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Cochrane Database of Systematic Reviews

Éducation des patients dans la prévention de l'ulcération du pied diabétique

Información

DOI:
https://doi.org/10.1002/14651858.CD001488.pub5Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 16 diciembre 2014see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Heridas

Copyright:
  1. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Contraer

Autores

  • Johannes AN Dorresteijn

    Department of Internal Medicine, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands

  • Didi MW Kriegsman

    Zonnehuisgroep Amstelland (KBO), Amstelveen, Netherlands

  • Willem JJ Assendelft

    Department of Primary and Community Care, 117 ELG, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands

  • Gerlof D Valk

    Correspondencia a: Department of Internal Medicine, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands

    [email protected]

Contributions of authors

JAN Dorresteijn extracted, checked and analysed data, undertook and checked quality assessment, completed the first draft of the review update, made an intellectual contribution to the review update, approved review update prior to submission and performed previous work that was the foundation of the current review.
DMW Kriegsman performed part of the writing and editing of the review update, made an intellectual contribution, approved final review update prior to submission and performed previous work that was the foundation of the current review.
WJJ Assendelft performed part of the writing and editing of the review update, made an intellectual contribution, approved final review update prior to submission and performed previous work that was the foundation of the current review.
GD Valk coordinated the review update, extracted, checked and analysed data, undertook and checked quality assessment, performed part of the writing and editing of the review update, made an intellectual contribution, approved final review update prior to submission, performed previous work that was the foundation of the current update and is guarantor of the review update.

Contributions of editorial base:

Nicky Cullum: edited the review, advised on methodology, interpretation and review content; approved the final review and review updates prior to submission.
Sally Bell‐Syer: coordinated the editorial process, advised on methodology, interpretation and content; edited the updates of the review.
Ruth Foxlee and Amanda Briant: designed the search strategy, ran the searches and edited the search methods section for the updates.

Sources of support

Internal sources

  • Dutch Cochrane Centre, Netherlands.

  • Leiden University Medical Center, Department of Public Health and Primary Care, Netherlands.

  • University Medical Center Utrecht, Department of Internal Medicine, Netherlands.

External sources

  • NIHR/Department of Health (England), (Cochrane Wounds Group), UK.

Declarations of interest

None known.

Acknowledgements

The authors would like to thank:

  • Nicky Cullum for putting her existing work on education for the diabetic foot at our disposal,

  • The Cochrane Wounds Group referees (Neil Baker, Althea Foster, Sue O'Meara, Jude Smith) and editors (Nicky Cullum, Andrew Jull) who commented on the original review

  • Anne Lawson, copy editor.

Version history

Published

Title

Stage

Authors

Version

2014 Dec 16

Patient education for preventing diabetic foot ulceration

Review

Johannes AN Dorresteijn, Didi MW Kriegsman, Willem JJ Assendelft, Gerlof D Valk

https://doi.org/10.1002/14651858.CD001488.pub5

2012 Oct 17

Patient education for preventing diabetic foot ulceration

Review

Johannes AN Dorresteijn, Didi MW Kriegsman, Willem JJ Assendelft, Gerlof D Valk

https://doi.org/10.1002/14651858.CD001488.pub4

2010 May 12

Patient education for preventing diabetic foot ulceration

Review

Johannes A N Dorresteijn, Didi M W Kriegsman, Willem JJ Assendelft, Gerlof D Valk

https://doi.org/10.1002/14651858.CD001488.pub3

2001 Oct 23

Patient education for preventing diabetic foot ulceration

Review

Gerlof D Valk, Didi M W Kriegsman, Willem JJ Assendelft

https://doi.org/10.1002/14651858.CD001488.pub2

1998 Jul 27

Educational interventions for patients in the prevention of diabetic foot ulceration

Protocol

Gerlof Valk, W JJ Assendelft

https://doi.org/10.1002/14651858.CD001488

Differences between protocol and review

In this updated review, we have excluded studies in which the intervention consisted of multiple combined strategies for the prevention of diabetic foot ulceration, where patient education was not the main comparator with the control intervention (Litzelman 1993). We have developed and published a further Cochrane review that provides a more comprehensive overview of the effects of such integrated prevention strategies (complex interventions) (Dorresteijn 2010a). In addition, we have redefined the previously used primary outcome 'infection' into the secondary outcome 'fungal infection'. Furthermore, while the Amsterdam‐Maastricht consensus list was used to score risk of bias in previous versions of this review (van Tulder 1997), we have adopted The Cochrane Collaboration's recommended tool for assessing risk of bias in this update (Higgins 2011).

Keywords

MeSH

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Figuras y tablas -
Figure 1

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Comparison 1 Effects of intensive versus brief education in high risk patient samples, Outcome 1 Foot ulcer incidence (1‐year follow‐up).
Figuras y tablas -
Analysis 1.1

Comparison 1 Effects of intensive versus brief education in high risk patient samples, Outcome 1 Foot ulcer incidence (1‐year follow‐up).

Comparison 1 Effects of intensive versus brief education in high risk patient samples, Outcome 2 Amputation Rate (1‐year follow‐up).
Figuras y tablas -
Analysis 1.2

Comparison 1 Effects of intensive versus brief education in high risk patient samples, Outcome 2 Amputation Rate (1‐year follow‐up).

Comparison 1 Effects of intensive versus brief education in high risk patient samples, Outcome 3 Foot ulcer incidence (1‐year follow‐up).
Figuras y tablas -
Analysis 1.3

Comparison 1 Effects of intensive versus brief education in high risk patient samples, Outcome 3 Foot ulcer incidence (1‐year follow‐up).

Comparison 1 Effects of intensive versus brief education in high risk patient samples, Outcome 4 Amputation rate (1‐year follow‐up).
Figuras y tablas -
Analysis 1.4

Comparison 1 Effects of intensive versus brief education in high risk patient samples, Outcome 4 Amputation rate (1‐year follow‐up).

Table 1. Results from trials

Study ID

Primary outcomes

Secondary outcomes

Barth 1991

No primary outcomes reported

Foot problems requiring treatment:
Significant reduction in intervention after 1 month (P < 0.001), maintained until final follow‐up at 6 months
Reduction was significantly smaller in control than in intervention after 1 month (P < 0.006), but not after 6 months (P = 0.216)

Foot care knowledge:
Significant increase in both groups at 1 month (P < 0.001), but more in intervention than in control (P < 0.001). Changes were maintained until final follow‐up at 6 months

Foot care routine compliance:
Significant increase in intervention after 1 month (P < 0.001), maintained until final follow‐up
Increase was significantly greater in intervention than in control after 1 month (P = 0.012)

Bloomgarden 1987

Ulcer or amputation:
people with no foot lesions at baseline:
intervention 2/83 vs control 2/63

people with callus, nail dystrophy or fungal infection at baseline: intervention 2/37 vs control 3/63

people with an ulcer or amputation at baseline: intervention 6/7 vs control 11/13

Callus, nail dystrophy and fungal infection:
people with no foot lesions at baseline: intervention 31/83 vs control 28/63 (ns)
people with callus, nail dystrophy or fungal infection at baseline: intervention 24/37 vs control 46/63 (ns)
people with an ulcer or amputation at baseline: intervention 1/7 vs control 1/13 (ns)

Behaviour assessment scores:
intervention from 3.4 to 4.3. Control from 3.6 to 4.1 (P = 0.10). Separate data for foot care not provided

Borges 2004

No primary outcomes reported

Patients' self‐reported behaviour assessment scores:
intervention from 4.7 to 5.6 (P < 0.01). RA from 4.8 to 5.2 (P = 0.06). C from 5.1 to 5.4 (P < 0.05)

Observed self‐care behaviour:
4 of 16 items significantly (P < 0.05) more observed in intervention than in control

Foot care knowledge scores:
Increased within the control group, but not in the intervention or RA groups

Cisneros 2010

Ulcer incidence:

people without a history of foot ulceration: intervention 8/21 vs control 8/14 (P = 0.317)

Patient with a history of foot ulceration: intervention 1/8 vs control 5/8 (P = 0.119)

All people: difference between the survival curves of intervention and control (P = 0.362) (HR not reported)

No secondary outcomes reported

Corbett 2003

No primary outcomes reported

Foot care knowledge scores:
intervention from 4.9 to 6.1 vs control from 4.6 to 5.2 (P = 0.03)

Foot care practice scores:
intervention from 4.3 to 5.6 vs control from 4.1 to 4.3 (P = 0.007)

Frank 2003

No primary outcomes reported

Foot care knowledge scores:
Means: intervention 20.98 (SD 2.46) vs control 18.60 (SD 2.93), (P < 0.001)
Mean differences: intervention 2.33 (SD 2.49) vs control 1.10 (SD 2.89), (P = 0.028)

Patients' behaviour assessment:
(mean number of days per week)
Checking feet: intervention 6.33 vs control 5.88 (P = 0.203). Mean differences: intervention 1.13 vs control 1.35 (P = 0.708)
Washing feet: intervention 5.75 vs control 5.94 (P = 0.573). Mean differences: intervention 0.58 vs control 0.52 (P = 0.863)
Applying lotion: intervention 5.96 vs control 4.94 (P = 0.044). Mean differences: intervention 1.42 vs control 0.75 (,P = 0.191)
Wearing shoes and socks: intervention 5.60 vs control 5.42 (P = 0.705). Mean differences: intervention 1.90 vs control 0.50 (P = 0.036)

Kruger 1992

No primary outcomes reported

Foot status:
No significant difference.

Foot care knowledge scores:
intervention from 9.1 to 10.0 vs control from 8.66 to 9.86, statistically significant increase in control group (P = 0.02), but not in the intervention group (P = 0.078)

Behaviour assessment:
Daily foot inspection: intervention from 52.5% to 66.7% vs control from 34.8% to 66.7% (ns)
Daily foot washing: intervention from 82.6% to 86.7% vs control from 74.1% to 73.3% (statistically significant increase in intervention group)
Use of pumice stones for corns: intervention from 4.3% to 26.7% vs control from 3.7% to 26.7% (ns)
Trimming toenails regularly: intervention from 34.8% to 80.0% vs control from 66.7% to 66.7% (statistically significant increase in intervention group)
Improvement in keeping toenails shorter: intervention from 30.4% to 80.0% vs control from 66.7% to 86.7% (ns)

Lincoln 2008

Ulcer incidence:
After 6 months: intervention 26 vs control 18, RR 1.41 (95% CI 0.84 to 2.38)
After 12 months: intervention 36 vs control 35, RR 1.00 (95% CI 0.70 to 1.44)

Amputation rate:
After 6 months: intervention 3 vs control 0, RR not estimable
After 12 months: intervention 9 vs control 9, RR 0.98 (95% CI 0.41 to 2.34)

Behaviour assessment scores:
intervention 42.0 vs control 38.7 (P = 0.03)

Malone 1989

Ulcer incidence:
intervention 8 vs control 26; significantly lower in intervention group (P ≤ 0.005)

Amputation rate:
intervention 7 vs control 21; significantly lower in intervention group (P < 0.025)

No secondary outcomes reported

Mazzuca 1986

No primary outcomes reported

Foot care knowledge scores:
No significant difference

Rettig 1986

No primary outcomes reported

Foot appearance scores (mean ±standard error):
intervention 70.2 ± 0.7 vs control 68.8 ±0.7 (ns)

Foot care knowledge scores:
intervention 62.2 ±1.7 vs control 53.1 ± 1.8 (P = 0.001). Significant increase in intervention group

Foot care skills scores:
intervention 71.8 ±2.0 vs control 68.9 ± 1.8 (ns)

Rönnemaa 1997

Amputation:
1‐year follow‐up: intervention 0 vs control 0

7‐year follow‐up: intervention 1 vs control 0

Foot ulceration:
1‐year follow‐up: intervention 1 vs control 0

7‐year follow‐up: intervention 1 vs control 1

Callus development:
1‐year follow‐up:

Calcaneal region:

  • presence of callus: intervention from 18.5% to 12.0% vs control from 16.8% to 15.5% (ns)

  • mean diameter: intervention from 40.5 mm (SD 30.8 mm) to 25.5 mm (SD 28.8 mm) vs control from 30.6 mm (SD 28.5 mm) to 28.3 mm (SD 26.8 mm); statistically significant decrease in area of callosities at calcaneal region in intervention group (P = 0.065)

Other regions:

  • presence of callus: intervention from 54.5% to 39.5% vs control from 51.3% to 48.2%; significant decrease in callosities in intervention group (P < 0.009)

  • mean diameter: intervention from 16.6 mm (SD 10.2 mm) to 11.4 mm (SD 10.3 mm) vs control from 15.2 mm (SD 9.8 mm) to 14.4 mm (SD 9.9 mm); statistically significant decrease in area of callosities in intervention group (P < 0.001)

7‐year follow‐up:

Calcaneal region:

  • presence of callus: intervention 12.4% vs control 12.9%, RR 0.96 (95% CI 0.55 to 1.70)

Other regions:

  • presence of callus: intervention 23.1% vs control 30.1%, RR 0.77 (95% CI 0.53 to 1.01)

Foot care knowledge scores:
1‐year follow‐up:

  • intervention from 26.7 (SD 11.4) to 32.1 (SD 10.8) vs control from 26.1 (SD 11.8) to 29.2 (SD 12.6); statistically significant increase in intervention group (P = 0.004)

7‐year follow‐up:

  • mean scores: intervention 33.6 (SD 10.5) vs control 33.0 (SD 11.1) (ns)

Patients' behaviour assessment scores:
1‐year follow‐up:

  • mean scores: intervention from 5.4 (SD 2.8) to 7.0 (SD 3.2) vs control 5.3 (SD 2.6) to 6.0 (SD 2.5); statistically significant increase in intervention group

7‐year follow‐up:

  • mean scores: intervention 6.6 (SD 2.7) vs control 6.4 (SD 2.7) (ns)

Abbreviations: CI = confidence interval, ns = no statistical significance, RA = group that received risk assessment only, RR = risk ratio, SD = standard deviation.

Figuras y tablas -
Table 1. Results from trials
Comparison 1. Effects of intensive versus brief education in high risk patient samples

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Foot ulcer incidence (1‐year follow‐up) Show forest plot

1

354

Risk Ratio (M‐H, Fixed, 95% CI)

0.31 [0.14, 0.66]

2 Amputation Rate (1‐year follow‐up) Show forest plot

1

354

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.15, 0.76]

3 Foot ulcer incidence (1‐year follow‐up) Show forest plot

1

172

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.70, 1.44]

4 Amputation rate (1‐year follow‐up) Show forest plot

1

172

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.41, 2.34]

Figuras y tablas -
Comparison 1. Effects of intensive versus brief education in high risk patient samples