Disability, Pain, and Wound-specific Concerns Self-reported by Patients at Risk of Limb Loss

There has been limited study of patient-reported outcomes (PROs) in patients at risk of limb loss. Our primary objective was to estimate the burden of disability in this patient population using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Secondary objectives were to determine whether the WHODAS 2.0 was clinically acceptable to these patients and the extent to which patient and wound characteristics, wound-specific concerns, and wound-related discomfort or distress predict their disability. We recruited patients referred to a university-affiliated limb-preservation clinic thought to be at risk of limb loss by a specialty wound care nurse and vascular surgeon. Patients self-reported their disability status using the 12-domain WHODAS 2.0. Severity of disability in each domain was scored from 1 = none to 5 = extreme and the total normalized to a 100-point scale. A total score ≥25 defined clinically significant disability. Based on published systematic reviews of PROs in vascular surgery, we also asked patients about wound-specific concerns and wound-related discomfort or distress. The WHODAS 2.0 had excellent clinical acceptability (100% of approached patients completed the questionnaire). We included 162 patients (Table). Reasons for clinic referral mostly included arterial-insufficient (37.4%), postoperative (25.9%), and mixed etiology (10.8%) wounds. Most wounds were located on the foot or ankle (61.2%). The mean overall WHODAS 2.0 disability score self-reported by included patients was 35.0 (standard deviation, 16.0). One hundred nineteen patients (73.5%) suffered from clinically significant disability. Patients reported that they had had the greatest difficulty walking a long distance (mean score, 4.2), standing for long periods of time (mean score, 3.6), taking care of their household responsibilities (mean score, 2.7), and dealing with the emotional impact of their health problems (mean score, 2.5) (Fig). In the 2 weeks prior to presentation, 87 patients (52.7%) also expressed concern over their wound(s), and 90 (55.6%) suffered a moderate amount or great deal of wound-related discomfort or distress. In adjusted ordinary least squares regression models, although WHODAS 2.0 disability scores varied with changes in wound volume (P = .03) and total revised photographic wound assessment tool scores (P < .001), the largest decrease in disability severity was seen in patients with less wound-specific concerns and wound-related discomfort and distress. The majority of people at risk of limb loss report suffering a substantial burden of disability, pain, and wound-specific concerns. Research is needed to further validate the WHODAS 2.0 in a multicenter fashion and determine how care and interventions may decrease this patient-centered burden.Table IBaseline characteristics of the 162 patients at risk of limb lossCharacteristic, No. (%)Overall (n = 162)Clinically significant disability (n = 119)No clinically significant disability (n = 43)Absolute standardized differenceaPersonal characteristics Age, years70.0 (62.0-78.0)70.0 (60.0-77.0)71.0 (66.0-78.0)0.18 Male gender96 (59.3)70 (58.8)26 (60.5)0.03 Rural residence67 (41.4)44 (37.0)23 (53.5)0.34 Long-term care facility resident5 (3.1)5 (4.2)0 (0)0.30 Current smoker38 (23.4)30 (25.2)8 (18.6)0.16 Past smoker62 (38.3)70.0 (60.0-77.0)71.0 (66.0-78.0)0.18Wound type (n = 139 with a documented etiology) Arterial52 (37.4)35/102 (34.3)17/37 (46.0)0.24 Venous13 (9.4)7/102 (6.9)6/37 (16.2)0.30 Diabetic10 (7.2)8/102 (7.8)2/37 (5.4)0.10 Mixed15 (10.8)11/102 (10.8)4/37 (10.8)0.0009 Postoperative36 (25.9)30/102 (29.4)6/37 (16.2)0.32 Other13 (9.4)11/102 (10.8)2/37 (5.4)0.20Wound location (n = 139 with a documented location) Groin3 (2.2)2/102 (2.0)1/37 (2.7)0.05 Thigh9 (6.5)6/102 (5.9)3/37 (8.1)0.09 Leg39 (28.1)30/102 (29.4)9/37 (24.3)0.11 Foot or ankle85 (61.2)62/102 (60.8)23 (62.2)0.03 Other3 (2.2)2/102 (2.0)1 (2.7)0.05Wound size, cm Width2.0 (1.0-4.0)1.8 (1.0-3.5)2.5 (1.2-5.0)0.38 Length3.5 (1.7-6.0)3.2 (1.7-6.0)3.6 (1.9-7.5)0.24 Depth0.40 (0.20-0.50)0.30 (0.20-0.50)0.40 (0.20-1.0)0.19 Area, cm27.5 (1.8-22.0)6.0 (2.0-18.0)8.6 (1.8-36.0)0.33 Volume, cm32.5 (0.54-11.1)2.2 (0.50-9.0)3.8 (0.75-16.8)0.26Comorbidities recorded in the 3 years before clinic visit Acute coronary syndrome60 (37.0)46 (38.7)14 (32.6)0.13 Cerebrovascular event (stroke or transient ischemic attack)22 (13.6)20 (16.8)2 (4.7)0.40 Chronic kidney disease37 (22.8)27 (22.7)10 (23.3)0.01 Chronic obstructive pulmonary disease21 (13.0)15 (12.6)6 (14.0)0.04 Coronary artery disease69 (42.6)55 (46.2)14 (32.6)0.28 Diabetes mellitus93 (57.4)74 (62.2)19 (44.2)0.37 Dialysis14 (8.6)12 (10.1)2 (4.7)0.21 Dyslipidemia99 (61.1)74 (62.2)25 (58.1)0.08 Heart failure35 (21.6)30 (25.2)5 (11.6)0.36 Hypertension126 (77.8)95 (79.8)31 (72.1)0.18Prior lower limb amputation Contralateral above- or below-knee amputation10 (6.2)9 (7.6)1 (2.3)0.24 Ipsilateral toe or ray amputation42 (25.9)30 (25.2)12 (27.9)0.14 Ipsilateral transmetatarsal amputation11 (6.8)9 (7.6)2 (4.7)0.12Ipsilateral lower limb revascularization procedures performed Iliac artery angioplasty and/or stenting23 (14.2)19 (16.0)4 (9.3)0.20 Femoral and/or popliteal artery angioplasty and/or stenting52 (32.1)40 (33.6)12 (27.9)0.12 Tibial and/or peroneal artery angioplasty50 (30.9)36 (30.3)14 (23.3)0.05 Aortofemoral or aortobifemoral bypass1 (0.6)1 (0.8)0 (0)0.13 Axillofemoral or axillobifemoral bypass10 (6.2)7 (5.9)3 (7.0)0.04 Iliofemoral or femoral endarterectomy27 (16.7)22 (18.5)5 (11.6)0.19 Femoral-popliteal bypass12 (7.4)11 (9.2)1 (2.3)0.30 Femoral-tibial or -peroneal bypass10 (6.2)7 (5.9)3 (7.0)0.04 Other revascularization procedure21 (13.0)13 (10.9)8 (18.6)0.22IQR, Interquartile range.Data are presented as number (%) or median (IQR).aThe absolute standardized difference allows comparison of the difference in prevalence of binary covariates, or the average of continuous covariates, between treatment groups without the influence of sample size. Values > .1 indicate substantive differences. Open table in a new tab