one sn s2210.052402.(0/0, Conti © 18 by Te Wiame & Wikns Co Vol. 22,No.10 Prine US A Burn Specific Health Scale BETSY BLADES, M.S.W., NICK MELLIS, M.A. ano ANDREW M. MUNSTER, MD. ‘The outcome of burn care is conventionally measured in terms of mortality. ‘To extend our understanding beyond this level, and specifically to develop insight into the morbidity and other sequelae of burn injury, we have constructed a Burn-Specific Health Scale (BSHS). The scale is composed of 114 items, based on the selection of items from a much larger pool by a group of professional and patient judges. The seale has been utilized to quantify dysfunction and distress across six ‘major domains of health. Preliminary internal consistency and reliability testing of the scale has proved satisfactory. ‘We present here the results of testing in 40 initial patients, with the following conclusions: 1) The psychosocial performance of patients with major ‘burns lags behind their performance in other areas, and we need to explore alternate clinical strategies for their support; 2) The BSHS can be used to determine both individual and group performance and needs for interven! 3) The postbura recovery is dynamic and undergoes marked changes for a prolonged period of time, at least 1 year post-hospitalization: this must be ‘considered when such patients are being evaluated for various purposes, ¢4 disability. In a previous published study (1), we demonstrated the feasibility of measuring the quality of life in survivors, of severe burn injury. Conventional mortality statistics alone do not provide sufficient information about the outcome of an injury in which the mortality rate is relatively low. Further, mortality statistics are unlikely to provide sufficient information on which to base changes in the clinical program, to compare the perform: ance of specialty centers for burn therapy or burn centers compared with community hospitals. Following our pilot, studies, we attempted to identify or develop an instru- ‘ment that would be widely acceptable to burn care pro- vviders, and this report is on our preliminary experience with the development, reliability testing, and field testing of this instrument. We made a number of basic assumptions in the devel- ‘opment of the Burn Specific Health Scale (BSHS). First, that the instrument should not rely on the patient's preinjury level of functioning, since this is almost impos- sible to validate. Second, that the scale should be com- prehensive, yet that it should be self-administered and short enough to assure patient compliance and accept- ance by other professionals, The questions we attempted From the Department of Surgers, The Johns Hopkins University School of Medicine, Baltimore Regional Burn Center, Baltimore Cy Hospitals, Baltimore, Maryiand, ‘Presenvd atthe Fourteenth Annual Meeting ofthe Americen Burn Association in Boston, Massachusetts, 13 May 1982 ‘Address for reprints Andrew M. Monster, M.D, Baltimore Regional Burn Center, Baltimore City Hospital, 440 Eastern Avenue, Balt ‘more, MD 21224 to answer, among others, included: 1) Could a single already existing instrument or combination of instru: ments meet these criteria and at the same time be relevant to the assessment of performance of burn pa: tients, with their special problems; 2) What domains of performance should be included in the comprehensive evaluation of a burn patient. MATERIALS AND METHODS After a review of existing measures of health, three validated and established instruments were selected: The Sickness Impact Profile (3), a 136-item inventory de- signed to measure health status in a general population; the Index of Activities of Daily Living (4), a six-item ‘measure of physical functioning, and the General Well- Being Schedule (2), a 64-item scale which is strongly psychologically oriented. A list of items from these measures was compiled. A survey of burned patients and Burn Center staff gener- ‘ated an additional 160 items that were felt to provide additional relevant information not included in the three general scales, This latter group was designated the ‘burn-specific items.” ‘The complete catalog of 369 items was circulated to a ‘group of 85 judges composed of both professionals in the field of burn treatment and rehabilitation, and a group of, former patients stratified by time postburn and by burn site, The judges were assigned the task of rating each item on an 1l-point seale according to its relevance in assessing the postburn performance of patients. ‘This anVol. 22, No. 10 process, as well as the relevant statistical maneuvers utilized during the analysis of the judges’ data, are de- scribed in detail elsewhere (5). Briefly, the 80 items which received the highest top median ratings by all the judges were used as the nucleus for the new BSHS; these 80 items contained portions of all three established scales submitted to the judges, as well as a substantial number of the burn-specific items. The 80 items fell into six major domains and a larger number of subdomains which we felt defined the comprehensiveness of the scale. In order to assign each subdomain a minimum of items for the purpose of statistical analysis, and to increase the preci- sion of the measurements, some items were added to the TABLET SHS domains and subdomains 1 Physical health ABurn Specific Health Scale 873 domains or expanded. A general health category was also ‘added based on literature more recently available (6). ‘The resulting 114 items comprise the Burn Specific Health Scale which is currently undergoing reliability and validity testing. Table I shows the scale’s principal domains and subdomains and the number of items in each. The vast majority (94) of these items are rated on ‘a 5-point scale (from 4= extremely to 0= not at all) according to the patient's level of agreement with the descriptor and the item. Bight items are rated yes/no, or ‘a 2-point scale, and 12 items relate to sexual function. Six of these question the patient’s own performance, the other six his concept of ‘ideal’ performance. Final ratings for the sexual health items are assigned according to the patient's performance compared with his own judgment of ideal. ‘The scale is self administered. Items are worded both negatively and positively, but since the direction of the scoring reflects dysfunction, appropriate corrections are made, in grading, of positive items. The final score is Motil 4 & Sereare 7 then expressed as a per cent of the maximam. Some @, Hand fenton representative illustrations of questions from the BSHS 4. Skin cenition 3 are shown in Table I ape w “The scale has been tested on an initial convenience IL Body image Hd sample of 40 adult burn patients interviewed after dis IV. Psychological health (affective) 6 charge from the Baltimore Regional Burn Center. All V. Social health 6 patients had flame burns (chemical, electrical, and scald i Sez eath u ‘bam patients were excluded from this initial analysis for ed Zz the sake of greater uniformity). All had suffered a com- Tet bination of second- and third-degree burns of more than inate Deveriptors and selected items from BSHS a Domino Sonne How much difcly do you have wit =a Diver Bpoine(O-— 1 Signing your name (hyena fenton) 8 Bathing tnependentty ‘Srouealal ca) 2 {phonation ‘To what extent do the following statements describe you? Bites point 25" atay home mat ofthe ne (physicl/mobitty 31 ike dong thing wth fiends (roca 89, At times think {have hat an emotional problem isener Towhat extent do the folowing statements Ges the 1witems 5 points (0-4) wey you fa? 41" Tam not happy with the way perform my duties onthe (physica activites) Fob ora ome 42. Ldonot ike the way my family acts toward me (sci eat) Hw much are you bothered tems point (9 hn (physcal/skin condition) 1 Your general appearance tbe image) 1 Th ey pone rene 308 tet age) 8, Thowthts or mage of your secient irvebslonelatectiv) 5 Feeling being ety ate ycolgealatectiv) -Anowor "Yes" No? tote following statements items 2 points 1) {0 Twork in ny jb performing my dates (niall activin £6. Ihave someone to whom can el my problems (ci ea) During the pet several months hw en id Jo items Sprint (0-8) 163" Hove sexual thoughts or fanesoe {08 Intercourse ‘What wuld be voor eal rien for he following items 9 points (0-8) 108. Sexual thoughts oF fantasies 114, Intercourse874 The Journal of Trauma 10% total body surface. Informed consent was obtained from each participant. RESULTS: ‘Table III shows the preliminary alpha coefficients of internal consistency /reliability analysis. The coefficients are good to excellent in five of six domains, with one domain (family relationships) in the fair to acceptable range. ‘Table IV summarizes the clinical material and the ‘mean scores and ranges of all patients. In this analysis, tthe last 12 items (103-114) of the seale, measuring sexual function, have not been included, and data given deal only with the first 102 items, The mean score was further divided into an analysis of scores by domain, and here we concentrated on the three domains found by internal consistency analysis to be ‘measuring with the highest degree of reliability, ie., the physical, the psychological (affective), and the body-im- age domains. Patients with burns exceeding 40% total body surface had the highest mean scores of dysfunction, but this was not statistically significant when compared with groups of patients with burns under 40% except in, the psychological (affective) and body-image domains, when patients with larger burns had significantly higher scores of dysfunction (<0.05). The postburn time of this, ‘group was greater (> 12 months). As indicated in Table V, comparing the scores of patients grouped by time postburn, patients who were tested less than 6 months postburn (Group 1) had a significantly smaller burn size than each of the other groups. The difference in burn size between patients tested at 6-12 months (Group Il) and those tested at over 1 yr (Group III) is not significant, but the difference TABLE TT Preliminary internal consistency/ domains of BSHS (N = 40) ibility estimates for 6 ‘Physical health 2 = 2 6 Family/social relationships 56 TABLE IW Overall results xe Mean ange ‘Age ‘Sig (18-55 yes), Burn size 902% 11-80%) "Time postburn B52 weeks (4-107 wha) Physical domain" pr our) Psychological domain® a49% 29.99) Body image domain* 138 (0-85.20) ‘Total sere (102 items)* 267% (3548) * Scores expressed as % of maximum possible point in each area October 1982 Pay Group by Tine Body (Burn Physi clog Poaturn) nwa She ME mae Sah T12monthe G38 1t 326161 43.7%) p< 005 Group Fv. Hand Group Tvs. {p= 005 Group I va. Tand Group HT yx TL {Ep © 0005 Group II va Tand Group 1 v1 {8p < 001 Group It vs T and Group TM vs. 1 in psychological dysfunction is highly significant (from 25A% to 61.3%, p < 0.005) while there is no significant difference in the physical domains. These data suggest the dynamic nature of recovery from the impact of burn injury. ‘Table VI indicates the scores by burn site, comparing patients with burns including the face and/or hands with patients who sustained dominantly trunk/lower extrem- ity burns. The total % burn of patients in the face/hand group is somewhat higher than the others, although not, significantly so. The significantly higher dysfunction of the patients with face/hand burns (p < 0.01) is greatly attributable to differences in the psychological domain (p < 0.025) and the body-image domain (<0.01). ‘There were no significant differences in any of our analyses attributable to sex or marital status. DISCUSSION ‘At this point in the development and testing of the Burn Specific Health Scale, we feel that some of our initial questions have been answered; others have been raised. We confirm, based on the 35-judge survey which, initiated the development of our instrument, that it is necessary to include items from a variety of sources rather than a single existing validated seale to provide a comprehensive measure of health for this particular pa- tient population, We have determined the definition of comprehensiveness by the domains of performance judged to be relevant, ‘The precise composition of our scale, item by item, will need to be revised as more data continue to be accumu- lated. Additional tests will be required to establish inter- nal consistency estimates of the subdomains within the psychological and physical domains. In the family rela- tions domain, items which are ambiguous and lower the correlation coefficient will have to be identified. Analysis of sexual health will be the subject of a later report, as well as the correlation of scores with other demographic and preburn considerations we are currently collecting. ‘Test-retest reliability and external validation measure- ments are being currently conducted.Vol. 22, No. 10 TABLE VI Scores by burn site —__ MewnScores rece * oa SE tas ty tne St MS wg ae Be el ee p< 001 NS. p<0095 p<00t NS._NS. Perhaps the most valuable potential use of the BSHS is in indicating the need for change in the treatment program. The fact that patients with hand and face burns, and particularly patients more than a year post- bur, have a significantly higher dysfunction in their psychological health and body image domain indicates the need to explore alternate strategies for psychosocial ‘treatment and support particularly in this patient popu- lation. The effectiveness of intervention can then be A Burn Specific Health Seale 875 monitored with the BSHS group scores. The ranges of, scores and the patients’ acceptance of the scale indicate its potential use in identifying individual treatment needs and progress. Finally, treatment facilities which provide different treatment programs can be evaluated and com- pared by utilizing group scores. Ultimately, such meas- urements could be utilized to evaluate the performance of, and the need for additional, specialized centers for, the management of burn injuries. REFERENCES 1. Blades, B.C: Jones, C, Munster, A.M: Quality of life after major ‘Duras J. Trauma, 19: 556-558, 1973 2. DaPuys, H. S: The General Well Being Schedule (Research Ka uot). National Center for Heath Statistics, June, 1878 8. Gilton, B.S, Gison, J. Bergner, Metal: The Sickness Impact ‘Profile: Development ofan outcome measure of health care. Ar. J. Publ. Health 8: 1904-1310, 1975. 4. Kat, 8, Ford, AB, Moskowitz, RW, etal: Stuies of ness in the aged, The index of ADL. A.M, 185: 914-917, 1963, unster, A.M, Blades, B, Mamon, J, etal: Development of an ‘outcome sale for burns Methods, problems and prospect. In Proceedings om Critical Iasues in Medical Technology. Boston, “Auburn Press, in pres, 1982 6, Ware, d-C, Brook, K. H., Davies Avery, A. otal: Conceptualiza ‘don and’ Measurement of Health For Adults in the Health Insurance Study. Vol 1. Model of Health & Methodology, Rand Comp, May, 1980,