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Health-related quality of life among adults living with diabetic foot ulcers: a meta-analysis

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Abstract

Purpose

To undertake a systematic review of the literature to investigate the HRQOL among adults living with DFUs.

Methods

A systematic search of the medical and nursing/health content databases including MEDLINE, CINAHL, and PsycINFO was conducted up to November 2018. The methodological quality of each study was assessed independently by all authors using the Joanna Briggs Institute checklist. Data analysis was conducted using the Comprehensive Meta-analysis software. All analyses were performed using random-effects models and heterogeneity was quantified.

Results

A total of 12 studies were included in the review. Overall, the HRQOL of participants in the studies was poor on four of eight subscales in the SF-36: physical functioning (mean = 42.75, SE 1.5); role physical (mean = 20.61, SE 3.4); general health (mean = 39.52, SE 1.7); and vitality (mean = 45.73, SE 2.8). In addition, presence of pain, high levels of C-reactive protein (> 10 mg/L), ulcer size > 5 cm2, Ankle Brachial Index < 0.9, high glycosylated haemoglobin and body mass index > 25 kg/m2 were associated with poorer HRQOL in people with DFUs.

Conclusions

This review has provided evidence indicating that people with DFUs have a significantly lower HRQOL. Evidence-based interventions to improve the HRQOL in this group of people is needed.

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References

  1. IDF (2016). Diabetes atlas. http://www.diabetesatlas.org/.

  2. WHO (2017). Diabetes fact sheets. http://www.who.int/mediacentre/factsheets/fs312/en/.

  3. Kostev, K., Jockwig, A., Hallwachs, A., & Rathmann, W. (2014). Prevalence and risk factors of neuropathy in newly diagnosed type 2 diabetes in primary care practices: A retrospective database analysis in Germany and UK. Primary Care Diabetes, 8(3), 250–255. https://doi.org/10.1016/j.pcd.2014.01.011.

    Article  PubMed  Google Scholar 

  4. Taiwo, A., Green, B. O., & Raghupathi, V. (2014). The awareness of diabetes, its complications, and preventive measures in a developing country. International Journal of Healthcare Management, 7(4), 247–250. https://doi.org/10.1179/2047971914Y.0000000074.

    Article  Google Scholar 

  5. Bradbury, S. E., & Price, P. E. (2011). Diabetic foot ulcer pain: the hidden burden (part one). EWMA Journal, 11(1), 11–22.

    Google Scholar 

  6. Sadosky, A., Schaefer, C., Mann, R., Bergstrom, F., Baik, R., Parsons, B., et al. (2013). Burden of illness associated with painful diabetic peripheral neuropathy among adults seeking treatment in the US: Results from a retrospective chart review and cross-sectional survey. Diabetes, Metabolic Syndrome And Obesity: Targets And Therapy, 6, 79–92. https://doi.org/10.2147/DMSO.S37415.

    Article  Google Scholar 

  7. Burant, C. F. (2008). Medical management of type 2 diabetes (Vol. Book, Whole). Alexandria: American Diabetes Association.

    Google Scholar 

  8. Dubský, M., Jirkovská, A., Bem, R., Fejfarová, V., Skibová, J., Schaper, N. C., et al. (2013). Risk factors for recurrence of diabetic foot ulcers: Prospective follow-up analysis in the Eurodiale subgroup. International Wound Journal, 10(5), 555–561. https://doi.org/10.1111/j.1742-481X.2012.01022.x.

    Article  PubMed  Google Scholar 

  9. Carlos De Meneses, L., Blanes, L., Francescato Veiga, D., Gomes, H. C., & Ferreirai, L. M. (2011). Health-related quality of life and self-esteem in patients with diabetic foot ulcers: Results of a cross-sectional comparative study. Ostomy Wound Management, 57(3), 36–43.

    Google Scholar 

  10. Holland, C. M. (2012). Diabetic peripheral neuropathy: A barrier to quality of life. Communicating Nursing Research, 45, 405.

    Google Scholar 

  11. Hosseini Nejhad, Z., Molavi Vardanjani, H., Abolhasani, F., Hadipour, M., & Sheikhzadeh, K. (2013). Relative effect of socio-economic status on the health-related quality of life in type 2 diabetic patients in Iran. Diabetes & Metabolic Syndrome, 7(4), 187–190. https://doi.org/10.1016/j.dsx.2013.10.024.

    Article  Google Scholar 

  12. Boutoille, D., Feraille, A., Maulaz, D., & Krempf, M. (2008). Quality of life with diabetes-associated foot complications: Comparison between lower-limb amputation and chronic foot ulceration. Foot Ankle International, 29(11), 1074–1078. https://doi.org/10.3113/FAI.2008.1074.

    Article  PubMed  Google Scholar 

  13. Sanjari, M., Safari, S., Shokoohi, M., Safizade, H., Rashidinezhad, H., Mashrouteh, M., et al. (2011). A cross-sectional study in Kerman, Iran, on the effect of diabetic foot ulcer on health-related quality of life. The International Journal of Lower Extremity Wounds, 10(4), 200–206. https://doi.org/10.1177/1534734611428728.

    Article  PubMed  Google Scholar 

  14. Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38(1), 21–37.

    Article  CAS  Google Scholar 

  15. Ribu, L., Birkeland, K., Hanestad, B. R., Moum, T., & Rustoen, T. (2008). A longitudinal study of patients with diabetes and foot ulcers and their health-related quality of life: Wound healing and quality-of-life changes. Journal of Diabetes and its Complications, 22(6), 400–407. https://doi.org/10.1016/j.jdiacomp.2007.06.006.

    Article  PubMed  Google Scholar 

  16. Garcia-Morales, E., Lazaro-Martinez, J. L., Martinez-Hernandez, D., Aragon-Sanchez, J., Beneit-Montesinos, J. V., & Gonzalez-Jurado, M. A. (2011). Impact of diabetic foot related complications on the Health Related Quality of Life (HRQol) of patients—A regional study in Spain. The International Journal of Lower Extremity Wounds, 10(1), 6–11. https://doi.org/10.1177/1534734611400257.

    Article  CAS  PubMed  Google Scholar 

  17. Zoungas, S., Woodward, M., Li, Q., Cooper, M. E., Hamet, P., Harrap, S., et al. (2014). Impact of age, age at diagnosis and duration of diabetes on the risk of macrovascular and microvascular complications and death in type 2 diabetes. DIABETOLOGIA, 57(12), 2465–2474.

    Article  PubMed  Google Scholar 

  18. Al Hayek, A. A., Robert, A. A., Saeed, A., Alzaid, A., A. A., & Al Sabaan, F. S. (2014). Factors associated with health-related quality of life among Saudi patients with type 2 diabetes mellitus: A cross-sectional survey. Diabetes & Metabolism Journal, 38(3), 220–229.

    Article  Google Scholar 

  19. Kim, E. S., Moon, S., Kim, H.-S., Lim, D. J., Cho, J. H., Kwon, H. S., et al. (2011). Diabetic peripheral neuropathy is associated with increased arterial stiffness without changes in carotid intima–media thickness in type 2 diabetes. Diabetes Care, 34(6), 1403–1405.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Ribu, L., Hanestad, B. R., Moum, T., Birkeland, K., & Rustoen, T. (2007). Health-related quality of life among patients with diabetes and foot ulcers: Association with demographic and clinical characteristics. Journal of Diabetes and its Complications, 21(4), 227–236. https://doi.org/10.1016/j.jdiacomp.2007.02.001.

    Article  PubMed  Google Scholar 

  21. Yao, H., Ting, X., Minjie, W., Yemin, C., Xiqiao, W., Yuzhi, J., et al. (2012). The investigation of demographic characteristics and the health-related quality of life in patients with diabetic foot ulcers at first presentation. The International Journal of Lower Extremity Wounds, 11(3), 187–193. https://doi.org/10.1177/1534734612457034.

    Article  PubMed  Google Scholar 

  22. Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2010). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. [Article]. International Journal of Surgery, 8, 336–341. https://doi.org/10.1016/j.ijsu.2010.02.007.

    Article  Google Scholar 

  23. JBI (2016). JBI critical appraisal checklist for analytical cross sectional studies. http://www.joannabriggs.org/assets/docs/critical-appraisal-tools/JBI_Critical_Appraisal-Checklist_for_Analytical_Cross_Sectional_Studies.pdf.

  24. JBI (2016). JBI critical appraisal checklist for cohort studies. http://www.joannabriggs.org/assets/docs/critical-appraisal-tools/JBI_Critical_Appraisal-Checklist_for_Cohort_Studies.pdf.

  25. Borenstein, M., Hedges, L., Higgins, J., & Rothstein, H. (2005). Comprehensive meta-analysis version 2 (p. 104). Englewood, NJ: Biostat.

    Google Scholar 

  26. Hedges, L. V., & Olkin, I. (1985). Olkin. Statistical methods for meta-analysis. Orlando: Academic Press.

    Google Scholar 

  27. Brockwell, S. E., & Gordon, I. R. (2001). A comparison of statistical methods for meta-analysis. Statistics in Medicine, 20(6), 825–840.

    Article  CAS  PubMed  Google Scholar 

  28. Kontopantelis, E., & Reeves, D. (2012). Performance of statistical methods for meta-analysis when true study effects are non-normally distributed: A simulation study. Statistical Methods in Medical Research, 21(4), 409–426.

    Article  PubMed  Google Scholar 

  29. Sterne, J. A., & Egger, M. (2001). Funnel plots for detecting bias in meta-analysis: Guidelines on choice of axis. Journal of Clinical Epidemiology, 54(10), 1046–1055.

    Article  CAS  PubMed  Google Scholar 

  30. Lau, J., Ioannidis, J. P., & Schmid, C. H. (1998). Summing up evidence: One answer is not always enough. The Lancet, 351(9096), 123–127.

    Article  CAS  Google Scholar 

  31. Goodridge, D., Trepman, E., Sloan, J., Guse, L., Strain, L. A., McIntyre, J., et al. (2006). Quality of life of adults with unhealed and healed diabetic foot ulcers. Foot Ankle International, 27(4), 274–280.

    Article  PubMed  Google Scholar 

  32. Siersma, V., Thorsen, H., Holstein, P. E., Kars, M., Apelqvist, J., Jude, E. B., et al. (2013). Importance of factors determining the low health-related quality of life in people presenting with a diabetic foot ulcer: The Eurodiale study. Diabetic Medicine, 30(11), 1382–1387. https://doi.org/10.1111/dme.12254.

    Article  CAS  PubMed  Google Scholar 

  33. Siersma, V., Thorsen, H., Holstein, P. E., Kars, M., Apelqvist, J., Jude, E. B., et al. (2017). Diabetic complications do not hamper improvement of health-related quality of life over the course of treatment of diabetic foot ulcers–the Eurodiale study. Journal of Diabetes and its Complications, 31(7), 1145–1151.

    Article  PubMed  Google Scholar 

  34. Winkley, K., Stahl, D., Chalder, T., Edmonds, M. E., & Ismail, K. (2009). Quality of life in people with their first diabetic foot ulcer: A prospective cohort study. Journal of the American Podiatric Medical Association, 99(5), 406–414.

    Article  PubMed  Google Scholar 

  35. Ribu, L., Rustøen, T., Birkeland, K., Hanestad, B. R., Paul, S. M., & Miaskowski, C. (2006). The prevalence and occurrence of diabetic foot ulcer pain and its impact on health-related quality of life. The Journal of Pain: Official Journal of The American Pain Society, 7(4), 290–299.

    Article  Google Scholar 

  36. Valensi, P., Girod, I., Baron, F., Moreau-Defarges, T., & Guillon, P. (2005). Quality of life and clinical correlates in patients with diabetic foot ulcers. Diabetes & Metabolism, 31(3 Pt 1), 263–271.

    Article  CAS  Google Scholar 

  37. Nemcová, J., Hlinková, E., Farský, I., Žiaková, K., Jarošová, D., Zeleníková, R., et al. (2017). Quality of life in patients with diabetic foot ulcer in Visegrad countries. Journal of Clinical Nursing, 26(9–10), 1245–1256. https://doi.org/10.1111/jocn.13508.

    Article  PubMed  Google Scholar 

  38. Hogg, F. R., Peach, G., Price, P., Thompson, M. M., & Hinchliffe, R. J. (2012). Measures of health-related quality of life in diabetes-related foot disease: A systematic review. DIABETOLOGIA, 55(3), 552–565. https://doi.org/10.1007/s00125-011-2372-5.

    Article  CAS  PubMed  Google Scholar 

  39. Siersma, V., Thorsen, H., Holstein, P. E., Kars, M., Apelqvist, J., Jude, E. B., et al. (2014). Health-related quality of life predicts major amputation and death, but not healing, in people with diabetes presenting with foot ulcers: The Eurodiale study. Diabetes Care, 37(3), 694–700. https://doi.org/10.2337/dc13-1212.

    Article  PubMed  Google Scholar 

  40. Valensi, P., Le Devehat, C., Richard, J. L., Farez, C., Khodabandehlou, T., Rosenbloom, R. A., et al. (2005). A multicenter, double-blind, safety study of QR-333 for the treatment of symptomatic diabetic peripheral neuropathy: A preliminary report. Journal of Diabetes and its Complications, 19(5), 247–253. https://doi.org/10.1016/j.jdiacomp.2005.05.011.

    Article  PubMed  Google Scholar 

  41. Wagner, F. (1979). A classification and treatment program for diabetic, neuropathic, and dysvascular foot problems. Instructional Course Lectures, 28(1), 143–165.

    Google Scholar 

  42. Lopes, C. R., Marcondes, F., Medeiros, Á., Larissa Marques Barreto Mello, S., & Valdeci Carlos, D. (2013). Evaluation of limitations of venous ulcers in legs. Jornal Vascular Brasileiro, 12(1), 5–9.

    Article  Google Scholar 

  43. Wachholz, P. A., Masuda, P. Y., Nascimento, D. C., Taira, C. M. H., & Cleto, N. G. (2014). Quality of life profile and correlated factors in chronic leg ulcer patients in the mid-west of São Paulo State, Brazil. Anais brasileiros de dermatologia, 89(1), 73–81.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Hopman, W., Buchanan, M., VanDenKerkhof, E., & Harrison, M. (2013). Pain and health-related quality of life in people with chronic leg ulcers. Chronic Diseases and Injuries in Canada, 33(3), 167–174.

    CAS  PubMed  Google Scholar 

  45. Obilor, H., & Adejumo, P. O. (2015). Assessment of diabetic foot ulcer-related pain and its relationship to quality of life. Wound Practice & Research: Journal of the Australian Wound Management Association, 23(3), 124.

    Google Scholar 

  46. Gonzalez-Consuegra, R. V., & Verdu, J. (2011). Quality of life in people with venous leg ulcers: an integrative review. Journal of Advanced Nursing, 67(5), 926–944.

    Article  PubMed  Google Scholar 

  47. Martin, C. L., Albers, J. W., Pop-Busui, R., & Group, D. E. r (2014). Neuropathy and related findings in the diabetes control and complications trial/epidemiology of diabetes interventions and complications study. Diabetes Care, 37(1), 31–38.

    Article  CAS  PubMed  Google Scholar 

  48. Herber, O. R., Schnepp, W., & Rieger, M. A. (2007). A systematic review on the impact of leg ulceration on patients’ quality of life. Health Qual Life Outcomes, 5, 44. https://doi.org/10.1186/1477-7525-5-44.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Khunkaew, S., Tungpunkom, P., Sim, J., & Fernandez, R. (2018). The experiences of people in Northern Thailand living with diabetic foot ulcers: A descriptive qualitative study. Pacific Rim Internation Journal Nursing Research, 22(4), 304–318.

    Google Scholar 

  50. Peker, A., & Karaöz, S. (2017). The effects of social support and hope in the healing of diabetic foot ulcers treated with standard care. Population Health Management, 20(6), 507–507.

    Article  PubMed  Google Scholar 

  51. Pols, A. D., Schipper, K., Overkamp, D., van Dijk, S. E., Bosmans, J. E., van Marwijk, H. W. J., et al. (2017). Process evaluation of a stepped-care program to prevent depression in primary care: patients’ and practice nurses’ experiences. BMC Family Practice, 18(1), 26–26. https://doi.org/10.1186/s12875-017-0583-7.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Swardfager, W., Yang, P., Herrmann, N., Lanctôt, K. L., Shah, B. R., Kiss, A., et al. (2016). Depressive symptoms predict non-completion of a structured exercise intervention for people with Type 2 diabetes. Diabetic Medicine: A Journal of the British Diabetic Association, 33(4), 529–536. https://doi.org/10.1111/dme.12872.

    Article  CAS  Google Scholar 

  53. Tušek-Bunc, K., & Petek, D. (2016). Comorbidities and characteristics of coronary heart disease patients: Their impact on health-related quality of life. Health and Quality of Life Outcomes, 14(1), 159–159.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Heisler, M. (2009). Different models to mobilize peer support to improve diabetes self-management and clinical outcomes: Evidence, logistics, evaluation considerations and needs for future research. Family practice, 27(suppl_1), i23–i32.

    PubMed  PubMed Central  Google Scholar 

  55. Edinburgh (2006). Clinical diabetes: translating research into practice/Vivian A. Fonseca (1st edn.). Philadelphia: Elsevier Saunders.

    Google Scholar 

  56. Noor, S., Zubair, M., & Ahmad, J. (2015). Diabetic foot ulcer—A review on pathophysiology, classification and microbial etiology. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 9, 192–199. https://doi.org/10.1016/j.dsx.2015.04.007.

    Article  Google Scholar 

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Funding

Funding to undertake this study was provided by the Thai government as part of a PhD project.

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Authors and Affiliations

  1. School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Building 41, Wollongong, NSW, 2522, Australia

    Saneh Khunkaew, Ritin Fernandez & Jenny Sim

  2. Centre for Research in Nursing and Health, St George Hospital, Research and Education Building, Level 1, Kogarah, NSW, 2217, Australia

    Ritin Fernandez

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  1. Saneh Khunkaew
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Correspondence to Saneh Khunkaew.

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Ethical approval was not required for conducting this systematic review.

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This systematic review was undertaken according to the PRISMA Statement For the conduct of systematic reviews (Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. International Journal of Surgery. 2010;8:336–41. https://doi.org/10.1016/j.ijsu.2010.02.007.).

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Khunkaew, S., Fernandez, R. & Sim, J. Health-related quality of life among adults living with diabetic foot ulcers: a meta-analysis. Qual Life Res 28, 1413–1427 (2019). https://doi.org/10.1007/s11136-018-2082-2

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