International mixed methods study protocol to develop a patient-reported outcome measure for all types of chronic wounds (the WOUND-Q)

The WOUND-Q Function and Symptoms Scales for Chronic Lower Extremity Wounds: A Validation Study

Objective: Determine the validity and reliability of the LIMB-Q scales, Function, and Symptoms in patients with chronic lower extremity wounds. Approach: Cognitive debriefing interviews with people with current or previous wounds were conducted to examine content validity. Scales were field-tested in an international sample of people with chronic lower extremity wounds sourced from an online platform (i.e., Prolific). Psychometric properties were examined using the Rasch Measurement Theory analysis. A test-retest reproducibility study was performed, and construct validity was examined. Results: Content validity was established after 10 cognitive interviews. A total of 233 people with lower extremity wounds (age 19-80 years, mean 39.3) participated in the field test. All 25 items tested demonstrated good fit to the Rasch model with ordered thresholds. One item had a fit residual outside ±2.5, but no items had significant χ2 values after Bonferroni adjustment. Reliability was high with the person separation index, Cronbach alpha, and intraclass correlation coefficient values >0.8. Strong correlations were found between the Function and Symptoms scales and EQ-5D dimensions measuring similar constructs as well as the EQ-5D global score. All hypotheses for construct validity were confirmed. Innovation: Patient-reported outcome measures are an important component of patient-centered care, as they capture the patient's perspective in a rigorous and reproducible way. Adding these two scales to the WOUND-Q provides a means to measure function and symptoms associated with lower extremity wounds. Conclusion: These new WOUND-Q scales can be used to measure outcomes important to patients with lower extremity wounds in clinical settings and research studies.

Switching from Galenic to Advanced Dressings or Vacuum Assisted Closure Therapy Can Improve Quality of Life of Patients with Chronic Non-Responsive Pressure Skin Ulcers: Preliminary Data with Italian Translation of WOUND-Q

Objective: A few studies have focused on the quality of life (QoL) of patients with chronic non-responsive pressure skin ulcers. The aim of this study was to assess how correct treatment (advanced wound care [AWC] dressings alone or vacuum assisted closure [VAC] therapy alone) changes the QoL of these patients. Approach: One hundred six patients with chronic non-responsive pressure skin ulcers, who had previously used galenic dressings, applied without proper therapeutic indication, were included in this study. We administered the WOUND-Q, at time 0 and after 1 month of appropriate therapy, to assess patient-reported outcome measures. Group 1 consisted of 30 patients treated with advanced dressings, Group 2: 22 patients treated with VAC therapy, and Group 3: 30 patients continuing conventional galenic dressings (Control group). Statistical analysis allowed us to analyze QoL changes over time and to compare WOUND-Q Group 1 and 2 deltas with those of Group 3. The study followed the STROBE statement. Results and Innovation: In all the scales evaluated (Assessment, Drainage, Smell, Life impact, Psychological, Social, Sleep and Dressing), there were significant improvements in mean values for Groups 1 and 2. Kruskal-Wallis tests with Dunn's multiple-comparisons tests and Brown-Forsythe and Welch Analysis of Variance tests demonstrated significant differences between deltas of Group 1 and Group 2 compared with those of Group 3 for most scales analyzed. Conclusions: Administration of the WOUND-Q demonstrated that the application of advanced dressings alone or VAC therapy alone positively affects the QoL of patients with chronic nonresponsive pressure wounds, in comparison with galenic dressings alone. The WOUND-Q has been shown to be a valid tool in studying changes in QoL of these patients.

Identifying health-related quality of life concepts to inform the development of the WOUND-Q

OBJECTIVE

The impact of hard-to-heal wounds extends beyond traditional clinical metrics, negatively affecting a patient's health-related quality of life (HRQoL). Yet treatment outcomes are seldom measured from the patient's perspective. The purpose of the present study was to perform in-depth qualitative interviews with patients diagnosed with varying types of hard-to-heal wounds to identify outcomes important to them.

METHOD

Participants were recruited from wound care clinics in Canada, Denmark, the Netherlands and the US, and were included if they had a hard-to-heal wound (i.e., lasting ≥3 months), were aged ≥18 years, and fluent in English, Dutch or Danish. Qualitative interviews took place between January 2016 and March 2017. An interpretive description qualitative approach guided the data analysis. Interviews were audio-recorded, transcribed and coded line-by-line. Codes were categorised into top-level domains and themes that formed the final conceptual framework.

RESULTS

We performed 60 in-depth interviews with patients with a range of wound types in different anatomic locations that had lasted from three months to 25 years. Participants described outcomes that related to three top-level domains and 13 major themes: wound (characteristics, healing); HRQoL (physical, psychological, social); and treatment (cleaning, compression stocking, debridement, dressing, hyperbaric oxygen, medication, suction device, surgery).

CONCLUSION

The conceptual framework developed as part of this study represents the outcome domains that mattered the most to the patients with hard-to-heal wounds. Interview quotes were used to generate items that formed the WOUND-Q scales, a patient-reported outcome measure for patients with hard-to-heal wounds.

Further psychometric validation and test-retest reproducibility of the WOUND-Q

WOUND-Q is a condition-specific patient-reported outcome measure developed for all types of chronic wounds, located anywhere on the body. To establish reliability and validity of a patient-reported outcome measure, multiple pieces of evidence are required. The purpose of this study was to examine the measurement properties of 9 of the 13 WOUND-Q scales and perform a test-retest reproducibility study in an international sample. In August 2022, we invited members of an international online community (Prolific.com) with any type of chronic wound to complete a survey containing the WOUND-Q scales, the Wound-QoL and EQ-5D. A test-retest survey was performed 7 days after the first survey. It was possible to examine the reliability and validity of eight of the nine WOUND-Q scales by Rasch Measurement Theory (RMT). To examine test-retest reproducibility intraclass correlation coefficients (ICCs), the standard error of the measurement and the smallest detectable change were calculated. In total, 421 patients from 22 different countries with 11 different types of chronic wounds took part in this study. Our analyses provided further evidence of the reliability and validity of the scales measuring wound characteristics (assessment, drainage, smell), health-related quality of life (life impact, psychological, sleep, social) and wound treatment (dressing).

Impact of Complex Wounds on Health-Related Quality of Life: A Descriptive Study

PURPOSE

To describe health-related quality of life (HRQoL) using the Wound-Quality of Life (Wound-QoL) questionnaire for those individuals referred to an academic medical center wound clinic.

DESIGN

Prospective, descriptive study.

SUBJECTS AND SETTING

One hundred eleven participants receiving care in an academic medical center wound clinic in the Southeastern United States. The sample comprised 67 males (60.4%) and 44 females (39.6%) with wounds of 6 major etiologies.

METHODS

From June 2019 through May 2020, a convenience sample of 111 individuals completed the Wound-QoL questionnaire at the initial visit to the wound clinic. The Wound-QoL questionnaire is a valid and reliable tool consisting of 17 questions related to wound-QoL measured on a 5-point Likert scale, ranging from 0 (not at all affected) to 4 (very much affected). The questions are assigned to the 3 subscales: "body," "psyche," and "everyday life." The Wound-QoL individual items, subscales, and the total wound score (TWS) were calculated as mean values of the item scores, ranging from 0 to 4, where higher values correspond to decreased HRQoL. The TWS is defined as the sum of the 17 item responses, with values ranging from 0 to 68. Descriptive and parametric statistics were used to analyze the data from the Wound-QoL questionnaire.

RESULTS

The mean TWS was approximately 3 points higher for Whites (n = 84) than for Blacks (n = 27) (32.42, SD = 17.96 vs 29.51, SD = 19.39), but this difference was not significant (P = .473). An independent-samples t test of TWS versus sex was not significant (P = .446). The TWS by age category was significant (P = .015), showing differences in mean scores based on age category. We found that the youngest (ages 17-39 years) and oldest (ages 70-98 years) participants were less bothered by their wounds in almost all respects than those in the middle age range (ages 40-69 years). The individual item means varied between 0.84 and 2.72, out of a possible range of 0 to 4. The highest means were for items on the emotional subscale with means from 1.93 to 2.72. Analysis of variance was used to examine the TWS and the 3 subscales over the 6 wound types; none were found to be significant (TWS: P = .454, body: P = .722, psyche: P = .452, everyday life: P = .087).

CONCLUSION

Wound-QoL questionnaire scores indicated that the greatest impact of a wound on HRQoL was on the emotional subscale. These 4 items are related to the individual expressing worry, fear, unhappiness, or frustration with wound healing. The Wound-QoL questionnaire may be used to evaluate the impact the wound has on the individual's HRQoL.

International study to develop the WOUND-Q patient-reported outcome measure for all types of chronic wounds

Patient‐reported outcome measures (PROMs) for chronic wounds mainly focus on specific types of wounds. Our team developed the WOUND‐Q for use with all types of wounds in any anatomic location. We conducted 60 concept elicitation interviews with patients in Canada, Denmark, the Netherlands, and the United States. Analysis identified concepts of interest to patients and scales were formed and refined through cognitive interviews with 20 patients and input from 26 wound care experts. Scales were translated into Danish and Dutch. An international field‐test study collected data from 881 patients (1020 assessments) with chronic wounds. Rasch measurement theory (RMT) analysis was used to refine the scales and examine psychometric properties. RMT analysis supported the reliability and validity of 13 WOUND‐Q scales that measure wound characteristics (assessment, discharge, and smell), health‐related quality of life (life impact, psychological, sleep impact, and social), experience of care (information, home care nurses, medical team, and office staff), and wound treatment (dressing and suction device). The WOUND‐Q can be used to measure outcomes in research and clinical practice from the perspective of patients with any type of wound.

Patient-reported experience measures are essential to improving quality of care for chronic wounds: An international qualitative study

Traditional quality measures for chronic wounds have focused on objective outcomes that are challenging to risk adjust, lack patient input, and have limited ability to inform quality improvement interventions. Patient-reported experience measures (PREMs) provide information from the patient perspective regarding health care quality and have potential to improve patient-centredness, increase care efficiency, and generate actionable data for quality improvement. The purpose of this study was to understand patient experiences and health care processes that impact quality of care among patients with chronic wounds. Sixty patients at least 18 years of age with various wound aetiologies were recruited from Canada, Denmark, The Netherlands, and the United States as part of a larger phase 1 qualitative study to develop a patient-reported outcome measure for chronic wounds (WOUND-Q). All patients had a chronic wound for at least 3 months, were fluent in their native speaking language, and able to participate in a one-on-one semi-structured interview. Interviews were digitally recorded and transcribed verbatim. Interpretive description was used to identify recurrent themes relating to patient experience and quality of care. We identified five domains (care coordination, establishing/obtaining care, information delivery, patient-provider interaction, and treatment delivery) and 21 sub-domains (access to patient information, interdisciplinary communication, encounter efficiency, provider availability, specialist referral, staff professionalism, travel/convenience, modality, reciprocity, understandability/consistency, accountability, continuity, credentials, rapport, appropriateness, complication management, continuity, environment/setting, equipment and supply needs, expectation, and patient-centred) as potential opportunities to measure and improve quality of care in the chronic wound population. PREMs for chronic wounds represent an important opportunity to engage patients and longitudinally assess quality across clinical settings and providers. Future research should focus on developing PREMs to complement traditional objective and patient-reported outcome measures for chronic wounds.