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Erschienen in: International Ophthalmology 2/2018

11.03.2017 | Original Paper

Treatment satisfaction of patients with neovascular age-related macular degeneration treated with anti-vascular endothelial growth factor agents

verfasst von: Theodoros P. Marakis, Chrysanthi Koutsandrea, Klio I. Chatzistefanou, Yannis Tountas

Erschienen in: International Ophthalmology | Ausgabe 2/2018

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Abstract

Purpose

To assess the psychometric properties of the Greek Macular Disease Treatment Satisfaction Questionnaire (MacTSQ) and evaluate the factors that influence treatment satisfaction of patients with neovascular age-related macular degeneration (nAMD).

Methods

The MacTSQ was translated into Greek and administered to 176 patients. All patients completed the SF-12 Health Survey and the Macular disease Dependent Quality of Life Questionnaire (MacDQoL) and underwent vision measurements. For test–retest reliability, a subset of 19 participants completed the MacTSQ twice, two weeks apart. Stepwise multiple linear regression analyses were performed to identify predictors of treatment satisfaction. Change in MacTSQ scores over time was assessed on 83 patients who completed the MacTSQ at a follow-up visit, one year later.

Results

The intraclass correlation coefficients between the first and second test–retest administration ranged from 0.88 to 0.98 for the items and total score. Internal reliability of the total score was adequate (Cronbach’s a = 0.837). Principal component analysis revealed three subscales (effectiveness, information provision and convenience, impact). The MacTSQ score showed significant correlations with SF-12 summary scales and MacDQoL scores (ρ = 0.16–0.27). The most important factor that determined the satisfaction was mental health. Distance visual acuity (VA) in better eye was the best predictor of the effectiveness subscale, and the total number of injections was a negative predictor for the convenience subscale. Treatment satisfaction increased at one-year follow-up, despite the deterioration in distance VA.

Conclusions

The Greek MacTSQ is a reliable and valid instrument for assessing nAMD patients’ perceptions of treatment satisfaction, especially using its three new subscales. Treatment satisfaction is multifactorial and was primarily determined by patients’ mental health status.
Literatur
1.
Zurück zum Zitat Bourne RR, Jonas JB, Flaxman SR, Keeffe J, Leasher J, Naidoo K, Parodi MB, Pesudovs K, Price H, White RA, Wong TY, Resnikoff S, Taylor HR, Vision Loss Expert Group of the Global Burden of Disease Study (2014) Prevalence and causes of vision loss in high-income countries and in Eastern and Central Europe: 1990–2010. Br J Ophthalmol 98:629–638CrossRefPubMed Bourne RR, Jonas JB, Flaxman SR, Keeffe J, Leasher J, Naidoo K, Parodi MB, Pesudovs K, Price H, White RA, Wong TY, Resnikoff S, Taylor HR, Vision Loss Expert Group of the Global Burden of Disease Study (2014) Prevalence and causes of vision loss in high-income countries and in Eastern and Central Europe: 1990–2010. Br J Ophthalmol 98:629–638CrossRefPubMed
3.
Zurück zum Zitat Cimarolli VR, Casten RJ, Rovner BW, Heyl V, Sörensen S, Horowitz A (2015) Anxiety and depression in patients with advanced macular degeneration: current perspectives. Clin Ophthalmol 10:55–63CrossRefPubMedPubMedCentral Cimarolli VR, Casten RJ, Rovner BW, Heyl V, Sörensen S, Horowitz A (2015) Anxiety and depression in patients with advanced macular degeneration: current perspectives. Clin Ophthalmol 10:55–63CrossRefPubMedPubMedCentral
4.
Zurück zum Zitat Comparison of Age-related Macular Degeneration Treatments Trials (CATT) Research Group, Maguire MG, Martin DF, Ying GS, Jaffe GJ, Daniel E, Grunwald JE, Toth CA, Ferris FL 3rd, Fine SL (2016) Five-year outcomes with anti-vascular endothelial growth factor treatment of neovascular age-related macular degeneration: the comparison of age-related macular degeneration treatments trials. Ophthalmology 123:1751–1761. doi:10.1016/j.ophtha.2016.03.045 CrossRef Comparison of Age-related Macular Degeneration Treatments Trials (CATT) Research Group, Maguire MG, Martin DF, Ying GS, Jaffe GJ, Daniel E, Grunwald JE, Toth CA, Ferris FL 3rd, Fine SL (2016) Five-year outcomes with anti-vascular endothelial growth factor treatment of neovascular age-related macular degeneration: the comparison of age-related macular degeneration treatments trials. Ophthalmology 123:1751–1761. doi:10.​1016/​j.​ophtha.​2016.​03.​045 CrossRef
5.
Zurück zum Zitat Holz FG, Tadayoni R, Beatty S, Berger A, Cereda MG, Cortez R, Hoyng CB, Hykin P, Staurenghi G, Heldner S, Bogumil T, Heah T, Sivaprasad S (2015) Multi-country real-life experience of anti-vascular endothelial growth factor therapy for wet age-related macular degeneration. Br J Ophthalmol 99(2):220–226CrossRefPubMed Holz FG, Tadayoni R, Beatty S, Berger A, Cereda MG, Cortez R, Hoyng CB, Hykin P, Staurenghi G, Heldner S, Bogumil T, Heah T, Sivaprasad S (2015) Multi-country real-life experience of anti-vascular endothelial growth factor therapy for wet age-related macular degeneration. Br J Ophthalmol 99(2):220–226CrossRefPubMed
6.
Zurück zum Zitat Finger RP, Wiedemann P, Blumhagen F, Pohl K, Holz FG (2013) Treatment patterns, visual acuity and quality-of-life outcomes of the WAVE study—a noninterventional study of ranibizumab treatment for neovascular age-related macular degeneration in Germany. Acta Ophthalmol 91(6):540–546CrossRefPubMed Finger RP, Wiedemann P, Blumhagen F, Pohl K, Holz FG (2013) Treatment patterns, visual acuity and quality-of-life outcomes of the WAVE study—a noninterventional study of ranibizumab treatment for neovascular age-related macular degeneration in Germany. Acta Ophthalmol 91(6):540–546CrossRefPubMed
7.
Zurück zum Zitat Souied EH, Oubraham H, Mimoun G, Cohen SY, Quere S, Derveloy A, TWIN Study Group (2015) Changes in visual acuity in patients with wet age-related macular degeneration treated with intravitreal ranibizumab in daily clinical practice: the TWIN study. Retina 35:1743–1749CrossRefPubMed Souied EH, Oubraham H, Mimoun G, Cohen SY, Quere S, Derveloy A, TWIN Study Group (2015) Changes in visual acuity in patients with wet age-related macular degeneration treated with intravitreal ranibizumab in daily clinical practice: the TWIN study. Retina 35:1743–1749CrossRefPubMed
8.
9.
Zurück zum Zitat Senra H, Ali Z, Balaskas K, Aslam T (2016) Psychological impact of anti-VEGF treatments for wet macular degeneration-a review. Graefes Arch Clin Exp Ophthalmol 254:1873–1880CrossRefPubMedPubMedCentral Senra H, Ali Z, Balaskas K, Aslam T (2016) Psychological impact of anti-VEGF treatments for wet macular degeneration-a review. Graefes Arch Clin Exp Ophthalmol 254:1873–1880CrossRefPubMedPubMedCentral
10.
Zurück zum Zitat Droege KM, Muether PS, Hermann MM, Caramoy A, Viebahn U, Kirchhof B, Fauser S (2013) Adherence to ranibizumab treatment for neovascular age-related macular degeneration in real life. Graefes Arch Clin Exp Ophthalmol 251(5):1281–1284. doi:10.1007/s00417-012-2177-3 CrossRefPubMed Droege KM, Muether PS, Hermann MM, Caramoy A, Viebahn U, Kirchhof B, Fauser S (2013) Adherence to ranibizumab treatment for neovascular age-related macular degeneration in real life. Graefes Arch Clin Exp Ophthalmol 251(5):1281–1284. doi:10.​1007/​s00417-012-2177-3 CrossRefPubMed
11.
Zurück zum Zitat Rodríguez Ramírez M, del Barrio Manso MI, Martín Sánchez MD (2014) Intravitreal injections: what do patients prefer? Analysis of patient’s satisfaction and preferences about where to perform intravitreal injections. Arch Soc Esp Oftalmol 89(12):477–483. doi:10.1016/j.oftal.2014.05.010 CrossRefPubMed Rodríguez Ramírez M, del Barrio Manso MI, Martín Sánchez MD (2014) Intravitreal injections: what do patients prefer? Analysis of patient’s satisfaction and preferences about where to perform intravitreal injections. Arch Soc Esp Oftalmol 89(12):477–483. doi:10.​1016/​j.​oftal.​2014.​05.​010 CrossRefPubMed
12.
Zurück zum Zitat Mitchell J, Brose LS, Bradley C (2007) Design of a measure of satisfaction with treatment for macular degeneration (MacTSQ). Qual Life Res A-120:2 Mitchell J, Brose LS, Bradley C (2007) Design of a measure of satisfaction with treatment for macular degeneration (MacTSQ). Qual Life Res A-120:2
13.
Zurück zum Zitat Chakravarthy U, Harding SP, Rogers CA, Downes SM, Lotery AJ, Culliford LA, Reeves BC, IVAN study investigators (2013) Alternative treatments to inhibit VEGF in age-related choroidal neovascularisation: 2-year findings of the IVAN randomised controlled trial. Lancet 382:1258–1267CrossRefPubMed Chakravarthy U, Harding SP, Rogers CA, Downes SM, Lotery AJ, Culliford LA, Reeves BC, IVAN study investigators (2013) Alternative treatments to inhibit VEGF in age-related choroidal neovascularisation: 2-year findings of the IVAN randomised controlled trial. Lancet 382:1258–1267CrossRefPubMed
15.
Zurück zum Zitat Gohil R, Crosby-Nwaobi R, Forbes A, Burton BJ, Hykin P, Sivaprasad S (2016) Treatment satisfaction of patients undergoing ranibizumab therapy for neovascular age-related macular degeneration in a real-life setting. Patient Prefer Adherence 10:949–955. doi:10.2147/PPA.S105536 PubMedPubMedCentral Gohil R, Crosby-Nwaobi R, Forbes A, Burton BJ, Hykin P, Sivaprasad S (2016) Treatment satisfaction of patients undergoing ranibizumab therapy for neovascular age-related macular degeneration in a real-life setting. Patient Prefer Adherence 10:949–955. doi:10.​2147/​PPA.​S105536 PubMedPubMedCentral
16.
Zurück zum Zitat Boyle J, Vukicevic M, Koklanis K, Itsiopoulos C, Rees G (2017) Experiences of patients undergoing repeated intravitreal anti-vascular endothelial growth factor injections for neovascular age-related macular degeneration. Psychol Health Med 9:1–21. doi:10.1080/13548506.2016.1274040 Boyle J, Vukicevic M, Koklanis K, Itsiopoulos C, Rees G (2017) Experiences of patients undergoing repeated intravitreal anti-vascular endothelial growth factor injections for neovascular age-related macular degeneration. Psychol Health Med 9:1–21. doi:10.​1080/​13548506.​2016.​1274040
17.
Zurück zum Zitat Topouzis F, Coleman AL, Harris A, Anastasopoulos E, Yu F, Koskosas A, Pappas T, Mavroudis L, Wilson MR (2006) Prevalence of age-related macular degeneration in Greece: the Thessaloniki Eye Study. Am J Ophthalmol 142:1076–1079CrossRefPubMed Topouzis F, Coleman AL, Harris A, Anastasopoulos E, Yu F, Koskosas A, Pappas T, Mavroudis L, Wilson MR (2006) Prevalence of age-related macular degeneration in Greece: the Thessaloniki Eye Study. Am J Ophthalmol 142:1076–1079CrossRefPubMed
19.
Zurück zum Zitat Chatziralli I, Mitropoulos P, Parikakis E, Niakas D, Labiris G (2016) Risk factors for poor quality of life among patients with age-related macular degeneration. Semin Ophthalmol 10:1–9. [Epub ahead of print] Chatziralli I, Mitropoulos P, Parikakis E, Niakas D, Labiris G (2016) Risk factors for poor quality of life among patients with age-related macular degeneration. Semin Ophthalmol 10:1–9. [Epub ahead of print]
20.
Zurück zum Zitat Bradley C, Lewis KS (1990) Measures of psychological well-being and treatment satisfaction developed from the responses of people with tablet-treated diabetes. Diabet Med 7:445–451CrossRefPubMed Bradley C, Lewis KS (1990) Measures of psychological well-being and treatment satisfaction developed from the responses of people with tablet-treated diabetes. Diabet Med 7:445–451CrossRefPubMed
22.
Zurück zum Zitat Wild D, Eremenco S, Mear I, Martin M, Houchin C, Gawlicki M, Hareendran A, Wiklund I, Chong LY, von Maltzahn R, Cohen L, Molsen E (2009) Multinational trials-recommendations on the translations required, approaches to using the same language in different countries, and the approaches to support pooling the data: the ISPOR patient-reported outcomes translation and linguistic validation good research practices task force report. Value Health 12:430–440. doi:10.1111/j.1524-4733.2008.00471.x CrossRefPubMed Wild D, Eremenco S, Mear I, Martin M, Houchin C, Gawlicki M, Hareendran A, Wiklund I, Chong LY, von Maltzahn R, Cohen L, Molsen E (2009) Multinational trials-recommendations on the translations required, approaches to using the same language in different countries, and the approaches to support pooling the data: the ISPOR patient-reported outcomes translation and linguistic validation good research practices task force report. Value Health 12:430–440. doi:10.​1111/​j.​1524-4733.​2008.​00471.​x CrossRefPubMed
23.
Zurück zum Zitat Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, Bouter LM, de Vet HC (2007) Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 60:34–42CrossRefPubMed Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, Bouter LM, de Vet HC (2007) Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 60:34–42CrossRefPubMed
24.
Zurück zum Zitat Kontodimopoulos N, Pappa E, Niakas D, Tountas Y (2007) Validity of SF-12 summary scores in a Greek general population. Health Qual Life Outcomes 5:55CrossRefPubMedPubMedCentral Kontodimopoulos N, Pappa E, Niakas D, Tountas Y (2007) Validity of SF-12 summary scores in a Greek general population. Health Qual Life Outcomes 5:55CrossRefPubMedPubMedCentral
25.
Zurück zum Zitat Marakis TP, Koutsandrea C, Chatzistefanou KI, Tountas Y (2017) Reliability, validity and responsiveness of the Greek MacDQoL individualized measure of the impact of macular degeneration on quality of life. Qual Life Res 26:183–191CrossRefPubMed Marakis TP, Koutsandrea C, Chatzistefanou KI, Tountas Y (2017) Reliability, validity and responsiveness of the Greek MacDQoL individualized measure of the impact of macular degeneration on quality of life. Qual Life Res 26:183–191CrossRefPubMed
26.
Zurück zum Zitat Ware JE, Kosinski M, Keller SD (1994) SF-36 physical and mental health summary scales: a user’s manual. The Health Institute, New England Medical Center, Boston Ware JE, Kosinski M, Keller SD (1994) SF-36 physical and mental health summary scales: a user’s manual. The Health Institute, New England Medical Center, Boston
27.
Zurück zum Zitat Mitchell J, Wolffsohn JS, Woodcock A, Anderson SJ, McMillan CV, Ffytche T, Rubinstein M, Amoaku W, Bradley C (2005) +Psychometric evaluation of the MacDQoL individualised measure of the impact of macular degeneration on quality of life. Health Qual Life Outcomes 3:25. doi:10.1186/1477-7525-3-25 CrossRefPubMedPubMedCentral Mitchell J, Wolffsohn JS, Woodcock A, Anderson SJ, McMillan CV, Ffytche T, Rubinstein M, Amoaku W, Bradley C (2005) +Psychometric evaluation of the MacDQoL individualised measure of the impact of macular degeneration on quality of life. Health Qual Life Outcomes 3:25. doi:10.​1186/​1477-7525-3-25 CrossRefPubMedPubMedCentral
28.
Zurück zum Zitat Ferris FL 3rd, Kassoff A, Bresnick GH, Bailey I (1982) New visual acuity charts for clinical research. Am J Ophthalmol 94:91–96CrossRefPubMed Ferris FL 3rd, Kassoff A, Bresnick GH, Bailey I (1982) New visual acuity charts for clinical research. Am J Ophthalmol 94:91–96CrossRefPubMed
29.
Zurück zum Zitat Pelli DG, Robson JG, Wilkins AJ (1988) The design of a new letter chart to measure contrast sensitivity. Clin Vis Sci 2:187–199 Pelli DG, Robson JG, Wilkins AJ (1988) The design of a new letter chart to measure contrast sensitivity. Clin Vis Sci 2:187–199
30.
Zurück zum Zitat Horton JC, Jones MR (1997) Warning on inaccurate Rosenbaum cards for testing near vision. Surv Ophthalmol 42:169–174CrossRefPubMed Horton JC, Jones MR (1997) Warning on inaccurate Rosenbaum cards for testing near vision. Surv Ophthalmol 42:169–174CrossRefPubMed
31.
Zurück zum Zitat Arditi A, Cagenello R (1993) On the statistical reliability of letter-chart visual acuity measurements. Invest Ophthalmol Vis Sci 34(1):120–129PubMed Arditi A, Cagenello R (1993) On the statistical reliability of letter-chart visual acuity measurements. Invest Ophthalmol Vis Sci 34(1):120–129PubMed
32.
Zurück zum Zitat Dubuc S, Wittich W, Gomolin JE, Kapusta M, Overbury O (2009) Beyond visual acuity: functional outcome and patient satisfaction following treatment for age-related macular degeneration. Can J Ophthalmol 44(6):680–685CrossRefPubMed Dubuc S, Wittich W, Gomolin JE, Kapusta M, Overbury O (2009) Beyond visual acuity: functional outcome and patient satisfaction following treatment for age-related macular degeneration. Can J Ophthalmol 44(6):680–685CrossRefPubMed
34.
Zurück zum Zitat McCloud C, Lake S (2015) Understanding the patient’s lived experience of neovascular age-related macular degeneration: a qualitative study. Eye (Lond) 29:1561–1569CrossRef McCloud C, Lake S (2015) Understanding the patient’s lived experience of neovascular age-related macular degeneration: a qualitative study. Eye (Lond) 29:1561–1569CrossRef
35.
Zurück zum Zitat Burton AE, Shaw RL, Gibson JM (2013) Experiences of patients with age-related macular degeneration receiving anti-vascular endothelial growth factor therapy: a qualitative study. Br J Vis Impair 31(3):178–188CrossRef Burton AE, Shaw RL, Gibson JM (2013) Experiences of patients with age-related macular degeneration receiving anti-vascular endothelial growth factor therapy: a qualitative study. Br J Vis Impair 31(3):178–188CrossRef
36.
Zurück zum Zitat Thetford C, Hodge S, Hardig S, Taylor S, Knox PC (2013) Living with age-related macular degeneration treatment: patient experiences of being treated with ranibizumab (Lucentis) intravitral injections. Br J Vis Impair 31:89–101CrossRef Thetford C, Hodge S, Hardig S, Taylor S, Knox PC (2013) Living with age-related macular degeneration treatment: patient experiences of being treated with ranibizumab (Lucentis) intravitral injections. Br J Vis Impair 31:89–101CrossRef
39.
Zurück zum Zitat Finger RP, Guymer RH, Gillies MC, Keeffe JE (2014) The impact of anti-vascular endothelial growth factor treatment on quality of life in neovascular age-related macular degeneration. Ophthalmology 121(6):1246–1251CrossRefPubMed Finger RP, Guymer RH, Gillies MC, Keeffe JE (2014) The impact of anti-vascular endothelial growth factor treatment on quality of life in neovascular age-related macular degeneration. Ophthalmology 121(6):1246–1251CrossRefPubMed
40.
Zurück zum Zitat Casten R, Rovner BW, Leiby BE, Tasman W (2010) Depression despite anti-vascular endothelial growth factor treatment of age-related macular degeneration. Arch Ophthalmol 128(4):506–508CrossRefPubMed Casten R, Rovner BW, Leiby BE, Tasman W (2010) Depression despite anti-vascular endothelial growth factor treatment of age-related macular degeneration. Arch Ophthalmol 128(4):506–508CrossRefPubMed
41.
Zurück zum Zitat Sloan FA, Hanrahan BW (2014) The effects of technological advances on outcomes for elderly patients with exudative age-related macular degeneration. JAMA Ophthalmol 132:456–463CrossRefPubMedPubMedCentral Sloan FA, Hanrahan BW (2014) The effects of technological advances on outcomes for elderly patients with exudative age-related macular degeneration. JAMA Ophthalmol 132:456–463CrossRefPubMedPubMedCentral
42.
Zurück zum Zitat Economou M, Angelopoulos E, Peppou LE, Souliotis K, Tzavara C, Kontoangelos K, Madianos M, Stefanis C (2016) Enduring financial crisis in Greece: prevalence and correlates of major depression and suicidality. Soc Psychiatry Psychiatr Epidemiol 51:1015–1024CrossRefPubMed Economou M, Angelopoulos E, Peppou LE, Souliotis K, Tzavara C, Kontoangelos K, Madianos M, Stefanis C (2016) Enduring financial crisis in Greece: prevalence and correlates of major depression and suicidality. Soc Psychiatry Psychiatr Epidemiol 51:1015–1024CrossRefPubMed
43.
Zurück zum Zitat Bertelmann T, Feltgen N, Scheffler M, Hufenbach U, Wiedon A, Wilhelm H, Ziemssen F (2016) Vision-related quality of life in patients receiving intravitreal ranibizumab injections in routine clinical practice: baseline data from the German OCEAN study. Health Qual Life Outcomes 14:132. doi:10.1186/s12955-016-0536-1 CrossRefPubMedPubMedCentral Bertelmann T, Feltgen N, Scheffler M, Hufenbach U, Wiedon A, Wilhelm H, Ziemssen F (2016) Vision-related quality of life in patients receiving intravitreal ranibizumab injections in routine clinical practice: baseline data from the German OCEAN study. Health Qual Life Outcomes 14:132. doi:10.​1186/​s12955-016-0536-1 CrossRefPubMedPubMedCentral
Metadaten
Titel
Treatment satisfaction of patients with neovascular age-related macular degeneration treated with anti-vascular endothelial growth factor agents
verfasst von
Theodoros P. Marakis
Chrysanthi Koutsandrea
Klio I. Chatzistefanou
Yannis Tountas
Publikationsdatum
11.03.2017
Verlag
Springer Netherlands
Erschienen in
International Ophthalmology / Ausgabe 2/2018
Print ISSN: 0165-5701
Elektronische ISSN: 1573-2630
DOI
https://doi.org/10.1007/s10792-017-0492-8

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