The Modified Patient and Observer Scar Assessment Scale

Abstract

Sir:FigureWe read with great interest the article by Fearmonti et al.1 regarding their proposal to modify the Patient and Observer Scar Assessment Scale. The Patient and Observer Scar Assessment Scale is a comprehensive scale that was designed for professionals and patients to give a numerical impression of the quality of all types of scars. It was introduced by Draaijers et al. in 2004. This version is now denominated as version 1.0 (POSASv1.0).2 At that time, its clinimetric performance was tested on burn scars. With some modifications, the Patient and Observer Scar Assessment Scale version 2.0 was tested on linear scars, and the results were published by the Patient and Observer Scar Assessment Scale group in this Journal in 2005.3 Today, the Patient and Observer Scar Assessment Scale serves as a primary outcome parameter in many clinical trials, and others have recommended its use.4–6 Fearmonti et al. proposed modifications to the original Patient and Observer Scar Assessment Scale based on theoretical considerations, presenting it as a new scale, without any form of evidence such as a clinimetric study. As an example, it is questionable whether the addition of the term “pathologic” will improve the clinical significance of the scale. If the authors considered this to be such an important issue, they should have elaborated on this and they should have provided some form of evidence in the same article. However, their article does not include (or refer to) a study that supports their assumption. The authors also attempted to include quality-of-life components into a scale that measures scar quality. This may seem a logical choice, as quality of life and scar quality are highly related. However, from a clinimetric point of view, quality of life is a complex concept with multiple dimensions. If the authors are interested in “quality of life,” why not create a separate scale to use parallel to the Patient and Observer Scar Assessment Scale? Both scales could then be used in a multidimensional scale after extensive evaluation of reliability and validity. Examples of multidimensional scales with which to measure quality of life are the universally accepted 36-Item Short Form Health Survey, which has well-established clinimetric properties,7 and the Burn Specific Health Scale.8,9 Although the Patient and Observer Scar Assessment Scale is free to use, we feel that scar assessment scales, such as the Patient and Observer Scar Assessment Scale, should not be modified too easily because doing so will reduce their general applicability and may hamper their clinimetric performance. The Patient and Observer Scar Assessment Scale group is currently working on several evidence-based modifications of the scale.10 Furthermore, the Web site www.POSAS.org was recently launched to provide all necessary general information on using the Patient and Observer Scar Assessment Scale. We invite everyone who is interested in scar evaluation to discuss possible modifications. Martijn B. A. van der Wal, M.D. Burn Center, Red Cross Hospital and, Association of Dutch Burn Centers, Beverwijk, The Netherlands, Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands Annekatrien L. van de Kar, M.D. Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Centre, Amsterdam, The Netherlands, Red Cross Hospital, Beverwijk, The Netherlands Wim E. Tuinebreijer, M.D., Ph.D. Association of Dutch Burn Centers, Beverwijk, The Netherlands Lieneke J. Draaijers, M.D. Burn Center, Red Cross Hospital, Beverwijk, The Netherlands Esther Middelkoop, Ph.D. Burn Center, Red Cross Hospital and, Association of Dutch Burn Centers, Beverwijk, The Netherlands, Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands Paul P. M. van Zuijlen, M.D., Ph.D. Burn Center, Red Cross Hospital and, Association of Dutch Burn Centers, Beverwijk, The Netherlands, Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, and, Academic Medical Centre, Amsterdam, The Netherlands, Red Cross Hospital, Beverwijk, The Netherlands On behalf of the Patient and Observer Scar Assessment Scale Group