Moving beyond survival as a measure of success: understanding the patient experience of necrotizing soft-tissue infections

BACKGROUND

Necrotizing soft tissue infections (NSTIs) represent a devastating spectrum of disease with high case mortality and resource intensive care. Treatment consists of wide surgical debridement and often prolonged periods of intensive care unit care. Major complications are common. The severity of the disease and the aggressive treatment requirements put survivors at risk for significant long-term sequelae related to the trauma of both disease and treatment. Information about the postdischarge impact of NSTIs on survivors is extremely limited. Qualitative approaches are typically used to explore new phenomena and to capture individuals' thoughts, feelings, or interpretations of meaning and process. Therefore, qualitative methods are ideally suited for hypothesis generation to guide future quantitative study and ensure measured outcomes are patient-centered.

MATERIALS AND METHODS

Semistructured interviews were conducted with survivors of NSTIs from a single regional referral center. Stratified purposive sampling was used to select interview candidates based on severity of illness. Descriptive thematic analysis was performed to identify major themes described by the patients.

RESULTS

Interviews with 18 survivors identified three primary domains of experience: (1) individual factors, (2) relational factors, and (3) societal factors. These domains were split into the following two categories: factors effecting the disease process and recovery, and factors that were outcomes of the disease process. Each category yielded between one and seven themes. Themes identified included physical, psychological, relationship, and employment aspects.

CONCLUSIONS

Patient's reported quality of life was significantly affected by their disease and recovery. The results demonstrate that many outcomes of importance for patients are not easily assessed by traditional measures of outcomes. This work illustrates the multidimensional nature of recovery from critical illness, and shows that it represents a massive transition period in the lives of survivors that affects the patient, their family, and the patient's ability to interact with society. Interviews with survivors ensure that the patient voice is heard before developing tools to assess long-term outcomes.

Development of a Health-Related Quality of Life Questionnaire (HRQL) for patients with Extremity Soft Tissue Infections (ESTI)

Background

Past clinical trials of antimicrobial treatment in soft tissue infections have focused on non-standardized clinical and physiological outcome variables, and have not considered the subjective experience of patients. The objective of this study was to develop a health-related quality of life questionnaire (HRQL) for patients with extremity soft tissue infections (ESTI) for future use in clinical trials.

Methods

The design of this study followed published guidelines and included item generation, item reduction, and questionnaire preparation. Study subjects were consenting English-speaking adults with acute ESTI requiring prescription of at least two days of outpatient intravenous antibiotic therapy.

Results

A list of 49 items that adversely impact the quality of life of patients with ESTI was generated by literature review, informal health professional feedback, and semi-structured interviews with twenty patients. A listing of these items was then administered to 95 patients to determine their relative importance on quality of life. A questionnaire was prepared that included the twenty most important items with a 5-point Likert scale response. Questionnaire domains included physical symptoms, problems performing their activities of daily living, impairment of their emotional functioning, and difficulties in their social interactions as related to their ESTI. The final questionnaire was pre-tested on a further ten patients and was named the ESTI-Score.

Conclusion

The ESTI-Score is a novel instrument designed to quantify the impact of ESTI on quality of life. Future study is required to determine its validity and responsiveness before use as an outcome measure in clinical trials.