Validation of Self-Reported Caprini Risk Assessment Score to Empower Urdu Speakers

Dear Sirs:

Venous thromboembolism (VTE), defined as deep vein thrombosis, and or pulmonary embolism affects an estimated 300,000-600,000 individuals in the U.S. each year, causing considerable morbidity and mortality. ¹ Nonfatal PE and DVT, not only cause post-operative mortality but also can cause long-term complications including pulmonary hypertension, chronic venous insufficiency, venous congestion, and chronic leg swelling. Risk assessment is the first step in preventing death and disability from VTE. Reducing the occurrence of VTE in postoperative patients is imperative in reducing long-term health complications, thus encouraging positive patient outcomes. Global public awareness is substantially lower for pulmonary embolism (54%) and deep-vein thrombosis (44%) than heart attack (88%) and stroke (85%). ² The Caprini Risk Assessment Score (CRS) is a risk assessment tool that has been tested and validated with more than 5 million patients across 250 studies. The tool is widely used to predict postoperative VTE in the Western world but has limited utility among resource-poor and developing countries such as Pakistan due to the limited English proficiency of potential instrument users. Urdu is the national language of Pakistan and is spoken by nearly 70 million people worldwide. Currently, there are no similar risk assessment tools available in the Urdu language.

Our study intended to translate the CRS tool to Urdu and validate its use in the Urdu-speaking population via the correlation of self-administered and healthcare professional-administered scores. Our study was modeled after a similar study conducted by Paz-Rio et al ³ in 2018, where a team of physicians validated a patient-completed CRS for Spanish, Arabic, and Polish speakers with excellent correlation and agreement when compared to the CRS completed by a trained physician.

The CRS was first translated into the Urdu language by a professional agency called Metaphrase. Our study utilized both qualitative and quantitative methods for conduction of the research. A qualitative analysis was conducted from August to September of 2021 which entailed two focus group interviews. A total of six participants were recruited for this phase. All six participants were fluent in both English and Urdu languages. In this phase, challenges associated with the translated CRS were identified. Data saturation was achieved with the identification of approximately twenty terms as “unclear”. Those terms/phrases were then modified and incorporated into the final translation version. The quantitative approach (validation phase), conducted from September to December 2021 included 30 participants who were recruited through a local community center. All 30 participants were native/fluent Urdu speakers. Self-administered CRS scores were compared to the score obtained by the APN administered CRS to the same participants, where the APN was blinded to the participants’ original answers. These answers were then compared using Pearson's correlation.

A multi-rator analysis was conducted to further test the reliability of the Urdu-translated CRS tool. Five experts in the medical field rated the relevance of each item on the CRS translated scale based on their experience and medical practice. Items were rated as not relevant, somewhat relevant, quite relevant, and highly relevant. Statistical analysis was performed using the SPSS v.23 to calculate the Pearson's correlation coefficient between patient- and APN-administered scores. Cronbach alpha coefficient was used to analyze the content validity index using five experts.

Conclusions

We translated and validated the only Urdu version of the patient-completed Caprini DVT risk assessment tool by utilizing rigorous reliability (Cronbach's alpha of .86) and validity procedures (High Content Validity Index and statistically significant Pearson's rho, p = <.01). The provision of this tool in the native Urdu language can help to avoid adverse clinical outcomes such as fatal pulmonary embolisms, especially among high-risk patients. This will allow for patients’ empowerment and increase shared decision-making as patients’ knowledge and comprehension levels improve with the use of the Urdu version of the tool. This study can be a springboard for a larger study in Pakistan with more participants and also for people with below-high school level education.