Development and usability testing of an electronic patient-reported outcome (ePRO) solution for patients with inflammatory diseases in an Advanced Therapy Medicinal Product (ATMP) basket trial

BACKGROUND

Electronic patient-reported outcome (ePRO) systems are increasingly used in clinical trials to provide evidence of efficacy and tolerability of treatment from the patient perspective. The aim of this study is twofold: (1) to describe how we developed an electronic platform for patients to report their symptoms, and (2) to develop and undertake usability testing of an ePRO solution for use in a study of cell therapy seeking to provide early evidence of efficacy and tolerability of treatment and test the feasibility of the system for use in later phase studies.

METHODS

An ePRO system was designed to be used in a single arm, multi-centre, phase II basket trial investigating the safety and activity of the use of ORBCEL-C™ in the treatment of patients with inflammatory conditions. ORBCEL-C™ is an enriched Mesenchymal Stromal Cells product isolated from human umbilical cord tissue using CD362+ cell selection. Usability testing sessions were conducted using cognitive interviews and the 'Think Aloud' method with patient advisory group members and Research Nurses to assess the usability of the system.

RESULTS

Nine patient partners and seven research nurses took part in one usability testing session. Measures of fatigue and health-related quality of life, the PRO-CTCAE™ and FACT-GP5 global tolerability question were included in the ePRO system. Alert notifications to the clinical team were triggered by PRO-CTCAE™ and FACT-GP5 scores. Patient participants liked the simplicity and responsiveness of the patient-facing app. Two patients were unable to complete the testing session, due to technical issues. Research Nurses suggested minor modifications to improve functionality and the layout of the clinician dashboard and the training materials.

CONCLUSION

By testing the effectiveness, efficiency, and satisfaction of our novel ePRO system (PROmicsR), we learnt that most people with an inflammatory condition found it easy to report their symptoms using an app on their own device. Their experiences using the PROmicsR ePRO system within a trial environment will be further explored in our upcoming feasibility testing. Research nurses were also positive and found the clinical dashboard easy-to-use. Using ePROs in early phase trials is important in order to provide evidence of therapeutic responses and tolerability, increase the evidence based, and inform methodology development.

TRIAL REGISTRATION

ISRCTN, ISRCTN80103507. Registered 01 April 2022, https://www.isrctn.com/ISRCTN80103507.

The Global Task Force for Chronic Pain in People with HIV (PWH): Developing a research agenda in an emerging field

Chronic pain is a common comorbidity in people with HIV (PWH), with prevalence estimates of 25-85%. Research in this area is growing, but significant gaps remain. A Global Task Force of HIV experts was organized to brainstorm a scientific agenda and identify measurement domains critical to advancing research in this field. Experts were identified through literature searches and snowball sampling. Two online questionnaires were developed by Task Force members. Questionnaire 1 asked participants to identify knowledge gaps in the field of HIV and chronic pain and identify measurement domains in studies of chronic pain in PWH. Responses were ranked in order of importance in Questionnaire 2, which was followed by a group discussion. 29 experts completed Questionnaire 1, 25 completed Questionnaire 2, and 21 participated in the group. Many important clinical and research priorities emerged, including the need to examine etiologies of chronic pain in PWH. Pain-related measurement domains were discussed, with a primary focus on domains that could be assessed in a standardized manner across various cohorts that include PWH in different countries. We collaboratively identified clinical and research priorities, as well as gaps in standardization of measurement domains, that can be used to move the field forward.

Prevalence of early postpartum depression and associated risk factors among selected women in southern Malawi: a nested observational study

BACKGROUND

The birth of a child should be a time of celebration. However, for many women, childbirth represents a time of great vulnerability to becoming mentally unwell, a neglected maternal morbidity. This study aimed to determine the prevalence of early postpartum depression (PPD) and its associated risk factors among women giving birth at health facilities in southern Malawi. Identifying women vulnerable to PPD will help clinicians provide appropriately targeted interventions before discharge from the maternity ward.

METHOD

We conducted a nested cross-sectional study. Women were screened for early PPD using a locally validated Edinburgh Postpartum Depression Scale (EPDS) as they were discharged from the maternity ward. The prevalence of moderate or severe (EPDS ≥ 6) and severe (EPDS ≥ 9) PPD was determined, including 95% confidence intervals (CI). Data on maternal age, education and marital status, income source, religion, gravidity, and HIV status, among others, were collected during the second trimester of pregnancy, and obstetric and infant characteristics during childbirth were examined as potential risk factors for early PPD using univariable and multivariable logistic regression analyses.

RESULTS

Data contributed by 636 women were analysed. Of these women, 9.6% (95% CI; 7.4-12.1%) had moderate to severe early PPD using an EPDS cut-off of ≥ 6, and 3.3% (95% CI; 2.1-5.0%) had severe early PPD using an EPDS cut-off of ≥ 9. Multivariable analyses indicated that maternal anaemia at birth (aOR; 2.65, CI; 1.49-4.71, p-value; 0.001) was associated with increased risk for moderate and/or severe early PPD, while live birth outcome (aOR; 0.15, 95% CI; 0.04-0.54, p-value; 0.004), being single compared to divorced/widowed (aOR; 0.09, 95% CI; 0.02-0.55, p-value; 0.009), and lower education level (aOR; 0.36, 95% CI; 0.20-0.65, p-value; 0.001) were associated with decreased risk. Being HIV positive (aOR; 2.88, 95% CI; 1.08-7.67, p-value; 0.035) was associated with severe PPD only.

CONCLUSION

The prevalence of early PPD was slightly lower in our selected sample compared to previous reports in Malawi and was associated with maternal anaemia at birth, non-live birth, being divorced/widowed and HIV-positive status. Therefore, health workers should screen for depressive symptoms in women who are at increased risk as they are discharged from the maternity ward for early identification and treatment.

Strategies and checklist for designing and conducting palliative care research with family carers: EAPC international expert elicitation study

BACKGROUND

Palliative care services seek to improve the wellbeing of family carers of people living with serious and life-limiting illness. To help achieve this goal, systematic reviews have recommended priority areas for family carer research and the need to improve the quality of study design. Policy makers have also advocated for enhanced family carer support. However, there are specific methodological considerations and challenges in designing and conducting carer research conducted during the course of the serious illness trajectory and in bereavement.

AIM

To develop strategies to improve the design and conduct of research with family carers.

DESIGN

Expert elicitation study using an adapted version of the 'Identify, Discuss, Estimate and Aggregate' elicitation protocol, supplemented with strategies from peer-reviewed literature.

SETTING/PARTICIPANTS

Nine members of the management committee of the European Association for Palliative Care's Reference group on family carer research, comprising international senior research academics in family caregiving.

RESULTS

A compilation of recommended strategies and checklist was created to: (a) help researchers plan research involving family carers focussing on: preparation, conduct and dissemination and (b) assist ethics committees and funding bodies to evaluate proposals.

CONCLUSIONS

The strategies and checklist for conducting research with family carers may enhance methodologically rigorous research. Consequently, researchers, practitioners and policy makers will not only gain a more comprehensive understanding of the unmet needs of family carers but also promote the development of empirically sound interventions.

Feasibility of a new electronic patient-reported outcome (ePRO) system for an advanced therapy clinical trial in immune-mediated inflammatory disease (PROmics): protocol for a qualitative feasibility study

INTRODUCTION

The use of electronic patient-reported outcome (ePRO) systems to capture PRO data in clinical trials is increasing; however, their feasibility, acceptability and utility in clinical trials of advanced therapy medicinal products (ATMPs) are not yet well understood. This protocol describes a qualitative study that aims to evaluate the feasibility and acceptability of ePRO data capture using a trial-specific ePRO system (the PROmics system) within an advanced therapy trial involving patients with immune-mediated inflammatory disease (rheumatoid arthritis, lupus, primary sclerosing cholangitis (PSC) and Crohn's disease).

METHODS AND ANALYSIS

This protocol for a remote, qualitative, interview-based feasibility study is embedded within the POLARISE trial, a single-arm, phase II, multisite ATMP basket trial in the UK. 10-15 patients enrolled in the POLARISE trial and 10-15 research team members at the trial sites will be recruited. Participants will take part in semistructured interviews which will be transcribed verbatim and analysed thematically according to the framework method. Data collection and analysis will occur concurrently and iteratively. Researcher triangulation will be used to achieve a consensus-based analysis, enhancing rigour and trustworthiness.

ETHICS AND DISSEMINATION

This study was approved by the London-West London and GTAC Research Ethics Committee (Ref: 21/LO/0475). Informed consent will be obtained from all participants prior to data collection. The study findings will be published in peer-review journals and disseminated via conference presentations and other media. Our patient and public involvement and engagement group and ATMP stakeholder networks will be consulted to maximise dissemination and impact.

TRIAL REGISTRATION NUMBER

ISRCTN80103507.

The ethical imperative to relieve suffering for people with tuberculosis by ensuring access to palliative care

Patients diagnosed with tuberculosis (TB) continue to experience clinical uncertainty and high mortality and to bear a high burden of symptoms and other concerns. Additional concerns may be family support needs and stigma, particularly the latter, as TB and human immunodeficiency virus (HIV) coinfection are common. Human rights covenants, global health policy and the End TB Strategy all recommend palliative care as an essential component of care services. As established in the resolution adopted by the World Health Assembly (WHA) on "Strengthening of palliative care as a component of comprehensive care throughout the life course", there is a "need for palliative care across disease groups (non-communicable diseases, and infectious diseases, including HIV and multidrug-resistant tuberculosis), and across all age groups". We address the ethical imperative to respect the dignity and fundamental rights of people with TB by providing palliative care. We review the evidence for the need for person-centred palliative care and highlight novel models that utilise the skills and training functions of specialist palliative care to achieve better care. We outline simple recommendations for the delivery of specialist and generalist palliative care, offer suggestions on how to ensure optimal coverage by enabling access to appropriate good-quality palliative care at all points of the health system, including alongside treatment. Finally, we set out the current priorities for research and policy to ensure that quality care is delivered to all who need it irrespective of treatment outcome, to minimise distress and to optimise engagement in treatment and care.

“I have failed to separate my HIV from this pain”: the challenge of managing chronic pain among people with HIV

Pain is a highly prevalent and burdensome symptom among people with HIV (PWH). This study aims to identify how the experience of living with HIV and chronic pain influences pain beliefs, health-seeking and pain management. Thirty-nine purposively sampled PWH with chronic pain (sample characteristics = 61% women, 79% Black, Asian and minority ethnic groups, 18% men who have sex with men, 45-54 median age category) participated in focus groups in London. Focus groups were co-facilitated with community members. Transcripts wereanalysed using a thematic approach. Findings revealed that HIV stigma, fractured care pathways, and general practitioners' lack of HIV training are barriers to supported pain management. Unaddressed pain results in poorer mental health and reduced quality of life, which has important clinical implications for HIV treatment adherence. Creating HIV-specific pain resources, activating social networks, and pain self-management techniques are potential solutions. Person-centred assessment and HIV training is needed to help clinicians identify PWH with chronic pain. Clear guidelines need to be developed to identify which health service providers are responsible for chronic pain management in PWH. This study generated a refined version of the Fear Avoidance Model that introduces a dimension of HIV-specific behaviours that impact PWHs seeking chronic pain management.

Are patient outcomes improved by models of professionally-led community HIV management which aim to be person-centred? A systematic review of the evidence

UNAIDS advocates person-centred care (PCC) for people living with HIV/AIDS (PLWHA) to improve outcomes and wellbeing. We appraised the evidence of person-centred models of community HIV care delivered or led by trained healthcare professionals and its impact on care outcomes. A systematic review was conducted in line with PRISMA guidance. Six electronic databases (CINAHL, Embase, PubMed, Medline, PsycINFO and Web of Science) were searched from January 1980 to April 2019. We included primary studies of any design of PCC models; for adults aged ≥15 years; that were delivered or led by trained HCP. Data were extracted including study location, design, quality, outcomes measured and effectiveness. Five out of 1393 studies met the inclusion criteria, of which four were from a high-income country and one a lower-middle income country. Of the PCC components (physical, psychological, social and spiritual wellbeing) delivered alongside HIV clinical management, one study delivered 2, two studies delivered 3 and two studies delivered all 4 components. This review highlights the lack of outcome evidence for person-centred HIV care, and of concurrent focus on all domains of concern for PLWHA within interventions. Clear articulation of the meaning, practice of PCC and implementation strategies are needed to meet policy recommendations.

The development and cognitive testing of the positive outcomes HIV PROM: a brief novel patient-reported outcome measure for adults living with HIV

BACKGROUND

People living with HIV experience burdensome multidimensional symptoms and concerns requiring person-centred care. Routine use of patient reported outcome measures can improve outcomes. There is no brief patient reported outcome measure (PROM) that currently reflects the breadth of concerns for people living with HIV. This study aimed to develop and cognitively test a brief novel patient reported outcome measure for use within routine adult HIV care- the "Positive Outcomes" HIV PROM.

METHODS

Development followed the COSMIN taxonomy and guidance for relevance and comprehensiveness, and Rothrock guidance on development of valid patient reported outcome measures. The Positive Outcomes HIV PROM was developed by a steering group (people living with HIV, HIV professionals and health services researchers) using findings from a previously reported qualitative study of priority outcomes for people living with HIV. The prototype measure was cognitively tested with a purposive sample of people living with HIV.

RESULTS

The Positive Outcomes HIV PROM consists of 23 questions (22 structured, and one open question) informed by the priorities of key stakeholders (n = 28 people living with HIV, n = 21 HIV professionals and n = 8 HIV commissioners) to ensure face and content validity, and refined through cognitive testing (n = 6 people living with HIV). Cognitive testing demonstrated high levels of acceptability and accessibility.

CONCLUSIONS

The Positive Outcomes HIV PROM is the first brief patient reported outcome measure reflecting the diverse needs of people living with HIV designed specifically for use in the clinical setting to support patient assessment and care, and drive service quality improvement. It is derived from primary data on the priority outcomes for people living with HIV and is comprehensive and acceptable. Further psychometric testing is required to ensure reliability and responsiveness.

A real-time electronic symptom monitoring system for patients after discharge following surgery: a pilot study in cancer-related surgery

Background

Advances in peri-operative care of surgical oncology patients result in shorter hospital stays. Earlier discharge may bring benefits, but complications can occur while patients are recovering at home. Electronic patient-reported outcome (ePRO) systems may enhance remote, real-time symptom monitoring and detection of complications after hospital discharge, thereby improving patient safety and outcomes. Evidence of the effectiveness of ePRO systems in surgical oncology is lacking. This pilot study evaluated the feasibility of a real-time electronic symptom monitoring system for patients after discharge following cancer-related upper gastrointestinal surgery.

Methods

A pilot study in two UK hospitals included patients who had undergone cancer-related upper gastrointestinal surgery. Participants completed the ePRO symptom-report at discharge, twice in the first week and weekly post-discharge. Symptom-report completeness, system actions, barriers to using the ePRO system and technical performance were examined. The ePRO surgery system is an online symptom-report that allows clinicians to view patient symptom-reports within hospital electronic health records and was developed as part of the eRAPID project. Clinically derived algorithms provide patients with tailored self-management advice, prompts to contact a clinician or automated clinician alerts depending on symptom severity. Interviews with participants and clinicians determined the acceptability of the ePRO system to support patients and their clinical management during recovery.

Results

Ninety-one patients were approached, of which 40 consented to participate (27 male, mean age 64 years). Symptom-report response rates were high (range 63–100%). Of 197 ePRO completions analysed, 76 (39%) triggered self-management advice, 72 (36%) trigged advice to contact a clinician, 9 (5%) triggered a clinician alert and 40 (20%) did not require advice. Participants found the ePRO system reassuring, providing timely information and advice relevant to supporting their recovery. Clinicians regarded the system as a useful adjunct to usual care, by signposting patients to seek appropriate help and enhancing their understanding of patients’ experiences during recovery.

Conclusion

Use of the ePRO system for the real-time, remote monitoring of symptoms in patients recovering from cancer-related upper gastrointestinal surgery is feasible and acceptable. A definitive randomised controlled trial is needed to evaluate the impact of the system on patients’ wellbeing after hospital discharge.

Cause of death among HIV patients in London in 2016

OBJECTIVES

Since 2013, the London HIV Mortality Review Group has conducted annual reviews of deaths among people with HIV to reduce avoidable mortality.

METHODS

All London HIV care Trusts reported data on 2016 patient deaths in 2017. Deaths were submitted using a modified Causes of Death in HIV reporting form and categorized by a specialist HIV pathologist and two HIV clinicians.

RESULTS

There were 206 deaths reported; 77% were among men. Median age at death was 56 years. Cause was established for 82% of deaths, with non-AIDS-related malignancies and AIDS-defining illnesses being the most common causes reported. Risk factors in the year before death included: tobacco smoking (37%), excessive alcohol consumption (19%), non-injecting drug use (10%), injecting drug use (7%) and opioid substitution therapy (6%). Thirty-nine per cent of patients had a history of depression, 33% chronic hypertension, 27% dyslipidaemia, 17% coinfection with hepatitis B virus and/or hepatitis C virus and 14% diabetes mellitus. At the time of death, 81% of patients were on antiretroviral therapy (ART), 61% had a CD4 count < 350 cells/μL, and 24% had a viral load ≥ 200 HIV-1 RNA copies/mL. Thirty-six per cent of deaths were unexpected; 61% of expected deaths were in hospital. Two-thirds of expected deaths had a prior end-of-life care discussion documented.

CONCLUSIONS

In 2016, most deaths were attributable to non-AIDS-related conditions and the majority of patients were on ART and virally suppressed. However, several potentially preventable deaths were identified and underlying risk factors were common. As London HIV patients are not representative of people with HIV in the UK, a national mortality review is warranted.

Towards person-centred care for people living with HIV: what core outcomes matter, and how might we assess them? A cross-national multi-centre qualitative study with key stakeholders

OBJECTIVES

People living with HIV (PLWH) have multidimensional concerns requiring person-centred care. Routine use of patient-reported outcome measures (PROMs) improves outcomes. No brief PROM currently reflects the breadth of concerns for PLWH. This study sought to identify priority outcomes for PLWH, model current practice, explore views on introducing PROMs into routine care, and devise a model for person-centred care incorporating the PROM.

METHODS

A cross-national multi-centre study (London, Brighton and Dublin) was carried out. Semi-structured qualitative interviews with adult PLWH, HIV health care professionals and HIV commissioners (responsible for planning and commissioning services) were performed. Interviews were analysed using thematic and framework analysis.

RESULTS

PLWH (n = 28), professionals (n = 21) and commissioners (n = 8) described concerns related to living with HIV across six domains: physical (e.g. pain and gastrointestinal symptoms), cognitive (e.g. memory and sleep), psychological (e.g. anxiety and depression), social (e.g. isolation and intimacy), welfare (e.g. finances and fears regarding change of immigration status), and information (e.g. long-term outcomes) needs. Themes were highly inter-related, impacting across domains of need (e.g. physical and cognitive problems impacting on psychological and social wellbeing). Perceived benefits of using PROMs in routine HIV care included improved person-centredness, patient empowerment, fewer missed concerns, increased engagement with services, and informed planning of services. Potential challenges included heterogeneity of PLWH, literacy, and utility for those who struggle to engage with care.

CONCLUSIONS

This study presents a novel model of person-centred care incorporating an HIV-specific PROM. The model reflects priorities of key stakeholders. Explicit use of PROMs in routine HIV care could afford benefits for PLWH, clinical teams and commissioners.

National Home Care Initiative in Jordan: A Demonstration Project

Background and context: The home healthcare market in Jordan is nascent with little service offered. It suffers from a highly fragmented and underregulated landscape. The limited access to qualified trustworthy home care services, lack of professional home care training, and lack of home health care insurance coverage have added to the heavy in-patient bed demand and delayed hospital discharges especially for disabled or terminally ill patients. Aim: To establish a comprehensive national home care program to improve the delivery of palliative and home care services in Jordan, and to conduct a situational analysis and generate policy recommendations. Strategy/Tactics: We used multiple strategies to reach our objectives. 1. Expansion of home care services at King Hussein Cancer Center (KHCC) to create a local demonstration project. 2. Building health care professional capacity by offering variety of educational programs. 3. Improving quality of service delivery by generating clinical practice guidelines, such as standards operating procedures and patient and family educational materials. 4. Use the pilot operational and financial data to generate an economic model to inform the development of similar home health care units in hospitals across Jordan. 5. National advocacy and building effective partnership with all related stakeholders to advance national policy. Program/Policy process: Between May 2016 and May 2017, 7818 home care visits were conducted by KHCC. For capacity building; 678 health care professionals were trained in palliative and home care, out of which 366 participants were females (54%). Palliative care was successfully recognized as a specialty by the Jordan Nursing Council and recognized as a subspecialty by the Jordan Medical Council. The palliative and home care standards of practice were included in the health care accreditation council. The analysis of economic evaluation data suggested that home care services decreased in-patient utilization and costs which is advantageous to a country with limited resources. As a result of the advocacy stream and a collaborative network, the national palliative and home care strategic framework was generated, and endorsed by the Ministry of Health. Outcomes: The NHCI resulted in a very successful pilot project and achieved specialty and subspecialty recognition. Furthermore, we were able to build the capacity of health care professionals and policy makers in the palliative and home care sector from public, private and academic institutions. In the advocacy and policy dimension, the Minister of Health officially approved and adapted the palliative and home care strategic framework that was developed by this initiative. What was learned: Cross-sector collaboration and effective partnership resulted in system change and policy advancement. Developing effective economic systems is essential in low resourced countries. The initiative was supported by a joint grant from the USAID and KHCC.

'It's a traumatic illness, traumatic to witness': a qualitative study of the experiences of bereaved family caregivers of patients with cutaneous T-cell lymphoma

BACKGROUND

Cutaneous T-cell lymphomas (CTCL) are rare cancers, which can be difficult to diagnose, are incurable and adversely affect quality of life, particularly in advanced disease. Families often provide care, but little is known about their experiences or needs while caring for their relative with advanced disease or in bereavement.

OBJECTIVES

To explore the experiences of bereaved family caregivers of patients with CTCL.

METHODS

Single, semi-structured qualitative interviews were conducted with bereaved family caregivers of patients with CTCL recruited via a supra-regional CTCL clinic. Transcribed interviews were analysed thematically, focusing on advanced disease, the approach of death and bereavement.

RESULTS

Fifteen carers of 11 deceased patients participated. Experiences clustered under four themes: (1) complexity of care and medical intervention; (2) caregiver roles in advanced CTCL; (3) person-centred vs. organization-centred care in advanced CTCL and (4) knowing and not knowing: reflections on dying, death and bereavement. Caregivers often had vivid recollections of the challenges of caring for their relative with advanced CTCL and some took on quasi-professional roles as a result. Advanced disease made high demands on both organizational flexibility and family resources. For many caregivers, seeing disease progression was a prolonged and profoundly traumatic experience. The extent to which they were prepared for their relative's death and supported in bereavement was highly variable. Sub-themes within each theme provide more detail about caregiver experiences.

CONCLUSIONS

Family caregivers should be considered part of the wider healthcare team, acknowledging their multiple roles and the challenges they encounter in looking after their relative with CTCL as the disease progresses. Their experiences highlight the importance of organizational flexibility and of good communication between healthcare providers in advanced CTCL.

Betamethasone-exposed preterm birth does not impair insulin action in adult sheep

Preterm birth is associated with increased risk of type 2 diabetes (T2D) in adulthood; however, the underlying mechanisms are poorly understood. We therefore investigated the effect of preterm birth at ~0.9 of term after antenatal maternal betamethasone on insulin sensitivity, secretion and key determinants in adulthood, in a clinically relevant animal model. Glucose tolerance and insulin secretion (intravenous glucose tolerance test) and whole-body insulin sensitivity (hyperinsulinaemic euglycaemic clamp) were measured and tissue collected in young adult sheep (14 months old) after epostane-induced preterm (9M, 7F) or term delivery (11M, 6F). Glucose tolerance and disposition, insulin secretion, β-cell mass and insulin sensitivity did not differ between term and preterm sheep. Hepatic PRKAG2 expression was greater in preterm than in term males (P = 0.028), but did not differ between preterm and term females. In skeletal muscle, SLC2A4 (P = 0.019), PRKAA2 (P = 0.021) and PRKAG2 (P = 0.049) expression was greater in preterm than in term overall and in males, while INSR (P = 0.047) and AKT2 (P = 0.043) expression was greater in preterm than in term males only. Hepatic PRKAG2 expression correlated positively with whole-body insulin sensitivity in males only. Thus, preterm birth at 0.9 of term after betamethasone does not impair insulin sensitivity or secretion in adult sheep, and has sex-specific effects on gene expression of the insulin signalling pathway. Hence, the increased risk of T2D in preterm humans may be due to factors that initiate preterm delivery or in early neonatal exposures, rather than preterm birth per se.

Statutory wills: Doing the right thing under the Mental Capacity Act 2005

Statutory wills are made under the Mental Capacity Act 2005 (MCA) for persons who lack testamentary capacity. Mental health practitioners are likely to be familiar with many of the provisions of the MCA and the test for testamentary capacity. However, they may not have encountered statutory wills. This article explains the procedure for applying for a statutory will, including the role of medical practitioners. Salient legal cases are summarised to highlight the difficulties in applying a best interests framework for decision-making in the context of statutory wills. Finally, this article considers how the United Nations Convention on the Rights of Persons with Disabilities (CRPD) might affect not only on statutory wills, but also the wider provisions of the MCA.

Learning Objectives

• Be able to explain statutory wills and the application procedure to a patient or carer

• Understand the differences between the test for testamentary capacity (as established inBanks v Goodfellow(1870)) and assessing capacity under the MCA

• Appreciate how the CRPD might affect the decision-making process, not only for statutory wills but for all decisions made under the MCA

Sociolegal and practice implications of caring for LGBT people with dementia

The needs of lesbian, gay, bisexual and trans (LGBT) people with dementia are poorly recognised. This is due partly to assumptions that all older people are heterosexual or asexual. One quarter of gay or bisexual men and half of lesbian or bisexual women have children, compared with 90% of heterosexual women and men, which means LGBT older adults are more likely to reside in care homes. Older LGBT people may be unwilling to express their sexual identities in care settings and this can affect their care. Members of older people's informal care networks must be recognised to ensure their involvement in the lives of residents in care settings continues. However, healthcare professionals may not always realise that many LGBT people rely on their families of choice or wider social networks more than on their families of origin. This article explores sociolegal issues that can arise in the care of older LGBT people with dementia, including enabling autonomy, capacity and applying legal frameworks to support their identities and relationships. It also highlights implications for practice.

IV. Civil Partnerships: A New Couple’s Conversation

The practicalities of introducing partnership registration for gay couples, with rights and responsibilities attached, are complex. But the case for doing it is clear and, I believe, strong. I believe there will be a day when gay couples dont have to struggle to have their partnerships, their families, recognized. (Barbara Roche, UK Labour MP1)

Successive switching of antiretroviral therapy is associated with high psychological and physical burden

HIV treatment and management is constantly evolving. This is as a result of more treatment options coming on stream, tolerance changes and progress in treatment management. HIV infection today, in resource-rich countries and in the presence of combination therapies, is experienced as lifelong treatment punctuated by adjustments to antiretroviral therapy (ART) regimens. People who are diagnosed as HIV positive face a number of challenges and changes around the decision to commence treatment, responses to treatment and changes in treatment regimens. This study was set up to examine the experience of switching treatments and the impact of such switches on psychological parameters. The method used was a cross-sectional questionnaire study. A group of 779 HIV-positive clinic attendees at four clinics in London and South East England participated in the study (86% response rate). They provided detail of their treatment switching experiences as well as demographic details, risk and optimism evaluations, quality of life, symptom burden, adherence and disclosure information. The sample ( n=779) comprised 183 (24%) females, 76 (10%) heterosexual males and 497 gay males (66%). Self-reported ethnicity was 67% white, 25% black, 3% Asian and 5% mixed/other ethnicity. One hundred and fifty-five (21%) were ART-naïve and 624 (79%) were ART experienced; 161 (22%) were receiving their first regimen, 135 (18%) had experienced one regimen switch, 196 (26%) had multiple switches and 99 (13.3%) had stopped treatment. Treatment naïve, non-switchers and single switchers generally reported lower symptom burden and higher quality of life. Multiple switchers reported higher physical symptom burden and higher global symptom distress scores. Those who had stopped treatment had significantly lower quality-of-life scores than all other groups. Suicidal ideation was high across the groups and nearly a fifth of all respondents had not disclosed their HIV status to anyone. Reported adherence was suboptimal – 79% of subjects were at least 95% adherent on self-report measures of doses taken over the preceding week. In conclusion, nearly half this clinic sample will have switched treatments. A holistic approach is needed to understand the psychological effects of such switches if lifelong treatment is to be maintained and those on antiretroviral treatment are to attain good quality of life and minimize symptom burden.

Comparative study of linear and curvilinear ultrasound probes to assess quadriceps rectus femoris muscle mass in healthy subjects and in patients with chronic respiratory disease

Introduction

Ultrasound measurements of rectus femoris cross-sectional area (RF_CSA) are clinically useful measurements in chronic obstructive pulmonary disease (COPD) and critically ill patients. Technical considerations as to the type of probe used, which affects image resolution, have limited widespread clinical application. We hypothesised that measurement of RF_CSA would be similar with linear and curvilinear probes.

Methods

Four studies were performed to compare the use of the curvilinear probe in measuring RF_CSA. Study 1 investigated agreement of RF_CSA measurements using linear and curvilinear probes in healthy subjects, and in patients with chronic respiratory disease. Study 2 investigated the intra-rater and inter-rater agreement using the curvilinear probe. Study 3 investigated the agreement of RF_CSA measured from whole and spliced images using the linear probe. Study 4 investigated the applicability of ultrasound in measuring RF_CSA during the acute and recovery phases of an exacerbation of COPD.

Results

Study 1 showed demonstrated no difference in the measurement of RF_CSA using the curvilinear and linear probes (308±104 mm² vs 320±117 mm², p=0.80; intraclass correlation coefficient (ICC)>0.97). Study 2 demonstrated high intra-rater and inter-rater reliability of RF_CSA measurement with ICC>0.95 for both. Study 3 showed that the spliced image from the linear probe was similar to the whole image RF_CSA (308±103.5 vs 263±147 mm², p=0.34; ICC>0.98). Study 4 confirmed the clinical acceptability of using the curvilinear probe during an exacerbation of COPD. There were relationships observed between admission RF_CSA and body mass index (r=+0.65, p=0.018), and between RF_CSA at admission and physical activity levels at 4 weeks post-hospital discharge (r=+0.75, p=0.006).

Conclusions

These studies have demonstrated that clinicians can employ whole and spliced images from the linear probe or use images from the curvilinear probe, to measure RF_CSA. This will extend the clinical applicability of ultrasound in the measurement of muscle mass in all patient groups.

Out of the shadows: non-communicable diseases and palliative care in Africa

Non-communicable diseases (NCDs) in Africa have been comparatively neglected, partly due to donor-driven funding priorities. This is despite NCDs being the principal cause of mortality globally, with the majority incidence occurring in low-income and middle-income nations. Most of the patients with NCDs will suffer from pain, breathlessness and other physical symptoms, or need support with psychosocial or spiritual problems. Reflecting regional disease prevalence, late-stage clinical presentation, limited funding and restricted access to curative therapies, palliative care need in Africa is significantly high. Although palliative care provision has advanced significantly on the continent in the past decade, much of this development was driven by services for adult HIV patients. However, recent international and regional political declarations and commitments constitute a new global NCD agenda that calls for the integration of palliative care into the NCD response. This could be achieved under a chronic care model of service provision in partnership with other clinical providers in an integrated care continuum spanning prevention, early detection, diagnosis, treatment, survivorship and the end of life. Four important challenges have to be addressed if palliative care is to contribute meaningfully to this NCD agenda: (1) existing variation in the ability of countries to deal with NCDs per se; (2) ensuring clinical partners are integrated effectively with palliative care; (3) agreeing implementation is linked to relevant national-level and patient-level metrics; and (iv) underpinning palliative care and NCD care with a rigorous and locally relevant evidence base demonstrating appropriate, feasible and effective care.

Benchmarking of a treatment planning system for spot scanning proton therapy: comparison and analysis of robustness to setup errors of photon IMRT and proton SFUD treatment plans of base of skull meningioma

PURPOSE

Base of skull meningioma can be treated with both intensity modulated radiation therapy (IMRT) and spot scanned proton therapy (PT). One of the main benefits of PT is better sparing of organs at risk, but due to the physical and dosimetric characteristics of protons, spot scanned PT can be more sensitive to the uncertainties encountered in the treatment process compared with photon treatment. Therefore, robustness analysis should be part of a comprehensive comparison between these two treatment methods in order to quantify and understand the sensitivity of the treatment techniques to uncertainties. The aim of this work was to benchmark a spot scanning treatment planning system for planning of base of skull meningioma and to compare the created plans and analyze their robustness to setup errors against the IMRT technique.

METHODS

Plans were produced for three base of skull meningioma cases: IMRT planned with a commercial TPS [Monaco (Elekta AB, Sweden)]; single field uniform dose (SFUD) spot scanning PT produced with an in-house TPS (PSI-plan); and SFUD spot scanning PT plan created with a commercial TPS [XiO (Elekta AB, Sweden)]. A tool for evaluating robustness to random setup errors was created and, for each plan, both a dosimetric evaluation and a robustness analysis to setup errors were performed.

RESULTS

It was possible to create clinically acceptable treatment plans for spot scanning proton therapy of meningioma with a commercially available TPS. However, since each treatment planning system uses different methods, this comparison showed different dosimetric results as well as different sensitivities to setup uncertainties. The results confirmed the necessity of an analysis tool for assessing plan robustness to provide a fair comparison of photon and proton plans.

CONCLUSIONS

Robustness analysis is a critical part of plan evaluation when comparing IMRT plans with spot scanned proton therapy plans.

'It's a huge maze, the system, it's a terrible maze': dementia carers' constructions of navigating health and social care services

Dementia is a challenging, progressive set of conditions which present a large care burden to informal, familial carers. A complex array of health and social care services are needed to support people living with dementia. Drawing on the interlinked 'Duties to Care' and 'Dementia Talking' projects, in this article we focus on British carers' talk about health and social care services. We explore data from a mixed-method questionnaire (n = 185), four focus groups and eleven interviews with informal carers of people living with dementia using thematic discourse analysis. Three themes are discussed: (1) services as a 'maze'; (2) services as overly limited - 'beyond our remit'; and (3) the battle and fighting discourse deployed by these carers. Our analysis highlights that carers find navigating systemic issues in dementia care time-consuming, unpredictable and often more difficult than the caring work they undertake.

If you had less than a year to live, would you want to know? A seven-country European population survey of public preferences for disclosure of poor prognosis

OBJECTIVE

With increasing European cancer deaths, clinicians must manage information regarding poor prognosis. This study aimed to determine European citizens' preferences, within a scenario of serious illness such as cancer with less than a year to live, for information disclosure regarding poor prognosis, the likely symptoms and problems, and the care options available, to measure variations between countries and to identify factors associated with preferences.

METHODS

A population-based cross-national telephone survey using random digit dialling in seven countries was conducted.

RESULTS

Among 9344 respondents, data revealed an international preference (73.9%) to always be informed in the scenario of having a serious illness such as cancer with less than a year to live. This varied from 67.6% in Italy to 80.7% in Flanders. A minority (21.1%) did not want such information unless they ask, or at all. People younger than 70 years (OR 0.72, 95% CI 0.62-0.83, p < 0.001), men (OR 1.23, 95% CI 1.10-1.37, p < 0.001), those with experience of illness (OR = 1.20. 95% CI 1.01-1.43, p < 0.05) and with more education (OR = 1.20, 95% CI 1.09-1.32, p < 0.001) were more likely to want to know of limited time left.

CONCLUSIONS

The models confirmed the influence of four factors in more than one country (age, gender, education and most concerning problem) and added 11 country-specific factors to which national policies and clinical practice should respond. These findings confirm a majority public preference to be informed in a scenario of poor prognosis. Policy clinical practice should facilitate elucidation and delivery of preferences. Evidence for effective communication skills-building interventions for clinicians is required.

'He was like a zombie': off-label prescription of antipsychotic drugs in dementia

This paper explores the legal position of the off-label prescription of antipsychotic medications to people with dementia who experience behavioural and psychological symptoms of dementia (BPSD). Dementia is a challenging illness, and BPSD can be very difficult for carers to manage, with evidence that this contributes to carer strain and can result in the early institutionalisation of people with dementia. As a result, the prescription of antipsychotic and other neuroleptic medications to treat BPSD has become commonplace, in spite of these drugs being untested and unlicensed for use to treat older people with dementia. In recent years, it has become apparent through clinical trials that antipsychotic drugs increase the risk of cerebrovascular accident (stroke) and death in people with dementia. In addition, these types of medication also have other risk factors for people with dementia, including over-sedation and worsening of cognitive function. Drawing on recent questionnaire (n = 185), focus group (n = 15), and interview (n = 11) data with carers of people with dementia, this paper explores the law relating to off-label prescription, and the applicability of medical negligence law to cases where adverse events follow the use of antipsychotic medication. It is argued that the practice of off-label prescribing requires regulatory intervention in order to protect vulnerable patients.

Preferences for place of death if faced with advanced cancer: a population survey in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain

BACKGROUND

Cancer end-of-life care (EoLC) policies assume people want to die at home. We aimed to examine variations in preferences for place of death cross-nationally.

METHODS

A telephone survey of a random sample of individuals aged ≥16 in England, Flanders, Germany, Italy, the Netherlands, Portugal and Spain. We determined where people would prefer to die if they had a serious illness such as advanced cancer, facilitating circumstances, personal values and experiences of illness, death and dying.

RESULTS

Of 9344 participants, between 51% (95% CI: 48% to 54%) in Portugal and 84% (95% CI: 82% to 86%) in the Netherlands would prefer to die at home. Cross-national analysis found there to be an influence of circumstances and values but not of experiences of illness, death and dying. Four factors were associated with a preference for home death in more than one country: younger age up to 70+ (Germany, the Netherlands, Portugal, Spain), increased importance of dying in the preferred place (England, Germany, Portugal, Spain), prioritizing keeping a positive attitude (Germany, Spain) and wanting to involve family in decisions if incapable (Flanders, Portugal).

CONCLUSIONS

At least two-thirds of people prefer a home death in all but one country studied. The strong association with personal values suggests keeping home care at the heart of cancer EoLC.

Are we heading in the same direction? European and African doctors' and nurses' views and experiences regarding outcome measurement in palliative care

OBJECTIVE

To examine and compare doctors' and nurses' views and experiences regarding outcome measurement in palliative care, including patient-reported outcome measures (PROMs).

METHODS

A web-based survey developed through expert review and piloting was conducted in Europe and Africa with palliative care professionals working in clinical care, audit and research.

RESULTS

The overall participation rate was 42% (663/1592) and the overall completion rate was 59% (392/663). Of these respondents, 196 were doctors (51% male, mean 47 years) and 104 were nurses (84% female, mean 45 years). Doctors' most common reported reasons for not using tools were time constraints followed by lack of training. For nurses, it was lack of training followed by time constraints. Provision of information and guidance influenced willingness to use measures. For those that used tools, most reported favourable outcome measurement experiences. Both prioritized brief PROMs, and measures that included physical and psychological domains. For clinical purposes, the main advantage for doctors was assessment/screening, and clinical decision making for nurses. For research, doctors were most influenced by a measure's comparability with national/international literature followed by its validation in palliative care. For nurses, validation in palliative care was followed by tool access.

CONCLUSION

Overall these respondents shared similar views and experiences, and both were influenced by similar factors. Multidisciplinary outcome measurement education and training is feasible and required. Multidimensional and brief PROMs that include physical and psychological domains need to be prioritized, and access to freely available, validated and translated tools is needed to ensure cross-national comparisons and coordination of international research.

Doctor-patient concordance during HIV treatment switching decision-making

OBJECTIVES

The aim of the study was to explore levels of doctor-patient concordance during the making of decisions regarding HIV treatment switching and stopping in relation to patient health-related outcomes.

METHODS

Adult patients attending five HIV clinics in the United Kingdom were requested to complete the study questionnaire, which included a Concordance Scale, and measures of symptoms [Memorial Symptom Assessment Short Form (MSAS) index], quality of life (EuroQol), satisfaction, adherence and sexual risk behaviour. Clinical health measures (HIV viral load and CD4 cell count) were also obtained. A total of 779 patients completed the questionnaire, giving a response rate of 86%; of these 779 patients, 430 had switched or stopped their HIV treatment and were thus eligible for inclusion. Of these patients, 217 (50.5%) fully completed the Concordance Scale.

RESULTS

Concordance levels were high (88% scored between 30 and 40 on the scale; score range 10-40). Higher concordance was related to several patient outcomes, including: better quality of life (P=0.003), less severe and burdensome symptom experience (lower MSAS-physical score, P=0.001; lower MSAS-psychological score, P=0.008; lower MSAS-global distress index score, P=0.011; fewer symptoms reported, P=0.007), higher CD4 cell count (at baseline, P=0.019, and 6-12 months later, P=0.043) and greater adherence (P=0.029).

CONCLUSIONS

High levels of doctor-patient concordance in HIV treatment decision-making are associated with greater adherence and better physical and psychological functioning. More research is needed to establish a causal relationship between concordance and these outcomes.