Motivational interviewing to improve adherence behaviours for the prevention of diabetic foot ulceration

Exploring the psychosocial burden of foot complications in diabetes: A cross-sectional survey and qualitative interview study in a United Kingdom coastal community

BACKGROUND

Foot complications in diabetes are common and destructive, resulting in substantial healthcare costs and high rates of morbidity. Coastal areas have a significantly higher burden of disease. People with diabetes experience disproportionately high rates of psychological health issues, including anxiety, depression and diabetes distress. These can affect self-management and concordance with preventive measures and treatments of foot complications, negatively impacting on outcomes. Access to psychological health services is variable across the United Kingdom and there is a paucity of high-quality evidence for the effectiveness of treatments for diabetes distress. This study aimed to explore experiences of psychosocial burden and perceptions and experiences of psychosocial support, among patients with diabetes and foot complications living in a coastal area.

METHODS

Patients were eligible to participate if they had experienced diabetes-related foot complications (amputation, ulceration and/or Charcot neuroarthropathy) within the last 5 years and scored positive for diabetes distress on a validated screening tool (DDS2). Eligible patients completed cross-sectional questionnaires describing symptoms of diabetes distress (DDS17), anxiety (GAD-7) and depression (PHQ-9) and to take part in a face-to-face, semi-structured interview. Questionnaires were analysed using frequencies and interviews were analysed using reflexive thematic analysis.

RESULTS

A total of 183 patients completed the DDS2 screening questionnaire. Of these, 56 (30.6%) screened positive for diabetes distress. Twenty-seven patients completed DDS17, GAD-7 and PHQ-9 questionnaires. Eleven (40.7%) participants indicated high levels of diabetes distress and four (14.8%) indicated moderate distress. Seventeen participants (age range 52-81 years; 12 men) took part in an interview. Four key themes were identified: impact of living with foot problems; emotional consequences of foot problems; experiences and perceptions of psychological support; and strategies to cope with the emotional impact of foot problems.

CONCLUSION

Diabetes distress was prevalent among patients with diabetes-related foot complications. Foot problems impacted on participants' daily activities, social lives and ability to work. Despite expressing feelings of ongoing fear, worry and depression relating to their foot problems, only one participant had accessed formal psychological support. Many participants relied on talking to podiatrists at routine appointments and described developing various strategies to cope. The psychosocial burden of living with foot complications in diabetes must not be overlooked by health professionals. Findings from this study can inform the design of future services and interventions.

Health Promotion Models for Improving Footcare in Older Adults: A Scoping Review

INTRODUCTION

Footcare is an important component of wellbeing in older adults and the promotion of appropriate footcare interventions is imperative for health professionals working with this population. In this scoping review, we describe the health promotion models informing footcare interventions for older adults. The objectives were to (i) understand the context(s) where health promotion models have informed footcare interventions; (ii) identify the health promotion models informing interventions; and (iii) document the effectiveness of theoretically informed health promotion interventions for improving footcare in older adults.

METHODS

Footcare interventions developed using health promotion models worldwide and published in English before July 2023 were searched using MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar.

RESULTS

A total of 2,078 articles were identified, of which 31 were retrieved and assessed for eligibility. Eight articles met the eligibility criteria, with most interventions delivered in Asia (n = 5) and using self-efficacy theory as their theoretical framework (n = 6). Most of the studies included people with diabetes (n = 6) and outcomes were measured using foot health outcomes, knowledge of foot health, and footcare behaviors and self-efficacy.

CONCLUSION

This scoping review has identified a range of footcare interventions, with evidence of promising outcomes on improving footcare in older adults. Approaches toward methods and dosage of intervention varied across the studies and more broadly, we identified that few studies report the health promotion model informing the design of intervention(s). Further research is required to ascertain which health promotion model, modality of promotion, and implementation approach are the most effective for improving footcare in older adults.

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

AIMS

Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.

MATERIALS AND METHODS

We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability.

RESULTS

For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice.

CONCLUSION

These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

The quest for wellness: How to optimise self-care strategies for diabetic foot management?

Diabetic foot ulceration (DFU) is common and highly recurrent, negatively impacting the individuals' quality of life. The 2023 guidelines of the International Working Group on the Diabetic Foot emphasise that adherence to foot self-care recommendations is one of the most important factors in DFU prevention. These guidelines also briefly mention that depression and other psychosocial problems can hamper treatment and ulcer healing. Moreover, a new clinical question was added on psychological interventions for ulcer prevention, although the evidence regarding the role of psychological and social factors is still limited. To help the field progress, this narrative overview discusses how a stronger focus on psychological factors by both researchers and clinicians could improve the care for people at high DFU risk. The review starts with a testimony of a person living with DFU, explaining that for him, the absence of shared decision-making has been a key barrier to successful foot self-care implementation. Intervention studies that address patient-reported barriers are still scarce, and are therefore urgently needed. Furthermore, the key elements of psychological interventions found to be successful in managing diabetes are yet to be implemented in DFU risk management. Importantly, research evidence indicates that commonly advocated foot self-care recommendations may be insufficient in preventing DFU recurrence, whereas digital technology appears to effectively reduce recurrent DFU. More research is therefore needed to identify determinants of patient acceptance of digital technology.

Whole versus hole: enabling community nurses to implement holistic wound care

OBJECTIVE

To improve wound-related quality of life (QoL) in clients with hard-to-heal wounds in their lower limbs and to increase referrals to multidisciplinary teams in the management of care for these clients.

METHOD

This was a quality improvement project with a two-group pretest-posttest interventional evaluation design. We implemented a package of interventions including the WounDS app, education related to wound care, and client engagement through a QoL self-assessment. Wound-related QoL was measured using the Cardiff Wound Impact Schedule and referrals to the multidisciplinary team were tracked through chart audits. We explored nurses' experiences with the interventions through semi-structured interviews.

RESULTS

Clients' average ratings for 'wellbeing', 'physical symptoms and daily living', and 'overall QoL' improved by 27%, 38% and 54%, respectively. The number of referrals increased by 78% post intervention. Nurses described the interventions as effective strategies that motivated them to implement a holistic approach to care.

CONCLUSION

The project was successful in creating a culture shift to practice holistic wound care. This package of interventions (WounDS app, education and client self-assessment of QoL) led to improvements in the QoL of clients with hard-to-heal wounds. Further studies are needed to generalise the findings. Strategies for sustainability include forming a champion group and providing the education and decision supports based on nurses' educational needs assessment.

Mobile Application for Adhering to Diabetic Foot Self-care: Randomized Controlled Clinical Trial

This study aimed to analyze the effectiveness of a mobile application for adherence to foot self-care in people with type 2 diabetes at risk for diabetic foot ulcer. A double-blind randomized controlled clinical trial was conducted with people with type 2 diabetes in a secondary healthcare unit. A total of 42 patients were recruited, matched, and allocated into two groups: one (intervention group) undergoing standard nursing consultations and application use and the other (control group) receiving only standard nursing consultations. The outcome variable was the adherence to foot self-care, measured by completing questionnaires on diabetes self-care activities and adherence to foot self-care. Measures of central tendency and dispersion were calculated, in addition to bivariate associations, considering a significance level of P ≤ .05. The intragroup and intergroup analyses regarding diabetes self-care did not show statistical significance; however, the intervention group showed a considerable increase in the frequency of daily assessments ( P = .048) and adherence to foot self-care ( P = .046). The use of the app, combined with the nursing consultation, increased adherence to foot self-care of people with type 2 diabetes. Brazilian Registry of Clinical Trials: U1111-1202-6318.

Perceptions of Australians with diabetes-related foot disease on requirements for effective secondary prevention

INTRODUCTION

Secondary prevention is essential in reducing recurrence of diabetes-related foot disease (DFD) but is frequently poorly implemented in clinical practice.

OBJECTIVE

To explore the perceptions of people with diabetes-related foot disease (DFD) on their self-perceived knowledge in managing DFD, facilitators and barriers influencing their DFD care, and ideas and preferences for a secondary prevention program.

DESIGN

Sixteen people with a history of DFD from Queensland and Victoria, Australia, underwent semi-structured interviews. Interviews were audio-recorded over telephone and transcribed and analysed following a thematic framework. Participants were asked about their experiences and perceptions relating to DFD and factors influencing the care they receive for DFD relevant to the development of a secondary prevention program for DFD.

FINDINGS AND DISCUSSION

Participants had high self-perceived knowledge in managing DFD, especially in implementing healthy lifestyle changes and conducting daily foot checks and foot care, though most received support from family members acting as carers. However, issues with access and adherence to offloading footwear, and a lack of clear education received on footwear and other aspects of DFD care were perceived as major barriers. Improved patient education, provided in a consistent manner by proactive clinicians was perceived as an essential part of secondary prevention. Telehealth was perceived positively through facilitating faster care and considered a good adjunct to standard care. Health and technological literacy were considered potentially major barriers to the effectiveness of remote care.

CONCLUSION

People with DFD require improved access to offloading footwear and education about secondary prevention, which could be provided by telehealth with adequate support.

A Comprehensive Therapeutic Patient Education May Improve Wound Healing and Reduce Ulcer Recurrence and Mortality in Persons With Type 2 Diabetes

OBJECTIVES

The impact of a comprehensive therapeutic patient education (TPE) on the prognosis of diabetic foot ulcer (DFU) has not yet been evaluated in the literature. The purpose of this study was to determine whether TPE is a predictor of outcome in type 2 diabetes patients with DFU.

METHODS

We evaluated 583 consecutive individuals with a recent and single DFU. They were treated and followed for 42.8±23.3 months. Patients were divided into 2 groups. The TPE group included subjects who had been receiving regular sessions of a comprehensive TPE, including a specific foot care education (FCE), for at least 12 months before DFU occurred (n=129). The non-TPE group comprised the remaining subjects (n=454). All 583 patients received intensive FCE during the treatment period.

RESULTS

We identified a significantly higher percentage of healed DFUs (96.0% vs 74.9%; p<0.0001) and a lower percentage of major amputations (0.8% vs 4.4%; p=0.0511), minor amputations (1.6% vs 12.3%; p=0.0003), DFU persistence (1.6% vs 8.4%; p=0.0069) and deaths (1.6% vs 21.4%; p<0.0001) in the TPE group than in the non-TPE group. Among 464 patients with healed ulcers, the proportion of subjects with re-ulceration was greater in the non-TPE group than in the TPE group (48.8% vs 6.5%; p<0.0001). Multivariate analysis showed that TPE can predict healing (odds ratio [OR], 4.202; 95% confidence interval [CI], 1.604 to 11.004; p=0.0035) and may significantly reduce DFU recurrence (OR, 0.093; 95% CI, 0.043 to 0.201; p<0.0001) and mortality (OR, 0.096; 95% CI, 0.022 to 0.410; p=0.0016).

CONCLUSION

A comprehensive TPE may have a positive impact on wound healing, ulcer recurrence and mortality in people with DFU.

Reliability of the evidence to guide decision-making in foot ulcer prevention in diabetes: an overview of systematic reviews

Background

Reliable evidence on the effectiveness of interventions to prevent diabetes-related foot ulceration is essential to inform clinical practice. Well-conducted systematic reviews that synthesise evidence from all relevant trials offer the most robust evidence for decision-making. We conducted an overview to assess the comprehensiveness and utility of the available secondary evidence as a reliable source of robust estimates of effect with the aim of informing a cost-effective care pathway using an economic model. Here we report the details of the overview. [PROSPERO Database (CRD42016052324)].

Methods

Medline (Ovid), Embase (Ovid), Epistomonikos, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE), and the Health Technology Assessment Journals Library were searched to 17th May 2021, without restrictions, for systematic reviews of randomised controlled trials (RCTs) of preventive interventions in people with diabetes. The primary outcomes of interest were new primary or recurrent foot ulcers. Two reviewers independently extracted data and assessed the risk of bias in the included reviews.

Findings

The overview identified 30 systematic reviews of patient education, footwear and off-loading, complex and other interventions. Many are poorly reported and have fundamental methodological shortcomings associated with increased risk of bias. Most concerns relate to vague inclusion criteria (60%), weak search or selection strategies (70%) and quality appraisal methods (53%) and inexpert conduct and interpretation of quantitative and narrative evidence syntheses (57%). The 30 reviews have collectively assessed 26 largely poor-quality RCTs with substantial overlap.

Interpretation

The majority of these systematic reviews of the effectiveness of interventions to prevent diabetic foot ulceration are at high risk of bias and fail to provide reliable evidence for decision-making. Adherence to the core principles of conducting and reporting systematic reviews is needed to improve the reliability of the evidence generated to inform clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01738-y.

The Effect of Foot Care Education for Patients with Diabetes on Knowledge, Self-Efficacy and Behavior: Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to synthesize randomized controlled trials on the impact of foot care education on knowledge, self-efficacy and behavior in patients with diabetes. A search was made using PubMed, Web of Science, Science Direct, Google Scholar, YOK National Thesis Center and Google Scholar electronic databases for studies published between March 2003-January 2022. The search medical subject headings (MeSH) terms were diabetic foot, knowledge, self-efficacy, and behavior. Studies suitable for the systematic review and the meta-analysis met the following criteria (PICOS): target participants would be diagnosed with diabetes (population), diabetic foot education (intervention), comparison of the group receiving diabetic foot care education and routine care education, and the control group receiving only routine care education (comparison), studies evaluating the levels of knowledge, self-efficacy and behavior (outcome), randomized controlled trials (study design). Twenty-six studies were included in systematic review. Three studies for knowledge, 5 studies for behavior, 8 studies for self-efficacy were included in the meta-analysis (total sample: 2534, experiment: 1464, control: 1071). All of the studies had low reporting bias. The mean duration of educations for knowledge was 5.2 months. This duration was 4.8 months for behavior and 4.5 months for self-efficacy. In the random effect (since the homogeneity test: P < .001, this model was used), there were significantly difference in terms of knowledge (standardized mean difference (SMD): 1.656, 95% [CI]: 1.014-2.299, P < .001), and behavior (SMD: 1.045, 95% CI: 0.849-1.242, P < .001). But no difference was observed in terms of self-efficacy (SMD: 0.557, 95%CI: -0.402-1.517, P > .05). The results of a systematic review of twenty-six studies and a meta-analysis of 9 studies showed that diabetic foot education improved the level of knowledge and behavior of patients with diabetes, while not affecting their self-efficacy. Educational interventions with long-term follow-up are needed to address the growing health care needs of patients with diabetes.

Site-Specific, Critical Threshold Barefoot Peak Plantar Pressure Associated with Diabetic Foot Ulcer History: A Novel Approach to Determine DFU Risk in the Clinical Setting

Background and Objectives: Barefoot peak plantar pressures (PPPs) are elevated in diabetes patients with neuropathic foot ulcer (DFU) history; however, there is limited reported evidence for a causative link between high barefoot PPP and DFU risk. We aimed to determine, using a simple mat-based methodology, the site-specific, barefoot PPP critical threshold that will identify a plantar site with a previous DFU. Materials and Methods: In a cross-sectional study, barefoot, site-specific PPPs were measured with normal gait for patients with DFU history (n = 21) and healthy controls (n = 12), using a validated carbon footprint system. For each participant, PPP was recorded at twelve distinct plantar sites (1st–5th toes, 1st–5th metatarsal heads (MTHs), midfoot and heel), per right and left foot, resulting in the analysis of n = 504 distinct plantar sites in the diabetes group, and n = 288 sites in the control group. Receiver operator characteristic curve analysis determined the optimal critical threshold for sites with DFU history. Results: Median PPPs for the groups were: diabetes sites with DFU history (n = 32) = 5.0 (3.25–7.5) kg/cm², diabetes sites without DFU history (n = 472) = 3.25 (2.0–5.0) kg/cm², control sites (n = 288) = 2.0 (2.0–3.25) kg/cm²; (p < 0.0001). Diabetes sites with elevated PPP (>6 kg/cm²) were six times more likely to have had DFU than diabetes sites with PPP ≤ 6 kg/cm² (OR = 6.4 (2.8–14.6, 95% CI), p < 0.0001). PPP > 4.1 kg/cm² was determined as the optimal critical threshold for identifying DFU at a specific plantar site, with sensitivity/specificity = 100%/79% at midfoot; 80%/65% at 5th metatarsal head; 73%/62% at combined midfoot/metatarsal head areas. Conclusions: We have demonstrated, for the first time, a strong, site-specific relationship between elevated barefoot PPP and previous DFU. We have determined a critical, highly-sensitive, barefoot PPP threshold value of >4.1 kg/cm², which may be easily used to identify sites of previous DFU occurrence and, therefore, increased risk of re-ulceration. This site-specific approach may have implications for how high PPPs should be investigated in future trials.

Effectiveness of at-home skin temperature monitoring in reducing the incidence of foot ulcer recurrence in people with diabetes: a multicenter randomized controlled trial (DIATEMP)

INTRODUCTION

The skin of people with diabetic foot disease is thought to heat up from ambulatory activity before it breaks down into ulceration. This allows for early recognition of imminent ulcers. We assessed whether at-home monitoring of plantar foot skin temperature can help prevent ulcer recurrence in diabetes.

RESEARCH DESIGN AND METHODS

In this parallel-group outcome-assessor-blinded multicenter randomized controlled trial (7 hospitals, 4 podiatry practices), we randomly assigned people with diabetes, neuropathy, foot ulcer history (<4 years, n=295), or Charcot's neuro-arthropathy (n=9) to usual care (ie, podiatric treatment, education, and therapeutic footwear) or usual care plus measuring skin temperatures at 6-8 plantar sites per foot each day (enhanced therapy). If ∆T>2.2°C between corresponding sites on the left and right foot for two consecutive days, participants were instructed to reduce ambulatory activity until this hotspot disappeared and contact their podiatrist. Primary outcome was ulcer recurrence in 18 months on the plantar foot, interdigital, or medial/lateral/anterior forefoot surfaces; secondary outcome was ulcer recurrence at any foot site.

RESULTS

On the basis of intention-to-treat, 44 of 151 (29.1%) participants in enhanced therapy and 57 of 153 (37.3%) in usual care had ulcer recurrence at a primary outcome site (RR: 0.782 (95%CI 0.566 to 1.080), p=0.133). Of the 83 participants in enhanced therapy who measured a hotspot, the 24 subsequently reducing their ambulatory activity had significantly fewer ulcer recurrences (n=3) than those in usual care (RR: 0.336 (95% CI 0.114 to 0.986), p=0.017). Enhanced therapy was effective over usual care for ulcer recurrence at any foot site (RR: 0.760 (95% CI 0.579 to 0.997), p=0.046).

CONCLUSIONS

At-home foot temperature monitoring does not significantly reduce incidence of diabetic foot ulcer recurrence at or adjacent to measurement sites over usual care, unless participants reduce ambulatory activity when hotspots are found, or when aiming to prevent ulcers at any foot site.

TRIAL REGISTRATION NUMBER

NTR5403.

Factors influencing diabetes self-management in adults: an umbrella review of systematic reviews

OBJECTIVE

The objective of this review was to identify and describe the factors influencing diabetes self-management in adults by summarizing the available evidence concerning their types, categories, and relative importance.

INTRODUCTION

A wide range of factors, acting simultaneously, influence diabetes self-management and interfere with its actual application by patients. There is a variety of systematic reviews of these factors; however, a more thorough examination of their influences was lacking.

INCLUSION CRITERIA

Systematic reviews of qualitative or quantitative literature focusing on factors influencing adult diabetes self-management in general or on individual behaviors (ie, management of oral antidiabetic medication and insulin injections, self-monitoring of blood glucose, foot care, healthy eating, regular exercise, and smoking cessation) will be included.

METHODS

We performed an extensive search of 11 bibliographic databases, including gray literature, up to June 2019. Quantitative and qualitative findings were summarized separately and labeled according to their types (eg, facilitator/barrier, strength and direction of association), categories (eg, demographic, social), and frequency of occurrence.

RESULTS

We identified 51 types of factors within 114 systematic reviews, which mostly addressed medication-taking behavior. Thirty-two (62.7%) factors were reported in both qualitative and quantitative literature. The predominant influences were psychological factors and behavioral attributes/skills factors. The most frequently reported facilitators of diabetes self-management were motivation to diabetes self-management, a favorable attitude to diabetes self-management, knowledge about the disease, medication and behaviors associated with diabetes self-management, skills, and self-efficacy/perceived behavioral control. The predominant barriers were the presence of depression, and polypharmacy or drug regimen complexity. The demographic factor of female sex was frequently reported for its negative influence on diabetes self-management, whereas older age was a positive factor. The social/cultural and physical environment were the least-studied categories. Other factors such as social support from family, friends, or networks; interventions led by health professionals; and a strong community environment with good social services favoring diabetes self-management were reported as major facilitators of diabetes self-management.

CONCLUSIONS

Essential components of interventions to promote effective diabetes self-management should aim to help adults manage the effects of specific factors related to their psychological and practical self-management experience. Screening for depression, in particular, should become an integral part of the support for adult diabetes self-management, as depression is a particular obstacle to the effectiveness of diabetes self-management. Future studies should more deeply examine the influence of factors identified in the sociocultural and physical environment categories. Research should properly consider and invest efforts in strengthening social support and innovative community care approaches, including pharmacist- and nurse-led care models for encouraging and improving adult diabetes self-management. Finally, researchers should examine non-modifiable factors - age, sex, or socioeconomic status - in the light of factors from other categories in order to deepen understanding of their real-world patterns of action on adult diabetes self-management.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018084665.

Harnessing Digital Health Technologies to Remotely Manage Diabetic Foot Syndrome: A Narrative Review

About 422 million people worldwide have diabetes and approximately one-third of them have a major risk factor for diabetic foot ulcers, including poor sensation in their feet from peripheral neuropathy and/or poor perfusion to their feet from peripheral artery disease. The current healthcare ecosystem, which is centered on the treatment of established foot disease, often fails to adequately control key reversible risk factors to prevent diabetic foot ulcers leading to unacceptable high foot disease amputation rate, 40% recurrence of ulcers rate in the first year, and high hospital admissions. Thus, the latest diabetic foot ulcer guidelines emphasize that a paradigm shift in research priority from siloed hospital treatments to innovative integrated community prevention is now critical to address the high diabetic foot ulcer burden. The widespread uptake and acceptance of wearable and digital health technologies provide a means to timely monitor major risk factors associated with diabetic foot ulcer, empower patients in self-care, and effectively deliver the remote monitoring and multi-disciplinary prevention needed for those at-risk people and address the health care access disadvantage that people living in remote areas. This narrative review paper summarizes some of the latest innovations in three specific areas, including technologies supporting triaging high-risk patients, technologies supporting care in place, and technologies empowering self-care. While many of these technologies are still in infancy, we anticipate that in response to the Coronavirus Disease 2019 pandemic and current unmet needs to decentralize care for people with foot disease, we will see a new wave of innovations in the area of digital health, smart wearables, telehealth technologies, and “hospital-at-home” care delivery model. These technologies will be quickly adopted at scale to improve remote management of diabetic foot ulcers, smartly triaging those who need to be seen in outpatient or inpatient clinics, and supporting acute or subacute care at home.

Risk assessments and structured care interventions for prevention of foot ulceration in diabetes: development and validation of a prognostic model

BACKGROUND

Diabetes-related foot ulcers give rise to considerable morbidity, generate a high monetary cost for health and social care services and precede the majority of diabetes-related lower extremity amputations. There are many clinical prediction rules in existence to assess risk of foot ulceration but few have been subject to validation.

OBJECTIVES

Our objectives were to produce an evidence-based clinical pathway for risk assessment and management of the foot in people with diabetes mellitus to estimate cost-effective monitoring intervals and to perform cost-effectiveness analyses and a value-of-information analysis.

DESIGN

We developed and validated a prognostic model using predictive modelling, calibration and discrimination techniques. An overview of systematic reviews already completed was followed by a review of randomised controlled trials of interventions to prevent foot ulceration in diabetes mellitus. A review of the health economic literature was followed by the construction of an economic model, an analysis of the transitional probability of moving from one foot risk state to another, an assessment of cost-effectiveness and a value-of-information analysis.

INTERVENTIONS

The effects of simple and complex interventions and different monitoring intervals for the clinical prediction rules were evaluated.

MAIN OUTCOME MEASURE

The main outcome was the incidence of foot ulceration. We compared the new clinical prediction rules in conjunction with the most effective preventative interventions at different monitoring intervals with a 'treat-all' strategy.

DATA SOURCES

Data from an electronic health record for 26,154 people with diabetes mellitus in one Scottish health board were used to estimate the monitoring interval. The Prediction Of Diabetic foot UlcerationS (PODUS) data set was used to develop and validate the clinical prediction rule.

REVIEW METHODS

We searched for eligible randomised controlled trials of interventions using search strategies created for Ovid® (Wolters Kluwer, Alphen aan den Rijn, the Netherlands), MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Randomised controlled trials in progress were identified via the International Standard Randomised Controlled Trial Number Registry and systematic reviews were identified via PROSPERO. Databases were searched from inception to February 2019.

RESULTS

The clinical prediction rule was found to accurately assess the risk of foot ulceration. Digital infrared thermometry, complex interventions and therapeutic footwear with offloading devices were found to be effective in preventing foot ulcers. The risk of developing a foot ulcer did not change over time for most people. We found that interventions to prevent foot ulceration may be cost-effective but there is uncertainty about this. Digital infrared thermometry and therapeutic footwear with offloading devices may be cost-effective when used to treat all people with diabetes mellitus regardless of their ulcer risk.

LIMITATIONS

The threats to the validity of the results in some randomised controlled trials in the review and the large number of missing data in the electronic health record mean that there is uncertainty in our estimates.

CONCLUSIONS

There is evidence that interventions to prevent foot ulceration are effective but it is not clear who would benefit most from receiving the interventions. The ulceration risk does not change over an 8-year period for most people with diabetes mellitus. A change in the monitoring interval from annually to every 2 years for those at low risk would be acceptable.

FUTURE WORK RECOMMENDATIONS

Improving the completeness of electronic health records and sharing data would help improve our knowledge about the most clinically effective and cost-effective approaches to prevent foot ulceration in diabetes mellitus.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016052324.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 62. See the NIHR Journals Library website for further project information.

Meta-analyses of randomized controlled trials reporting the effect of home foot temperature monitoring, patient education or offloading footwear on the incidence of diabetes-related foot ulcers

AIM

The aim of this study was to perform an up-to-date systematic review and meta-analysis of randomized controlled trials (RCTs) examining the efficacy of home foot temperature monitoring, patient education and offloading footwear in reducing the incidence of diabetes-related foot ulcers.

METHODS

A literature search was performed using MEDLINE, PubMed, CINAHL, Scopus and Cochrane databases to identify relevant original studies. Meta-analyses were performed using intention-to-treat principals for worst (main analysis) and best (sub-analysis) case scenarios. Leave-one-out sensitivity analyses were used to assess the consistency of findings.

RESULTS

Of 7575 unique records, 17 RCTs involving 2729 participants were included. Four tested home foot temperature monitoring (n = 468), six examined patient education (n = 823) and seven assessed offloading footwear (n = 1438). Participants' who performed home foot temperature monitoring [odds ratio (OR) 0.51, 95% confidence interval (CI) 0.31 to 0.84; n = 468] and those provided offloading footwear (OR 0.48, 95% CI 0.29 to 0.80; n = 1438) were less likely to develop a diabetes-related foot ulcer. Patient education programmes did not significantly reduce diabetes-related foot ulcer incidence (OR 0.59, 95% CI 0.29 to 1.20; n = 823). Sensitivity analyses suggested that offloading footwear findings were consistent, but home foot temperature findings were dependent on the individual inclusion of one trial. All RCTs had either high or unclear risk of bias.

CONCLUSION

This meta-analysis suggests that offloading footwear is effective in reducing the incidence of diabetes-related foot ulcers. Home foot temperature monitoring also appears beneficial but larger trials are needed (PROSPERO registration no.: CRD42019135226).

A collaborative approach in patient education for diabetes foot and wound care: A pragmatic randomised controlled trial

Foot care education is an important strategy in reducing lower limb complications. There is evidence that contemporary communication approaches can improve patient education outcomes. To inform the potential of such methods in diabetic foot education, we trialled a collaborative approach in patient education counselling in a podiatry clinic. We conducted a single-blind pragmatic randomised controlled trial on 52 diabetes patients who had an active foot ulcer. Participants were randomised to either collaborative education or traditional didactic education. Outcomes on knowledge and self-care behaviours were collected via a pre and post study questionnaire (max score: 75). The study ended at 12 weeks or when the wound healed prior. 42 (80.7%) participants completed the study. The collaborative patient education group had a significant increase in score post-study (38.8 ± 8.5) compared to pre-study (32.8 ± 6.9; P < .001). The control group had no significant increase in score post study. The difference in scores between groups had a moderate effect size (d = 0.54). The use of a collaborative approach in patient education was able to produce significantly greater increase in knowledge retention and self-care behaviours, without the need for additional consultation time in a podiatry clinic.

Factors influencing Australian podiatrists' behavioural intentions to adopt a smart insole into clinical practice: a mixed methods study

BACKGROUND

Diabetes is the leading cause of lower limb amputation in Australia, costing the Australian health care system an estimated A$1.6 billion annually. Podiatrists are the primary foot health care provider in Australia. Research suggests that health professional attitudes can impact patient utilisation of e-health technologies, such as wearable foot monitoring devices aimed at preventing foot ulceration. The aim of this study was to explore factors that impact the intentions of Australian podiatrists to adopt smart insole foot monitoring technology.

METHODS

A mixed methods explanatory sequential design was undertaken. One hundred and eleven Australian podiatrists completed an online version of the validated Unified Theory of Acceptance and Use of Technology (UTAUT) questionnaire. Multiple regression analysis was used to determine the strongest predictive model of podiatrists' behavioural intention to adopt technology. Additionally, two focus groups were conducted, and thematic analysis was performed to explore podiatrists' perceived barriers and enablers to smart insole adoption.

RESULTS

One hundred and eleven Australian podiatrists completed the online UTAUT questionnaire. The majority of respondents practiced in the private sector (58.6%) and were female (50.5%), with Victoria the most common practice location (39.6%). Significant positive correlations existed between behavioural intention and six psychosocial domains including performance expectancy (r = 0.64, p < 0.001), effort expectancy (r = 0.47, p < 0.001), attitude (r = 0.55, p < 0.001), social influence (r = 0.45, p < 0.001), facilitating conditions (r = 0.36, p < 0.001), and self-efficacy (r = 0.30, p < 0.002). Multiple regression analysis determined that performance expectancy alone was most predictive of behavioural intention to adopt a smart insole into clinical practice (adjusted R2 = 42%, p < 0.001). Qualitative analyses revealed that podiatrists believed that the insole would increase patient knowledge, engagement and self-efficacy. However, concerns were raised about cost, footwear issues and the device's utility with elderly and remote populations.

CONCLUSIONS

Performance expectancy was the most important psychosocial factor predicting the intentions of Australian podiatrists to adopt smart insole foot monitoring technologies. While Australian podiatrists are open to adopting smart insoles into clinical practice, evidence of the device's efficacy is a precursor to adoption. Other perceived barriers to adoption including device cost, compatibility with off-loading, footwear issues and patient age also need to be addressed prior to implementation and clinical adoption.

The role of foot pressure measurement in the prediction and prevention of diabetic foot ulceration-A comprehensive review

The predominant risk factor of diabetic foot ulcers (DFU), peripheral neuropathy, results in loss of protective sensation and is associated with abnormally high plantar pressures. DFU prevention strategies strive to reduce these high plantar pressures. Nevertheless, several constraints should be acknowledged regarding the research supporting the link between plantar pressure and DFUs, which may explain the low prediction ability reported in prospective studies. The majority of studies assess vertical, rather than shear, barefoot plantar pressure in laboratory-based environments, rather than during daily activity. Few studies investigated previous DFU location-specific pressure. Previous studies focus predominantly on walking, although studies monitoring activity suggest that more time is spent on other weight-bearing activities, where a lower "peak" plantar pressure might be applied over a longer duration. Although further research is needed, this may indicate that an expression of cumulative pressure applied over time could be a more relevant parameter than peak pressure. Studies indicated that providing pressure feedback might reduce plantar pressures, with an emerging potential use of smart technology, however, further research is required. Further pressure analyses, across all weight-bearing activities, referring to location-specific pressures are required to improve our understanding of pressures resulting in DFUs and improve effectiveness of interventions.

PoDFEd: Podiatrists and Diabetes Footcare Education Survey - How do Australian podiatrists provide diabetes education?

BACKGROUND

Podiatrists provide care and education to people with diabetes. This often includes the use of education relating to complications of the disease and how to prevent them. It is currently unknown how Australian podiatrists provide this education. This study aimed to describe the foot related diabetes education being delivered to people with diabetes within the Australian podiatry setting.

METHODS

This cross-sectional cohort study contacted Australian podiatrists to complete an online survey regarding their provision of diabetes education. The Qualtrics online survey application was advertised to Australian podiatrists via social media, at state conferences and through the Australian Podiatry Association and other similar association group emails. A multivariate stepwise progression was utilised to collate and decipher data. A chi-squared test was used to determine significant links between podiatrist's method of education, demographic variables and topics of education.

RESULTS

Findings linked the use of visual, written, generic handout and individualised handouts to various components of education and demographic information of Australian podiatrists. Verbal education had no significant links to demographic and topics of education relating to diabetes.

CONCLUSIONS

This paper discovered a range of topics covered and methods used by Australian podiatrists during consultations with patients with diabetes.

Preventing foot ulceration in diabetes: systematic review and meta-analyses of RCT data

AIMS/HYPOTHESIS

Foot ulceration is a serious complication for people with diabetes that results in high levels of morbidity for individuals and significant costs for health and social care systems. Nineteen systematic reviews of preventative interventions have been published, but none provides a reliable numerical summary of treatment effects. The aim of this study was to systematically review the evidence from RCTs and, where possible, conduct meta-analyses to make the best possible use of the currently available data.

METHODS

We conducted a systematic review and meta-analysis of RCTs of preventative interventions for foot ulceration. OVID MEDLINE and EMBASE were searched to February 2019 and the Cochrane Central Register of Controlled Trials to October 2018. RCTs of interventions to prevent foot ulcers in people with diabetes who were free from foot ulceration at trial entry were included. Two independent reviewers read the full-text articles and extracted data. The quality of trial reporting was assessed using the Cochrane Risk of Bias tool. The primary outcome of foot ulceration was summarised using pooled relative risks in meta-analyses.

RESULTS

Twenty-two RCTs of eight interventions were eligible for analysis. One trial of digital silicone devices (RR 0.07 [95% CI 0.01, 0.55]) and meta-analyses of dermal infrared thermometry (RR 0.41 [95% CI 0.19, 0.86]), complex interventions (RR 0.59 [95% CI 0.38, 0.90], and custom-made footwear and offloading insoles (RR 0.53 [95% CI 0.33, 0.85]) showed beneficial effects for these interventions.

CONCLUSIONS/INTERPRETATION

Four interventions were identified as being effective in preventing foot ulcers in people with diabetes, but uncertainty remains about what works and who is most likely to benefit.

Measuring Plantar Tissue Stress in People With Diabetic Peripheral Neuropathy: A Critical Concept in Diabetic Foot Management

Excessive stress on plantar tissue over time is one of the leading causes of diabetic foot ulcers among people with diabetic peripheral neuropathy. Plantar tissue stress (PTS) is a concept that attempts to integrate several well-known mechanical factors into one measure, including plantar pressure, shear stress, daily weight-bearing activity, and time spent in prescribed offloading interventions (adherence). Despite international diabetic foot guidelines recommending the measure of each of these individual mechanical factors in people with neuropathy, only recently has technology enabled their combined measurement to determine PTS. In this article we review the concept of PTS, the mechanical factors involved, and the findings of pivotal articles reporting measures of PTS in people with neuropathy. We also discuss key existing gaps in this field, including the lack of standards to measure and report PTS, a lack of practical solutions to measure shear stress, and the lack of PTS thresholds that may indicate benefit or detriment to people with neuropathy. To address some of these gaps, we propose recommended clinical and research standards for measuring and reporting PTS in people with neuropathy. Last, we forecast future clinical, research, and technological advancements that may use PTS to highlight the importance of this critical concept in the prevention and management of diabetic foot ulcers.

The impact of multimorbidity on foot health outcomes in podiatry patients with musculoskeletal foot pain: a prospective observational study

Background

Multimorbidity is prevalent and adversely affects health outcomes. Foot pain is common and one of the primary reasons for utilisation of podiatry services. At present, little is known about the impact of multimorbidity on foot health and related outcomes following podiatric intervention. The aims of this study were to evaluate whether there is a difference in foot health outcomes following exposure to podiatric foot care for people with and without multimorbidity; and ii) to evaluate whether the presence or absence of multimorbidity affects patients’ perceptions of change in foot pain.

Methods

The PROMFoot study is a prospective cohort study of adults with a new episode of foot pain attending the podiatry service within the NHS Greater Glasgow and Clyde health board. Baseline medical comorbidity status (no condition, single condition, multiple conditions), longitudinal data on foot health measured using the Foot Health Status Questionnaire (FHSQ), and patient rating of change scores for foot pain were obtained from the PROMFoot study at baseline, and 3 and 6 months after podiatric intervention. Foot health scores (pain, function, footwear and general foot health) and perceptions of change for foot pain were compared between comorbidity groups.

Results

A total of 115 participants (59% female) with a mean age of 55 years were included. Multimorbidity was common, affecting 61 participants (53%); while 28 (24.3%) and 26 (22.6%) reported single or no medical comorbidities respectively. Significantly worse foot health scores for all FHSQ domains were observed for the multimorbidity group at baseline, 3 and 6 months. Change scores for foot pain were similar between groups and demonstrate modest improvements, however multimorbidity group membership was strongly associated with a perceptions of change in foot pain. Multimorbidity was independently associated with poorer foot function outcomes at 3 months, and poorer foot pain and foot function outcomes at 6 months.

Conclusions

Multimorbidity was associated with poor foot health outcomes and lower rates of self-perceived improvement in foot pain over 6 months following podiatric intervention in a sample of patients attending podiatric biomechanics clinics for a new episode of foot pain.

Electronic supplementary material

The online version of this article (10.1186/s13047-019-0346-x) contains supplementary material, which is available to authorized users.