Validation of "Wound QoL" Hebrew version disease-specific questionnaire for patients with lower extremity ulcerations

Assessing health-related quality of life using the Wound-QoL-17 and the Wound-QoL-14-Results of the cross-sectional European HAQOL study using item response theory

For assessing health-related quality of life in patients with chronic wounds, the Wound-QoL questionnaire has been developed. Two different versions exist: the Wound-QoL-17 and the Wound-QoL-14. For international and cross-cultural comparisons, it is necessary to demonstrate psychometric properties in an international study. Therefore, the aim of this study was to test both questionnaires in a European sample, using item response theory (IRT). Participants were recruited in eight European countries. Item characteristic curves (ICC), item information curves (IIC) and differential item functioning (DIF) were calculated. In both questionnaires, ICCs for most items were well-ordered and sufficiently distinct. For items, in which adjacent response categories were not sufficiently distinct, response options were merged. IICs showed that items on sleep and on pain, on worries as well as on day-to-day and leisure activities had considerably high informational value. In the Wound-QoL-14, the item on social activities showed DIFs regarding the country and age. The same applied for the Wound-QoL-17, in which also the item on stairs showed DIFs regarding age. Our study showed comparable results across both versions of the Wound-QoL. We established a new scoring method, which could be applied in international research projects. For clinical practice, the original scoring can be maintained.

Validation of the Wound-QoL-17 and the Wound-QoL-14 in a European sample of 305 patients with chronic wounds

The Wound-QoL assesses the impact of chronic wounds on patients' health-related quality of life (HRQoL). A 17-item and a shortened 14-item version are available. The Wound-QoL-17 has been validated for multiple languages. For the Wound-QoL-14, psychometric properties beyond internal consistency were lacking. We aimed to validate both Wound-QoL versions for international samples representing a broad range of European countries, including countries for which validation data had yet been pending. Patients with chronic wounds of any aetiology or location were recruited in Austria, Lithuania, the Netherlands, Poland, Slovakia, Spain, Switzerland and Ukraine. Psychometric properties were determined for both Wound-QoL versions for the overall sample and, if feasible, country-wise. We included 305 patients (age 68.5 years; 52.8% males). Internal consistency was high in both Wound-QoL-17 (Cronbach's α: 0.820-0.933) and Wound-QoL-14 (0.779-0.925). Test-retest reliability was moderate to good (intraclass correlation coefficient: 0.618-0.808). For Wound-QoL-17 and Wound-QoL-14, convergent validity analyses showed highest correlations with global HRQoL rating (r = 0.765; r = 0.751) and DLQI total score (r = 0.684; r = 0.681). Regarding clinical data, correlations were largest with odour (r = -0.371; r = -0.388) and wound size (r = 0.381; r = 0.383). Country-wise results were similar. Both Wound-QoL versions are valid to assess HRQoL of patients with chronic wounds. Due to its psychometric properties and brevity, the Wound-QoL-14 might be preferrable in clinical practice where time is rare. The availability of various language versions allows for the use of this questionnaire in international studies and in clinical practice when foreign language patients are being treated.

Patient-Reported Outcome Measures of Quality of Life in People Affected by Diabetic Foot: A Psychometric Systematic Review

OBJECTIVES

This psychometric systematic review aimed to identify the most suitable patient-reported outcome measures (PROMs) of quality of life (QoL) in people affected by diabetic foot.

METHODS

We performed a literature search in MEDLINE (PubMed), CINAHL (EBSCOhost), and PsycINFO (EBSCOhost) databases from inception to February 1, 2022. We also searched gray literature databases. Eligible studies were full-text reports developing a QoL condition-specific PROM or assessing one or more of its measurement properties in people affected by diabetic foot. We assessed the methodological quality of included studies independently using the "Consensus-Based Standards for the Selection of Health Measurement Instruments Risk of Bias" checklist. The measurement properties were evaluated using specific criteria. We graded the quality of the evidence using a "Grading of Recommendations Assessment, Development and Evaluation" approach modified by Consensus-Based Standards for the Selection of Health Measurement Instruments.

RESULTS

Forty-three reports (46 studies) providing information on the measurement properties of 10 different PROMs were included. We did not identify any instruments that could be recommended for use. We identified 2 PROMs that were not recommended for use and 8 that were potentially recommended but would require further investigation. Of these 8 PROMs, 4 had better evidence for content validity.

CONCLUSIONS

Available PROMs to measure QoL in people affected by diabetic foot have limited evidence for their measurement properties. There is no fully suitable PROM. Pending further evidence, 4 PROMs could potentially be recommended for use.

Translation and validation of 17-item Wound-QoL questionnaire in a Chinese population

We aimed to translate the 17-item questionnaire to measure the quality of life of patients with chronic wounds (Wound-QoL-17) and verify its reliability and validity in the Chinese population. The standard Chinese version of the Wound-QoL-17 was determined through translation, back translation, and cultural adaptation. A total of 121 patients with chronic wounds from the wound center of a tertiary hospital in Beijing were recruited. Through a questionnaire and physical examination, we tested the criterion-related validity, known group validity, structural validity, internal consistency coefficient (Cronbach's alpha), and test-retest correlation. A new structure of four factors was extracted by exploratory factor analysis, and the cumulative contribution rate was 72.23%. The total score and that of the four factors, which were significantly correlated with the EuroQol Five Dimensions Questionnaire (EQ-5D) and the Short Form-36 Health Survey (SF-36) (P < 0.05), also showed statistically significant differences between patients with different pain grades, with or without wound odour, and between different groups of patients reporting wound changes in the past 2 weeks. Cronbach's alpha was between 0.779 and 0.906, while the test-retest reliability was between 0.532 and 0.802. We concluded that the Chinese Wound-QoL-17 has good reliability and validity and is suitable for evaluating the quality of life of patients with chronic wounds.

Clinical evaluation of UrgoStart Plus dressings in real-life conditions: results of a prospective multicentre study on 961 patients

AIMS

This study aimed to evaluate the performances of lipid colloid technology with nano-oligosaccharide factor (TLC-NOSF) dressings with polyabsorbent fibres in an unselected population of patients under real-life conditions.

METHODS

A large, prospective, multicentre, observational study with three polyabsorbent TLC-NOSF dressings (UrgoStart Plus Pad, UrgoStart Plus and UrgoStart Plus Border, Laboratoires Urgo, France) was conducted in Germany between January 2019 and June 2020. Main outcomes included wound healing rate, clinical assessment of wound healing progression, local tolerance and acceptance of dressings, and changes in health-related quality of life (HRQoL) of the patients, assessed with the validated Wound-QoL questionnaire.

RESULTS

A total of 961 patients with wounds of various aetiologies (leg ulcers (LU), diabetic foot ulcers (DFU), pressure ulcers (PU) and other types of wounds) were treated with the evaluated dressings in 105 centres for a mean duration of 62 days (standard deviation 37 days). By the last visit, a wound closure or an improvement in wound healing was reported in 92.0% of the treated wounds. The highest wound closure rates were achieved when the dressings were used as first-line treatment: 71.3% in DFUs, 52.9% in LUs, 53.6% in PUs and 61.8% in the other wounds. Improvement of the wound healing process was also associated with an 87.5% relative reduction of sloughy tissue, a decrease of the level of exudate in 68.9% of the wounds, and an improvement in the periwound skin condition in 66.4% of the patients at the final visit. The dressings were 'very well' or 'well' tolerated and 'very well' or 'well' accepted by the large majority of patients. The HRQoL questionnaires were completed both at initial and final visits by 337 patients, representative of the total cohort. Despite the relatively short duration of the wounds, the HRQoL of the patients was already impaired at baseline, with 81.6% of the patients being severely affected in at least one aspect of their HRQoL. By the final visit, significant improvements in each dimension of the patients' HRQoL were reported (p<0.001), along with a reduction of the proportion of patients in need of intervention and in the number of actions needed per patient in relation to their HRQoL.

CONCLUSIONS

These results are consistent with previous clinical evidence on TLC-NOSF dressings. They confirm the good healing properties and safety profile of these dressings, and that a significant improvement in patient HRQoL is achieved in non-selected patients treated in real-life practice. These data support the use of such dressings as a first-line intervention and until wound healing in the management of chronic wounds, in association with appropriate standard of care.

Telemedicine versus face-to-face care for treatment of patients with lower extremity ulcers

OBJECTIVE

Lower extremity ulcers (LEUs) are associated with a decline in patients' quality of life (QoL). Better healthcare availability in remote regions, facilitated by telemedicine (TM), may improve patient wellbeing. The aim of this study was to compare the QoL of patients treated via synchronous video TM with that of patients treated with standard face-to-face (FTF) care.

METHOD

The study was performed in a large health services provider in Israel (Maccabi Healthcare Services). TM was used in four remote locations; the FTF method was applied in two regional clinics. The treatment protocol was performed by a nurse and supervised by the regional physician in both treatment modes. A validated Wound-QoL questionnaire in Hebrew was used to assess patient outcomes.

RESULTS

A total of 83 patients were treated via TM and 94 patients were treated FTF. The mean QoL for patients treated via TM was 0.546±0.249 compared with 0.507±0.238 for the FTF group. A similarity relating to outcomes in both treatment methods was demonstrated by a difference of 0.039 (95% confidence interval -0.33-0.111) and p=0.291. The probability of the difference being within the limits of the interval in a replicated study was 83.4%. The equivalence/non-inferiority was established within the accepted Δ=0.12 range.

CONCLUSION

The results indicated no reduced QoL for patients with LEUs treated with telemedicine versus with standard FTF care.

DECLARATION OF INTEREST

The authors have no conflicts of interest.

The Danish wound-quality of life (Wound-QoL) questionnaire: Translation and psychometric properties

Hard to heal (HTH) wounds often result in a prolonged and painful healing process that affects different dimensions of patients' quality of life. Currently, there is no Danish patient-reported instrument to help professionals and patients identify and measure these different aspects of quality of life. Wound-quality of life (Wound-QoL) is a German 17-item questionnaire measuring dimensions of wound-specific quality of life. The aim was to translate and cross-culturally adapt the Wound-QoL into Danish and to evaluate its psychometric properties. Translation was conducted in accordance with international guidelines. Validity, reliability and responsiveness were evaluated in accordance with the COSMIN guideline. The Wound-QoL was successfully translated to Danish and content validity showed to be very good in a Danish context. A total of 172 patients with HTH wounds were included in the study and all participants completed the Wound-QoL. Out of these, respectively 54 and 155 patients were included in the analyses of test-retest reliability and responsiveness. Correlations for construct validity (EQ-5D-5L vs. Wound-QoL) ranged between 0.64 and 0.73. Cronbach's alpha values for internal consistency ranged between 0.77 and 0.92. Intra-class-correlation coefficients for test-rest reliability ranged between 0.73 and 0.88. Smallest detectable change scores at individual and group level ranged from 0.77 to 1.26 and 0.10 to 0.17, respectively. Minimal important change scores ranged from 1.20 to 1.33. Results of the responsiveness analyses showed sensitivity and specificity values between 56.1 to 62.2 and 57.7 to 63.2, respectively. In conclusion, the Danish Wound-QoL is a valid and reliable patient-reported outcome measure for assessing aspects of health-related quality of life in patients with hard ho heal wounds. However, the Wound-QoL demonstrated limited ability to discriminate between patients with clinically relevant improvements and patients that showed no changes. Thus, the responsiveness of the Wound-QoL should be taken into consideration if to be used as treatment effect measure.

Assessing the quality of life of people with chronic wounds by using the cross-culturally valid and revised Wound-QoL questionnaire

The Wound-QoL is an often used reliable and valid measure, originally developed in Germany. It has been sequentially translated and validated for other languages/countries, for the measurement of health-related quality of life (HRQoL) in patients with chronic wounds. However, a study from the United States postulated its benefits from further adaptations. Furthermore, some patients struggled to provide an answer for some of the items. We aimed to test the cross-cultural structure and psychometric performance of the questionnaire to suggest necessary revisions. This cross-sectional analysis of existing data sets included 1185 patients from Germany, the US, the Netherlands, Spain, Sweden, and Israel. Patients in the U.S. Wound Registry completed the Wound-QoL during routine care. Different studies comprised the data collection in the other countries. Almost half of the patients were women (48.4%). Furthermore, 42.6% were diagnosed with leg ulcers. Their average age was 66 years. We used a confirmatory factor analysis and an unconstrained graded response model. We revised and shortened the Wound-QoL from 17 to 14 items. In addition, we supported the cross-cultural metric invariance of the revised Wound-QoL questionnaire. The new version with 14 items and three dimensions revealed good psychometric properties with Cronbach's alpha (α) of 0.913 for the total score, and 0.709-0.907 for different dimensions. Furthermore, we provided strict invariance for different clinical variables. In conclusion, the revised Wound-QoL is a reliable and cross-cultural instrument to measure the HRQoL on patients with chronic wounds. Future studies should analyse the revised Wound-QoL for convergent validity with generic HRQoL questionnaires as well as for determining its sensitivity to clinical change.

Association of wound genesis on varying aspects of health-related quality of life in patients with different types of chronic wounds: Results of a cross-sectional multicentre study

Patients with chronic wounds are significantly impaired in their health‐related quality of life (HRQoL). The validated Wound‐QoL questionnaire allows assessing the impact of chronic wounds on different aspects of HRQoL including physical, psychological, and everyday life‐related impairments. The aim of our study was to investigate associations of these HRQoL dimensions with age, sex, and particularly wound genesis. In this retrospective, cross‐sectional, multicentre study, Wound‐QoL questionnaires from clinical routine of patients with venous leg ulcers, arterial leg ulcers, mixed leg ulcers, and diabetic foot ulcers (DFU) were evaluated. Effects of wound genesis, sex, and age were assessed with analysis of variance as well as correlation and multiple linear regression analyses. The completed questionnaires of 381 patients (f = 152/m = 229; mean age 68.9) were included. The wound genesis groups showed significantly different distributions of age and sex. We also found significant differences between those groups in everyday life‐related QoL, with the greatest impairments in patients with DFU. Physical QoL scores showed significant differences between men and women depending on diagnosis group: in patients with venous leg ulcers, women had greater impairment of physical QoL than men. Independent of the underlying diagnosis, women had significantly higher scores in the psychological subscale as well as in the Wound‐QoL sum scale. Within the subgroup of arterial leg ulcer patients, overall HRQoL sum score was significantly worse in older patients. Regression analyses supported negative effects of DFU diagnosis and female sex on HRQoL. Our data offer evidence that HRQoL shows clinically relevant differences between patients with chronic wounds of different genesis. Moreover, our data revealed that HRQoL is associated with age and sex, which should be considered when treating the patient groups. In order to be able to capture these important aspects and to offer individualised and patient‐oriented treatments, the Wound‐QoL should be implemented as a quick and uncomplicated standard instrument in daily routine. Patients with chronic wounds are significantly impaired in their health‐related quality of life. Validated Wound‐QoL questionnaire is a quick and easy‐to‐use instrument for daily practice. Wound‐related quality of life shows clinically relevant differences between patients with chronic wounds of different genesis. Wound‐related quality of life is associated with age and sex, which should be considered when treating these patient groups. Health‐related quality of life should be regularly objectified in all patients with chronic wounds with a validated measuring instrument.

Determining the Minimal Important Difference for the Wound-QoL Questionnaire

BACKGROUND

The questionnaire for the quality of life with chronic wounds (Wound-QoL) is a valid and reliable instrument to determine the disease-specific health-related QoL of patients with chronic wounds. For the interpretation of HRQoL scores, it is additionally important to know which differences in scores are considered meaningful. The minimal important difference (MID) is defined as a change in HRQoL that a patient would consider meaningful, such that the patient would judge a treatment to be beneficial and worthy of repeating.

OBJECTIVE

To interpret changes in the Wound-QoL scores and draw conclusions regarding the relevance of detected changes; the purpose of this study was to estimate the MID of the Wound-QoL global score and its subscales for patients with chronic wounds.

PATIENTS AND METHODS

Patients completed the Wound-QoL before and four to six weeks after treatment and additionally gave a global rating of wound status change after treatment. The global rating of change served as an anchor question. MIDs were calculated based on an anchor-based and a distribution-based method.

RESULTS

In total, 227 patients participated in the study. The mean age of the study population was 66.9 (± 12.7) median was 69.5, and 51.5% of the patients were female. MIDs for the Wound-QoL global score ranged from 0.47 to 0.52, proposing an overall estimation of 0.50.

CONCLUSION

The results can be used to measure and interpret changes in wound-specific QoL over time.

Validation of "Wound QoL" Hebrew version disease-specific questionnaire for patients with lower extremity ulcerations

The slow healing process and high recurrence rate of lower extremity ulcerations (LEU) impose a considerable medical and economic burden and affect quality of life (QoL). Analyses of LEU-related QoL in Israel are limited due to lack of a validated Hebrew disease-specific evaluation instrument. The aim of this study was to validate the disease-specific Hebrew "Wound QoL" questionnaire. The validation of the "Wound QoL" disease-specific instrument, translated from English to Hebrew, was based on a comparison with the valid Hebrew version of the SF12v.2 health-related questionnaire. The convenience sample for the "Wound QoL" validation (n = 32) was obtained from patient populations in the Maccabi Health Services' outpatient clinics at the northern and southern parts of Israel. The study was conducted between June and September 2017. Face/construct validity was accepted by specialists' consensus. Internal consistency assessed by Cronbach's α was .893. Concurrent validity reflected by Pearson's correlations between the tools was in the range of 0.830 to 0.950. The Wound QoL Hebrew version is a valid and reliable instrument suitable for implementation in an Israeli cultural environment.