
Previous scar assessment tools have not consistently considered or reflected the patient's point of view. While most burn practitioners recognize the importance of the patient's own subjective thoughts about their scars, few of the available scar rating methods consider the patient's perspective. A study of 20 adult burn victims with 37 scars by Martin et al 16 comparing a rehabilitation therapist's rating of the scar using the Vancouver scar scale and the patient's subjective assessment of the scar found poor correlation between therapist and patient ratings, especially early after injury. Unlike the Vancouver scar scale, the patient and observer scar assessment scale does in fact include an important extra dimension, which is the patient's opinion that is mandatory for complete scar evaluation. 8 The importance of gender and scar location on patient's perceptions of their scars has been studied by a number of investigators. For example, women with burn scars generally have a more negative body image than men with burn scars. 17 Another study found that burns on visible areas of the body were perceived as worse than those that could be covered with clothing. 18 In contrast, Andreasen and Norris 17 did not find an association between subjective scar perceptions and body location. Patient preferences are also important when determining which therapies work best for them. Nilsson et al 19 studied burn patient preferences with regards to the method of sedation during painful procedures and found that patients preferred patient controlled sedation to sedation administered by an anesthesiologist. In addition, nurses also considered wound care easier with patient controlled vs anesthesiologist-controlled sedation.
The notion that patient and practitioner priorities and preferences may not be similar is further highlighted by a survey aimed at determining whether the reconstructive goals of children with burns are similar to those of their parents and practitioners. This study found that the children with burns indicated fewer and different desired reconstruction sites than their physicians or parents. 20 To determine the anticipated relative importance of a variety of outcomes and aspects related to burn care and their possible association with patient and burn characteristics, a formal survey of burn patients was conducted.
METHODS

Study Design
A standardized, structured survey was used to determine the relative importance of various aspects of burn care and healing among burn patients. The study was approved by our institutional review board, and all patients, or their legal representatives, gave written informed consent.
Setting and Patients
The study was conducted at a 600-bed suburban academic tertiary care medical center with an eightbed burn unit that admits approximately 175 burn patients a year. Our center serves a population of over 1.5 million residents. Our burn service maintains an ongoing longitudinal prospective burn registry that was established in 2008 and funded by our local Volunteer Firefighters Fund. All patients with any type of burn injury presenting to our burn service were eligible for inclusion in this study.
Measures and Outcomes
A standardized, structured, data collection form including demographic (e.g., age, gender, race), clinical, and burn characteristics (e.g., location, cause, size, depth) was completed on all study patients during their first visit with the burn service, early after injury. Patients were then asked to complete a survey regarding their personal perception of the anticipated importance of various burn outcomes. Patients were asked to rate the importance of cosmetic appearance, function, or absence of pain and/ or itching each using a four-point Likert scale including the following options: not important, important, very important, and extremely important. These general categories of burn outcomes were chosen based on their inclusion in previously reported burn outcome scales, such as the Vancouver and patient and observer scar assessment scales.
4-8

Data Analysis
Categorical data were summarized as the percentage frequency of occurrence. Continuous data were summarized using means, SDs, and 95% confidence intervals. Comparisons were performed using χ 2 or nonparametric tests as appropriate. Multivariate analysis was used to explore the association between potential predictor variables (such as age, gender, TBSA, and burn location) and patient anticipated priorities with respect to burn outcomes.
RESULTS
During the study period, 776 patients were included in the institutional burn registry. A summary of patients' demographic characteristics is shown in Table 1 . Patient mean (SD) age was 30 (22) years; 58% were males; 69% were white. A total of 94% of the burns were thermal, 2% were chemical, 2% were electrical, and 2% were of unspecified cause. The most common types of thermal burns were scalds (49%), flame (25%), and contact burns (24%). Burn location is presented in Table 2 and included extremities (72%), trunk (14%), and head/neck (14%). The median TBSA burned was 3% (interquartile range: 1-5%, range: 1-90%).
Surveys on anticipated priorities regarding burn outcomes were completed by 753 of the 776 patients (97%). Overall, the ability to return to normal function was extremely important to 96% of patients, the lack of pain and/or itching was extremely important to 85% of patients, and the cosmetic appearance of the burn was extremely important to 59% of patients. Further information concerning patient priorities is presented in Table 3 .
The appearance of the burn was extremely important to more females than males (69 vs 52%; P < .001) and the mean age of patients in whom cosmesis was extremely important was lower than those in whom it was not (25 vs 40; P < .001). The cosmetic appearance of the burns was more commonly extremely important in head/neck than extremity burns (67 vs 57%; P < .001). Levels of importance for function and lack of pain and/or itching did not differ by gender, age, TBSA, or burn location.
DISCUSSION
The results of our study in nearly 800 patients who sustained burns and were treated by a burn service over a 6-year period indicate that early after injury burn victims anticipate that what will matter most to them, in descending order of importance, are resumption of normal function, pain-and itch-free recovery and the cosmetic appearance of their burn scars. Furthermore, patient preferences and priorities with regards to burn outcomes were associated with some but not all demographic and burn characteristics. The cosmetic appearance of the burns was more important to females, younger patients, and those with burns located on their head or neck. In contrast, the importance of function and pain-and itch-free recovery did not differ by gender, age, burn size, or burn location.
Traditionally, there has been little involvement of burn victims in determining priorities in both the medical care and research agenda of burn practitioners. A survey of 224 participants comparing the research priorities of burn survivors and practitioners found considerable overlap, especially with regards to biomedical and clinical research on wound healing and scar management. 21 However, there were differences with regards to the importance of research Location of burn (patients may have burns in more than one location). on the treatment of itching and edema on scars and donor sites. Also burn survivors put greater emphasis on psychosocial aftercare. A previous study 22 evaluated patient priorities with traumatic lacerations among 724 patients, of whom 53% had a previous traumatic laceration. The most important aspects of care in descending order were achieving restoration of normal function (28%), avoiding infection (20%), scar aesthetics (17%), and pain-free healing (17%). These findings are similar to those found in this study in patients with burns.
Our study has several limitations. First, we only assessed patient preferences within the first few days after injury. As the burns heal and the patient comes to terms with and adjusts to their injury, these preferences may evolve or change. Thus, we only measured the anticipated importance of the various burn aspects. Second, we lumped pain and itching together as a single category and did not distinguish between the two subjective characteristics. It is possible that patients may have rated the relative importance of pain and itching differently. Third, our study is limited to a single center of mostly affluent, English-speaking patients, which may not reflect the opinions, or perceptions of other demographic groups. Another serious limitation is the small average TBSA of 3%. This makes the findings less generalizable to larger burns.
In conclusion, early after injury patients with burns anticipate that function and pain-/itch-free recovery are more important to them than the cosmetic appearance of their burns. The cosmetic appearance of burns appears to be more important in women, younger patients, and in those with burns located over their head and neck area. Patient priorities should be considered when caring for burn victims.

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