Patient education for diabetic patients. An integral part of quality health care

What is the Lived Experience of the ‘Three Great Pathologies’ of Diabetic Foot Disease? An Interpretative Phenomenological Analysis of the Independent Thinking of Podiatrists in Diabetes Secondary Care

Researching the podiatrists’ lived experience of The Three Great Pathologies may help improve the quality of patient care. The aim of this research using an Interpretative Phenomenological Analysis approach is to report on insights relating to the Three Great Pathologies of diabetic foot disease – infection, ischaemia and amputation. To do this, data was collected from six New Zealand diabetes care Podiatrists. Three superordinate themes resulted with subordinate themes. They are compromised health status, podiatric challenges and best outcomes. The findings are firstly, patient education remains a priority; secondly, there is an unmet need for postgraduate podiatry education; and thirdly, early intervention is a key measure for reducing the influence of the Three Great Pathologies. This study demonstrates that focussing on a group of six specialist podiatrists contributes to new priorities of care for dealing with the Three Great Pathologies of diabetic foot disease.

Improving preventive foot care for diabetic patients participating in group education

BACKGROUND

Diabetic foot care has yet to be enhanced in a universal health-care system in which specialized podiatric medical services are unavailable. This baseline assessment surveyed diabetic patients attending group education to improve current foot-care practices.

METHODS

Of 302 diabetic patients receiving usual outpatient care, 155 received group patient education on general diabetes-related information, which included foot care and an annual checkup by a diabetes association during the previous 2 years, and 147 did not. Patient foot-care behaviors, physician practice patterns, and patient self-perceived foot risk as cross-checked with the neurologic and vascular assessments were investigated by conducting retrospective medical record reviews and structured interviews.

RESULTS

More than half of the patients in both groups reported inappropriate self-care behaviors (eg, walking barefoot and heating or soaking their feet). The percentages of patients receiving documented examinations and referrals for foot problems were low in both groups and were not significantly different. Among at-risk patients, 56% of the diabetes association group but only 30% of the non-diabetes association group perceived themselves to be at risk for future foot problems (P<.01).

CONCLUSIONS

Many diabetic patients were not offered adequate foot-specific information during group lectures, even those with high-risk foot problems. To improve this, combining caregiver and patient education in foot-care practices is important, and systems of networked multidisciplinary professionals are believed to be needed, particularly in delivering customized interventions to at-risk patients based on the initial evaluation.

Can the use of a topical antifungal nail lacquer reduce risk for diabetic foot ulceration? Results from a randomised controlled pilot study

The purpose of this study was to determine whether the routine use of a topical antifungal nail lacquer (AFL) could reduce the risk for ulceration by theoretically increasing the frequency of patient self-inspection. In this randomised controlled trial, 70 persons at high risk for diabetic foot ulceration were enrolled into a preventative care program involving daily self-inspection with the possible use of an AFL (ciclopirox 8%) versus self-inspection instructions alone (NAFL). Patients were followed for 12 months or until ulceration. Using an intent to treat analysis, there was no significant difference in proportion of persons ulcerating in the AFL versus the NAFL groups (5.9% versus 5.6% P = 0.9). There was also no difference in the number of unexpected visits (P = 0.2) or missed appointments (P = 0.7) between treatment arms. Interestingly, while there was no difference in proportion of patients with clinically diagnosed hyperkeratosis or tinea pedis on entry into the study (P = 0.2), a significantly lower proportion of AFL patients had a clinical diagnosis on study termination (52.9% versus 77.8% P = 0.03, OR = 1.7, 95% confidence interval = 1.1-2.7). The results of this study suggest that there may be no immediate prophylactic benefit through the use of AFL to prevent wounds. The incidental finding of a potential reduction in hyperkeratosis and tinea pedis is a compelling one and may deserve further investigation.

Diabetic neuropathy: pathophysiology and prevention of foot ulcers

Diabetic neuropathy, which affects 60% to 70% of those with diabetes mellitus, is one of the most troubling complications for persons with diabetes, often leading to foot ulcers and potentially to lower limb amputations, both of which are preventable. The physiologic, structural, and functional changes associated with diabetic neuropathy and foot ulcers are discussed. Advanced practice nurses are in a unique position to implement strategies for the prevention of serious and debilitating complications from diabetic neuropathy, including foot assessment, education, and specialist referrals. Research evidence is given to support the use of the Semmes-Weinstein monofilaments to evaluate decreased plantar sensation, a common precursor to ulceration. Ongoing patient and family education can emphasize the importance of preventive self-care measures. Referrals for specialist care and therapeutic footwear can be made by advanced practice nurses. If begun early, these interventions can prevent foot ulcers from diabetic neuropathy, thereby improving the quality of life and reducing healthcare costs for this chronic disease.