How Does Quality Of Life Affect Diabetes Treatment Compliance?

Given that patients with diabetes can face extensive treatments due to the risk of complications, adherence to treatment regimens may be a problem due to a perceived decline in their quality of life.

A new study finds that although end-stage complications have the greatest effect on quality of life, comprehensive treatments affect quality of life to the degree that some patients were willing to forego years of healthy living to avoid treatments.

In the study, which was recently published in Diabetes Care, researchers interviewed 701 patients with diabetes and evaluated nine disease complications and 10 treatment states. Researchers asked patients not to consider the treatments’ long-term effects on complications but to concentrate on the treatments’ daily effects on quality of life. The study notes that researchers also questioned patients on their perceptions of their quality of life with comprehensive diabetes care, which the study authors described as cholesterol-lowering medication, aspirin, intensive blood pressure control, intensive glucose control, diet and exercise.

Twelve to 50 percent of patients said they would give up eight of 10 years of perfect health to avoid life with complications, according to the study. In addition, 10 to 18 percent of patients said they would sacrifice eight of 10 years of life in perfect health to avoid a life with treatments.

Recognizing The Challenges Of Changing Patient Perspectives
The study notes that DPMs may educate patients early in the disease course to allay their concerns “about the true nature of optimal diabetes care by incorporating their preferences into treatment decisions, and by acknowledging patient preferences and quality of life concerns in public health efforts to improve the quality of diabetes care.”

Matthew Claxton, DPM, notes the challenge of improving patient perspectives on diabetes. He says most have had bad family experiences with the disease as they may have had parents or grandparents lose their eyes, kidney function or limbs.

“If we are to effectively treat diabetics with the ‘team’ mentality, then each team member must be responsible for giving hope,” says Dr. Claxton, who is in private practice in Belleville, Ill. However, he does note that sometimes he has to explain to the patient what other members of the multidisciplinary care team should have explained.

At an initial visit, Dr. Claxton says he will spend 20 to 30 minutes helping patients understand their diet and why they are receiving referrals to multiple doctors. He also encourages patients to recognize that diabetes should not control their lives and emphasizes that diet and exercise are not punishments but goals for healthy living. Dr. Claxton says this approach has been successful in facilitating a positive mental attitude as these patients “are very happy and continue to improve their control of diet and exercise.”

As far as the importance of education goes, lead study author Elbert Huang, MD, MPH, emphasizes involving patients with self-management so they can take ownership of their diabetes. He also advocates prioritizing different aspects of care so patients can win small battles.

“If a patient is willing to take an aspirin or an ACE inhibitor, that is a form of success even if the patient continues to resist other treatments,” says Dr. Huang, an Assistant Professor of Medicine at the University of Chicago.

Dr. Huang also relates the idea of shared decision-making, which involves education as well as DPMs being sensitive to patients’ treatment preferences. He says advocates of the technique ensure that patients understand their decisions and if patients choose not to take a medicine, it is their choice.

“We have to take a step back sometimes to realize that our patients do not need to be frightened or threatened into compliance, but encouraged,” points out Dr. Claxton.

He wonders whether patients in the study were polled on the negative comments doctors may have given them regarding self-management of their diabetes.

“For example, one of the only two endocrinologists in my practice area has pictures of foot ulcers and amputated limbs on his office walls,” points out Dr. Claxton. “What kind of message does this send to people?”

Dr. Claxton recalls a patient in his 70s who had been diagnosed with diabetes in the 1930s. Although he remembered the days of using glass syringes and the testing of urine for glucose, the man’s only complication was slightly poor vision, which Dr. Claxton says is a message that many can lead long, full lives with diabetes.

Study Assesses Risk Factors For Ex-Fix Complications
By Brian McCurdy, Senior Editor

A recently published study offers a closer look at risk factors associated with post-op complications that can occur among patients with Ilizarov frames.

In the study, which was recently published in the Journal of Foot and Ankle Surgery, researchers reviewed the records of 16 limbs in 15 patients with diabetes who received Ilizarov frames following Charcot foot reconstruction or soft tissue offloading surgery. The study found serious pin tract infections in 31 percent of patients, pin breakages in 25 percent of patients and surgical wound dehiscence in 56 percent of patients. The study concluded that a younger age, elevated preoperative glucose and length of tourniquet time were associated with such complications.

While researchers said it was surprising to see that younger age was associated with complications, they noted that age may be linked to a more physically aggressive rehabilitation, which can lead to pin breakage, infection and wound dehiscence.

What treatment alternatives could be effective in patients at a high risk for complications with Ilizarov frames? Study co-author Lee Rogers, DPM, points out that most candidates for Charcot reconstruction have some degree of risk as they usually have diabetes and multiple comorbidities.

For patients who cannot undergo surgical reconstruction because of an unstable medical condition, he says bracing with a Charcot restraint orthotic walker (CROW) and/or confinement to a wheelchair may help to delay or prevent an amputation. In the presence of a wound, he notes preventing infection can prevent amputation. Silver- and iodine-based products also aid in reducing bacterial bioburden and can prevent infections, according to Dr. Rogers, the Director of the Amputation Prevention Center at Broadlawns Medical Center in Des Moines, Iowa.

To lower glucose levels and thus decrease the risk of Ilizarov complications, Dr. Rogers suggests establishing a close relationship with an internist or a diabetologist. If the patient’s preoperative glucose is elevated above 190 mg/dL, he advocates insulin management to lower it. For a patient with extremely elevated glucose (above 350 mg/dL) or for a patient whose glucose cannot be decreased below 190 mg/dL, Dr. Rogers advocates postponing the surgery until one can stabilize the patient. He says doing so may prevent pin tract infections and wound dehiscence.

For further reading, see “Mastering Complications In External Fixation” in the August 2005 issue of Podiatry Today or “Can A New Ex-Fix Device Have An Impact In Deformity Correction?” in the June 2005 issue. Also check out the archives at www.podiatrytoday.com.

What A Study Reveals On Articular Talar Injuries In Athletes
By Brian McCurdy, Senior Editor

A recent study in the American Journal of Sports Medicine compares two treatments for articular talar injuries in athletes.

The study examined 26 microfracture procedures and 20 talus grafts in athletic patients with articular injuries to the talar dome. Researchers assessed patients’ American Orthopedic Foot and Ankle Society (AOFAS) scores two to eight years following surgery and found that scores for both groups increased significantly.

Bone grafting patients had a longer return to activity at 19.6 ± 5.9 weeks in comparison to 15.1 ± 4 weeks for patients who underwent microfracture surgery, according to the study. The study also notes that patients with anterolateral lesions had a quicker return to activity and better postoperative scores than those with lesions at other sites.

As lead study author Amol Saxena, DPM, notes, surgeons should reserve microfracture procedures only for chondral injuries and use bone grafts only for bony defects. He adds that previous failed surgery may be a relative contraindication.

Sometimes podiatric surgeons may combine microfracture surgery with joint distraction, especially with the midfoot joints, as it is not ideal to fuse such joints in athletes, according to Dr. Saxena, a Fellow of the American College of Foot and Ankle Surgeons.