Experience of health care at a reference centre as reported by patients and parents of children with rare conditions

Rare diseases, or conditions, are defined as those that affect less than 1 in 2000 of the population [1]. There are probably around 8000 discrete rare conditions that affect 3 million people in the United Kingdom (UK) [2, 3] and around 75% of these may be children and can have life-limiting or disabling effects [4, 5]. Many diseases are chronic, offer no effective treatment and are frequently incurable [5]. The rare disease plans that have been developed by several countries provide important guidance for improving health and social care but their implementation is uneven across countries [6] and the effect of the implementation has rarely been measured at the level of a service provider.

Although scientific and medical advances have led to marked improvements in reaching a diagnosis and improving the prognosis of those with a rare condition [3], concerns remain about the time taken to reach a diagnosis [7, 8], the level of care that may be available to individual patients and their carers [9‐11] and the participation of patients in research [12]. These uncertainties prevent an optimal understanding of the illness, and can impede advanced care planning including palliative care [13]. The quality of life of the carers as well as the patients with a rare condition can be markedly affected [3, 14‐16] but it is unclear as to the level of support that is available for the routine family. It is possible that studies that consult expert patient or professional groups are prone to some selection bias and some studies in the past may have been based on historical experience that predates the recent advances in diagnostics and therapeutics. Many studies have also had limited value due to their condition-specificity and not including a broader variety of rare conditions [14]. To understand the current impact of the rare condition on patients and families with rare conditions and the care they receive locally, there is a need to explore new methods that can continuously monitor patient/parented reported experience of the available support and clinical care as well as participation in research. In January 2017 the Office for Rare Conditions was founded in Glasgow, Scotland, following funding from the Glasgow Children’s Hospital Charity. The aim of the Office was to develop local solutions for raising awareness of rare conditions amongst healthcare professionals, to enhance support and clinical care of patients with rare conditions, and to promote participation in research. The aim of the current study was to measure these aspects at a specialist children’s hospital in the UK through a questionnaire survey. It is anticipated that the results would provide a current benchmark that can be used for improving local services for all people with rare conditions.

In April 2018 the Office developed a questionnaire to determine the quality of care patients with rare conditions received at a tertiary children’s hospital in Glasgow. The questionnaire was developed following input from the Office’s Patient Advisory Group, the Steering Committee and external organisations including the Genetic Alliance and consisted of questions on six themes including: 1. diagnosis; 2. provision of information; 3. availability of support; 4. satisfaction with healthcare team; 5. awareness and support for life-limiting conditions; 6. participation in research (Table 1). The majority of questions had a binary response and could, therefore, be analysed quantitatively, however there was an option for comments following each question to enrich qualitative data. Further questions were added to the original questionnaire in January 2019 exploring theme 5; and in February 2020 questions were included on theme 6 (Table 1). The questionnaire did not collect any personally identifiable fields and had been locally approved as an evaluation of routine health care.

Between April 2018 and March 2020, the Office for Rare Conditions in Glasgow approached patients and carers who were in the outpatient waiting area, in the inpatient wards, who were visiting the Office’s exhibition stand in the Royal Hospital for Children, Glasgow or attending any education seminars organised by the Office and asked them to complete the above questionnaire in an electronic or a paper form. In addition, the electronic questionnaire was also promoted by the Office’s social media platforms including Facebook (@orcglasgow) and Twitter (@orcglasgow). Any patient with a rare condition, or parent/carer with a child diagnosed or awaiting diagnosis of a rare condition was eligible to complete the questionnaire if they were attending any hospital within the NHS Great Glasgow & Clyde Health Board. Although there were no exclusion criteria for completing the survey, the current report focuses on those patients who presented under the age of 18 years.

The quantitative aspects of the questionnaire were analysed using descriptive statistics. Qualitative responses were grouped and categorised.

Between June 2018 and March 2020, 130 questionnaires had been completed and returned on behalf of 134 people. Four parents answered the questionnaire in support of both of their affected children. Of the 130 questionnaires, 115 (88%) were completed by parents/carers, two (2%) were completed by grandparents, and the remaining 13 (10%) were completed by the patients themselves. Of the 130 questionnaires, six (5%) were not fully completed due to time constraints. No participants reported any difficulties with answering the questionnaire. Of the 56 who responded to the question about the location of their specialist care, 48 (86%) attended the Royal Hospital for Children in Glasgow.

The results of this survey provide a unique and objective insight into the health care experience of patients and their families at a regional specialist centre in the UK. It explores key topics including diagnostic timeframes, provision of information and support, wider healthcare team involvement, research participation and awareness and support for life-limiting conditions.

The results show that about 15% of the respondents were diagnosed within the neonatal period whilst a fifth had obtained a diagnosis within 6 months of developing symptoms and another fifth obtained a diagnosis within 1–3 years. With previous studies showing around 40% of patients having difficulty obtaining a diagnosis [14, 17, 18], the current study shows that 85% of the respondents received a diagnosis in childhood, and 80% of these diagnoses were within a shorter period than the 5-year time frame that is often reported [6, 19, 20]. Many previous studies have focussed only on a specific cohort of rare conditions and have, thereby, highlighted specific challenges associated with individual conditions. A strength of the current survey was the large range of rare conditions that had been covered, thus the results can be applied more generally. It is possible that several disease specific factors may have influenced the care outcomes examined in this study but an investigation of these factors was not within the scope of this work. There was no sample bias with only a maximum of five patients with the same condition. However, there may have been a selection bias as participants were recruited through social media platforms and via independent representatives approaching families for written responses.

Although the majority of participants did obtain a formal diagnosis within childhood, 4% had a suspected diagnosis and 11% were currently undiagnosed within the study. A delay in diagnosis can lead to patient or family stress and frustration, unnecessary investigations and disease progression [7, 8]. Factors that contribute to diagnostic delays include limited awareness amongst healthcare professionals and the public, inadequate testing opportunities, long waiting times and delays in obtaining results [8].

Patients with a rare condition should have a high standard of medical knowledge, easily accessible care pathways, research and treatment opportunities [2], yet this survey, along with some others [8, 21, 22] has shown the lack of information that parents had at initial diagnosis. Limited knowledge about their own condition can create major challenges for patients’ abilities to seek health care [23]. The current study confirmed this with over half of respondents who felt they were provided little or no information about the condition at the time of diagnosis, and only 40% reported to be content with the information they had received. Given that the majority of the affected children presented in early infancy, efforts for provision of information from the healthcare team at this critical period need to be intensified. This study considered the healthcare team as a whole, including the lead medical clinician and wider team, however looking at individual clinicians in their role in providing support and information at the time of diagnosis requires further study.

Patient support groups perform an increasingly vital role in the diagnosis and management of rare conditions, and are an important source of data surrounding these conditions [10, 24, 25]. Often they provide the sole source of information for patients and families [24]. It was interesting to note that over half of the respondents were a member of a support group and almost a quarter relied on peer support groups and social media rather than health care professionals as their primary source of information emphasising the critical role played by these groups, Other reports in similar settings suggest that membership of support groups may be less frequent [14]. Online patient networks can be a promising resource for peer support [26] and with increasing acceptability of technology across all ages [27] internet-based support groups may be of benefit for patients as well as their carers [28]. Given the wide range of conditions covered in this survey it is not surprising that a substantial proportion of respondents were not members of a support group and whether online support groups need to be particularly condition specific needs further exploration in the future.

Presently, there are very limited studies that explore the impact of rare conditions in children and their families [14]. The current survey explored the support from a variety of sources including family, the healthcare team, primary health care practitioners, other community based healthcare, schools and friends and showed that almost two-thirds of people felt well supported and highlighted the important role played by family members. Although the primary health care practitioner commonly serves as the point of access to specialist services in the UK, becoming familiar with all rare conditions is generally felt to be difficult especially in the primary care setting [9] and this can be compounded by the fact that often patients with rare conditions do not feel “unwell”, but perhaps just different [9] and care often involves multiple disciplines [15]. It was reassuring to note that a large majority of participants felt they had a consistent team of healthcare professionals taking overall responsibility of their condition and were satisfied with how much healthcare professionals know about their condition. It has often been suggested that the care of the patient with a rare condition is poorly coordinated [17]. It was, therefore, encouraging to discover that over two thirds of respondents felt part of the healthcare team in this survey and knew who to contact for guidance and the majority felt one specialist service had taken the lead. Overall, three quarters of respondents were satisfied with the support they received from healthcare professionals.

Support is essential at the time of diagnosis, however it is also crucial throughout the journey of a patient with a rare condition, particularly as many conditions can be life limiting or debilitating [5]. The current survey shows that 75% of families may not have a clear understanding of whether their child has a life limiting condition or not, perhaps reflecting on the lack of discussion on this topic as well as the gaps and barriers that may currently exist for the provision of palliative and end-of life care. Communication is a fundamental component of the palliative and end-of-life patient experience, with the term ‘palliative’ frequently misunderstood. It should be greater advocated that palliative care can also be given alongside traditional treatments [13], and the gap should be bridged between medical and palliative services, to allow for advanced care planning. Additionally, of those who felt their child did have a life-limiting condition, only a small percentage (17%) felt that they were being provided with specialist support for this.

Research is considered to be a vital aspect of improving the care of people with rare conditions [5, 14]. As the question enquiring whether patients/families’ involvement in research was added more recently in the survey, the response numbers were small, and only a quarter of respondents were actively taking part in research whilst the remainder were all keen on participating in research. There are many factors that could play a role in the limited participation, for example, lack of awareness of current research trials [17], selective recruitment criteria, geographical challenges, socioeconomic status [6, 12] or the time commitments when already caring for a child who may need around the clock care [5]. The present questionnaire could be adapted to explore this further and could even be used as a means of recruiting patients for future study. A recent study from 63 countries showed that just over one third of respondents actively participated in research (12) demonstrating that there is a global need for increased research participation.

Although their diagnoses may differ, there are many commonalities experienced amongst families with rare conditions. Whilst the survey has shown that although there are several aspects of care where the results were more positive than expected, there are several indicators of care that require improvement. The indicators that we describe here can be considered to be key performance indicators that focus on the quality of care and may be of interest to reference centres within regional, national or international clinical networks such as European Reference Networks. The unique insight provided by this survey can be used as a platform to improve service delivery at a local level and can also act as a benchmark against which the quality of care can be compared across multiple centres.