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Patient Assessments of Scarring: Patient-Reported Impact of Scars Measure or Patient Scar Assessment Questionnaire?

Durani, Piyush M.R.C.S.

Plastic and Reconstructive Surgery: April 2011 - Volume 127 - Issue 4 - p 1744-1745
doi: 10.1097/PRS.0b013e31820a667c
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Department of Plastic Surgery; Leicester Royal Infirmary; Infirmary Square; Leicester LE1 5WW, United Kingdom; pd1977@gmail.com

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Sir:

I would like to commend Brown et al.1 for their rigorous approach in developing the Patient-Reported Impact of Scars Measure, a patient-reported outcomes measure on the impact of scarring; however, I would like to challenge their assertion that this is “the first scar-specific patient-reported outcome measure to assess the impact of scars from the patient's perspective for use in clinical settings, research, and trials.” A comprehensive review of the literature would have highlighted our group's own endeavors in producing a validated patient-reported measure for scar, the Patient Scar Assessment Questionnaire (using an alternative but widely accepted traditional technique based on classic test theory) and the subsequent publication of that work in this very Journal.2 It is important to assess in which situations each of the two measures is more appropriate, if investigators decide to use one or the other.

The Patient-Reported Impact of Scars Measure has been derived by a robust interview-based methodology that continued until “theme-exhaustion”; however, a missing construct is the patient's perception of scar appearance. Other themes of importance may have been elucidated had the sample of 34 interviewees been more reflective of different scar groups. The cause or site of the scars in this sample group is not clearly stated, and it is accepted that such factors are important in scar perception. Further testing of the Patient-Reported Impact of Scars Measure in different scar population groups (from traumatic wounds and surgical populations) will be important in demonstrating that it has discriminative validity and can truly detect “known group differences.”

The study does not present adequate evidence as yet that the Patient-Reported Impact of Scars Measure can be reliably applied to the many different scar populations in clinical trials. The calibration of this scale has been specific to scar types at the poor end of the spectrum (the sample subjects for interview were selected from a “specialist scar clinic,” and in the subsequent validation survey, 77 percent of the subjects rated their scars as fair to very poor, nearly 60 percent hypertrophic or keloid). Importantly, many trials will evaluate therapies that may only improve certain aspects of the scar—appearance, symptoms, or psychological and functional impact. The ability to detect change along these separate domains will be an important attribute of a criterion standard multidimensional scale.

In conclusion, the Patient-Reported Impact of Scars Measure is likely to be more useful in evaluating therapeutic efficacy of interventions that improve the functional limitations related to scar symptoms (unlike the Symptoms subscale in the Patient Scar Assessment Questionnaire that requires further work) or psychological impact—more relevant for the very poor, potentially disfiguring hypertrophic or keloid scars. There is no evidence to suggest the measure can detect changes in scars caused by novel interventions that specifically change appearance in a wider range of scar types. In this regard, the Appearance and Satisfaction with Appearance subscales of the Patient Scar Assessment Questionnaire have already demonstrated an ability to detect change. Both studies have strengths and weaknesses, and an appreciation of the differences will highlight where further work and collaboration may be useful to produce a truly comprehensive patient-reported outcome measure instrument for scarring that covers all important domains.

Piyush Durani, M.R.C.S.

Department of Plastic Surgery

Leicester Royal Infirmary

Infirmary Square

Leicester LE1 5WW, United Kingdom

pd1977@gmail.com

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REFERENCES

1. Brown BC, McKenna SP, Solomon M, Wilburn J, McGrouther DA, Bayat A. The Patient-Reported Impact of Scars Measure: Development and validation. Plast Reconstr Surg. 2010;125:1439–1449.
2. Durani P, McGrouther DA, Ferguson MW. The Patient Scar Assessment Questionnaire: A reliable and valid patient-reported outcomes measure for linear scars. Plast Reconstr Surg. 2009;123:1481–1489.

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