Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers

Patient experience of the process to diagnosis of chronic limb-threatening ischaemia: A qualitative study

INTRODUCTION

Delays exist at each stage of the chronic limb-threatening ischaemia (CLTI) care pathway, but there is little known about patient factors influencing delay to diagnosis of CLTI. This study explores the experiences and perceptions of patients recently diagnosed with CLTI.

METHODS

A qualitative interview study was conducted. Sixteen participants underwent semi-structured interviews. Reflexive thematic analysis was performed on the data, aiming to understand factors which can influence delay in the CLTI care pathway.

RESULTS

Five interrelated themes were developed: CLTI is a devastating condition; Reluctance to ask for help; When we are empowered we get better care; Luck plays a role in the process to diagnosis; and Vascular units can do better, comprising sub-themes of information transfer-consider communication and arterial versus non-arterial centres-proximity isn't everything.

CONCLUSIONS

The five themes generated from the interview data describe factors relevant to delay given meaning by participants who have lived experience of CLTI. Theme content should be noted by clinicians, commissioners and providers looking to improve care pathways for patients with CLTI. The importance of awareness for the public, patients and clinicians linked ideas in some themes and interventions to raise awareness should be considered.

A Systematic Review and Classification of Factors Influencing Diabetic Foot Ulcer Treatment Adherence, in Accordance With the WHO Dimensions of Adherence to Long-Term Therapies

PURPOSE

Effective treatment of diabetic foot ulcers (DFUs) involves a multidisciplinary treatment plan to promote wound healing and prevent complications. Given the lack of consensus data on the factors affecting patient adherence, a systematic review was performed to identify and classify factors according to the WHO Dimensions of Adherence to Long-Term Therapies.

METHODS

Six hundred and forty-three articles from PubMed, Embase, and Scopus were reviewed. The inclusion criteria included qualitative and quantitative studies which discussed factors affecting patient adherence to DFU treatment, had study populations that comprised patients with either prior history of or existing DFU, and had either prior history of DFU treatment or were currently receiving treatment. Factors, and associated measures of adherence, were extracted and organized according to the WHO Dimensions of Adherence to Long-Term Therapies.

RESULTS

Seven quantitative and eight qualitative studies were included. Eleven patient-related factors, seven condition-related factors, three therapy-related factors, five socioeconomic factors, and five health system-related factors were investigated by the included studies. The largest proportion of factors studied was patient-related, such as patient insight on DFU treatment, patient motivation, and patient perception of DFU treatment. There was notable overlap in the range of discussed factors across various domains, in the socioeconomic (including social support, income, social and cultural acceptability of DFU therapy, cost) and therapy-related domains (including duration of treatment, offloading footwear, and reminder devices). Different studies found that specific factors, such as gender and patients having a low internal locus of control, had differing effects on adherence on different cohorts.

CONCLUSION

Current literature presents heterogeneous findings regarding factors affecting patient adherence. It would be useful for future studies to categorize factors as such to provide more comprehensive understanding and personalized care to patients. Further research can be done to explore how significant factors can be addressed universally across different cohort populations in different cultural and socioeconomic contexts.

Web-based interventions on the resilience of informal caregivers: a systematic review and meta-analysis

Informal caregivers play an increasingly important role in the provision of care services, especially for the ageing population. At present, the evidence on the resilience of the Internet to family caregivers is still limited. The purpose of this study was to evaluate the factors related to the resilience of the Internet to family caregivers. We searched retrieved randomized controlled trials (rct) of the effects of Internet interventions on resilience in informal caregivers from the beginning of the database to 1 November 2022. A preliminary search identified 3348 studies, 5 of which met the inclusion criteria. The studies involved 482 participants from four countries. Our results show that compared to the control group, internet intervention can effectively improve the resilience level of caregivers [SMD = 0.65, 95%CI(0.04，1.26), P ≤ 0.05]. In our study, Web-based interventions can significantly improve the adaptability of informal caregivers. In addition, our research also pointed out many resources that can be used, such as online learning, online answers and online psychological counseling provided for caregivers through the Internet, which can effectively reduce their burden of care and thus improve their resilience. In the future, these findings can be used to develop projects to improve the resilience of caregivers through personalized Internet intervention, so as to meet the care needs of patients.

Collaboration and Partnership in a 5-Level Engagement Framework for Diabetic Foot Ulcer Management: A Patient-oriented Scoping Review

OBJECTIVE

The management of diabetic foot ulcers (DFUs) is complex, and patient engagement is essential for DFU healing, but it often comes down to the patient's consultation. Therefore, we sought to document patients' engagement in terms of collaboration and partnership for DFUs in 5 levels (direct care, organizational, policy level, research, and education), as well as strategies for patient engagement using an adapted engagement framework.

METHODS

We conducted a scoping review of the literature from inception to April 2022 using the Joanna Briggs Institute method and a patient-oriented approach. We also consulted DFU stakeholders to obtain feedback on the findings. The data were extracted using PROGRESS+ factors for an equity lens. The effects of engagement were described using Bodenheimer's quadruple aims for value-based care.

RESULTS

Of 4,211 potentially eligible records, 15 studies met our eligibility criteria, including 214 patients involved in engagement initiatives. Most studies were recent (9 of 15 since 2020) and involved patient engagement at the direct medical care level (8 of 15). Self-management (7 of 15) was the principal way to clinically engage the patients. None of the studies sought to define the direct influence of patient engagement on health outcomes.

CONCLUSIONS

Very few studies described patients' characteristics. Engaged patients were typically men from high-income countries, in their 50s, with poorly managed type 2 diabetes. We found little rigorous research of patient engagement at all levels for DFUs. There is an urgent need to improve the reporting of research in this area and to engage a diversity of patients.

Decision-making processes for non-emergency diabetes-related lower extremity amputations: A scoping review

Living with a diabetes-related foot ulcer has significant lifestyle impacts. Whilst often considered a last resort, amputation can overcome the burden of ulcer management, for an improved quality of life. However, limited research has been conducted to understand how the decision to amputate is made for people with a chronic ulcer when amputation is not required as a medical emergency. Therefore, the aim was to identify and map key concepts in the literature which describe the decision-making for diabetes-related amputations. This review followed Arksey and O'Malley's PRISMA scoping review framework. Five electronic databases and grey literature were searched for papers which described clinical reasoning and/or decision-making processes for diabetes-related amputation. Data were extracted and mapped to corresponding domains of the World Health Organisation's International Classification of functioning, Disability and Health (ICF) framework. Ninety-four papers were included. Personal factors including emotional wellbeing, quality of life, and treatment goals are key considerations for an elective amputation. It is important to consider an individual's lifestyle and personal circumstances, as well as the pathology when deciding between amputation or conservative management. This highlights the importance of a holistic and shared decision-making process for amputation which includes assessment of a person's lifestyle and function.

Potential applications of artificial intelligence and machine learning on diagnosis, treatment, and outcome prediction to address health care disparities of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is the most advanced form of peripheral artery disease. CLTI has an extremely poor prognosis and is associated with considerable risk of major amputation, cardiac morbidity, mortality, and poor quality of life. Early diagnosis and targeted treatment of CLTI is critical for improving patient's prognosis. However, this objective has proven elusive, time-consuming, and challenging due to existing health care disparities among patients. In this article, we reviewed how artificial intelligence (AI) and machine learning (ML) can be helpful to accurately diagnose, improve outcome prediction, and identify disparities in the treatment of CLTI. We demonstrate the importance of AI/ML approaches for management of these patients and how available data could be used for computer-guided interventions. Although AI/ML applications to mitigate health care disparities in CLTI are in their infancy, we also highlighted specific AI/ML methods that show potential for addressing health care disparities in CLTI.

Diabetic foot complications among Indigenous peoples in Canada: a scoping review through the PROGRESS-PLUS equity lens

Introduction

Indigenous peoples in Canada face a disproportionate burden of diabetes-related foot complications (DRFC), such as foot ulcers, lower extremity amputations (LEA), and peripheral arterial disease. This scoping review aimed to provide a comprehensive understanding of DRFC among First Nations, Métis, and Inuit peoples in Canada, incorporating an equity lens.

Methods

A scoping review was conducted based on Arksey and O'Malley refined by the Joanna Briggs Institute. The PROGRESS-Plus framework was utilized to extract data and incorporate an equity lens. A critical appraisal was performed, and Indigenous stakeholders were consulted for feedback. We identified the incorporation of patient-oriented/centered research (POR).

Results

Of 5,323 records identified, 40 studies were included in the review. The majority of studies focused on First Nations (92%), while representation of the Inuit population was very limited populations (< 3% of studies). LEA was the most studied outcome (76%). Age, gender, ethnicity, and place of residence were the most commonly included variables. Patient-oriented/centered research was mainly included in recent studies (16%). The overall quality of the studies was average. Data synthesis showed a high burden of DRFC among Indigenous populations compared to non-Indigenous populations. Indigenous identity and rural/remote communities were associated with the worse outcomes, particularly major LEA.

Discussion

This study provides a comprehensive understanding of DRFC in Indigenous peoples in Canada of published studies in database. It not only incorporates an equity lens and patient-oriented/centered research but also demonstrates that we need to change our approach. More data is needed to fully understand the burden of DRFC among Indigenous peoples, particularly in the Northern region in Canada where no data are previously available. Western research methods are insufficient to understand the unique situation of Indigenous peoples and it is essential to promote culturally safe and quality healthcare.

Conclusion

Efforts have been made to manage DRFC, but continued attention and support are necessary to address this population's needs and ensure equitable prevention, access and care that embraces their ways of knowing, being and acting.

Systematic review registration

Open Science Framework https://osf.io/j9pu7, identifier j9pu7.

Knowledge and Practice of the Preventive and Care Methods for Diabetic Foot Among the Caregivers of Diabetic Patients in Saudi Arabia

Background Diabetic foot syndrome is a complex and multifactorial disease process involving neuropathy, peripheral arterial disease, osteomyelitis, diabetic foot ulcer (DFU), and amputation. DFUs are a common and burdensome manifestation of the syndrome, responsible for diabetes-related morbidity and mortality. Successful management of DFU requires collaboration between patients and caregivers. This study assesses the knowledge, experience, and practices of the caregivers of diabetic foot patients in Saudi Arabia, highlighting the need for targeted interventions to improve knowledge and practices in certain subgroups of caregivers. Method The primary objective of this study was to evaluate the proficiency and practicality of caregivers who provide care to patients with diabetic foot in the Kingdom of Saudi Arabia. To accomplish this, a cross-sectional study was conducted among caregivers of diabetic foot patients who were aged 18 years or older and living in Saudi Arabia. The participants were randomly chosen to ensure that the sample was representative. The data collection process involved the distribution of a structured online questionnaire via various social media platforms. Prior to the distribution of the questionnaire, the participants were informed about the study's objectives, and their informed consent was obtained. Additionally, adequate measures were taken to ensure the confidentiality of the participants and their caregiving status. Results Among the initial pool of 2990 participants, 1023 individuals were excluded from the study due to their status as non-caregivers of diabetic patients or being under the age of 18 years. Consequently, the final sample size consisted of 1921 caregivers. The majority of the participants were female (61.6%), married (58.6%), and had a bachelor's degree (52.4%). The findings revealed that 34.6% of caregivers were attending to patients with diabetic foot, of which 8.5% reported poor foot status and 9.1% reported amputation. Caregivers reported examining the patient's feet in 75.2% of cases, and the feet were cleaned and moisturized by either the patient or caregiver. Nails were trimmed by 77.8% of caregivers, and 49.8% of them did not permit patients to walk barefoot. Moreover, knowledge of diabetic foot care was positively correlated with being female, having a post-graduate degree, having personal experience with diabetes, caring for a patient with diabetic foot, and having prior experience in treating diabetic foot. Conversely, lower knowledge levels were associated with divorced or unemployed caregivers and those residing in the northern region. Conclusion The present study highlights that caregivers of diabetic foot patients in Saudi Arabia possess a satisfactory level of knowledge and follow appropriate practices regarding foot care. Nonetheless, it is imperative to identify specific subgroups of caregivers who may require additional education and training to improve their knowledge and practices concerning diabetic foot care. The results of this study could potentially inform the design of tailored interventions aimed at reducing the significant burden of morbidity and mortality attributed to diabetic foot syndrome in the Saudi Arabian context.

Informal Family Caregiving of Patients with Diabetic Extremity Wounds: An Integrative Review

Annually, 26 million people worldwide develop diabetic extremity wounds, adversely impacting the lives of patients and their family caregivers, who provide vital health assistance to these patients. This integrative review synthesized scientific literature of informal caregiving experiences for patients with diabetic extremity wounds. Five databases were searched for relevant English-language quantitative or qualitative research; ten studies were included in the final analysis. The caregiving experience included disrupted routines, frustration, guilt, poor health care communication, helplessness, and anxiety. Increased caregiver burden and decreased quality of life were associated with higher patient amputation level, worsening wound appearance and patient pain, poor health care communication, lack of social support and/or caregiving help, and lack of caregiver employment outside the home. Future research opportunities include further exploration of caregiver tasks and priorities, caregiving experiences in settings lacking family support structures and equitable health system access, and relationships between the caregiver experience and patient health system utilization.

The Influence of 6-Month Interdisciplinary Accompaniment on Family Caregivers’ Knowledge and Self-Efficacy Regarding Diabetic Wound Care

Introduction

Diabetes mellitus (DM) is a global health issue. Diabetic wounds have become a severe health complication. Interdisciplinary education and the use of homecare have led to improvements in the health of patients with chronic disease. The family caregiver's knowledge and self-efficacy positively impact the DM patient's self-care in the physical and psychological dimensions. There is still a need for interdisciplinary education to enhance family caregivers’ knowledge and self-efficacy regarding diabetic wound care.

Objective

To determine the effect of 6 months of interdisciplinary education on family caregivers’ knowledge and self-efficacy regarding diabetic wound care.

Methods

A quantitative longitudinal study with a quasi-experimental, one-group, pretest–posttest design was conducted. Family caregivers received 6 months of interdisciplinary education regarding diabetic wound care. The Foot Care Confidence Scale (FCCS) was used to measure the family caregivers’ knowledge and self-efficacy regarding diabetic wound care. The dependent samples t test and the Wilcoxon signed-rank test were used for statistical analysis.

Results

Sixteen caregivers of patients with diabetic ulcer wounds in the homecare unit participated in this intervention with a 6-month follow-up. Six months of interdisciplinary education significantly increased the family caregivers’ knowledge ( p = 0.001) and self-efficacy ( p = 0.001). However, there was no significant correlation between self-efficacy and gender, age, education level, or duration of wound care ( p = 0.91; 0.93; 0.38; 0.40, respectively). Long-term interdisciplinary education improved caregiver performance across genders, ages, education levels, and wound care experience durations.

Conclusion

Long-term interdisciplinary education of family caregivers is recommended as one method to enhance the family support system with respect to diabetic ulcer care management. In addition, interprofessional collaboration could be performed to enhance the understanding of healthcare, especially diabetic ulcer care.