Remote Wound Care

Reference: Kilic M, Karadağ A. Developing and evaluating a mobile foot care application for persons with diabetes mellitus: a randomized pilot study. Wound Manag Prev. 2020;66(10):29–40.

Rationale: Widespread global use of mobile phones presents an opportunity for patients to increase both their education and motivation to engage in diabetic foot care as recommended in international guidelines. However, recent reviews indicate that there is insufficient evidence to support the effects of patient education on improving diabetic foot care outcomes.

Objective: The authors developed and tested the efficacy of mobile phone diabetic foot care software (m-DAKBAS) in improving knowledge, motivation to practice positive foot care, and self-efficacy for managing foot self-care of patients with diabetes.

Methods: In a Turkish outpatient diabetes clinic, following ethics board review and obtaining patient consent, the authors conducted a 10-patient pilot study of the m-DAKBAS software application, which mentored patients on diabetic foot definitions, risk factors, and ulcer prevention methods (phase 1). After power calculations determined that 44 patients per group were needed for a clinically important 30% difference to be statistically significant, demographic and clinical characteristic data were evaluated for the 88 enrolled patients in phase 2. The randomized, prospective, 2-group, pretest/posttest study compared 3 primary outcomes: (1) diabetic foot care knowledge measured as true, false, and I don’t know answer options to 20 validated items related to diabetic foot care; (2) self-care behavior was measured using a validated Turkish adaptation of the 15-item Foot Self-Care Behavior Scale, which was based on the Foot Care Observation Guide,⁸ answered on 5-point Likert scale from 1 (never) to 5 (always); and (3) self-efficacy was measured using a validated Turkish translation of the Diabetic Foot Care Self-Efficacy Scale⁹ consisting of 9 items, each of which were rated by the patient on a visual analog scale (0 to 10) from 0 (I find it totally insufficient) to 10 (I find it totally sufficient). These were measured before and after 24 weeks of patient care using the app, which sent the clinic daily blood glucose and foot observations and encouraged and engaged patients in the test group adhering to guideline-appropriate foot care uploaded to their mobile phones (n = 44). Control subjects (n = 44) received one 30-minute baseline training session on m-DAKBAS software content, including daily foot care, but did not have the mobile app on their phones. All participants received a 6-month follow-up appointment for a clinic checkup and posttest. A significant effect was set at P less than .05. Chi-square was used to test baseline group differences for categorical data. Student’s t test assessed for normally distributed outcome data, and the McNemar test was used for dichotomous foot examination outcomes. The Mann-Whitney test compared independent group effects. Wilcoxon tests evaluated significance of outcome differences over time.

Results: The groups were comparable at baseline on demographics and all 3 outcomes tests except for a higher ratio of females to males in the test group and more participants with prior foot care training in the control group. Both groups increased knowledge, behavior, and self-efficacy from baseline to the 24-week study end (P < .02). The test group increased in knowledge more than the control patients (P = .000) and improved more over time in wearing appropriate footwear and having fewer diabetic foot skin cracks (P < .01). Most test patients enjoyed using the app, wanted to recommend the app to other patients, and rated it as contributing to diabetic foot health while enabling communication with health care personnel.

Authors’ Conclusions: Education about diabetic foot care improved related knowledge, behavior, and self-efficacy. Further development and refinement of mobile apps to increase patient education and improve diabetic foot care knowledge, practice, and self-efficacy are warranted.

Reference: Téot L, Geri C, Lano J, Cabrol M, Linet C, Mercier G. Complex wound healing outcomes for outpatients receiving care via telemedicine, home health, or wound clinic: a randomized controlled trial. Int J Low Extrem Wounds. 2020;19(2):197–204. doi:10.1177/1534734619894485

Rationale: Despite the rapid growth in telemedicine, few RCTs support the efficacy and safety of telehealth in wound care.

Objective: The authors conducted an RCT comparing outcomes of patients with complex wounds who received professional home care with or without telehealth guidance from a remote expert or who attended a clinic for professional wound care.

Methods: Using methods consistent with the Helsinki Accord, an RCT documented wound outcomes of patients with reduced mobility, comorbidities, and complex wounds who were randomly assigned to receive professional wound care in a university wound clinic (n = 25) or in the home with (n = 89) or without (n = 59) expert advice via telemedicine from a publicly funded network of nurses and physicians highly experienced in wound healing in France. Standardized wound healing outcomes, patient mortality, and transportation costs were reported for up to 6 months. The pre-established level of statistical significance for all comparisons was P less than .05.

Results: Transportation costs were significantly less (P < .01) for the 2 home care groups to achieve healing, which occurred marginally but not significantly faster for clinic patients (average healing time: 56 days) compared with those receiving home telemedicine (67 days) and home care without remote advice (69 days). Mortality outcomes were comparable for all 3 groups.

Authors’ Conclusions: Wound healing clinicians using telemedicine expert advice offered a safe, effective, and low-cost home care option to manage patients with chronic complex wounds and limited mobility.

These 2 studies illustrate multiple ways in which telemedicine can positively impact wound management outcomes by both the patient and the wound care professional. Telemedicine informed patients with valuable knowledge that improved their wound care behavior and outcomes.⁶ In addition, experts used telemedicine to share wound care knowledge with home wound care professionals to optimize wound outcomes for patients who were high-risk.⁷

Kilic and Karadağ⁶ illustrated how patient behavior can affect outcomes just as clinician interventions do. Why not reward patients for beneficial behaviors with motivating messages (or insurance benefits like those for safe drivers)? What a brilliant strategy to empower patients to support their own care plans with knowledge and reward effective behaviors that reinforce professional interventions!

Téot et al⁷ demonstrated how telemedicine can offer a network of remote expert wound care support for patients, saving home wound care givers and patients costly travel and time.⁷

Outcomes data from both studies populated registries, which were analyzed and then published to teach wound care specialists how to improve health or economic outcomes. Just as Hippocrates transformed medical practice based on observed outcomes and Florence Nightingale transformed the abysmal outcomes of those wounded in the Crimean War by measuring and documenting those results, wound care professionals can learn from the findings of Kilic and Karadağ⁶ as well as Téot et al.⁷ Patients at high risk of developing chronic wounds can be transformed into well-informed participants, regarding the maintenance of healthy skin. Chronic wounds can transition into healing wounds by channeling expert advice to where it is needed most. The quality of learning from these registries depends on the reliability and validity of the outcome measures populating them. Kilic and Karadağ⁶ did a remarkable job of using valid, reliable measures of patient knowledge, behavior, and self-efficacy. It is a credit to their meticulous work that none of the 88 participants developed a diabetic foot ulcer or experienced an amputation during the 24-week study.⁶ How well and reliably are wound care professionals measuring valid, risk-adjusted outcomes in current practice? How well is each medical practice documenting, improving, and communicating its key outcomes?