DO NOT DUPLICATE. Results of a One-Day, Descriptive Study of Quality of Life in Patients with Chronic Wounds FEATURE

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1 FEATURE Results of a One-Day, Descriptive Study of Quality of Life in Patients with Chronic Wounds Vijay K. Shukla, MS, MCh(Wales), FAMS; Dinesh Shukla, MBBS; Anuj K. Tripathi, MBBS; Saurabh Agrawal, MBBS; Satyendra K. Tiwary, MS; and Vivek Prakash, MS Quality of life is a subjectively interpreted phenomenon that can be profoundly altered by the presence of a wound. Particularly when complete and expedient healing seems unrealistic, quality of life becomes the focus of care. To assess the influence of a variety of chronic wounds on patient quality of life, a 1-day, descriptive study was conducted among 50 consecutive outpatients (64% men, 36% women; age range 14 to 78 years) with chronic wounds who attended the Wound Clinic of the University Hospital, Varanasi, India. A quality-of-life questionnaire containing six parameters (physical, feelings, household duties, leisure time, social relations, and general ) was developed and administered. Demographic information was available as a result of a previous study at this institution. Quality-of-life scores were grouped as satisfactory and unsatisfactory and participants were grouped by age (<30 years old, 30 to 60 years old, >60 years old). Wounds were classified by cause (diabetes, venous disease, pressure ulcer, and tuberculosis) and size (<10 cm 2, 10 to 50 cm 2, >50 cm 2 ). The most common site was the lower limb or foot (39, 78%), followed by upper limb (six, 12%) and head, neck, and trunk (five, 10%). More than half (28, 56%) of all patients had an unsatisfactory overall quality-of-life score. The percentage of patients with satisfactory scores was higher in patients with smaller versus larger wounds and wounds located on upper rather than lower limbs, as well as in middle-aged versus younger or older patients. This patient-centered instrument helped document important quality-of-life concerns among chronic wound patients. KEYWORDS: chronic wound, quality of life Ostomy Wound Management 2008;54(5):43 49 Dr. VK Shukla is a Professor, Dr. D Shukla is a Resident, and Dr. Tripathi is a Resident, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. Dr. Agrawal is a Resident, Department of Orthopedics, Institute of Medical Sciences, Banaras Hindu University. Dr. Tiwary is a Senior Resident and Dr. Prakash is a Senior Service Resident, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University. Please address correspondence to: Dr. VK Shukla, MCh (Wales), FAMS, Professor, Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi , Índia; vkshuklabhu@gmail.com. May 2008 Vol. 54 Issue 5 43

2 Quality of life (QoL) is a vague, ethereal construct that reflects an individual s perspective on life satisfaction regardless of the Physical situation a subjective phenomenon that can be measured only by the patient. 1 Patient QoL can be profoundly altered by the presence of a wound. 2 Despite optimum care, many wounds will not heal expediently; due to inherent alterations in their pathophysiology, wounds may Household duties become chronic and healing protracted, variable, and nonuniform. 3 It may be clear from Leisure time the onset that wounds in some patients are unlikely to heal or Social relations that healing is not the priority of care. In such situations, QoL becomes a particularly important part of the care plan. Quality of life in an individual with a chronic wound incorporates such variables as General pain and suffering, financial healthcare costs, strain on personal resources, and overall impact of the wound on life and of daily liv- TABLE 1 QUALITY-OF-LIFE INSTRUMENT Questions Completely free of aches, pain, or discomfort Energetic Can get in or out of bed without assistance Able to use stairs, public transport Able to move around home without assistance Able to be as physically active as needed Happy and cheerful Sorrow and depressed Satisfied with life Attention to the needs of the house Helps in household duties Takes interest in flowers, garden, pets, reading, prayer, playing Goes outside for break Enjoys talking with or being with friends/relatives/neighbors/co-workers Pays attention to children (offspring/children of relatives and neighbors) Relationship with friends or relatives are major problems or conflicts Interested in problems of other people (family and neighbors) Looks forward to getting together with friends or relatives Vision for the future Follows religious/spiritual routine Material and Methods ing. Observing these variables, the authors conducted a 1-day descriptive study to assess the effect of chronic A 1-day, descriptive study was conducted among 50 consecutive patients with chronic wounds wounds on various aspects of patient quality of life. attending the wound clinic of the University Hospital in Varanasi, India. This study Ostomy Wound Management 2008;54(5):43 49 was a continuation of a previously published pain study 4 and included the same KEY POINTS study population. This study was The authors developed a quality-of-life instrument based on clinical observations in their chronic wound patient population. of University Hospital, Banaras Hindu approved by the ethics review committee During the course of 1 day, the questionnaire was administered to University, Varanasi, India. The study and 50 consecutive patients visiting the outpatient wound clinic. questionnaire were explained to all participants. Most patients had an overall unsatisfactory quality-of-life score but While volunteers had participated differences between patient groups (young versus old, small versus in other pain studies, the questionnaire larger wounds, male versus female) were observed. for this study had not been administered before. In this situation, the questions 44 OstomyWound Management

3 TABLE 2 DISTRIBUTION OF QUALITY-OF-LIFE PARAMETERS Physical Household duties Leisure time Social relations General (%) (%) were read to the participants and a volunteer recorded the answers. A short (six segments comprising two to six statements each), easy-to-use questionnaire was developed for implementation in a range of healthcare settings for both research and clinical practice. (Demographic information had been collected as part of a previous study.) The questions/indicators were compiled based on the authors observations of variables influenced by the presence of a chronic wound: physical, feelings (ie, overall emotional status), household duties, leisure time, social relations, and general (see Table 1). Questions related to the variables were answered using a five-point rating Quality of life scale (1= completely disagree to 5 = totally agree). Physical The scores for each of the 50 patients were added and the mean value for each of the six sections of the tool was obtained by statistical analysis. Scores above the Household duties mean (17±3) were classified satisfactory and those below Leisure time the mean unsatisfactory. The actual mean for each of the six scores coincidentally Social equaled 17. relations The study group was General further divided into three classes based on participant age: young (<30 years P * P <0.05 ; <0.01 old), middle-aged (30 to 60 years old), and old (>60 years). Wound size was divided into three categories: small (<10 cm 2 ), medium (10 to 50 cm 2 ), and large (>50 cm 2 ). Descriptive statistics were used for demographic variables and z-test and Fisher s exact test were used to test differences between the proportions. Other QoL measurement tools are the 36-item Medical Outcomes Short Form Health Survey (SF- 36); EuroQol (EQ); McGill Short Form Pain Questionnaire (SF-MPQ) and the Frenchay Activities Index (FAI). 5 These scales were not used due to technical problems. Results The study group comprised 50 patients (64% men, 36% women). Patient age ranged from 14 years to 78 years; according to the age classification, 16% were young, 50% middle-aged, and 34% old. The most common wound site was the lower limbs (78%), followed by upper limbs (12%) and head, neck, and trunk (10%). Overall, diabetes mellitus (38%) was the leading underlying cause of wounds, followed by TABLE 3 DISTRIBUTION OF QUALITY-OF-LIFE OUTCOMES BY PATIENT AGE Age groups (years) <30 (1) 1(13) 7(87) (2) 17(68) 8(32) >60 (3) 5(29) 12(71) 2(25) 6(75) 4(50) 4(50) 3(37.5) 5(62.5) 2(25) 6(75) 3(37.5) 5(62.5) 17(68) 8(32) 18(72) 7(28) 12(48) 13(52) 17(68) 8(32) 15(60) 10(40) 5(29) 12(71) 5(30) 12(70) 3(17.6) 14(82.4) 4(23.5) 13(76.5) 4(23.5) 13(76.5) 1 Vs * Z Values 2 Vs * 2.45 * * * 1 Vs May 2008 Vol. 54 Issue 5 45

4 TABLE 4 DISTRIBUTION OF QUALITY-OF-LIFE OUTCOMES BY GENDER Physical Household duties Leisure time Social relations General Quality of life * P <0.05 ; P <0.01; P <0.001 Gender Males Females (1) (2) 19(59.4) * 4(22.2) 13(40.6) 14(77.8) 12(37) 20(63) 0(0) 32(100) 13(40.6) 19(59.4) 11(34) * 21(66) 15(46.9) 17(53.1) 12(67) 6(33) 13(62.2) 5(27.8) 5(27.8) 13(72.2) 12(67) 6(33) 7(38.9) 11(61.1) venous disease (26%), pressure ulcers (18%), and tuberculosis (8%). Lower leg wounds most commonly were the result of diabetes; head, neck, and trunk wounds were caused by diabetes (6%) and tuberculosis (4%). Wound size was classified as small (46%), medium (34%), and large (20%). Overall, patients rated physical (54%), feelings (52%), social relations (54%), household (52.6%), leisure time (64%), and general (56%) unsatisfactory (see Table 2). Middle-age participants had higher proportions of satisfactory scores for physical, feelings, and social relations than young or old participants (P <0.05 and P <0.01, respectively). The proportion of middle-aged patients with satisfactory scores for leisure time, household duties, and general was higher than in old patients (P <0.05) (see Table 3). The proportion of men whose QoL score was satisfactory with regard to physical, leisure time, and general was higher than in women (P <0.05); whereas, the latter enjoyed an overall better quality of life (P <0.05) in terms of Z Values 1 Vs * 1.98 * * 0.55 household duties (P <0.001) and social relations (P <0.05) (see Table 4). Compared to patients with medium or large wounds, the proportion of patients whose QoL score was satisfactory was higher in the following domains: physical activity (P <0.05), household duties (P <0.01), feelings (P <0.05) and social relations (P <0.05) (see Table 5). More patients with wounds located over the lower limbs rated physical activity, feelings, household duties, social relations, and general unsatisfactory than patients with wounds on their upper limbs. By contrast, the number of patients with an unsatisfactory QoL score for social relations and leisure time was higher when the wound was located on the head and neck than in other parts of the body (see Table 6). Discussion Health-related QoL refers to the impact of disease and treatment on disability and daily living, or as a patient-based focus on the impact of a perceived health state on the ability to lead a fulfilling life. 6 In 1993, Patrick and Erickson 7 defined QoL as the value assigned to the duration of life and modified by impairments. In a study of patients with chronic wounds, Franks and Moffatt 8 noted that when an individual with a chronic wound is feeling ill, he/she likely is experiencing feelings of pain and discomfort or change in usual functioning and feeling. This is the core consideration in healthrelated quality of life: the individual s sense of wellbeing is the most important factor, not what a healthcare provider might determine it to be. 9 Culture also influences the patient s perception of QoL. 8 A wound is defined as a disruption in the integrity and function of body tissue; having a wound implies imperfection, which impacts physical and emotional vulnerability. 10 Any visible wound leads to greater emotional or psychological trauma than a wound on location that is not typically visible because of the feelings of shame and embarrassment that might occur. 8 Studies have shown that patients with chronic wounds have a decreased QoL 11,12 : Phillips et al 11 conducted a subjective/descriptive study in 73 patients with chronic leg ulcers (two groups: persons with 46 OstomyWound Management

5 venous ulcers and younger patients) and Franks and Moffatt 12 studied 473 patients with venous ulcerations. Various factors have been implicated in decreased QoL: frequency and regularity of dressing changes that affect daily routine; continued fatigue due to lack of adequate sleep; restricted mobility; pain; wound infections; and social isolation. The requirements and consequences of having a chronic wound also have an enormous impact on the patient s social life. The loss of independence associated with functional decline can lead to several, sometimes subtle, changes in overall health and wellbeing: altered eating habits, depression, social isolation, and a gradual reduction in activity levels. These factors, along with immobility, not only increase the likelihood of additional wounds, but also exacerbate their severity and jeopardize their ability to heal. 3 In the present study, it was observed that the proportion of participants with satisfactory QoL scores for physical and social relations was higher in middle-aged patients than in younger or older patients. The proportion of middle-aged patients reporting satisfactory leisure time, household duties, and general was also higher than in older patients. Philips et al s study 11 demonstrated more negative emotions related to their ulcers and mobility in middle-aged than older individuals (P <0.001). Older individuals were found to be more able to cope effectively with their limitations and disabilities than younger study participants. Similar findings were reported by Franks and Moffatt 9 in their study. In a cross-sectional study of age- and gender-matched leg ulcer patients (n = 758) that used the Nottingham Health Profile, younger men reported poorer QoL TABLE 5 DISTRIBUTION OF QUALITY-OF-LIFE OUTCOMES BY WOUND SIZE Physical Household duties Leisure time Social relations General * P <0.05 ; P <0.01 Quality of life Size of Wound (cm 2 ) Small (1) 16(69.6) * 7(30.4) Medium (2) 5(29.4) 12(70.6) Large (3) 2(20) 8(80) 15(65.2) 8(34.8) 17(74) * 6(26) 8(34.8) 15(65.2) 15(65.3) 8(34.7) 9(39.1) 14(60.9) 7(41.2.) 10(58.8) 4(23.5) 13(76.5) 6(35.3) 11(64.7) 6(35.3) 11(64.7) 8(47.1) 9(52.9) 2(20) 8(80) 3(30.0) 7(70.0) 4(40) 6(60) 2(20) 8(80) 5(50) 5(50) 1 Vs * Z Values 2 Vs Vs * 2.37 * * 0.58 than older men. Conversely, age was not found to be a statistically significant QoL factor in a descriptive study of 63 chronic leg ulcer patients. 6,13 The present study showed that the proportion of men with satisfactory QoL scores was higher than in women in terms of physical, leisure time, and general ; whereas, more women than men had satisfactory feelings, household duties, and social relations QoL scores. Reported effects of gender on QoL are inconsistent in the literature. In a retrospective study 13 of 758 leg ulcer patients, women were found to have lower QoL scores than men. Results vary with gender in relation to specific factors. When pain and physical mobility were considered as part of a 125-person subjective study of patients with chronic leg ulcers, QoL scores were lower in men than women, 14 and with regard to vitality and social and physical functioning, women had lower QoL scores than men. 6 Overall, in the general non-wound population, average women s QoL scores are lower than those of men, particularly in older age groups. Thus, poorer May 2008 Vol. 54 Issue 5 47

6 Physical Household duties Leisure time Social relations General TABLE 6 DISTRIBUTION OF QUALITY-OF-LIFE OUTCOMES BY WOUND LOCATION Quality of life LL = lower limit; UL = upper limit Trunk, Head, and Neck (1) 2(40) 3(60) 2(40) 3(60) 5(100) 0(0) 0(0) 5(100) 1(20) 4(80) 2(40) 3(60) Site of Wound Foot Leg and Thigh (2) (3) 7(42.9) 8(57.1) 4(26.7) 11(73.3) 10(41.7) 14(58.3) 11(45.8) 13(54.2) 10(41.7) 14(58.3) 10(41.7) 14(58.3) QoL scores in women with ulcers may be more closely related to gender than to the ulcers. 9 Wound size also influenced patient QoL. The proportion of patients with satisfactory quality-of-life scores related to physical activity, household duties, feelings, and social was higher in patients with small wounds than in patients with larger wounds. Compared to patients with upper limb wounds, more patients with lower limb wounds had below-average QoL scores for physical activity, feelings, household duties, social relations, and general parameters while the number of patients with unsatisfactory QoL scores for social relations and leisure time was higher in patients with head and neck wounds than in patients with wounds in other locations. These effects of lower limb wounds on QoL have previously been reported. Franks et al 15 evaluated QoL in 118 patients with chronic venous leg ulceration using the SF-36 questionnaire and observed that patients with leg ulcers had significantly lower mean scores than age-sex adjusted normative published scores in the following domains: role-emotional, social-functioning, role-functioning, rolephysical, and bodily pain. In an in-depth analysis of patients experience with foot ulcers, Ashford et al 16 observed that the majority of patients expressed problems with footwear, working life, pain, mobility, and relationships. While the absence of a control group limits ability to interpret the findings of this study, results are consistent with previously published studies. The instrument will benefit from further use and assessment of its reliability to provide an accurate picture of patient QoL. Most important will be clinician utilization of the information obtained to respond to QoL issues in their patients. Conclusion Upper Limb (4) 5(83.3) 1(16.7) 5(83.3) 1(16.7) 6(100) 0(0) 2(33.3) 4(66.7) 4(66.7) 2(33.3) 4(66.7) 2(33.3) Fisher s exact test 1 Vs Vs. 4 LL.20 UL.98 LL 0.20 UL 0.98 LL.21 UL LL The results of a prospective, descriptive study of 50 outpatients with chronic wounds suggest that the presence of a chronic wound affects physical, psychological, emotional, and social QoL parameters. - LL 0.27 UL 1.00 LL.18 UL.99 LL 0.39 UL OstomyWound Management

Although clinicians cannot change these factors, awareness of the effect of the wound should be enhanced and this knowledge used to improve approaches to care, particularly when full healing is not a

7 Although clinicians cannot change these factors, awareness of the effect of the wound should be enhanced and this knowledge used to improve approaches to care, particularly when full healing is not a realistic expectation. Studies assessing the effects of wound management on patient QoL are needed. - OWM References 1. Jocham HR, Dassen T, Widdershoven G, Halfens R. Quality of life in palliative care cancer patients: a literature review. J Clin Nurs. 2006;15(9): Goodridge D, Trepman E, Embil JM. Health-related quality of life in diabetic patients with foot ulcers: literature review. J WOCN. 2005;32(6): Enoch S, Price PE. Cellular, molecular and biochemical differences in the pathophysiology of healing between acute wounds, chronic wounds, and wounds in the aged. World Wide Wounds August Available at: Accessed April 10, Shukla D, Tripathi AK, Agrawal S, Ansari MA, Rastogi A, Shukla VK. Pain in acute and chronic wounds: a descriptive study. Ostomy Wound Manage. 2005;51(11): Walters SJ, Morrell CJ, Dixon S. Measuring health-related quality of life in patients with venous leg ulcers. Qual Life Res. 1999;8(4): Price P, Harding K. Measuring health-related quality of life in patients with chronic leg ulcers. Wounds. 1996;8(3): Patrick DL, Erickson P. Health Status and Health Policy: Quality of Life in Health Care Evaluation and Resource Allocation. New York, NY: Oxford University Press;1993: Franks PJ, Moffatt CJ. Quality of life issues in patients with chronic wounds. Wounds. 1998;10(suppl E):1E 9E. 9. Franks PJ, Moffatt CJ. Who suffers most from leg ulcers? J Wound Care. 1998;7(8): van Rijswijk L, Gottlieb D. Like a terrorist. Ostomy Wound Manage. 2000;46(5): Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: financial, social, and psychologic implications. J Am Acad Dermatol. 1994;31(1): Franks PJ, Moffatt CJ. Health related quality of life in patients with venous ulceration: use of the Nottingham health profile. Qual Life Res. 2001;10(8): Lofland JH, Schaffer M, Goldfarb N. Evaluating health-related quality of life: cost-comparison of computerized touchscreen technology and traditional paper systems. Pharmacotherapy. 2000;20(11): Lindholm C, Bjellerup M, Christensen OB, Zederfeldt B. Quality of life in chronic leg ulcer patients. An assessment according to the Nottingham Health Profile. Acta Derm Venereol. 1993;73(6): Franks PJ, McCullagh L, Moffatt CJ. Assessing quality of life in patients with chronic leg ulceration using the Medical Outcomes Short Form-36 questionnaire. Ostomy Wound Manage. 2003;49(2): Ashford RL, McGee P, Kimmond K. Perception of quality of life by patients with diabetic foot ulcers. The Diabetic Foot. 2000;3(4): May 2008 Vol. 54 Issue 5 49

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