Nottingham Health Profile or Cardiff Wound Impact Schedule? Choosing Health Related Quality of Life Instruments in the Assessment of Patients With Leg Ulcers

Patients with chronic leg ulcers usually live with a wide variety of disabilities, related both to the severity of their disease and to an array of seemingly nonrelated psychosocial factors. In an attempt to improve the quality of life of this patient population, Health Related Quality of Life has been extensively researched in patients with leg ulceration to isolate the factors that significantly influence it. This review examines the existing literature regarding the generic Nottingham Health Profile and the disease-specific Cardiff Wound Impact Schedule, and the use of these tools in patient assessment.

Chronic leg ulcers present a challenge for both health care providers and for the patients themselves due to their persistent nature and long healing periods. Patients with chronic leg ulcers usually suffer from a wide variety of disabilities, related both to the severity of their disease and to an array of seemingly nonrelated psychosocial factors. Thus, this condition imparts a detrimental effect on patients’ Health Related Quality of Life (HRQoL) at different levels. In an attempt to improve the quality of life of this patient population, HRQoL has been extensively researched in patients with leg ulceration to isolate the factors that significantly influence it. These instruments include generic HRQoL instruments, as well as disease-specific ones.¹ The aim in this study is to review the existing literature regarding the generic Nottingham Health Profile (NHP) and the disease-specific Cardiff Wound Impact Schedule (CWIS), as well as the reported results, and to provide a better grasp regarding their role in patient assessment.

The following databases were searched: PubMed, Cochrane Library, and Ovid using the terms “quality of life” OR “health related quality of life” OR “chronic wound” OR “Nottingham Health Profile” OR “Cardiff Wound Impact Schedule.” The search was limited to publications with abstracts in the last 20 years and in English. In addition, citations within obtained papers were scrutinized to identify additional studies.

Nottingham Health Profile is a generic tool for assessing QoL² that has been evaluated for use for patients with chronic wounds. In a study by Franks and Moffatt³ of NHP results for patients with chronic venous leg ulcers, an acceptable internal consistency (IC) was demonstrated for most of the fields included in the NHP questionnaire (> 0.7), with only 2 variables (energy and social isolation) scoring lower (0.63 and 0.65). Their study has established the high construct validity of the NHP when compared to another well-accepted generic QoL assessment tool such as the Short Form-36 (SF-36). In their study, Franks and Moffat³ suggested that NHP might be more responsive to patients’ ulcer status when compared to SF-36. These results contradict the work of Brazier et al,⁴ who demonstrated an advantage of the SF-36 over the NHP in terms of the floor and ceiling effects. Franks and Moffatt³ concluded by recommending the use of NHP in the assessment of patients with chronic leg ulcerations. Furtado et al⁵ found the NHP to correlate with the Euroqol and visual analogue (VA) pain questionnaires only in the aspect of bodily pain when compared in chronic leg ulcers.   Hunt et al² as well as Simon et al,⁶ in a more contemporary study, demonstrated the high acceptability of the NHP among elderly people while pointing to an important limitation of the NHP—that it only investigates and measures negative aspects of health and neglects the positive ones. This has prompted Hunt et al² to later decree that the NHP cannot be used to assess positive feelings of well-being.   The Cardiff Wound Impact Schedule (CWIS) is a recently developed questionnaire that focuses on the impact of chronic wounds on HRQoL.⁷ Internal consistency was found to be above the acceptable 0.7 in all of the subscales.⁸ Reproducibility of results, calculated using a test-retest method, was significant at P < 0.001 for all items, and construct validity when compared to the SF-36 was also high (P < 0.001). Upon examination, the ability of the CWIS to discriminate between different health states (healed wound vs nonhealed) indicates that it can isolate responses attributed to the wound from others related to concomitant disorders of old age.⁷ However, a pilot study on the effects of topical negative pressure on QoL, using the CWIS, failed to differentiate between healed wounds and healing states and revealed a large ceiling effect⁹ similar to the trends noted for the NHP3 that could reflect decreased responsiveness to small changes in QoL.¹⁰ Nevertheless, CWIS constitutes an appropriate tool for patients with chronic wounds and could be used alone or in concurrence with a generic tool. A summary of relevant studies is detailed in Table 1.

This review of the literature further clarifies the advantages and drawbacks of different kinds of HRQoL assessment tools. Condition-specific tools have advantages over generic ones by investigating items that are more relevant to the specific patient group and detecting small changes that are important to caregivers as well as patients.^11-13 On the other hand, generic HRQoL instruments might possess an advantage over disease-specific ones when it comes to assessing general variables that reflect QoL.⁷

Several authors postulated that different chronic conditions have unique profiles of HRQoL¹⁶ while other authors stipulated opposite results¹⁵ and recommended the use of generic tools.¹ Condition-specific tools focus directly on the symptoms of the disease but may be less sensitive than generic tools on aspects concerning a more general level of functioning. The choice between the 2 should depend on the research question, after it is clearly ascertained.¹⁶

Oren Weissman, MD; Josef Haik, MD, MPH; Noam Domniz, MD; Hadar Israeli Ben-Noon, MD; Omer Trivizki, MD; and Eyal Winkler, MD are from the Chaim Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel. Demetris Stavrou, MD is from the Chaim Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel and University of Nicosia Medical School, Nicosia, Cyprus.

Address correspondence to: Demetris Stavrou, MD University of Nicosia Medical School 44 Makedonitissas Ave 1700 Nicosia, Cyprus drstavrou@drstavrou.com

Disclosure: The authors disclose no financial or other conflicts of interest.