In this study, we explored the HRQOL of patients with AA by utilizing LPA to investigate the heterogeneity of their HRQOL and identify the factors contributing to the various latent groups. To our knowledge, this is the first study to use LPA to explore the heterogeneity of HRQOL among AA patients. Our study revealed significant individual differences of HRQOL among AA patients, who were classified into three groups: the poor HRQOL with RE limitation, the moderate HRQOL with RP limitation, and the good HRQOL subgroups, respectively. These characteristics used to define these groups were similar to those utilized by Lidia et al. to define the potential categories for exploring HRQOL among older age groups through LPA[31]. The HRQOL for the three groups, as determined by LPA, showed statistically significant, which indicated that the categorization results were reasonable to some extent. Our findings confirmed that household annual income, have children or not, comorbidities, transfusion-dependence and AA-related symptoms were all significant factors associated with the identified HRQOL groups.
Group 1, which had members of all the diagnostic groupings, was the smallest group (23.58%). Focusing on each subscale of the SF-36 v2, Group 1 had the lowest RP and RE scores. Moreover, the RE subscale scores exhibited the greatest discrepancy with those of Group 2 and Group 3, indicating a polarized state. This implies that compared to PF, MH might be the primary factor influencing the lowest level of HRQOL for individuals with AA. AA patients experience psychological symptoms that impede their ability to engage in work and daily activities, potentially leading to reduced treatment adherence, poorer prognosis and lower HRQOL. Martin et al.[32] emphasized the unique impacts of both physical and mental illnesses on mortality and disability, argued that the lack of MH is equivalent to the absence of PF. Thus, it is imperative for medical staff in clinical practice to focus not only on physical symptoms of AA patients but also their psychological problems, and to provide tailored interventions to patients in need of help.
The composition of Group 2 was very interesting. Despite displaying a positive psychological state, these patients still encountered notable limitation in RP, such as limited mobility and decreased independence, due to physical health issues. Compared with those in the other two groups, more than 50% of the patients in Group 2 exhibited a higher prevalence of comorbidities, transfusion-dependence, and had the shortest time since diagnosis. Notably, RP was strongly correlated with RE in AA patients in this study. Thus, it may be necessary for health professional to tailor individualized interventions for patients in this group in order to decrease the probability of progression to Group 1. Julius et al.[33], stated that PF can influence MH through lifestyle choices and social capital. In clinical practice, healthcare professional can enhance patients' health through health investments (such as health education) and social interactions (such as patients’ families participate in decision-making). Furthermore, the composition of Group 2 highlighted the advantages of using LPA to analyze HRQOL, and identifying AA patients with this specific level of HRQOL solely based on the characteristics of the SF-36 v2 can pose a significant challenge.
Group 3 was characterized by high levels of HRQOL, even exceeding the average HRQOL level of the general population (matched for age and sex[27]). Patients within this group demonstrated the highest scores across all subscales of the SF-36 v2 scale (Fig. 2). Moreover, Group 3 also have the most members of patients (51.97%), encompassing individuals from various diagnostic group, underscoring the prognostic significance of HRQOL for a substantial portion of AA patients. Response shift has been extensively documented in HRQOL researches[34, 35], indicating that the experience of a condition such as cancer can alter survivors’ perceptions of their HRQOL[19]. AA patients who possess a redefined perception of HRQOL and adjusted expectations during the period from diagnosis to treatment may demonstrated unexpectedly elevated levels of HRQOL in this study. Furthermore, these patients exhibited favorable prognosis following prompt initiation of treatment, which may also explain the high proportion of patients in this group.
Previous studies[36, 37] have validated the clinical significance of the ECOG-PS score, indicating an association between a worse prognosis and higher scores, which was consistent with the findings of this study. Patients with higher ECOG-PS scores were more likely to be classified into the "poor HRQOL with RE limitation" group. This relationship can be attributed to the decline in physical condition, activity endurance, and overall PF associated as the ECOG-PS scores increased, which heightens the likelihood of experiencing severe somatic symptoms. On the other hand, the ECOG-PS can also indirectly impact the HRQOL of patients by affecting negative emotions[38]. The deterioration in physical health may lead to changes in patients’ original life status and negative emotions due to unfulfilled social roles, ultimately leading to a diminished HRQOL[33]. Due to its 5-level scale, the ECOG-PS score is simple and allows medical staff to evaluate a patient's physical status quickly[39]. It could be an effective tool for assessing and examining a patient's HRQOL in clinical practice.
Consistent with previous studies, AA patients with higher annual household incomes tend to report higher levels of HRQOL[40–42]. However, our study diverges from prior studies by demonstrating that AA patients without children exhibited a higher HRQOL[43, 44]. This discrepancy may be attributed to the reduced financial burden of patients free of child-rearing expenses. AA patients without financial pressure could receive a standardized treatment and free of negative emotions, resulting in greater HRQOL. Nevertheless, a study by Hurmuz et al.[43] indicated that intimate interpersonal relationships can provide emotional support, maintain and enhance patients' physiological functioning, and increase motivation for recovery. Thus, medical staff should prioritize the evaluation of AA patients’ financial capacity, promptly identify patients facing financial difficulties and increase the reasonable utilization of healthcare. Moreover, medical staff should encourage patients’ families to participate in patient care as much as possible to ensure that patients receive more positive social support[45].
Our study findings revealed that the likelihood of transfusion-independent patients being attributed to "good HRQOL" group was 3.174 times greater than that of patients being attributed to “poor HRQOL with RE limitation” group. Vaht et al.[8] discovered that the lifespan of AA patients with transfusion dependence was considerably shorter than that of those without. Frequent blood transfusions during treatment may result in complications such as transfusion-related infections, iron overload, and inefficient transfusions, which can significantly impact the survival and HRQOL of these patients[46, 47]. Clinical staff should pay close attention to the HRQOL of AA patients who are transfusion-dependent. Furthermore, AA patients who are transfusion-dependent tend to have more severe disease and experience more clinical symptoms than those who are not[48]. The results of our study indicated that patients with AA-related symptoms were more likely to be in the "poor HRQOL with RE limitation" group. AA patients with clinical symptoms tend to be more concerned and excessively worried about any changes in their bodies[14], potentially exacerbating disease burden, resulting in poor HRQOL. Thus, health education should be improved in order to enhance patients’ awareness of disease understanding and provide tailor interventions for AA-related symptoms to prevent and minimize complications, alleviate disease burden, and improve patients’ HRQOL.
Limitations
Our study was designed initially as cross-sectional, preventing the determination of changes in HRQOL groups for AA patients over time and whether the predictors of their group status had changed. Second, the participants in our study were all recruited from a single hospital, which may restrict the generalizability of the results. Multicentre, large-sample studies are needed to further validate the present results. Last but not least, in our study, we only explored the effects of sociodemographic and disease factors on different groups of HRQOL in AA patients. However, other significant factors, such as social support and psychological resilience, weren’t evaluated in this study and warrant further investigation.