Wounds Measured From Digital Photographs
Traditional wound tracing technique consists of tracing the perimeter of the wound on clear acetate with a fine-tip marker, then placing the tracing on graph paper and counting the grids to calculate the surface area. Standard wound measurement technique for calculating wound surface area (wound tracing) was compared to a new wound measurement method using digital photo-planimetry software ([DPPS], PictZar® Digital Planimetry).
Methods. Two hundred wounds of varying etiologies were measured and traced by experienced examiners (raters). Simultaneously, digital photographs were also taken of each wound. The digital photographs were downloaded onto a PC, and using DPPS software, the wounds were measured and traced by the same examiners. Accuracy, intra- and interrater reliability of wound measurements obtained from tracings and from DPPS were studied and compared. Both accuracy and rater variability were directly related to wound size when wounds were measured and traced in the traditional manner.
Results. In small (< 4 cm), regularly shaped (round or oval) wounds, both accuracy and rater reliability was 98% and 95%, respectively. However, in larger, irregularly shaped wounds or wounds with epithelial islands, DPPS was more accurate than traditional measuring (3.9% vs. 16.2% [average error]). The mean inter-rater reliability score was 94% for DPPS and 84% for traditional measuring. The mean intrarater reliability score was 98.3% for DPPS and 89.3% for traditional measuring. In contrast to traditional measurements, DPPS may provide a more objective assessment since it can be done by a technician who is blinded to the treatment plan. Planimetry of digital photographs allows for a closer examination (zoom) of the wound and better visibility of advancing epithelium.
Conclusion. Measurements of wounds performed on digital photographs using planimetry software were simple and convenient. It was more accurate, more objective, and resulted in better correlation within and between examiners.
The treatment of acute and chronic wounds continues to be a challenge in the medical community. Today, a clinician has more choices than ever to select a particular treatment regimen for a patient. Investigating the wound etiology and classifying the wound is only the beginning of the decision process. Treatment decisions are based on clinical impressions and observations, most notably, the response of a wound to the chosen treatment. For most wounds, wound closure is the goal or end point that is desired by both clinicians and patients alike. Patients often become frustrated and disappointed with the process when wounds deteriorate or respond less than optimally during treatment. Patients and clinicians tend to forget the original presentation of the wound when the treatment plan is selected. Many weeks and months may pass during the treatment period of a chronic wound. The initial presentation and evaluation of a wound is important to archive and should include the wound morphology (size, shape, location, etc.) along with photographic documentation. Additionally, there are other reasons medically and legally to adequately record and archive wound images during treatment. Wound photographs and measurements provide a history, along with objective information by which progress, or lack thereof, can be monitored. More importantly, accurate wound measurements that signal improvement after 4–6 weeks may be a reliable predictor for complete healing. For example, the percent change in diabetic foot (neuropathic) ulcer surface area over 4 weeks of care predicts 12-week healing. In the retrospective analysis of data from a 203-patient diabetic foot ulcer trial, Sheehan et al demonstrated that 91% of patients who healed at 12 weeks had been correctly diagnosed as likely to heal based on their 4-week reduction in wound surface area. In pressure ulcers, a 39% reduction in ulcer surface area during the first 4 weeks of care predicts more expedient (less complicated) healing. In a non-selected population of venous ulcer patients, a 50% reduction in wound area within 6 weeks was a robust predictor (93% sensitivity) of complete closure within 12 weeks. Furthermore, a retrospective analysis of a large multicenter venous ulcer trial to establish prognostic factors for healing concluded that ulcers that were slow to heal (< 40% decrease in surface area) after 3 weeks are unlikely to heal rapidly and might benefit from alternative therapies. The predictability of healing based on reduction in wound area after weeks can help determine if a patient should continue with standard wound care, requires more advanced wound care therapy, or whether the goals for treatment should be modified to include other non-healing (palliative) endpoints.
Reimbursement is another reason to record accurate, serial wound measurements. Medicare and insurance companies require wound surface dimension data to determine the amount to pay for specialized (advanced) treatments, such as negative pressure wound therapy (NPWT), specialty support surfaces, and bioengineered skin constructs. Today, the US Centers for Medicare & Medicaid Services (CMS) reimbursement for wound debridement is based on the total surface area and not on the number of wounds debrided.
Abstract and Introduction
Abstract
Traditional wound tracing technique consists of tracing the perimeter of the wound on clear acetate with a fine-tip marker, then placing the tracing on graph paper and counting the grids to calculate the surface area. Standard wound measurement technique for calculating wound surface area (wound tracing) was compared to a new wound measurement method using digital photo-planimetry software ([DPPS], PictZar® Digital Planimetry).
Methods. Two hundred wounds of varying etiologies were measured and traced by experienced examiners (raters). Simultaneously, digital photographs were also taken of each wound. The digital photographs were downloaded onto a PC, and using DPPS software, the wounds were measured and traced by the same examiners. Accuracy, intra- and interrater reliability of wound measurements obtained from tracings and from DPPS were studied and compared. Both accuracy and rater variability were directly related to wound size when wounds were measured and traced in the traditional manner.
Results. In small (< 4 cm), regularly shaped (round or oval) wounds, both accuracy and rater reliability was 98% and 95%, respectively. However, in larger, irregularly shaped wounds or wounds with epithelial islands, DPPS was more accurate than traditional measuring (3.9% vs. 16.2% [average error]). The mean inter-rater reliability score was 94% for DPPS and 84% for traditional measuring. The mean intrarater reliability score was 98.3% for DPPS and 89.3% for traditional measuring. In contrast to traditional measurements, DPPS may provide a more objective assessment since it can be done by a technician who is blinded to the treatment plan. Planimetry of digital photographs allows for a closer examination (zoom) of the wound and better visibility of advancing epithelium.
Conclusion. Measurements of wounds performed on digital photographs using planimetry software were simple and convenient. It was more accurate, more objective, and resulted in better correlation within and between examiners.
Introduction
The treatment of acute and chronic wounds continues to be a challenge in the medical community. Today, a clinician has more choices than ever to select a particular treatment regimen for a patient. Investigating the wound etiology and classifying the wound is only the beginning of the decision process. Treatment decisions are based on clinical impressions and observations, most notably, the response of a wound to the chosen treatment. For most wounds, wound closure is the goal or end point that is desired by both clinicians and patients alike. Patients often become frustrated and disappointed with the process when wounds deteriorate or respond less than optimally during treatment. Patients and clinicians tend to forget the original presentation of the wound when the treatment plan is selected. Many weeks and months may pass during the treatment period of a chronic wound. The initial presentation and evaluation of a wound is important to archive and should include the wound morphology (size, shape, location, etc.) along with photographic documentation. Additionally, there are other reasons medically and legally to adequately record and archive wound images during treatment. Wound photographs and measurements provide a history, along with objective information by which progress, or lack thereof, can be monitored. More importantly, accurate wound measurements that signal improvement after 4–6 weeks may be a reliable predictor for complete healing. For example, the percent change in diabetic foot (neuropathic) ulcer surface area over 4 weeks of care predicts 12-week healing. In the retrospective analysis of data from a 203-patient diabetic foot ulcer trial, Sheehan et al demonstrated that 91% of patients who healed at 12 weeks had been correctly diagnosed as likely to heal based on their 4-week reduction in wound surface area. In pressure ulcers, a 39% reduction in ulcer surface area during the first 4 weeks of care predicts more expedient (less complicated) healing. In a non-selected population of venous ulcer patients, a 50% reduction in wound area within 6 weeks was a robust predictor (93% sensitivity) of complete closure within 12 weeks. Furthermore, a retrospective analysis of a large multicenter venous ulcer trial to establish prognostic factors for healing concluded that ulcers that were slow to heal (< 40% decrease in surface area) after 3 weeks are unlikely to heal rapidly and might benefit from alternative therapies. The predictability of healing based on reduction in wound area after weeks can help determine if a patient should continue with standard wound care, requires more advanced wound care therapy, or whether the goals for treatment should be modified to include other non-healing (palliative) endpoints.
Reimbursement is another reason to record accurate, serial wound measurements. Medicare and insurance companies require wound surface dimension data to determine the amount to pay for specialized (advanced) treatments, such as negative pressure wound therapy (NPWT), specialty support surfaces, and bioengineered skin constructs. Today, the US Centers for Medicare & Medicaid Services (CMS) reimbursement for wound debridement is based on the total surface area and not on the number of wounds debrided.
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