AJOPS | ORIGINAL ARTICLE

PUBLISHED: 24-09-2018

Measuring quality of life and patient satisfaction in hand

conditions
Kyra L Sierakowski MD BAppSci,1,3 Kathleen A Evans Sanchez BSc (Hons),1,3 Rachael A Damarell
BA, Grad Dip Info Stud,4 Nicola R Dean FRACS (Plas) PhD,1,3 Philip A Griffin MBBS FRACS (Plas),1
Gregory I Bain FRACS(Ortho) PhD2,3

1 Department of Plastic and Reconstructive Surgery Abstract

Flinders Medical Centre
Bedford Park, South Australia Background: Patient reported outcomes (PROs) are
AUSTRALIA important for the assessment of the effectiveness of
surgical interventions. If patient reported outcome
2 Department of Orthopaedic Surgery
measures (PROMs) are used to prioritise resources
Flinders Medical Centre
Bedford Park, South Australia
then it is important to ensure that the instruments
AUSTRALIA are scientifically valid. This review aims to assess
whether the currently available PROMs in hand
3 College of Medicine and Public Health
surgery adhere to international development
Flinders University
guidelines and whether they incorporate the use of
Bedford Park, South Australia
item response theory (IRT) or Rasch Analysis (RA).
AUSTRALIA

4 Gus Fraenkel Medical Library

Flinders University
Bedford Park, South Australia
AUSTRALIA
OPEN ACCESS
Correspondence
Name: Dr Kyra Sierakowski
Address: Department of Plastic and Reconstructive Surgery
Flinders Medical Centre
Flinders Drive,
Bedford Park, South Australia, 5042
AUSTRALIA
Email: Kyra.sierakowski@flinders.edu.au
Telephone: +61 431 306 997
Citation: Sierakowski KL, Evans Sanchez KA, Damarell RA,
Dean NR, Griffin PA and Bain GI. Measuring quality of life
and patient satisfaction in hand conditions. Aust J Plast
Surg. 2018;1(2):85–99.
Accepted for publication: 2 May 2018.
Copyright © 2018. Authors retain their copyright in the
article. This is an open access article distributed under
the Creative Commons Attribution Licence which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Methods: A systematic review was performed to
identify all PROMs that are relevant to the field
of hand surgery. An a priori protocol with strict
inclusion and exclusion criteria was followed. Only
instruments developed in the English language were
included. A comprehensive search of nine databases
was undertaken. The development methodology
of the identified instruments was then analysed,
followed by examination of the domain content and
initial psychometric validation of each instrument.
Results: A total of 3,039 article citations were
retrieved, 139 citations went on to a full text review.
A total of 24 patient reported outcome instruments
were identified. This consisted of 10 regional upper
limb, six hand and/or wrist specific and a further
eight condition specific instruments. Documentation
of the details of PROM development was lacking for
many instruments.
Conclusion: The field of hand surgery has many
instruments available but few fulfil international
development guidelines or use IRT or RA
psychometric techniques. There are limitations in
either the breadth of the domains explored or the
developmental methodology used in all currently
available instruments.

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Keywords: hand, psychometrics, patient reported
outcome measures, surveys and questionnaires,
treatment outcome
Background
In the current health landscape it is important to
collect meaningful information on the outcome of
interventions performed in order to justify their
value.1,2 Increasingly, outcome measurement is
broadening to include patient reported metrics
that gauge satisfaction and health-related quality
of life.3 In hand surgery, traditional indicators such
as mortality or rate of postoperative complications
are not sensitive enough to distinguish variations.4
Clinical measurements such as range of motion
or grip strength do not take into account the
patient’s perspective. Constructs such as pain, or
a patient’s perception of their ability, cannot be
directly measured and this is where self-reported
outcomes are useful.5 Patient reported outcomes
(PROs) have become an important contributor to
the overall picture of appraising outcomes at both
the individual and health service level. Therefore,
it is important that scientifically rigorous PROMs
are used when evaluating the impact of an injury
or disease and the associated treatment.6
Operative interventions that reduce symptoms,
improve functionality or change the appearance
of the hand produce effects that influence multiple
domains. As hands are a highly functional body
part, it is logical that measuring physical function
is a priority. However, hands are also integral
in much of our day-to-day ability to perform
in our social, professional and personal lives.
Questionnaires and instruments that are limited to
the measurement of only a single domain, such as
physical function, do not capture the full spectrum
of change produced by surgical or therapeutic
interventions.
For hand conditions, there are different categories
of PROMs: those that relate to the upper extremity
as a whole functional unit, those that focus on
the region of the hand (with or without the wrist)
and those that are focused on the symptoms and
disability that result from a specific pathology.
There are benefits to each of these approaches,
depending on the requirement for use. Ideally,
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instruments should be developed in keeping
with the internationally established criteria of
the scientific advisory committee of the Medical
Outcomes Trust (SAC) for health related outcome
measures.7
There is robust debate in the field of psychometrics
concerning the best methodology for PROM
development.8 Classical test theory (CTT) is being
increasingly overtaken by item response theory
(IRT) and Rasch analysis (RA).9 The benefits of IRT
and RA are numerous; they allow for both person
and item parameters to be placed on the same
scale and can be used to compare results between
different populations.
Methods
A systematic review of English-language literature
was performed using a broad range of relevant
databases to identify PROs developed for use in
patients with hand or upper limb conditions and/
or surgery. Search terms included: ‘quality of life’,
‘health related quality of life’, ‘quality adjusted
life years’, ‘health status’ or ‘functional status’
or ‘well being’ or ‘wellbeing’ or ‘patient reported
outcome’ or ‘PROM’ or ‘PRO’ or ‘PROS’. Other
search terms used included the specific names of
hand PROs: DASH (disabilities of the arm, shoulder
and hand), PRWE (patient-rated wrist evaluation)
MHQ (Michigan hand outcomes questionnaire),
PEM (patient evaluation measure), POS–Hand/
Arm (patient outcomes of surgery-hand/arm) and
PROMIS (patient-reported outcomes measurement
information system). The terms ‘hand’,
‘metacarpus’, ‘finger/s’, ‘wrist’, ‘thumb’ and ‘surg*’
were used to limit the results to the anatomical
region of interest: the hand.
Papers that had been published in peer-reviewed
literature and that discussed the development
or psychometric analysis of PROMs used in hand
conditions were included. Eligible instruments
were limited to hand or upper limb or conditions
specific to this region (for example, carpal tunnel,
Dupuytren’s disease). Relevant review articles were
also included using manual searching to identify
any missing PROMs evaluating quality of life,
impairment and disability or patient satisfaction
after hand surgery.
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Exclusion criteria were if an instrument was 1). Key publications describing each instrument’s
clinician reported (therefore not a true PRO development are listed in Table 1.
instrument) or if they were specific for an Tables 2a and 3a give a summary of each
anatomical site other than the hand (for example, instrument’s adherence to the development and
of the elbow or shoulder). Also excluded were validation criteria set by the SAC7 and the FDA
articles reporting on a non-English instrument.14 guidelines.15 Tables 2b and 3b summarise the
Instruments that were developed specifically for domain analysis of the identified instruments.
a subpopulation such as children, the elderly or
Figure 1: Search strategy and results
workers compensation claimants were likewise
excluded.
Two reviewers independently screened titles
and abstracts for duplicates, discussed any
discrepancies and established consensus. The lead
author conducted the full text review and data
extraction. Identified instruments were appraised
according to their adherence to SAC 7 and the
United States Food and Drug Administration (FDA)
guidelines.15 The consensus-based standards for
the selection of health measurement instruments
(COSMIN)16 checklist was not used as synthesis
of measurement properties was not the primary
interest of this review but rather the methodology
used for PROM development.
Information regarding the development process
and psychometric evaluation of the PROMs was
extracted from the articles. The identified PROMs
that met the inclusion criteria were then analysed
for content. In the case where more than one
version of a tool was available, all versions were
PROMs=patient-reported outcome measures
included in the analysis to ensure a thorough QoL=quality of life
PRO=patient-reported outcome.
review. Guidelines for preferred reporting items
for systematic reviews and meta-analyses were
adhered to where pertinent.17

Results
The search resulted in 3,039 papers after the
removal of duplicates. Following screening of titles
and abstracts, 139 relevant papers underwent full
text review. A total of 87 articles met the inclusion
criteria, 20 instruments were identified as being
relevant to hand surgery. Further searching
identified another four eligible instruments. In
summary, 24 instruments were identified; 16
regional instruments (consisting of 10 upper
extremity and six hand/wrist instruments) and
eight condition specific instruments (see Figure

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Table 1: Identified patient reported outcome instruments relevant to hand conditions and the key papers that
describe their development

Instruments Key publications

Upper extremity
DASH Disabilities of the arm, shoulder and hand Hudak 1996,18 Kennedy 201119
M2DASH Manchester modified DASH Khan 2008 and 200921, 22
MAM16 Manual ability measure16 Chen 200524
MAM36 Manual ability measure36 Chen 201025
POS-HA Patient outcome of surgery hand-arm Cano 200423
PROMIS-PF-UE Patient reported outcome measurement Hays 2013,28 Doring 201429
information system—physical function upper
extremity
QD Quick DASH Beaton 200520
UEFI Upper extremity functional index Stratford 200127
UEFI 15 Upper extremity functional index15 Hamilton 201313
ULFI Upper limb functional index Gabel 200626
Hand-wrist specific
BMHQ Brief Michigan hand outcomes questionnaire Waljee 20114
HAT Hand assessment tool Naidu 200932
MASS07 Modernised activity subjective survey Alexander 200834
MHQ Michigan hand outcomes questionnaire Chung 199830
PEM Patient evaluation measure Macey 199533
PRWHE Patient rated wrist/hand evaluation MacDermid 199631
Condition specific
6-CTS SS 6-item carpal tunnel syndrome symptom scale Atroshi 2009,9 Atroshi 201137
AUSCAN Australian/Canadian osteoarthritis hand index Bellamy 200239,40
BCTQ Boston carpal tunnel questionnaire Levine 199336
NELSON SCORE NELSON hospital score Citron 200742
SDSS Southampton Dupuytren's scoring scheme Mohan 201435
TASD Trapeziometacarpal arthrosis symptoms and Becker 201641
disability questionnaire
TDX Thumb disability exam Noback 20163
VAS-HAND Visual-analogue scale hand Massy-Westropp 200238

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Table 2a: Development and validation criteria—regional PRO instruments

Upper Extremity Hand /Wrist

Criteria DASH QD M2DASH POS-HA MAM16 MAM36 ULFI UEFI UEFI15 PROMIS MHQ BMHQ PRWHE HAT PEM MASS07
UEF

Item generation

Patient interviews • * • * •

Literature • • * • • * • • * * • * • • •

Expert opinion • • * • • * • * * • * • •

Develop conceptual model • * * • *

Item reduction

Expert opinion • • • • • • • • •

Item redundancy • • • • •

Endorsement frequencies • • • • • • • •

Missing data • • • •

Factor analysis • • • • • • •

Tests of scaling assumptions •

Rasch/item response theory • • •

Psychometric analysis

Acceptability • • • • • •

Internal consistency • • • • • • • • • • •
reliability

Item total correlations • • • • •

Interrater reliability

Test-retest reliability • • • • • • • • • • •

Validity within scale • • • • • • • •

Validity comparison with • • • • • • • • • • • • • •

other measures

Validity hypothesis testing • • • • • • • • • • • •

Responsiveness • • • • • • • •

* item generation based on pre-existing instrument

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Table 3a: Development and validation criteria—condition-specific PRO instruments

Criteria SDSS BCTQ 6 CTS SS Hand- AUSCAN TDX TASD NELSON

VAS Score
Item generation
Patient interviews • • • • • • •

Literature • • • •

Expert opinion • • • • •

Develop conceptual model

Item reduction

Expert opinion •

Item redundancy • • • •

Endorsement frequencies • • •

Missing data • •

Factor analysis • • • •

Tests of scaling assumptions

Item misfit (ra/irt)
Psychometric analysis
Acceptability • •

Internal consistency reliability • • • • • • •

Item total correlations •

Interrater reliability
Test-retest reliability • • • • • • •

Validity within scale • •

Validity comparison with other • • • • • • • •

measures
Validity hypothesis testing • • • •

Responsiveness • • • • • •

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Table 2b: Domain analysis—regional PRO instruments

Upper Extremity Hand/Wrist

DASH QD M2 POS-HA MAM 16 MAM 36 ULFI UEFI UEFI 36 PROMIS MHQ BMHQ PRWHE HAT PEM MASS 07
DASH UEF

Physical functioning

Limitations of whole upper limb • • • • • • • • • •

Limitations of hand/wrist • • • • • •

Limitations of hand/digits • • • • •

Limitations of thumb • • • • •

Ability to perform ADLs • • • • • • • • • • • • • • • •

Ability to use smart phone / • •

modern technology

Ability to work • • • • • • • • • •

Ability to travel • • • •

Ability to participate socially • • • • • • •

Symptoms

Pain issues • • • • • • • • •

Sensory changes (tingling/ • • • • • • •

numbness)

Stiffness • • • • • •

Swelling • • • • • •

Weakness • • • • • •

Reduced ROM • • •

Insomnia • • • • • • • •

Change in appetite •

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Upper Extremity Hand/Wrist

DASH QD M2 POS-HA MAM 16 MAM 36 ULFI UEFI UEFI 36 PROMIS MHQ BMHQ PRWHE HAT PEM MASS 07
DASH UEF

Health-related QOL

Satisfaction with treatment • •

Satisfaction with outcome/ • • • •

overall assessment

Inconvenience of medical/
hospital

Concerns re: post op •

complications/recovery

Expectations • •

Psychological functioning

Self confidence/self esteem • • •

Avoidance of uncomfortable •
situations

Negative feelings about self • •

Change in mood • • •

Body image

Concerns regarding scarring •

Self-consciousness • • • •

Satisfaction with hand • • • • • •

appearance

Sexual functioning • •

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Table 3b: Domain analysis—condition specific PRO instruments

SDSS BCTQ 6 CTS SS Hand- AUSCAN TDX TASD NELSON

VAS Score
Physical Functioning
Limitations of whole upper limb
Limitations of Hand / wrist • •
Limitations of Hand / digits • • • • • •
Limitations of Thumb • • • •
Ability to perform ADLs • • • • • •
Ability to use smart phone /
modern technology
Ability to work •
Ability to travel •
Ability to participate socially • • •
Symptoms
Pain issues • • • • • • •
Sensory changes (tingling/ • •
numbness)
Stiffness • •
Swelling •
Weakness • • • •
Reduced ROM • • •
Insomnia • • • •
Change in appetite • • •
Health-related QOL
Satisfaction with treatment
Satisfaction with outcome / • •
Overall assessment
Inconvenience of medical /
hospital
Concerns Re: post op
complications / Recovery
Expectations

Psychological functioning
Self confidence / self esteem
Avoidance of uncomfortable
situations
Negative feelings about self
Change in mood • •
Body Image
Concerns regarding scarring
Self-consciousness
Satisfaction with hand •
appearance
Sexual functioning

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Regional PROMS—upper extremity
Patient outcomes of surgery-hand/arm – POS–HA
The POS–HA developed by Cano et al6 in 2004 is
the only instrument identified in this review that
satisfies the gold-standard methodology of the
SAC.7 This instrument includes a post-surgery
component that asks the patient about their
satisfaction and whether expectations have been
met. However, the POS-HA does not employ IRT or
RA. Instruments that have been developed using
IRT or RA include: the manual ability measure
(MAM–16, MAM–36)24,25 PROMIS physical function
upper extremity or PROMIS PF–UE,28 and the upper
extremity functional index (UEFI–15)13,27 however,
these instruments are focussed mainly on function
and do not explore other domains as demonstrated
in Table 3a.
Disabilities of the arm, shoulder and hand – DASH,
QuickDASH and M2DASH
The DASH, developed in 1996, is designed as a
brief, self-administered instrument that measures
upper extremity disability at the individual
level.18 Content was developed from literature
review, expert panels and existing scales.15,18 A
shorter version, the QuickDASH, was developed
in 2005 using concept retention methodology.
It has been reported that neither instrument is
specific to the upper limb, with the DASH unable
to reliably differentiate between upper and lower
limb pathology if completed by an individual
with pathology in both regions.43,44 The M2DASH
(Manchester-modified DASH), developed in 2008,
was designed to alleviate this issue by the retention
of items that are upper limb-specific.21,22
Upper limb functional index—ULFI
The ULFI developed in 200626,45 is unique in that it
is composed of three sections including a patient-
specific index and a visual analogue scale rating
overall status.
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Regional PROMS—hand/wrist
Michigan hand outcomes questionnaire – MHQ and
BMHQ
The MHQ developed in 1998 is a hand-specific
outcomes instrument composed of 25 questions
to be answered for each hand and a further 12
questions relating to both hands, totaling 62
questions.46,47 These items are separated into six
domains: overall hand function, activities of daily
living, pain, work performance, aesthetics and
patient satisfaction with hand function. Each hand
is evaluated separately and this is the only PROM
identified that performs this analysis.46 The MHQ
has been developed using robust methodology,
however, information regarding item reduction
is minimal in the literature. The psychometric
validation of the MHQ has been thorough.30,46
The same developers produced the brief MHQ
(BMHQ) in 2011.4 Item reduction was performed
using a concept-retention technique that allows
items that are deemed to be clinically relevant
regardless of their statistical value. Two items were
retained from each scale, resulting in 12 items in
the BMHQ. The items selected were chosen based
on their correlation with the original MHQ score,
thus the psychometric properties of the original
MHQ are maintained. Unlike its forbearer, the
BMHQ does not differentiate between the hands.
Patient-rated wrist evaluation—PRWE
The PRWE was developed in 1996 to measure
the outcome following distal radius fracture.31 It
was developed from a survey of wrist experts to
determine the structure and content of the scale.
They identified the most important issues to be
pain, functional ability and patient satisfaction.31
The PRWE was modified to the PRWHE in 2004
by changing the word ‘wrist’ to ‘wrist/hand’
throughout the questionnaire.48
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Patient evaluation measure—PEM
The PEM developed in 1995 originated
from an international consensus meeting of
multidisciplinary hand surgery experts in Derby,
United Kingdom. There is no published detail on
the development process used for item generation,
item reduction or initial validation.49,50
Modern activity subjective survey – MASS07
The MASS07, developed in 2008, is designed to
specifically assess hand function during high-
frequency activities such as mobile phone or
computer use.34
Hand assessment tool - HAT
The HAT developed in 2009 measures activity
limitation for the hand, wrist and forearm axis. The
majority of items relate to function but some ask
about pain, hand appearance and sensory issues.
The HAT, MASS and the PRWHE do not assess
broader concepts such as patient satisfaction and
the psychological impact of the hand condition.
Condition-specific PROMs
Boston carpal tunnel questionnaire—BCTQ
The BCTQ, developed in 1993, is the original
condition-specific PROM relevant to hand surgery.
This instrument is composed of a symptom severity
scale and functional status scale. Atroshi shortened
the scale in 2009 using IRT to create the six-item
CTS.9
The Southampton Dupuytren’s scoring scheme
(SDSS) was developed in keeping with the
recommendations of the Derby outcomes
conference. For osteoarthritis patients, the
Australian-Canadian osteoarthritis hand index
(AUSCAN) was developed to measure pain, stiffness
and physical function using separate scales.
The only instrument specific to rheumatoid
arthritis was the visual analogue scale – hand
(VAS-Hand). This is a single item measure that asks
patients the impariment level due to rheumatoid
arthritis in their hands. The Nelson Hospital
score is specific for base of thumb arthritis but
has been widely criticised for employing poor
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methodological quality.41 In 2016, two alternative
instruments for this pathology were developed:
the thumb disability examination (TDX) and the
trapeziometacarpal arthrosis symptoms and
disability questionnaire (TASD).3,41 Both have used
sound techniques but neither have used IRT or RA
in their development processes.
Discussion
All of the instruments discussed in this review
aim to measure patients’ subjective experiences
of their hand surgery or hand condition. The
quality of the questionnaires is variable in terms
of their development and psychometric properties.
Despite the multitude of instruments that have
been identified, it remains the case that ‘no gold
standard, objective criterion measurement tools
for patient-rated hand outcomes exist’.46 The POS–
HA is the only instrument that has been developed
in accordance with the criteria of the SAC and FDA
guidelines.7,15,51
The most widely used PROM for the upper
limb is commonly accepted as the DASH.32 As
evident in Table 2a, this instrument fails to
reach accepted international guidelines15 due
to the lack of qualitative patient input during
development.52 Furthermore, it has been proven
to fail unidimensionality testing which is a
requirement for accurate measurement and, as a
result, the meaning of the overall DASH score is
compromised.53,54
The assessment of the upper limb as a whole
functional unit is attractive in terms of simplicity
of implementation, however, this approach results
in significant disadvantages. Instead of measuring
the effects of a given intervention on the hand,
the score may reflect other injuries or conditions
affecting the upper limb. Due to the frequency
of coexisting upper limb pathologies, the DASH
cannot discriminate the changes specific to the
intervention of interest.3 Due to the heterogeneity
of hand surgery, no single scale will be able
to measure clinically important change in all
treatments and therefore the use of a regional
instrument has the risk of marginalising the effects
of interventions.55 Another consideration is that the
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DASH is not specific for upper limb disability, as it
has been shown to reflect lower limb and cervical
spine pathology.21,44
Since the development of the most commonly used
hand PROMS in the 1990s, there has been much
progress in the field of psychometrics. Classical test
theory (CTT) is based on the assumptions that:
1. the more items on a scale, the less it will affect-
ed by random error
2. reliability and validity estimates are only ap-
plicable to the sample studied or a population
well represented by the sample, and
3. any changes to the scale would require re-eval-
uation of the psychometrics of the scale.56
Traditional instruments that are widely used, such
as the DASH, MHQ, PRWHE, provide scores in
ordinal format which is not suitable for measuring
change (ordinal data does not have consistent
spacing between digits and therefore measuring
change cannot be accurately performed). An
advantage of IRT and RA psychometric techniques
is that they produce an interval scoring system
which makes it mathematically sound to compare
measurement outcomes over time.13 These are also
suitable for use in clinical practice for individual
patients, as opposed to traditional instruments
which are only valid for use in comparing groups
of patients.
The transition away from traditional psychometric
techniques, used in the majority of the instruments
identified in this study, to those based on IRT
and RA (such as UEFI–15, MAM16, MAM36 and
the PROMIS PF–UE) has resulted in instruments
that are more scientifically sound and allow for
valid application between populations and more
meaningful measurement of change over time.
Condition-specific instruments
There has been an increase in the PROMs available
to measure the outcome of specific hand conditions
such as the BCTQ,36 SDSS35 and the TDX.3 Condition-
specific instruments are more sensitive to relevant
surgical intervention offering improved face
validity, less likelihood of missing data and more
appropriate measurement of change (although
few use interval format which makes measuring
change more scientifically robust). The difficulty
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with the implementation of condition-specific
instruments as a routine clinical measure is that,
in any given hand clinic, a whole suite of different
questionnaires would be required, each with their
own instructions, format and scoring systems. This
would simply not be practical in the majority of
hand services.
Hand aesthetics measures
The aesthetic appearance of the hands is an
important issue for many hand surgery patients;
particularly those with osteoarthropathies and
Dupuytren’s contracture.57,58 Hands are highly
visible within daily practices and anomalies of
the hands often draw unwanted attention. Despite
the acknowledged importance of this, there is no
accepted measure for hand aesthetics.57 Hand
aesthetics is a scale in the MHQ and a single question
in the PRWHE. A possible reason why a hand
aesthetics PROM has not been suitably explored
may be due to the objective of scale designers to
have a single overall score. Hand aesthetics may
not align itself with other measures of outcome
and thus is not suitable to be summed in with other
domains such as function or satisfaction.
Patient satisfaction
Patient satisfaction and the perioperative
experience is an area that is not adequately
explored by existing instruments. There are
several areas within hand surgery where the
functional outcomes between different surgical
approaches are deemed equivalent. Therefore,
the patient’s preference should be a consideration
in assessing which technique is used. Patient
satisfaction is a complex concept that is not
suitably measured by a single item, as has been
the common practice.59 Indeed, as Graham states,
‘it is crucial that we approach the measurement of
satisfaction with the same methodological rigour
and insight that we consider all of our clinical
outcomes’.59 Currently available PROMs that
attempt to measure patient satisfaction do not tend
to address the complexity of the concept. The PEM,
POS–HA and the MHQ all have a scale dedicated
to measuring patient satisfaction. The POS–HA
asks about scar lumpiness, the speed of recovery
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compared to patient expectation and whether
the patient would recommend the operation to a
friend with a similar issue. The MHQ has a cluster
of six questions exploring patient satisfaction with
their hand function, motion, strength, pain and
sensation. The PEM has three items that explore
patient satisfaction with hospital and their hand
and attempts to gauge whether the patient’s
expectations have been met given their original
injury.33 This is something that the field of hand
surgery needs to establish a better understanding
of so that we can improve the experience of hand
surgery for our patients.
This review has systematically examined
seminal papers on all identified PROMs with a
focus on instrument development. It does not
include all papers that have reported on the
use or measurement properties of the included
PROMs. In order to perform a comprehensive
review of the measurement properties of these
instruments a further review based on the COSMIN
recommendations would be required. This review
only included instruments developed in English
and this could certainly be considered a limitation
as it excluded instruments such as the measure of
manual ability in chronic stroke patients called
ABILHAND60 and Unité Rhumatologique des
Affections de la Main (URAM).14
Conclusion
Despite the number of PROMs that have been
developed for patients with hand conditions there
are few instruments that satisfy international
guidelines for PROM development. There are no
condition-specific instruments that have been
developed using IRT or RA. There is still much
work to be done in this field to achieve accurate,
clinically integrated outcome measurement.
There is need for an instrument to be developed
according to international guidelines, to allow
for measurement of all the concepts relevant to
patients with hand conditions.7,15 The use of IRT or
RA will result in interval level scores that can be
accurately used to measure change over time and
to compare scores across patient populations. This
would ensure that the most sensitive and specific
Australasian Journal of Plastic Surgery 97
AJOPS | ORIGINAL ARTICLE
scales are being used but with the convenience and
clinical utility of a single PROM system.
Disclosure
The authors have no financial or commercial
conflicts of interest to disclose.
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Australasian Journal of Plastic Surgery 99 Volume 1 Number 2 2018