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Hassan S, Rac VE, Hodges B, Leake P, Cobbing S, Gray CM, Bartley N, Etherington A, Abdulwasi M, Cheung HCK, Anderson M, Woods NN. Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review. BMJ Open 2024; 14:e081006. [PMID: 38262651 PMCID: PMC10806612 DOI: 10.1136/bmjopen-2023-081006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/09/2024] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE We aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented. DESIGN We used realist synthesis based on Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidance. DATA SOURCES We searched the Medline, Embase, PsycINFO, CINAHL, ERIC, Web of Science Core Collection, and Scopus databases and the grey literature (Google Scholar, ProQuest Dissertations and Theses) up to November 2022. ELIGIBILITY CRITERIA We included experimental and non-experimental articles in English that either described mechanisms or discussed expected outcomes for educational interventions for patients and family caregivers or healthcare providers, both regulated and unregulated. We also included articles that evaluated the impact of foot care programmes if the UCPs' training was described. DATA EXTRACTION AND SYNTHESIS The lead author extracted, annotated and coded uploaded relevant data to identify contexts, mechanisms and outcome configurations using MAXQDA (a qualitative data analysis software). We used deductive and inductive coding to structure the process. Our team members double-reviewed and appraised a random sample of 20% of articles at all stages to ensure consistency. RESULTS Our search identified 52 articles. Evidence suggested the necessity of developing upskilling foot screening programmes within the context of preventive care programmes that also provide education in diabetes, and early referrals for appropriate interventions. Multidisciplinary programmes created an ideal context facilitating coordination between UCPs and their regulated counterparts. Engaging patients and community partners, using a competency-based model, and incorporating cultural competencies were determinants of success for these programmes. CONCLUSION This review provides a realistic programme theory for the mechanisms used, the context in which these programmes were developed, and the expected outcomes to train UCPs to provide preventive foot care for systematically marginalised populations. PROSPERO REGISTRATION NUMBER CRD42022369208.
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Affiliation(s)
- Samah Hassan
- University Health Network, Toronto, Ontario, Canada
- Program for Health System and Technology Evaluation, Ted Rogers Centre for Heart Research at Peter Munk Cardiac Centre, Toronto General Hospital Research Institute (TGHRI), University Health Network (UHN), Toronto, Ontario, Canada
| | - Valeria E Rac
- University Health Network, Toronto, Ontario, Canada
- Program for Health System and Technology Evaluation, Ted Rogers Centre for Heart Research at Peter Munk Cardiac Centre, Toronto General Hospital Research Institute (TGHRI), University Health Network (UHN), Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation (IHPME), Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute (TGHRI), University Health Network (UHN), Toronto, Ontario, Canada
- Diabetes Action Canada, CIHR SPOR Network, Toronto, Ontario, Canada
| | - Brian Hodges
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Patti Leake
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
| | - Saul Cobbing
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Department of Physiotherapy, University of KwaZulu-Natal, Durban, South Africa
| | - Catharine Marie Gray
- University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Nicola Bartley
- University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Andrea Etherington
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
| | - Munira Abdulwasi
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
| | - Hei-Ching Kristy Cheung
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
| | - Melanie Anderson
- University Health Network, Toronto, Ontario, Canada
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Nicole N Woods
- University Health Network, Toronto, Ontario, Canada
- The Institute of Education Research, University Health Network, Toronto, Ontario, Canada
- The Michener Institute of Education, University Health Network, Toronto, Ontario, Canada
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Tayade A, Kumar P, Kumar S, Ghyar R, Shrivastava A, Ravi B. Perceptions of primary and secondary care clinicians treating diabetic foot: A pan India study and quantitative analysis. Diabetes Res Clin Pract 2023; 206:111008. [PMID: 37952602 DOI: 10.1016/j.diabres.2023.111008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/17/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Abstract
AIM The study quantifies clinicians' perceptions and challenges during different stages of diabetic foot treatment. Diabetic neuropathy (DN), which is a major consequence of diabetes, significantly increases the risk of lower limb amputation. This can be prevented to a large extent by foot care, early detection, and lesion treatment. METHODS Ninety-two Indian clinicians of various demographics, medical specializations, and experiences were interviewed. Diabetic foot treatment by primary and secondary care clinicians was assessed. This study evaluates aspects related to patient awareness, compliance, and shortcomings of current diagnostic techniques. RESULTS A two-sample Mann-Whitney statistical method was used to infer the perceptions of clinicians on hypothesis questions. Primary and secondary care clinicians' perceptions differed for the hypotheses related to objective assessment (p-value = 0.001), operator variability (p-value = 0.03), and patient compliance (p-value = 0.047). Conversely, both groups held comparative perspectives for the awareness (p-value = 0.369) and examination time (p-value = 0.276) hypotheses. CONCLUSIONS All clinicians strongly supported the need for an objective assessment to reduce the misdiagnosis of DN. Further, DNis often underdiagnosed due to a lack of awareness and knowledgeamong people with diabetes. Secondary care clinicians acknowledged a need for trained operators to reduce reliability errors. These insights provide directions for future research in this field.
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Affiliation(s)
- Apakrita Tayade
- Mechanical Engineering Department, Indian Institute of Technology Bombay, Mumbai, India.
| | - Prabhat Kumar
- Mechanical Engineering Department, Indian Institute of Technology Bombay, Mumbai, India.
| | - Saurav Kumar
- Mechanical Engineering Department, Indian Institute of Technology Bombay, Mumbai, India.
| | - Rupesh Ghyar
- Biomedical Engineering & Technology Innovation Centre, Indian Institute of Technology Bombay, Mumbai, India.
| | - Amber Shrivastava
- Mechanical Engineering Department, Indian Institute of Technology Bombay, Mumbai, India
| | - Bhallamudi Ravi
- Mechanical Engineering Department, Indian Institute of Technology Bombay, Mumbai, India
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Pérez-Panero AJ, Ruiz-Muñoz M, Cuesta-Vargas AI, Gónzalez-Sánchez M. Prevention, assessment, diagnosis and management of diabetic foot based on clinical practice guidelines: A systematic review. Medicine (Baltimore) 2019; 98:e16877. [PMID: 31464916 PMCID: PMC6736276 DOI: 10.1097/md.0000000000016877] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/26/2019] [Accepted: 07/25/2019] [Indexed: 02/06/2023] Open
Abstract
AIM Diabetic foot complications are the main reason for hospitalization and amputation in people with diabetes and have a prevalence of up to 25%. Clinical practice guidelines are recommendations based on evidence with the aim of improving health care. The main aim of this study was to carry out a systematic review of the levels of the evaluation and treatment strategies that appear in the clinical practice guidelines focus on diabetic foot or diabetes with diabetic foot section. Another objective of this study was to perform an analysis of the levels of evidence in support of the recommendations made by the selected clinical practice guidelines. METHODS A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and a quality assessment by the Appraisal of Guidelines for Research and Evaluation (AGREE II) were performed. The databases checked were "NICE", "Cinahl", "Health Guide", "RNAO", "Sign", "PubMed", "Scopus" and "NCG". The search terms included were "diabetic foot", "guideline(s)", "practice guideline(s)" and "diabetes." RESULTS Twelve articles were selected after checked inclusion criteria and quality assessment. A summary and classification of the recommendations was completed. CONCLUSIONS The heterogeneity of levels of evidence and grades of recommendation of the CPGs included regarding the management, approach and treatment of DF makes it difficult to interpret and assume them in clinical practice in order to select the most correct procedures. Despite this and according to the detailed study of the guidelines included in this work, it can be concluded that the highly recommendable interventions for DF management are debridement (very high level of evidence and strongly recommended), foot evaluation (moderate level of evidence and fairly recommended) and therapeutic footwear (moderate level of evidence and fairly recommended).
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Affiliation(s)
| | | | - Antonio I. Cuesta-Vargas
- Department of Physiotherapy, University of Málaga, Arquitecto Francisco Peñalosa, s/n. Ampliación campus de Teatinos 29071, Málaga, Spain
| | - Manuel Gónzalez-Sánchez
- Department of Physiotherapy, University of Málaga, Arquitecto Francisco Peñalosa, s/n. Ampliación campus de Teatinos 29071, Málaga, Spain
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Abstract
The diabetic foot is a major cause of morbidity and mortality. The present review aims to outline current treatment options for this ghastly diabetic complication. Although considerable progress has been achieved over the past years, there is still a long way to go. Indeed, the International Working Group of the Diabetic Foot reported 2 years ago that a lower extremity was amputated every 30 seconds due to diabetes somewhere in the world. Established therapeutic modalities (revascularisation, casting and debridement) remain the cornerstone of management. At the same time, new treatments (e.g. growth factors, bioengineered skin substitutes, extracellular matrix proteins, etc.) are continuously being developed and explored to improve treatment. Nonetheless, it should not be underestimated that both new and old treatments must be incorporated in a prudent and zealous therapeutic strategy. Essentially, only multidisciplinary foot clinics have demonstrated that the reduction of amputation rates is feasible. The endeavour should be coupled with widespread education on the elementary rules to achieve both primary and secondary prevention.
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Affiliation(s)
- N Papanas
- Outpatient Clinic of Obesity, Diabetes and Metabolism, Second Department of Internal Medicine, Democritus University of Thrace, Greece.
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