Use of n-of-1 (single patient) trials to assess the effect of age of transfused blood on health-related quality of life in transfusion-dependent patients

The future of myelodysplastic syndrome-patient priorities and outcomes that matter

Background

Without a definitive curative option available to many patients, learning to live with myelodysplastic syndrome (MDS) and manage symptoms effectively becomes a priority in their care. Anaemia is an almost universal feature of MDS. Individuals suffer differently and better individualisation of care is needed. Most MDS patient information offers scant appreciation for disease heterogeneity, variable response to treatment and each patient's likely trajectory.

Methods

We undertook a two-part, online workshop to discuss what matters most to people living with MDS. Patients generated questions about their condition which they felt should be addressed by research or change how their care is delivered. Patients voted on the importance of each topic, creating a "prioritised" list of issues.

Results

Fourteen participants of varying age and experience took part raising 56 unique questions under the themes of: prognosis; end of life; treatment; supportive care; medical staff training; diagnosis and communication. These reflect the symptoms of MDS, improving quality of life (QoL) and communication.

Discussion

Although haemoglobin (Hb) levels have correlation to QoL, it is widely reported that other factors are important in determining QoL and need for transfusions varies despite stable Hb levels. We showed that Hb level and the need for transfusions is not comparable between different patients and even non-comparable over time meaning that the maximal benefit and timing of transfusions cannot be determined from Hb alone. This workshop highlighted patient dissatisfaction with the "numbers-led" approach and the need for an alternative method to determine when to transfuse.

Do anemia treatments improve quality of life and physical function in patients with myelodysplastic syndromes (MDS)? A systematic review

Anemia is common in Myelodysplastic Syndromes (MDS). Different anemia treatments have been tested in clinical studies, but the full impact on patients' health-related quality of life (HRQoL) and physical function is unknown. The main aim of this review was to assess whether improvements in anemia are associated with changes in HRQoL/physical function. Twenty-six full-text publications were identified, enrolling 2211 patients: nine randomized trials (RCTs), fourteen non-randomized studies of interventions and three cross-sectional studies. Interventions included: growth factors/erythropoiesis-stimulating agents (n = 14), red cell transfusion (n = 9), erythroid maturation agents (n = 1), or a combination (n = 2). Five RCTs reported no changes in HRQoL despite erythroid response to the intervention, raising the question of whether anemia treatment alone can effectively improve HRQoL. Many studies were considered at high risk of bias for assessing HRQoL. There is a pressing need for future clinical trials to better define the nature of the relationship between anemia and HRQoL/functional outcomes.

Process Evaluation of a Sport-Based Supportive Care Intervention for Testicular Cancer Survivors: A Mixed Methods Study

Testicular cancer survivors report unmet supportive care needs that are associated with poorer physical and mental health, yet engagement in traditional supportive care is low. The Ball’s in Your Court intervention was designed to engage testicular cancer survivors in supportive care by leveraging a community-based sport and exercise model. Age-appropriate, gender-sensitized, and disease specific elements were reflected in the intervention design, setting, content, and delivery. The intervention included five weekly health promotion sessions among a group of testicular cancer survivors. The purpose of this study was to explore the intervention’s (i) feasibility and acceptability, (ii) effects on testicular cancer survivors’ perceived health, and (iii) gain feedback for intervention refinement. A total of 10 testicular cancer survivors participated in the pilot and completed questionnaires on demographics, cancer history, perceived health, and physical activity behavior at baseline (pre-intervention) and perceived health and satisfaction with intervention components (post-intervention). Open-ended feedback surveys were collected after each weekly session and researcher field notes were recorded by three members of the study team. One month following the intervention, a focus group was conducted with intervention participants. All participants were satisfied with the intervention. Content analysis of the qualitative data supported intervention acceptability. Visual analysis conducted at the individual level indicated that perceived health either remained stable or improved from pre- to post-intervention. The Ball’s in Your Court intervention provides a feasible and acceptable approach for the delivery of supportive care aimed at improving testicular cancer survivors’ health and wellness. Recommendations for intervention refinement were provided and require future examination.

Outpatient transfusions for myelodysplastic syndromes

Patients with myelodysplastic syndromes (MDS) often need extended periods of red blood cell or platelet transfusion support, with the goal to manage symptoms of anemia and thrombocytopenia, respectively, and improve quality of life. Many questions about the optimal approach to transfusion management in MDS, especially in the outpatient setting, remain unanswered, including hemoglobin and platelet thresholds for transfusion. Restrictive transfusion approaches are often practised, but whether these are appropriate for outpatients with MDS, who are often older and may be frail, is not known. Current schedules for transfusion-dependent patients are burdensome, necessitating frequent visits to hospitals for sample collection and blood administration. Questions of optimal schedule and dosage are being explored in clinical trials, including the recently completed REDDS study. Patient-reported outcomes and functional assessments are increasingly being incorporated into research in this area so that we can better understand and improve transfusion support for patients with MDS.

Fresh Red Cells for Transfusion in Critically Ill Adults: An Economic Evaluation of the Standard Issue Transfusion Versus Fresher Red-Cell Use in Intensive Care (TRANSFUSE) Clinical Trial

OBJECTIVES

Trials comparing the effects of transfusing RBC units of different storage durations have considered mortality or morbidity as outcomes. We perform the first economic evaluation alongside a full age of blood clinical trial with a large population assessing the impact of RBC storage duration on quality-of-life and costs in critically ill adults.

DESIGN

Quality-of-life was measured at 6 months post randomization using the EuroQol 5-dimension 3-level instrument. The economic evaluation considers quality-adjusted life year and cost implications from randomization to 6 months. A generalized linear model was used to estimate incremental costs (2016 U.S. dollars) and quality-adjusted life years, respectively while adjusting for baseline characteristics.

SETTING

Fifty-nine ICUs in five countries.

PATIENTS

Adults with an anticipated ICU stay of at least 24 hours when the decision had been made to transfuse at least one RBC unit.

INTERVENTIONS

Patients were randomized to receive either the freshest or oldest available compatible RBC units (standard practice) in the hospital transfusion service.

MEASUREMENTS AND MAIN RESULTS

EuroQol 5-dimension 3-level utility scores were similar at 6 months-0.65 in the short-term and 0.63 in the long-term storage group (difference, 0.02; 95% CI, -0.00 to 0.04; p = 0.10). There were no significant differences in resource use between the two groups apart from 3.0 fewer hospital readmission days (95% CI, -5.3 to -0.8; p = 0.01) during follow-up in the short-term storage group. There were no significant differences in adjusted total costs or quality-adjusted life years between the short- and long-term storage groups (incremental costs, -$2,358; 95% CI, -$5,586 to $711) and incremental quality-adjusted life years: 0.003 quality-adjusted life years (95% CI, -0.003 to 0.008).

CONCLUSIONS

Without considering the additional supply cost of implementing a freshest available RBC strategy for critical care patients, there is no evidence to suggest that the policy improves quality-of-life or reduces other costs compared with standard transfusion practice.