Patient education for preventing diabetic foot ulceration - A systematic review

Ulceration of the feet, which can result in loss of limbs and death, is a major health problem for people with diabetes mellitus. The objective of this review was to assess the effectiveness of patient education to prevent diabetic foot ulcers. We conducted a systematic review of randomized controlled trials (RCTs) that evaluated educational programs for the prevention of foot ulcers in people with diabetes mellitus. We used standard search methods of the Co-chranes Wounds Group. Two reviewers working independently extracted data and assessed study quality. The methodologic quality of the 8 included RCTs was poor. The internal validity score (range 0-10) of individual RCTs ranged from 2 to 4. Four trials compared the effect of intensive with brief educational interventions; 2 of these reported clinical endpoints. One study involving high-risk patients reported a reduction in ulcer incidence (OR 0.28, 95% confidence interval [95% CI] 0.13-0.59) and amputation rate (OR 032, 95% Cl 0.14-0.71) after I year. The other RCT did not find an effect after 7 years of follow-up. Two trials showed that participants' foot care knowledge significantly improved with education. In one trial, foot care knowledge was significantly worse at 6 months, although foot care behavior improved significantly. One RCT, which compared patient foot care education as part of a general diabetes education program to usual care, showed no reduction in the risk of foot ulceration. In one RCT, patient education as part of a complex intervention targeted at both people with diabetes and doctors reduced the prevalence of serious foot lesions at 1 year (OR 0.41, 95% Cl 0.16-1.00) and improved foot care behavior. Evidence from two RCTs comparing the effect of patient-tailored education in addition to usual care was conflicting. Evidence, limited by poor methodologic quality and conflicting results, suggests that patient education may have positive but short-lived effects on foot care knowledge and behavior of patients and may reduce foot ulceration and amputations, especially in high-risk patients. High-quality randomized controlled trials are needed to establish the efficacy of patient education to prevent diabetic foot ulcerations.