Validation of the EQ-5D questionnaire in burn injured adults
Introduction
Being afflicted with an extensive burn is one of the most catastrophic events an individual can experience. A severe burn is a life threatening state and affects all main integrating systems in the body [1]. Acute care involves both pain and stress [2], [3]. Furthermore, the incident can have social consequences such as injured relatives, or even loss of family members as well as loss of property. The process of rehabilitation often continues for many years after the burn and involves physical, psychological and social demands [2], [4], [5], [6]. Even with optimal treatment, scarring is inevitable after deep burns, and permanent changes in appearance and physical function can occur [7], [8]. In addition to functional status, patient-based outcome measures are important aspects of outcome when evaluating processes of rehabilitation and adaptation after burn [6], [9], [10], [11]. Patient-based outcomes in burned injured adults have been referred to and reported as perceived health, quality of life (QoL) and/or health-related quality of life (HRQoL) [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22].
Health-related quality of life is a subjective measure of well-being, and can be defined as the individual's perception of physical, mental and social health over time [23]. Assessment of HRQoL comprises the individual's perception of his or her injury or illness and how this interferes with the ability to live a fulfilling life [24].
Instruments used to measure HRQoL may be disease-specific or generic. Disease-specific instruments focus on certain aspects of a given disease. The most well known disease-specific instrument for use in burn care is the Burn Specific Health Scale (BSHS), developed in 1982 [25] and revised several times [26], [27]. The latest version is the Burn Specific Health Scale-Brief (BSHS-B), which has undergone more psychometrically evaluation than previous versions [28], [29]. BSHS-B captures burn-related health in nine subscales, simple abilities, hand function, heat sensitivity, treatment regimens, body image, affect, interpersonal relationships, sexuality and work.
Generic HRQoL instruments are designed to reflect a spectrum of core concepts of HRQoL that may apply to different diseases and populations. Generic instruments can also be used to assess the impact of a disease on HRQoL in comparison with the HRQoL of the general population. One such instrument is the widely used Short-Form 36 Health Survey (SF-36), which captures both physical and mental health phenomena in the eight subscales physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health [30]. SF-36 has also been used in studies of HRQoL after burn [11], [12], [13], [14], [15], [31].
Another generic instrument is the EQ-5D, which consists of five dimensions: mobility, self-care, usual activities, pain and anxiety/depression. The EQ-5D provides three different measures: a descriptive health profile, a self-rated health status using a Visual Analogue Scale (VAS) and a summarized index [32], [33]. The index can be used as the qualitative weight when computing a quality-adjusted life-year. Recently, EQ-5D was used to calculate the total cost of specialized burn care [34].
Van Beeck and colleagues [35] recently proposed the use of EQ-5D in studies on injury-related disability. However, according to a review published in 2006, there is limited use of HRQoL instruments in burn recovery studies [6], and development and evaluation of such instruments is scarce [36]. No previous study has been found that focuses on validation of the EQ-5D in a population of adults with burn injury. Thus, the aim of this study was to analyze the psychometric properties of the generic instrument EQ-5D in the assessment of HRQoL after burns. Based on clinical experience and the burn literature [11], [13], [14], [37] we hypothesized that EQ-5D would show a lower perceived HRQoL in individuals with bigger burns than in individuals with smaller burns but that such differences would fade over time [11], [19], [20]. Based on previous information [38], [39] we further hypothesized that EQ-5D would report lower perceived HRQoL at 12 months in the subgroup with psychiatric morbidity prior to the burn or in those non-working after the burn [15].
Section snippets
Participants
This study is part of an ongoing prospective longitudinal study concerning physical and psychological outcome after burn trauma. The study was conducted at the Uppsala Burn Unit, one of two national burn units in Sweden. Consecutive burn patients admitted to the Burn Unit between March 2000 and March 2006 were included if they were (1) 18 years of age or older, (2) Swedish speaking, (3) without documented mental retardation or dementia, and (4) had ≥5% total body surface area (TBSA) burned or a
Results
Of the 95 patients who fulfilled the study criteria, two were missed due to administrative reasons and 15 declined participation, leaving 78 participants (82%) for analysis. There were no significant differences between the 78 participants and the 17 non-participants with respect to age, sex, burn size, or length of hospital stay. The 78 participants included 17 females and 61 males with a mean age of 43.6 years (range: 19–89; SD = 15.1). The mean TBSA was 24.3% (SD = 19.7) of which 10.3% (SD = 14.0)
Discussion
The aim of the present study was to analyze the psychometric properties of the EQ-5D in burn-injured adults. The low proportion of missing or invalid responses for the questionnaires shows that the instrument is well understood and accepted in adults with burns, and indicates good feasibility. The EQ-5D and EQ VAS showed small floor and ceiling effects at all time points. The high proportion of individuals who perceived poor HRQoL at baseline, as indicated by an index below zero (“death or
Conclusion
Overall, the EQ-5D showed good psychometric properties. The descriptive system, the EQ VAS and the EQ index are useful tools for describing aspects of HRQoL after burn injury, and for comparing outcomes with other trauma or diseases. Further, the EQ-5D is short and easy to administer. Taken together, the results of this study support the use of the EQ-5D in burn injured adults as an adjunct to burn-specific instruments.
Conflict of interest
There are no conflicts of interest to declare.
Acknowledgments
This research was supported by the Swedish Research Council and the Swedish Council for Working Life and Social Research. The authors would like to thank Professor Bengt Gerdin, Department of Surgical sciences, Plastic surgery and Burn Unit, University Hospital, Uppsala University for valuable comments in previous versions of the manuscript.
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