We hypothesize that tSCS can activate motor neurons that are intact and restored by medication, slow the decline in motor activity, and contribute to the development of motor skills in SMA patients. Thirty-seven children and adults with SMA types 2 and 3 participated in this study. The median duration of drug treatment was over 20 months. The application of tSCS was performed during physical therapy for 20-40 min per day for ~12 days. Outcome measures were specific SMA motor scales, goniometry of contractured joints, and forced vital capacity. Significant increases in motor function, improved respiratory function, and decreased contracture were observed in both type 2 and 3 SMA participants. The magnitude of functional changes was not associated with participant age. Further studies are needed to elucidate the reasons for the beneficial effects of spinal cord electrical stimulation on SMA.

The socioeconomic burden of spinal muscular atrophy in Saudi Arabia: a cross-sectional pilot study

Background

Spinal muscular atrophy (SMA) is a rare debilitating condition with a significant burden for patients and society. However, little is known about how it affects Saudi Arabia's population. The socioeconomic and medical characteristics of affected SMA patients and their caregivers are lacking.

Purpose

This study aimed to describe the socioeconomic and medical characteristics of SMA patients and caregivers in Saudi Arabia.

Patients and methods

A cross-sectional questionnaire-based study was conducted using snowball sampling. Assessment tools including EuroQol (EQ-5D-5L) and visual analog scale (EQ-VAS), Generalized Anxiety Disorder 7-item (GAD-7), Patient Health Questionnaire (PHQ-9), and Costs for Patients Questionnaire (CoPaQ) were used to assess the quality of life (QoL), anxiety, depression, and out-of-pocket expenditures.

Results

Sixty-four caregivers of SMA patients participated. Type I patients had higher sibling concordance, ICU hospitalization, and mechanical support needs. Type III patients had better QoL. Type I patients' caregivers had higher depression scores. Type III patients' caregivers had higher out-of-pocket expenditures. Forty-eight percent received supportive care, while others received SMA approved therapies.

Conclusion

SMA imposes a significant socioeconomic burden on patients and caregivers, requiring more attention from the healthcare system. Access to innovative therapies varied across SMA types. Pre-marital screening and early detection are crucial to reduce disease incidence and ensure timely treatment.

Evaluating case management for caregivers of children with spinal muscular atrophy type I and II-an exploratory, controlled, mixed-methods trial

Introduction

Spinal muscular atrophy (SMA) is a rare neuromuscular disease requiring various clinical specialists and therapists to provide care. Due to the disease's dynamic nature and the long distances between specialized centers and local providers, integrating care between disciplines can be challenging. Care that is inadequately integrated can compromise the quality of care and become a burden for patients and families. This trial aimed to improve the care of patients through a case management (CM) intervention.

Methods

We conducted an exploratory, controlled, two-arm trial with pre-, post-, and follow-up measures (process and outcome evaluation). Proof of efficacy based on statistical significance was not our primary study objective since we were investigating a rare disease. Primary outcomes were caregivers' HRQoL and caregiver-rated quality of care integration. Our secondary outcome was the children's HRQoL.

Results

Questionnaires and semi-structured interviews yielded heterogeneous results depending on caregivers' level of experience and desire (or possibility) to delegate care tasks.

Discussion

Despite differing perceptions, all participants supported the establishment of a care coordination model. We recommend CM immediately after diagnosis to provide the greatest benefit to families. We hope that our trial will support the further development of CM interventions that can be customized for specific diseases.

Barriers and facilitating factors of care coordination for children with spinal muscular atrophy type I and II from the caregivers' perspective: an interview study

BACKGROUND

Children with medical complexity (CMC) require long-term care accompanied by different health- and social care professionals. Depending on the severity of the chronic condition, caregivers spend a lot of time coordinating appointments, communicating between providers, clarifying social legal issues, and more. Effective care coordination is seen as key to addressing the fragmented care that CMC and their families often face. Spinal muscular atrophy (SMA) is a rare genetic, neuromuscular disease which care involves drug therapy and supportive treatment. We examined the care coordination experiences through a qualitative interview analysis of n = 21 interviews with caregivers of children with SMA I or SMA II.

RESULTS

The code system consists of 7 codes and 12 sub-codes. "Disease and coordination management of the caregivers" describes the management of coordination-related illness demands. "General conditions of care" include enduring organizational aspects of the care network. "Expertise and skills" refers to both parent and professional expertise. "Coordination structure" describes the assessment of existing coordination mechanisms as well as the need for new ones. "Information exchange" defines the information exchange between professionals and parents as well as the exchange of parents among themselves and the perceived exchange between professionals. "Role distribution in care coordination" summarizes parents' "distribution" of coordinative roles among care network actors (including their own). "Quality of relationship" describes the perceived quality of the relationship between professionals and family.

CONCLUSION

Care coordination is influenced peripherally (e.g., by general conditions of care) and directly (e.g., by coordination mechanisms, interaction in the care network). Access to care coordination appears to be dependent on family circumstances, geographic location, and institutional affiliation. Previous coordination mechanisms were often unstructured and informal. Care coordination is frequently in the hands of caregivers mainly as the care network's interface. Coordination is necessary and must be addressed on an individual basis of existing resources and family barriers. Existing coordination mechanisms in the context of other chronic conditions could also work for SMA. Regular assessments, centralized shared care pathways, and staff training and empowerment of families for self-management should be central components of all coordination models.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00018778; Trial registration date 05. December 2019-Retrospectively registered; https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00018778 .

The experience of living with Niemann-Pick type C: a patient and caregiver perspective

BACKGROUND

Niemann-Pick disease type C (NPC) is a rare inherited lysosomal storage disease typified by accumulation of cholesterol and other lipids in late endosomes/lysosomes, thereby resulting in a spectrum of neurological, psychiatric, and systemic symptoms (notably liver disease). Though it is well-known that NPC exacts a physical and emotional toll on both patients and caregivers, the burden of NPC can vary between patients, while the challenges of living with NPC can evolve over time (i.e., from time of diagnosis to the present day). To further grasp patient and caregiver perceptions and experiences with NPC, we carried out focus group discussions with pediatric and adult individuals with NPC (N = 19), with partial or full representation of the patient by their caregiver. Furthermore, we utilized our NPC focus group discussion to provide guidance on study design parameters and feasibility of prospective investigations aiming to characterize the central manifestations of NPC using neuroimaging, specifically, magnetic resonance imaging (MRI) methodology.

RESULTS

Focus group discussions revealed that neurological signs, including declining cognition, memory loss, and psychiatric symptoms, as well as increasingly impaired mobility and motor function, are among the most pressing past and current concerns for patients and caregivers. Moreover, several participants also expressed concern over a loss of independence, social exclusion, and uncertainty for what the future holds. Caregivers described the challenges that participation in research poses, which included logistical difficulties mainly due to traveling with medical equipment and the need for sedation in a minority of patients when undergoing MRI.

CONCLUSIONS

The findings derived from focus group discussions highlight the outstanding challenges that NPC patients and their caregivers face daily, while also providing direction on the potential scope and feasibility of future studies focusing on the central phenotypes of NPC.