Confirmatory Factor Analyses and Differential Item Functioning of the Patient Experience with Treatment and Self-Management (PETS vs. 2.0): A Measure of Treatment Burden

The Medication-Related Burden Quality of Life (MRB-QoL) tool: A confirmatory factor analysis of the Arabic version

Background

The Medication-Related Burden Quality of Life (MRB-QoL) Arabic version is a 31-item valid and reliable measure of medication burden on functioning and well-being.

Objective

To examine the factor structure of the MRB-QoL Arabic in a sample of adults living with long-term conditions (LTC).

Methods

Three hundred forty-three patients (≥ 18 years old) living with at least one LTC were recruited from 4 tertiary hospitals in the United Arab Emirates. Confirmatory factor analysis (CFA) was performed using Maximum likelihood estimation with bootstrap. Two models (first order and second order) were examined. Model fit indices, composite reliability (CR), and average variance extracted (AVE) were used to assess the model's goodness of fit, reliability, and convergent/discriminant validity, respectively. The model's fit was evaluated using absolute fit, comparative fit, and parsimony-adjusted indices. The RMSEA and SRMR ≤0.08, χ2/df < 5, and CFI, IFI, and TLI ≥ 0.90 were considered indicators of good model fit. PNFI and PCFI >0.5 were also considered as indicators of good fit. CR ≥ 0.7, AVE ≥ 0.5, and AVE greater than squared factors correlation were considered as evidence indicating reliability, convergent validity, and discriminant validity, respectively.

Results

The first-order model showed an excellent fit (χ2/df = 3.262, RMSEA = 0.08, SRMR = 0.05, CFI = 0.913, TLI = 0.914, IFI = 0.914, PNFI = 0.810, PCFI = 0.841) as did the second-order model (χ2/df = 2.845, RMSEA = 0.073, SRMR = 0.072, CFI = 0.934, TLI = 0.923, IFI = 0.915, PNFI = 0.820, PCFI = 0.851). All domains of the MRB-QoL met the convergent/discriminant validity and reliability criteria.

Conclusions

The study supports the factor structure from previous research and confirms the MRB-QoL Arabic as a valid and reliable measure. This tool can be used to assess medicines burden from patient perspectives and facilitate person-centred care in medicines optimisation services across Arabic-speaking countries.

Treatment burden in multimorbidity: an integrative review

BACKGROUND

People living with multimorbidity experience increased treatment burden, which can result in poor health outcomes. Despite previous efforts to grasp the concept of treatment burden, the treatment burden of people living with multimorbidity has not been thoroughly explored, which may limit our understanding of treatment burden in this population. This study aimed to identify the components, contributing factors, and health outcomes of treatment burden in people with multiple diseases to develop an integrated map of treatment burden experienced by people living with multimorbidity. The second aim of this study is to identify the treatment burden instruments used to evaluate people living with multimorbidity and assess the comprehensiveness of the instruments.

METHODS

This integrative review was conducted using the electronic databases MEDLINE, EMBASE, CINAHL, and reference lists of articles through May 2023. All empirical studies published in English were included if they explored treatment burden among adult people living with multimorbidity. Data extraction using a predetermined template was performed.

RESULTS

Thirty studies were included in this review. Treatment burden consisted of four healthcare tasks and the social, emotional, and financial impacts that these tasks imposed on people living with multimorbidity. The context of multimorbidity, individual's circumstances, and how available internal and external resources affected treatment burden. We explored that an increase in treatment burden resulted in non-adherence to treatment, disease progression, poor health status and quality of life, and caregiver burden. Three instruments were used to measure treatment burden in living with multimorbidity. The levels of comprehensiveness of the instruments regarding healthcare tasks and impacts varied. However, none of the items addressed the healthcare task of ongoing prioritization of the tasks.

CONCLUSIONS

We developed an integrated map illustrating the relationships between treatment burden, the context of multimorbidity, people's resources, and the health outcomes. None of the existing measures included an item asking about the ongoing process of setting priorities among the various healthcare tasks, which highlights the need for improved measures. Our findings provide a deeper understanding of treatment burden in multimorbidity, but more research for refinement is needed. Future studies are also needed to develop strategies to comprehensively capture both the healthcare tasks and impacts for people living with multimorbidity and to decrease treatment burden using a holistic approach to improve relevant outcomes.

TRIAL REGISTRATION

DOI: https://doi.org/10.17605/OSF.IO/UF46V.

The Chinese version of patient experience with treatment and self-management (PETS vs. 2.0): translation and validation in patients with multimorbidity in primary care in Hong Kong

BACKGROUND

Validated and comprehensive tools to measure treatment burden are needed for healthcare professionals to understand the treatment burden of patients in China. The study aimed to translate and validate the Chinese version of Patient Experience with Treatment and Self-management (PETS vs. 2.0) in patients with multimorbidity in primary care.

METHODOLOGY

The translation process of the 60-item PETS vs. 2.0 followed the Functional Assessment of Chronic Illness Therapy (FACIT) Translation, Formatting, and Testing Guidelines. Computer-assisted assessments were conducted in adult primary care patients with multimorbidity from three general out-patient clinics in Hong Kong. A sample of 502 patients completed the assessments from July to December 2023. Internal reliability was examined using Cronbach's alphas for each domain of the PETS vs. 2.0. Concurrent validity was assessed through the correlations between different domains of PETS vs. 2.0 with established measures including quality of life, frailty, and depression. Confirmatory Factor Analysis (CFA) with maximum likelihood method was carried out to assess the construct validity.

RESULTS

The mean age of participants was 64.9 years old and 56.2% were female. Internal consistency reliability was acceptable (alpha ≥ 0.70) for most domains. Higher scores of PETS domains were significantly correlated with worse quality of life, higher level of frailty, and more depressive symptoms (p < 0.05). In CFA, after setting the covariances on the error variances, the adjusted model revealed an acceptable model fit (χ2/df = 1.741; root mean square error of approximation (RMSEA) = 0.038; standardized root mean square residual (SRMR) = 0.058; comparative fit index (CFI) = 0.911; Tucker-Lewis Index (TLI) = 0.903). All standardized factor loadings were 0.30 or above. Significant positive correlations between the latent factors were found for all factor pairs (correlation coefficient < 0.8).

CONCLUSIONS

The Chinese version of PETS vs. 2.0 is a reliable and valid tool for assessing the perceived treatment burden in patients with multimorbidity in primary care. All domains and items in the original questionnaires were retained.

Adaptation and content validation of a patient-reported measure of treatment burden for use in stroke survivors: the patient experience with treatment and self-management in stroke (PETS-stroke) measure

PURPOSE

Stroke survivors often live with significant treatment burden yet our ability to examine this is limited by a lack of validated measurement instruments. We aimed to adapt the 60-item, 12-domain Patient Experience with Treatment and Self-Management (PETS) (version 2.0, English) patient-reported measure to create a stroke-specific measure (PETS-stroke) and to conduct content validity testing with stroke survivors.

MATERIALS AND METHODS

Step 1 - Adaptation of PETS to create PETS-stroke: a conceptual model of treatment burden in stroke was utilised to amend, remove or add items. Step 2 - Content validation: Fifteen stroke survivors in Scotland were recruited through stroke groups and primary care. Three rounds of five cognitive interviews were audio recorded and transcribed. Framework analysis was used to explore importance/relevance/clarity of PETS-stroke content. COSMIN reporting guidelines were followed.

RESULTS

The adapted PETS-stroke had 34 items, spanning 13 domains; 10 items unchanged from PETS, 6 new and 18 amended. Interviews (n = 15) resulted in further changes to 19 items, including: instructions; wording; item location; answer options; and recall period.

CONCLUSIONS

PETS-stroke has content that is relevant, meaningful and comprehensible to stroke survivors. Content validity and reliability testing are now required. The validated tool will aid testing of tailored interventions to lessen treatment burden.

Protocol for the development and validation of a patient reported measure (PRM) of treatment burden in stroke

Background

Treatment burden is the workload of healthcare for people with long-term conditions and the impact on wellbeing. A validated measure of treatment burden after stroke is needed. We aim to adapt a patient-reported measure (PRM) of treatment burden in multimorbidity, PETS (Patient Experience with Treatment and Self-Management version 2.0), to create a stroke-specific measure, PETS-stroke. We aim to examine content validity, construct validity, reliability and feasibility in a stroke survivor population.

Methods

1) Adaptation of 60-item PETS to PETS-stroke using a taxonomy of treatment burden. 2) Content validity testing through cognitive interviews that will explore the importance, relevance and clarity of each item. 3) Evaluation of scale psychometric properties through analysis of data from stroke survivors recruited via postal survey (n=340). Factor structure will be tested with confirmatory factor analysis and Cronbach's alpha will be used to index internal consistency. Construct validity will be tested against: The Stroke Southampton Self-Management Questionnaire; The Satisfaction with Stroke Care Measure; and The Shortened Stroke Impact Scale. We will explore known-groups validity by exploring the association between treatment burden, socioeconomic deprivation and multimorbidity. Test-retest reliability will be examined via re-administration after 2 weeks. Acceptability and feasibility of use will be explored via missing data rates and telephone interviews with 30 participants.

Conclusions

We aim to create a validated PRM of treatment burden after stroke. PETS-stroke is designed for use as an outcome measure in clinical trials of stroke treatments and complex interventions to ascertain if treatments are workable for patients in the context of their everyday lives.

Scoping review of measures of treatment burden in patients with multimorbidity: advancements and current gaps

OBJECTIVES

To identify, assess, and summarize the measures to assess burden of treatment in patients with multimorbidity (BoT-MMs) and their measurement properties.

STUDY DESIGN AND SETTING

MEDLINE via PubMed was searched from inception until May 2021. Independent reviewers extracted data from studies in which BoT-MMs were developed, validated, or reported as used, including an assessment of their measurement properties (e.g., validity and reliability) using the COnsensus-based Standards for the selection of health Measurement INstruments.

RESULTS

Eight BoT-MMs were identified across 72 studies. Most studies were performed in English (68%), in high-income countries (90%), without noting urban-rural settings (90%). No BoT-MMs had both sufficient content validity and internal consistency; some measurement properties were either insufficient or uncertain (e.g., responsiveness). Other frequent limitations of BoT-MMs included absent recall time, presence of floor effects, and unclear rationale for categorizing and interpreting raw scores.

CONCLUSION

The evidence needed for use of extant BoT-MMs in patients with multimorbidity remains insufficiently developed, including that of suitability for their development, measurement properties, interpretability of scores, and use in low-resource settings. This review summarizes this evidence and identifies issues needing attention for using BoT-MMs in research and clinical practice.

Identifying and Managing Treatment Nonadherence

Nonadherence to medical treatment is exceptionally common and associated with poor clinical outcomes, a negative impact on quality of life, and a large financial burden on health care systems. This article first addresses key contributors to nonadherence from patient-specific, treatment-specific, and health care system-specific factors. Second, it outlines tools for the practicing clinician to identify, evaluate, and manage nonadherence across the spectrum of chronic disease in partnership with patients.

Longitudinal trajectories of treatment burden: A prospective survey study of adults living with multiple chronic conditions in the midwestern United States

Objectives

Determine whether there are different longitudinal patterns of treatment burden in people living with multiple chronic conditions (MCC) and, if so, explore predictors that might reveal potential routes of intervention.

Methods

We analyzed data from a prospective mailed survey study of 396 adults living with MCC in southeastern Minnesota, USA. Participants completed a measure of treatment burden, the Patient Experience with Treatment and Self-management (PETS), and valid measures of health-related and psycho-social concepts at baseline, 6, 12, and 24 months. Latent class growth mixture modeling (LCGM) determined trajectories of treatment burden in two summary index scores of the PETS: Workload and Impact. Multivariable logistic regressions were used to identify independent predictors of the trajectories.

Results

LCGM supported a 2-class model for PETS Workload, including a group of consistently high workload (N = 69) and a group of consistently low workload (N = 311) over time. A 3-class model was supported for PETS Impact, including groups of consistently high impact (N = 62), consistently low impact (N = 278), and increasing impact (N = 51) over time. Logistic regression analyses showed that the following factors were associated with patterns of consistently high or increasing treatment burden over time: lower health literacy, lower self-efficacy, more interpersonal challenges with others, and worse subjective reports of physical and mental health (all p < .05).

Conclusions

Different longitudinal patterns of treatment burden exist among people with MCC. Raising health literacy, enhancing self-efficacy, and lessening the effects of negative social interactions might help reduce treatment burden.

Cancer-related fatigue and treatment burden in surgically treated colorectal cancer patients - A cross-sectional study

OBJECTIVE

This cross-sectional study aimed to describe cancer-related fatigue (CRF) in colorectal cancer (CRC) patients who were surgically treated with curative intent, identify subgroups at risk of elevated fatigue levels and explore associations between CRF and treatment burden.

BACKGROUND

CRF is a prominent symptom among cancer patients. In patients treated for CRC, CRF is associated with adjuvant treatments, low quality of life and reduced ability to self-manage.

METHODS

One hundred thirty-four patients with CRC treated at a Norwegian university hospital between 2016-2018 were included. The Schwartz Cancer Fatigue Scale-6 and the Patient Experience with Treatment and Self-management questionnaires were applied for data collection. Statistical analyses included descriptive statistics and non-parametric approaches to analyse correlations and identify differences between groups. The study adhered to STROBE Statement checklist for reporting of cross-sectional studies.

RESULTS

Median fatigue level was 10.0 (range: 7.0-13.0). Physical fatigue was higher than perceptual fatigue, with medians of 6.0 (interquartile range [IQR]: 3.0-13.0) and 4.0 (IQR: 3.0-12.0), respectively. Higher fatigue levels were associated with age <60 years, advanced cancer and adjuvant treatments. Increased CRF was significantly associated with higher treatment burden on seven of the nine dimensions, adjusted for demographic and clinical variables. The association of fatigue and treatment burden was stronger in survivors <60 years, with advanced cancer, 6-12 months since surgery or who had more comorbid conditions.

CONCLUSIONS

This study showed patients at risk of experiencing CRF following CRC treatment. It established proof of associations between CRF and treatment burden and identified subgroups of CRC patients where this association was stronger.

RELEVANCE TO CLINICAL PRACTICE

Screening of CRF in CRC patients can help clinicians provide individualized treatment and care to manage CRF. Clinicians should consider the association between CRF and treatment burden, especially in subgroups of CRF patients.

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

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