Reply to: "Comment on "Quality of life and unmet needs in patients with chronic liver disease: A mixed-method systematic review"".

To the Editor:

We appreciate the comments made by Drs. Valery and Powell with regard to our newly published mixed method systematic review and we thank the Editors for given us the opportunity to respond.

Drs. Valery and Powell note concerns that potentially suitable studies were ignored. However, we remain confident that all relevant studies were included. It is important to notice that we conducted this review according to the Joanna Briggs Institute methodology for mixed method systematic reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with strict criteria for search strategy, selection, and data extraction. These criteria are described in the methods section of the published review. The mentioned studies by Zandi et al. and Valery et al. were not included as we only included quantitative data on quality of life from observational analytical or descriptive studies and not from intervention studies or systematic reviews. The studies by Rakoski et al. and Valery et al. were not included as we only included studies using either generic or liver-specific quality of life questionnaires to explore the quality of life of patients with liver disease. The mentioned study by Bajaj et al. was included in our review’s introduction section to describe the negative impact of liver disease on family and social life, employment, financial status, and maintenance of health insurance.

The aim of our mixed method systematic review was to develop a convergent, integrated synthesis of quantitative and qualitative studies on the perceived quality of life in patients with chronic liver disease. Thus, we did not include data on perceived unmet practical and psychological needs of patients with liver disease. In the review, we presented quantitative data as textual descriptions and assembled it with qualitative data. We categorized the assembled data based on the similarity in their meanings in an attempt to reveal unmet patient needs and to suggest directions to meet these needs and improve quality of life. The review showed a reduced quality of life in our patients – regardless of etiology of the liver disease. This was due to unmet needs for information, support, and perceived stigmatization. This is in accordance with the study of Valery et al., who demonstrated that cirrhosis is associated with significant patient concerns. Our review also suggests changes in patient management to improve quality of life. We suggest: i) providing better education and information, ii) raising awareness of liver disease among the general population to reduce misconceptions and stigmatization, and iii) being more aware of patients’ need for psychosocial support.

We acknowledge that a tool such as the Supportive Needs Assessment Tool for Cirrhosis (SNAC) developed by Valery et al. may be useful to measure type and amount of perceived supportive needs in patients with cirrhosis. This tool could help to ascertain a patient-centered approach in liver disease care, which accommodates patients’ individual experiences and needs, and give patients the necessary skills to manage their disease and everyday life and increase quality of life. However, further studies using this tool are needed.

We again would like to thank Drs. Valery and Powell for their interest in our work.

Financial support

Lea Ladegaard Grønkjær received a grant from the Region of Southern Denmark’s Foundation for Health Research in connection with the development of the mentioned review. The funder played no role in the writing of the review or this response.

Authors’ contribution

Both authors contributed to the conceptualization and writing of this response.

Conflict of interest

The authors do not have any conflicts of interest. Please refer to the accompanying ICMJE disclosure forms for further details.