Quality-of-life with leg ulcers

Abstract

Sir, The article quality of life (QOL): Venous leg ulcers by V Vishwanath[1] was well written. Leg ulceration has a major impact both on individual patients and on the health service in general in terms of cost, staff requirements, and nursing time. The assessment of health-related QOL in patients with leg ulcers provides important information for clinical decision-making, evaluation of therapeutic benefits, and prediction of survival probabilities. The author has covered the topic in a very informative manner and very eloquently listed all the QOL indices used in various studies to evaluate leg ulcers. Both the medical outcomes study (MOS) short form (SF-36) and the Nottingham health profile (NHP) have been commonly used as tools to measure the impact of venous ulceration on the patient's QOL.[2 3] Both forms are suitable, but the NHP was found to be more sensitive to the patient's ulcer status and would, therefore, seem likely to be a better tool to measure the effect of recurrent ulceration on the patient's perceived QOL.[2] However, Walshe, in a phenomenological study designed to describe the patient's experience of venous leg ulceration, concluded that if treatment is to meet the needs of those suffering from venous leg ulceration, then symptom control must be the highest priority.[4] Clearly, compliance with both treatment and preventative therapy will be the greatest if it addresses these issues and controls symptoms. In a systematic review encompassing 24 studies and spanning two decades from the year 1990 to 2006, pain was described in both quantitative and qualitative studies as the worst thing about having an ulcer despite other important medical problems.[5] Qualitative studies on patients with leg ulceration have highlighted that health care professionals may seem to lack the necessary skills or time to help them and may not always empathise with their needs.[6] The difficulty is defining a suitable tool with which to measure the impact of a specific disease process and care on a patient's perceived QOL.[6 7] The generic instruments most commonly used in another recent review were SF-36 and adaptations, the NHP and EuroQol-5, whilst the disease-specific tools were Hyland, Cardiff wound impact schedule, and Charing cross venous leg ulcer questionnaire. Two new instruments were also identified, venous leg ulcer QOL and Sheffield preference-based venous leg ulcer 5D.[8] The review findings suggested that the Charing cross venous leg ulcer questionnaire is the most appropriate instrument due to its disease-specific psychometric characteristics. In another recent study involving 100 patients, split-thickness skin grafting resulted in statistically significantly better health-related QOL and self-esteem in patients with venous leg ulcers than did compression therapy with the Unna boot. The study used MOS 36-item SF health survey SF-36 and the Rosenberg self-esteem scale.[9] Both healing the patient's ulcer and normalizing the patient's life should form the basis of care. The challenge is to move from a focus on wound management to understand the specific needs of each individual. Achieving normality in a chronic recurring condition, especially like venous ulceration with its demand for continued compression therapy, is a challenge yet to be met effectively by health care providers. Guidelines on leg ulcer management do not account for many of the far-ranging effects of leg ulceration. Therefore, they need to be adjusted in order to improve nursing and medical care in the future. QOL assessment has a significant role to play in this endeavor and should, therefore, be an integral part of the management protocol of patients with leg ulcers.