Original articleA longitudinal study of patients with diabetes and foot ulcers and their health-related quality of life: wound healing and quality-of-life changes
Introduction
Diabetic foot ulcers (DFUs) often fail to heal despite appropriate treatment and often become chronic (Jeffcoate, Price, & Harding, 2004). The shortest healing time is observed in neuropathic ulcers, compared with ulcers of ischemic or mixed etiology (Pound, Chipchase, Treece, Game, & Jeffcoate, 2005). Obviously, DFUs are highly heterogeneous, and comparing different ulcer populations is difficult. In one study, 31% of neuropathic ulcers had healed after 20 weeks of appropriate treatment (Margolis, Kantor, & Berlin, 1999). In another study, after 6 months of treatment, 48% of ulcers had healed, 40% of ulcers were unhealed, 3% of patients had lost a lower limb, and 6% had died (Jeffcoate & Harding, 2003). Boulton, Meneses, and Ennis (1999), using a multidisciplinary team and standard wound care approach, found that the majority of wounds (88%) healed.
Foot ulcers that last for >4 weeks are associated with the worst outcome and an increased risk of amputation (American Diabetes Association, nd, Jeffcoate et al., 2004). Patients with previous ulcers have a high risk for new ulcerations and further amputations, and have an increased mortality rate (Apelqvist, 1998). According to the American Diabetes Association's (1999) Consensus Development Conference on Diabetic Foot Wound Care, the incidence of ulcers at the same site or at different sites in a foot with prior ulceration is >50% over 2–5 years.
A number of studies have demonstrated that health-related quality of life (HRQL) is negatively affected by DFUs, and some of the studies have shown that patients with current foot ulcers rated their HRQL lower than did patients with healed ulcers (Goodridge et al., 2006, Nabuurs-Franssen et al., 2005, Tennvall & Apelqvist, 2000, Valensi et al., 2005). Furthermore, HRQL was lower for patients with a current ulcer compared with those with a minor amputation, but HRQL was still lower in those with a major amputation (Tennvall & Apelqvist, 2000).
Using the SF-36 Health Survey, a frequently used HRQL questionnaire (Ware, Kosinski, & Gandek, 2000), Meijer et al. (2001) found that the presence of DFUs had a great impact on physical health, and Ahroni and Boyko (2000) found that changes in foot ulcer status were significantly associated with changes in the SF-36 subscales of physical functioning and role limitation—physical. Only a few studies have prospectively investigated patients with DFU (Abetz et al., 2002, Nabuurs-Franssen et al., 2005). One study followed patients over a period of 3 months and noted higher HRQL scores in physical and social functionings in patients with healed ulcers compared with patients with unhealed ulcers (Nabuurs-Franssen et al., 2005).
The aims of the present study were as follows:
- 1.
To assess wound healing during a 1-year follow-up in patients with DFUs;
- 2.
To compare HRQL in these patients at baseline, and after 6 and 12 months of follow-up; and
- 3.
To assess whether wound healing is related to changes observed in patients' HRQL.
Section snippets
Methods
The study design was prospective and observational. A group of patients who were referred for DFUs and who received routine treatment for ulcers at six outpatient clinics in Oslo, Norway, was studied. Data were collected at baseline (T1), and at 6 months (T2) and 12 months (T3) after inclusion. The 6-month test point was chosen in order to compare clinical data with the data of previous studies (Jeffcoate & Harding, 2003). The 12-month follow-up was chosen to assess long-term development and
Sociodemographic and clinical characteristics of patients
The sociodemographic and clinical characteristics of the patients are given in Table 1. The mean age was 61 years (S.D.=13.8), and the majority of the patients were elderly, were obese men, were living alone, had low education, and were not on regular work at the time of inclusion (Ribu, Hanestad, Moum, Birkeland, & Rustoen, 2006). Of all the patients, 29% had type 1 diabetes, and the mean duration of diabetes was 19 years (S.D.=12.9). The patients' mean HbA1c level was 8.6 (S.D.=1.9); the mean
Conclusions
As far as we know, this is the first study to have examined HRQL in patients with DFUs over a period of 12 months and to have assessed their HRQL in relation to wound healing. Only 37% of the patients were ulcer-free 12 months after inclusion in the study, indicating the seriousness of DFUs in these patients. As previous studies have shown that patients with DFUs have a mortality risk that is more than double that of patients without DFUs (Boyko, Ahroni, Smith, & Davignon, 1996), our findings
Acknowledgment
This study was supported by Oslo University College (Oslo, Norway). The authors thank the patients, the nurses in diabetes clinics, and the hospitals for making this study possible. We wish to thank Reidun Mosand and Sissel Martinsen (Aker University Hospital); Anita Skafjeld and Kari Ihlen (Ulleval University Hospital); Elsa Orvik and Beate Sogaard (Asker and Baerum Hospital); Elisa Horntvedt Ellefsen (Diakonhjemmet Hospital); Anne-Kristin Bakkeli and Elisabeth Huseby (Lovisenberg Diakonale
References (37)
- et al.
Responsiveness of the SF-36 among veterans with diabetes mellitus
Journal of Diabetes and its Complications
(2000) Wound healing in diabetes. Outcome and costs
Clinics in Podiatric Medicine and Surgery
(1998)- et al.
Methods to explain the clinical significance of health status measures
Mayo Clinic Proceedings
(2002) - et al.
Diabetic foot ulcers
Lancet
(2003) - et al.
Translation and performance of the Norwegian SF-36 Health Survey in patients with rheumatoid arthritis: I. Data quality, scaling assumptions, reliability, and construct validity
Journal of Clinical Epidemiology
(1998) - et al.
The prevalence and occurrence of diabetic foot ulcer pain and its impact on health-related quality of life
Journal of Pain
(2006) - et al.
Assessing meaningful change in quality of life over time: A user's guide for clinicians
Mayo Clinic Proceedings
(2002) - et al.
Quality of life and clinical correlates in patients with diabetic foot ulcers
Diabetes and Metabolism
(2005) - et al.
The Diabetic Foot Ulcer Scale (DFS): A quality of life instrument for use in clinical trials
Practical Diabetes International
(2002) - ADA: American Diabetes Association : Consensus Development Conference on Diabetic Foot Wound Care, 7–8 April 1999,...
Diabetic foot ulcers: A framework for prevention and care
Wound Repair Regen
Increased mortality associated with diabetic foot ulcer
Diabetic Medicine
The Norwegian College of General Practitioner's program for general practice
The measurement of atherosclerotic peripheral arterial disease in epidemiological surveys
International Journal of Epidemiology
Quality of life of adults with unhealed and healed diabetic foot ulcers
Foot and Ankle International
Morbidity and health-related quality of life among ambulant elderly citizens
Aging Clinical Experimental Research
Dimensions of quality of life in people with non-insulin-dependent diabetes
Quality of Life Research
Self-rated health and mortality: A review of twenty-seven community studies
Journal of Health and Social Behavior
Cited by (83)
Amputation and infection are the greatest fears in patients with diabetes foot complications
2022, Journal of Diabetes and its ComplicationsPhysical Activity Participation in People With an Active Diabetic Foot Ulceration: A Scoping Review
2022, Canadian Journal of DiabetesA Longitudinal Study on the Association Between Diabetic Foot Disease and Health-Related Quality of Life in Adults With Type 2 Diabetes
2020, Canadian Journal of DiabetesImpact of patient-education on health related quality of life of diabetic foot ulcer patients: A randomized study
2019, Clinical Epidemiology and Global HealthCitation Excerpt :DFU is a major burden for the individuals from the patient's immediate surroundings because it is the duty of caregivers to regularly support in wound care and cope with physical disabilities and emotional distress. Some studies show that patients with unhealed wounds were frustrated and anxious about healing, found it difficult to cope with daily living activities, inappropriate foot wear, and complained of a limited social life.14,15 Studies have shown that foot-education improves knowledge-level and satisfaction among high risk DFU patients.16