A scoping review has been done. The JBI scoping review methodological approach was used in the execution of this scoping review.20 The academic literature recognizes the JBI scoping review guideline for its rigor, transparency, and reliability.21 A protocol was established by the review team to clarify the review question, goals and eligibility requirements.

The primary review question for this study is: What quality of life assessment instruments are used in relation to patients who have a PIVC, MC and PICC vascular access devices? The PCC framework20 (P = population, C = concept and C = context) was used to carry out this review.

The search strategy was designed to identify both published and unpublished studies. An initial search was conducted to identify relevant articles, which assisted identifying the keywords used within the search strategy alongside the content knowledge of the review team. The databases searched included CINAHL, Embase, Cochrane, Scopus and the ProQuest database was searched for theses and dissertations. The search strategy developed, using free-text keywords and index terms, was adapted for each database. The search strategies used are described in Appendix I. Each search was conducted in December 2023.

Once the search was completed in each database all identified sources were collated into EndNote® reference manager22 and the duplicates were removed. The remaining sources were then exported from Endnote into Rayyan cloud-based software application tailored for researchers conducting systematic literature reviews and meta-analyses for screening.23 The screening process was carried out in two stages. For the first stage of the process, the review team (OH, CD, VA, SL, PC, SU) independently screened the title and abstract of each source for inclusion into the review. We screened the full text of the remaining sources for eligibility. The study selection process alongside rationales for sources excluded at the full text screening stage are presented in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.24 Any disagreements between reviewers in the screening stage was resolved via discussion or by other reviewers.

Data from the included studies was extracted by four independent reviewers. A data extraction developed by the reviewers was used. The tool was piloted by four reviewers (OH, CD, VA, SL) initially on one study each to ensure consistency with the extraction. Any disagreements between reviewers in the screening stage were resolved via discussion or by other reviewers (PC, SU). Data extraction was an iterative process, and as the writers gained greater familiarity with the sources and underlying relational principles, they made modifications to the data-extraction form. Extracted data included geographical location, methodology, type of vascular access device studied, the QoL instrument used, aim and main findings.

Quality appraisal is not expected in Scoping reviews, however, results were analysed and then reported using the PAGER framework principles.25 The JBI rules for reporting scoping reviews are supplemented by the PAGER framework, which contains five domains: Patterns, Advances, Gaps, Evidence for practice, and Research recommendations.

PICCs were the primary focus in seven studies. All remaining studies included more than one device, PIVC and totally implantable venous access device (TIVAD) (n = 3), PICC, TIVAD and non-tunnelled catheter (NTC) (n = 1), PICC and MC (and short midline) (n = 2), PICC and TIVAD (n = 4), PICC and tunnelled central catheter (TCC) (n = 1), TIVAD including arm location and PICC (n = 1). Of the 21 included studies, eight papers used the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Three of these eight studies employed an additional, independently developed, device-specific questionnaire. The Short Form Health Survey (SF-36) was used by three studies led by researcher from China. Two studies used the Karnofsky scale. Other studies used the Functional Living Index-Cancer (FLI-C) questionnaire,26 the Palliative Care Outcome Scale27 and the FACT-B questionnaire,28 specifically designed for breast-cancer patients. Two papers failed to clearly define a specific scale, one retrospective study described a scoring system measuring psychological function, physical function, social function and self-evaluation29 whereas a three-round expert inquiry was used to modify a questionnaire in an observational study by Fang et al.30 The main characteristics of the instruments used in the included studies are shown in Appendix II.

Of the 19 primary papers, specifically focusing on the VADs the use of ultrasound in the insertion of at least some of the devices was noted in seven papers. In relation to device insertion, nine studies did not refer to who inserted the devices of interest. The remaining papers referred to the following professional disciplines as inserters, nurses (n = 5), physicians, (n = 2), interventional radiologist (n = 1), interventional radiologist and nurse (n = 1) and vascular access device team (n = 1).

An inconsistency in the timeline that quality of life was assessed in the 17 studies was found26–28,30–43 while two studies did not mention when data about quality of life was collected.29,44 Baseline data measurement, was performed before catheter insertion in 5 studies.28,32,36,38,42 In two studies this was reported at the time of insertion.31,40 Some studies established this time of QoL measurement occurring at the first chemotherapy cycle.26,33

With regard to post insertion follow up assessment, most of the studies report this occurring after 3 mo of catheter insertion and in 4 cases after 6 mo.31,34,35,38 Longer periods were considered 7, 9 and 12 mo.31,37 In one study shorter periods were considered 3, 7 and 14 days27 while Kang et al. reported a median time of 27 days.40 One study that reported catheter removal was included in a list of QoL measures.30 Numerous factors, including age, gender, co-morbidities, and setting, were gathered in the various studies. These are presented in Table 2 together with the specific QOL evaluation scale used.

The current state of research on QoL studies reveals a predominant focus on cancer patients. Of the 19 primary studies included in this review 17 studies referred to cancer patients, the remaining 2 studies included palliative care patients. However, the two palliative care studies included cancer patients in their population group. Considering VADs are integral to delivering intravenous chemotherapy45 it is not surprising that most studies included cancer cohorts. While this emphasis has yielded valuable insights, there exists a notable gap in the exploration of QoL in patients with conditions other than cancer. The evidence underscores the importance of evaluating QoL in all patients with VADs irrespective of their specific medical condition. To enhance the breadth of knowledge, future research needs to investigate QoL in individuals with common pathologies or those requiring longer-term treatment. A limitation of this study is that we did not include patients requiring VADs for haemodialysis and from screening identified sources we did note a large number of papers on this patient group. However, there are other patients’ conditions which have not been explored. One example may be patients who are receiving outpatient parenteral antimicrobial therapy (OPAT), where at minimum patients receive two doses of parenteral antimicrobial therapy on different days without requiring hospitalisation.46,47 We identified one study which measure health-related quality of life of patients on OPAT however this study did not appear to refer to the patients VAD.48 It is important that we evaluate the quality of life in all patients with PIVC, MC and PICC regardless of clinical condition and to elaborate on the VAD type used. Therefore, future research studies are required to evaluate the quality of life of all patients who require PIVC, MC and PICC for their medical treatments. This inclusive approach aims to contribute to a more comprehensive understanding of the impact of these VAD types on the quality of life across diverse patient populations.

The only vascular access device type that was independently evaluated was PICCs (n = 7).28,31,36,38,40,42,49 Different therapies were assessed in connection to PICC and QoL, including Tai Chi36 and cognitive behavioural therapy.42 In an observational study30 and a network meta-analysis,50 several VADs, including PICCs, TIVAD, and NTCs, were examined. Both studies indicated that the TIVAD group had a greater QoL.

The majority of studies comparing the quality of life in PICC versus TIVAD (n = 5) found that the PICC group’s score was significantly lower than the TIVAD group.29,33,37,43 However, one observational study using the EORTC QLQ-C30 tool that included patients with breast and colonic carcinoma found no differences in QOL.34

Regarding PICC versus MC (n = 2), both studies27,32 described a notable increase in the patients’ overall QoL. One prospective observational study39 examined QoL in connection to PICC and TCC in 50 patients. It was shown that there were little statistically significant differences in quality-of-life issues between the patient groups with PICCs and TCCs using a specially designed questionnaire.39

When compared to PIVC, TIVAD significantly enhanced patient-reported quality-of-life benefits in patients receiving chemotherapy for solid tissue malignancies, according to one RCT involving 120 patients undergoing the treatment.35 This contrasts with research comparing quality of life of 130 patients with colorectal cancer based on the device choice (between TIVAD and PIVC), which found no differences in quality of life except from social function.44 An RCT examined the benefits and drawbacks of implanting a TIVAD rather than a PIVC in patients at the start of a chemotherapy regimen to prevent potential peripheral venous access issues.26 Interestingly, in this study there was no discernible difference between TIVAD and PIVC in terms of functional quality of life.

Of the 21 papers included, two were systematic reviews. In one study, out of the fifteen papers included in the study by Robinson et al. on the best vascular access devices for early-stage breast cancer, only three papers (one of which included PIVC) addressed quality of life.41 In one non-randomized comparative study of patients with breast cancer, Singh et al.51 reported chemotherapy administered via PIVC to be acceptable but linked with worse satisfaction in patients receiving more than six treatment cycles as compared to chemotherapy via TIVADs. In the other systematic review and network meta-analysis by Yeow et al.50 QoL was reported in 7 studies. Of these 7 studies, 4 papers included PICC. 3 papers investigated PICC vs PORT33,52,53 and one compared PICC with TIVAD and Hickman.54

Papers with MC devices were not included in the synthesised reviews however, if QoL is an outcome of interest in vascular access research more research is needed on these devices so that they can be included in future synthesis. This review revealed that the term “quality of life” is not used in many studies; instead, it is represented by patient satisfaction or experience. Additionally, some papers do not mention the VAD type even though the patients surveyed required one for therapy, for example oncology care or OPAT. Therefore, to ensure a more thorough synthesis there is a need for standardisation of terminology. Given the number of RCT data located, meta-analysis is justified, however, we suggest first to develop for more evidence on QoL instruments for PIVCs and MCs.

Advancements in standardizing instruments for assessing QoL involve the use of established instruments such as the EORTC QLQ-C30 and EQ-5D across various studies.31–35,40,44,50 Standardized instruments serve as a common nomenclature for QoL assessment, aiding healthcare providers with evidence-based decision-making and outcome comparison across diverse patient populations.55 This contributes to a stronger evidence base for comprehending VADs’ impact on QoL. Ongoing efforts are crucial to promoting the consistent use of recognized QoL assessment instruments in studies. Such approaches can facilitate better comparison and synthesis of findings as standardization enhances comparability between studies, fostering a more comprehensive understanding of patient-reported outcomes.56 However, gaps persist due to non-validated use of QoL assessment instruments. This hinders future evidence synthesis and conclusions, as we found no consensus on the optimal tool for specific QoL aspects in the context of VADs we included.30,33,34,39,43,50

Future research avenues should explore the development of tailored instruments for specific patient populations or treatment contexts, maintaining cross-study comparability.57 Additionally, there is a need for instruments assessing the influence of new VADs, for example PICC and PORT, on patients’ QoL, distinguishing its impact from the underlying disease. Such instruments may include considerations of body image change, specific care requirements, and concerns about potential complications beyond those inherent to the pathology.58 To further enrich the research landscape, exploring the feasibility of using modifications or adaptations of existing questionnaires could be particularly interesting.

In general, most authors acknowledge the importance of identifying the appropriate moment to measure the quality of life when a catheter is inserted but there is not a consensus related to the most appropriate moment to measure quality of life.

Baseline measurement is necessary in order to know the starting point of the patient who requires intravenous vascular access, before the patient becomes familiar with the catheter, and to measure any changes. It was recognised that it should be close to the moment of insertion31,40 or before the procedure.28,32,36,38,42 However, in some studies this measure was not collected.29,44

Changes in the quality of life may not happen as soon as some authors suggest in their publications (3 days, 14 days). Considering this, there is a need to establish an agreed period to assess the impact of the vascular device in the daily life. Apparently, doing the first measurement three months after inserting the device during the follow-up period could be a reasonable option. However, this may not be enough to collect comprehensive data.

We found no consensus on the timing of measurements beyond three months, as after six to nine months catheter removal could occur and not enough information could be obtained to make longer-term estimates.

If improvement is to occur, an appropriate strategy needs to be defined to identify the correct moment to measure the impact of the VAD type in patients’ quality of life. Specifically, the correct moment to collect baseline measurement and the subsequent moments during follow up period. In addition, it is highly recommended to recognize, anticipate and reduce potential biases that may arise if these measurements are carried out at the same time as the chemotherapy is administered or if it may be affected by patients’ other conditions (patients’ hospital admissions, side effects of treatment, patient's clinical conditions, etc.).

It is essential to consider the extent to which the effects of chemotherapy may affect QoL when measuring the impact of vascular access on quality of life. Hilarius et al. studied chemotherapy-induced nausea and vomiting and found that the prevalence of both was twice as high one week after chemotherapy administration59 and this supports the evaluation of QoL after infusion regimen.

Although there are studies evaluating the QoL of patients with vascular access, those using validated instruments are scarce. The instruments we have identified in this review are not designed to measure the impact of the device, but rather to measure QoL at a general level with different dimensions and include general aspects for example physical activity, emotional, general well-being, and pain.

In fact, some of the instruments used are generic; they measure QoL in a wide variety of situations, but do not specifically measure aspects relevant to cancer patients. In this study the EuroQol 5-dimensions 5-level (EQ 5D-5L), Medical Outcomes Study 36-Item Short Form (SF-36) have been identified. In contrast, cancer-specific instruments such as the EORTC Core Quality of Life Questionnaire (EORTC QLQ-C30) and Functional Living Index (FLIC) designed for cancer patients in general have also been identified. Using the EORTC QLQ-C30 and adding a supplement, the EORTC QLQ-C15-PAL and the EORTC QLQ-LC13 are specifically designed for use in patients with advanced, incurable, and symptomatic cancer with a median life expectancy of a few months and lung cancer respectively have been used. In addition, an adaptation of another generic questionnaire (FACT-C) for cancer patients with a specific supplement for breast cancer patients (FACT-B) has been used. All these questionnaires report a good level of validity and reliability. On the other hand, there seems to be an interest in the research community in studying the impact of vascular access, as seen in studies that have used ad-hoc designed instruments. However, the instruments need to be further developed and validated as they lack validity and reliability, suggesting VAD related QoL is needed for patients with cancer.

Apart from ad-hoc designed instruments, none of the questionnaires focuses on the impact of vascular access on these patients, so it is not possible to compare which devices have a lower impact on their quality of life. This could be a relevant factor to consider when selecting the most appropriate device for each patient, but this requires validated instruments and studies that compare quality of life with different devices and in different types of patients. Patients’ cohorts could include those with cancer or those needing OPAT.

One of the limitations of this study is that authors often use instruments that assess satisfaction, acceptability or performance to measure the QoL of patients with vascular access. For example, the Karnofsky scale measuring the ability perform ordinary tasks is used as an instrument to measure quality of life. As an implication for future research, the aim of the studies needs to be properly defined and the tool to be used needs to be selected accordingly.

This scoping review identified few QoL studies on three of the most common VADs in use in healthcare. Future instruments for QoL for PIVC, MC and PICC are required and should include patient and public contributions with the variety of healthcare and industry professionals included in any membership.

As the evidence base for vascular access continues to evolve, we suggest this should happen along with patient outcomes influencing best healthcare practice. If this is to be realised we suggest future research should prioritise the impact of VADs on QoL. We recommend the use of validated methodological guidance is required to develop a QoL instrument for PIVC, MC and PICC prior to external validation and implementation amongst different populations and treatment regimes.