Perceptions on Home-Administration of Biologics in the Context of Severe Asthma: An International Qualitative Study

BACKGROUND

Biologics are an effective therapy for severe asthma. Home administration of biologics by patients is likely to facilitate their accessibility. Yet little is known about patients' and health care providers' (HCPs) perceptions regarding home administration of biologics.

OBJECTIVE

The aim of this study is to create more insight into the perceptions and experiences of patients and HCPs regarding home administration of biologics in the context of the treatment of severe asthma.

METHODS

A qualitative international study was performed in the Netherlands, United States, Australia, and United Kingdom. In each country, 2 focus groups were held with potential/recent and long-term users of biologics at home. Prior to the focus groups, patients were prompted with themes on online forums. For triangulation purposes, interviews were held with HCPs to discuss salient findings from forums and focus groups. Data were analyzed with qualitative content analysis.

RESULTS

In total, 75 patients participated in the forums, of which 40 participated in the focus groups. Furthermore, 12 HCPs were interviewed. The following overarching themes were identified: living with severe asthma; practical aspects of using biologics; the role of HCPs regarding biologics; social support from family, friends, and others; effectiveness of biologics and other treatments; side effects of biologics.

CONCLUSIONS

This study showed that, for those using biologics for severe asthma, the benefits of home administration of biologics usually outweigh inconvenience and side effects. Guided practice, accessible support contact, and monitoring including social support should be central in the transition from hospital to home administration of asthma biologics.

I don't want to think about it: a qualitative study of children (6-18 years) with rheumatic diseases and parents' experiences with regular needle injections at home

BACKGROUND

Overall outcomes of pediatric rheumatic diseases (RD) have improved due to treatment with biologic agents and methotrexate. For many children, this treatment often entails regular needle injections. Pain and fear of needle injections are common in childhood, but how children and parents handle long-term needle injections at home has not been fully explored. This study aimed to explore how regular needle injections affect children with RD and their parents in their daily living.

METHODS

This explorative qualitative study used individual interviews and focus groups to ensure a comprehensive investigation of the topic. Children aged 6 to 16 years (n = 7) and their parents (n = 8) were interviewed individually 4 to 6 months after the onset of needle injection treatment. The focus groups included children aged 11 to 17 years (n = 9) and parents (n = 8) with a minimum of 6 months of experience with injection treatment. Data were analyzed using thematic analysis.

RESULTS

The main themes; "challenges," "motivational factors," and "routines" captured experiences and strategies that influenced the continuation of needle injections at home. Many children feared the moment immediately before the needle stick, although they had become accustomed to the pain. Most parents felt insecure about handling needle injections and lacked follow-up from healthcare providers. The children's experience of treatment effects and self-confidence were essential to maintain motivation for further injections. A number of coping strategies helped children focus away from injection related discomfort, often discovered by chance. Facilitating firm routines and shared responsibility within families helped children develop self-confidence during the procedure. Children and parents struggled to find suitable information on the Internet.

CONCLUSIONS

Children and parents experienced long-term needle injections challenging. They used their own limited resources and cooperated within the families to create routines and to introduce coping strategies necessary to manage and keep up with the procedure. Although the injection itself was not experienced very painful, the discomfort, worries and impact on daily life represented far more than a little needle stick, and thus needs more attention from healthcare providers.

Children's fear of needle injections: a qualitative study of training sessions for children with rheumatic diseases before home administration

BACKGROUND

Treatment of rheumatic diseases in children often includes long-term needle injections, which represent a risk for refusing medication based on potential needle-fear. How nurses manage children's fear and pain during the initial educational training session of subcutaneous injections, may affect the management of the subsequent injections in the home settings. The aim of this study was to explore how children expressed fear and pain during these training sessions, and how adults' communication affected children's expressed emotions.

METHODS

This qualitative explorative study used video observations and short interviews during training sessions in a rheumatic hospital ward. Participants were children between five and fifteen years (n = 8), their parents (n = 11) and nurses (n = 7) in nine training sessions in total. The analysis followed descriptions of thematic analysis and interaction analysis.

RESULTS

The children expressed fears indirectly as cues and nonverbal signs more often than direct statements. Three children stated explicit being afraid or wanting to stop. The children worried about needle-pain, but experienced the stinging pain after the injection more bothersome. The technical instructions were detailed and comprehensive and each nurse shaped the structure of the sessions. Both nurses and parents frequently offered coping strategies unclearly without sufficient time for children to understand. We identified three main adult communication approaches (acknowledging, ambiguous and disregarding) that influenced children's expressed emotions during the training session.

CONCLUSIONS

Children's expression of fear was likely to be indirectly, and pain was mostly related to the injection rather than the needle stick. When adults used an acknowledging communication and offered sufficient coping strategies, children seemed to become involved in the procedure and acted with confidence. The initial educational training session may have a great impact on long-term repeated injections in a home setting by providing children with confidence at the onset.

Estimation of Health and Economic Benefits of Clinic Versus Home Administration of Omalizumab and Mepolizumab

BACKGROUND

Biologic therapy is a paradigm-shifting management strategy for many patients with asthma and chronic urticaria, but concerns for therapy-associated anaphylaxis may limit access to these therapies for patients unable to travel to medical clinics.

OBJECTIVE

To characterize the cost-effectiveness of in-clinic versus at-home biologic therapy with omalizumab and mepolizumab.

METHODS

Economic evaluation using microsimulations was performed from societal and health care sector perspectives for patients with asthma or chronic spontaneous urticaria receiving omalizumab or mepolizumab in an allergy clinic, primary care provider (PCP) office, or at home over a 1-year time horizon (12 injections per year in each base case with sensitivity analysis to 24 injections per year). Travel times and distances were applied to a population attending a tertiary care allergy clinic in Northern New England receiving omalizumab or mepolizumab, using a willingness-to-pay value of $10 million per death prevented and in-clinic administration reducing anaphylaxis fatality and hospitalization 10- to100-fold. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

One-way allergy clinic travel distances significantly exceeded local PCP offices (49 miles, 95% CI, 42-56, vs 12 miles, 95% CI, 10-15). In the omalizumab societal analysis, annual PCP and allergy clinic administration cost $1369.14 (mean) ± $51.33 (SD) and $1916.68 ± $40.86, respectively. Small reductions in medication-related fatalities with in-clinic administration were offset by the potential increase in automobile fatalities resulting from traveling to the allergy clinic (14.6 ± 15.0 per million person-years for this strategy). Compared with at-home administration, in-clinic omalizumab administration was not cost-effective, with an incremental cost-effectiveness ratio of $500,648,430 (PCP), and with allergy clinic administration dominated by higher costs and automobile-related fatalities. Routine mepolizumab clinic administration was dominated by at-home administration unless anaphylaxis rates or self-administration teaching costs were high.

CONCLUSIONS

For many patients, at-home administration of omalizumab or mepolizumab may be a cost-effective strategy.

Colistin methanesulfonate infusion solutions are stable over time and suitable for home administration

The stability of colistin methanesulfonate (CMS) was determined in quadruplicate in elastomeric home infusion pumps containing 1, 2 or 3 MU CMS and in infusion bags with 2 MU CMS all in 100 mL normal saline. Infusions were stored at room temperature (20°C-24°C) with or without exposure to natural light or refrigerated (4°C-8°C) and protected from light up to 2 weeks. In the initial solution of 2 MU CMS in 100 mL saline sampled immediately after reconstitution and dilution, 1.5% of CMS was hydrolysed to colistin. When stored at room temperature and exposed to natural light, colistin concentration in elastomeric infusion pumps increased to 2.6% in 8 days and to 2.1% when stored at 4°C. CMS stability increases at lower temperatures and higher concentrations. Based on the current data, chemical stability of CMS infusion solution is sufficient for a shelf life of 7 days refrigerated plus 1 day at room temperature.