Evaluating the cost-effectiveness of diabetic foot ulcer management by wound care specialists in Indonesia.

Diabetic foot ulcers affect quality of life and economically burden patients and the Indonesian healthcare system. The comparative cost-effectiveness of wound care specialists in private practices (e.g., wound clinics) and wound care nurses in national hospitals remains unknown. Thus, we used a decision tree to compare the cost and healing rates for patients after 12 weeks of wound care. Uncertainty was addressed using one-way and probabilistic sensitivity analyses. Among 89 participants (42 in the national hospital and 47 in the private practice), no significant differences were observed between the two groups in terms of sex, age, education level, smoking status, duration of diabetes, Wagner wound classification, glycated haemoglobin levels, neuropathy status, ankle-brachial index, baseline characteristics, quality of life, DMIST (depth, maceration, inflammation/infection, size, tissue type of the wound bed, type of wound edge, and tunnelling/undermining) score and wound location (p > 0.05). However, significant differences were observed for days from first visit/assessment until complete healing, mean quality of life (p ≤ 0.001) and wound size (p = 0.047). Wound care specialists in private practices had a significantly lower cost of 2,804,423.3 Indonesian rupiah compared to 6,483,493.4 Indonesian rupiah for wound care nurses in national hospitals. The incremental cost-effectiveness ratio was -165,723.9. Therefore, wound care specialists in private practices are more cost-effective for managing diabetic foot ulcers. Probability sensitivity analysis confirmed that 80%-90% of the scenarios were cost-effective. These findings may inform healthcare resource allocation in Indonesia. Additionally, evidence-based cost-effectiveness measures were strengthened in private practices and national hospitals.

Impact of foot ulcer-related factors on quality of life in patients with diabetes: Prospective observational study.

Quality of life (QOL) may be impacted by foot ulcer-related factors, with prevention of diabetes-related foot ulcers or more effective early healing helping to improve overall patient QOL. This study, which examined the relationship between foot ulcer-related factors and QOL in patients with diabetes, was conducted as a secondary analysis of a prospective observational study entitled: "Factors associated with the discontinuation of wound care specialist clinic visits in patients with diabetic foot ulcers". We investigated EQ-5D-5L, patient characteristics and foot ulcer-related factors of 73 patients with diabetes-related foot ulcers who visited one wound clinic in Indonesia between August 2020 and February 2021. Results showed that the mean health utility was 0.294 ± 0.371. Factors selected for the multiple regression analysis included inflammation/infection of DMIST, first-ever foot ulcer, and size of DMIST. First-ever foot ulcer (ß = 0.309, p = 0.003) and size of DMIST (ß = -0.316, p = 0.015) were significantly associated with the health utility (p < 0.001). Significant improvement in the health utility of 15 patients was observed when the ulcer healed (Wilcoxon signed-rank sum test, p = 0.001). In conclusion, not only ulcer severity but also the first-ever foot ulcer itself affected the QOL in patients with diabetes. These results suggest there will be a greater impact on the QOL of patients who develop diabetes-related foot ulcers for the first time, along with the importance of prevention and early healing, through early infection control and wound size reduction.

Relationship between items of DMIST and healing of diabetic foot ulcers.

A monitoring tool for the wound-healing process of diabetic foot ulcers (DFUs) was developed. It comprises seven domains, namely, depth, maceration, inflammation/infection, size, tissue type of the wound bed, type of wound edge, and tunnelling/undermining. It was named "DMIST" based on the initials of its domains. Although DMIST is useful for assessing wound-healing processes, the monitoring items related to wound healing remain unclear, thereby making the selection of optimal care based on the assessment difficult. We identified the relationship between the DMIST items and wound healing. This study was a secondary analysis of five previous investigations and was conducted using DMIST based on the diabetic foot ulcer assessment scale score and DFU images. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) after simultaneously controlling for potential confounders. The examined DFU healing status revealed that some DFUs healed at 4 weeks from baseline, whereas some DFUs did not. Variables considered in the models were the scores of each DMIST domain. The study population comprised 146 Indonesian patients and 33 Japanese patients. Depth, maceration, and size were associated with DFU healing at 4 weeks from baseline [depth: OR = 0.317 (95% CI: 0.145-0.693, P = 0.004); maceration: OR = 0.445 (95% CI: 0.221-0.896, P = 0.023); size: OR = 0.623 (95% CI: 0.451-0.862, P = 0.004)]. Our findings suggest that appropriate management of maceration promotes DFU healing.

Increased temperature at the healed area detected by thermography predicts recurrent pressure ulcers.

Preventing recurrent pressure ulcers is an important challenge in healthcare. One of the reasons for the high rate of recurrent pressure ulcers is the lack of assessment methods for their early detection. Therefore, this study aimed to determine the thermographic characteristics of the healed area and to consider the predictive validity of thermographic images for recurrent pressure ulcers within a 2-week period. This observational study was conducted at a long-term care facility in Japan between July 2017 and February 2019 among patients whose pressure ulcers had healed. Thermographic images of the healed area were recorded once a week until recurrence or until the end of the study. We enrolled 30 participants, among whom 8 developed recurrent pressure ulcers. The generalised estimation equation revealed that the thermographic finding of increased temperature at the healed area compared to that of the surrounding skin was significantly associated with recurrent pressure ulcers (odds ratio: 101.13, 95% confidence interval: 3.60-2840.77, p = .007); the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio for recurrent pressure ulcers within 2 weeks were 0.80, 0.94, 0.62, 0.97, 12.9 and 0.2, respectively. Our thermographic findings revealed that the temperature of the healed area was higher than that of the surrounding skin; this could be a useful predictor of pressure ulcer recurrence within 2 weeks, even in the absence of macroscopic changes.

Evaluation of foot ulcer incidence in diabetic patients at a diabetic foot ulcer prevention clinic over a 10-year period.

The present study aimed to evaluate diabetes patients over a 10-year period that visited our outpatient clinic for prevention of diabetic foot ulcers and then investigate the incidence and aetiology of diabetic foot ulcers. The Department of Diabetes and Metabolic Diseases of a university hospital was in charge of the clinic that provided diabetes patients with individual education via the use of visualisation techniques. In this prospective cohort study, a total of 942 diabetes patients who visited the clinic were evaluated for neuropathy, angiopathy and medical history between November 2006 and March 2017. Using the patients' medical records, diabetic foot ulcer development was evaluated between the day of the first visit and December 31, 2018, with 20 out of 942 participants developing these ulcers. Over a period of 12, 60 and 120 months, the diabetic foot ulcer cumulative incidence was 0.2%, 2.4% and 5.8%, respectively. A history of diabetic foot ulcers and the male sex were shown by a Cox regression analysis to be correlated with diabetic foot ulcer development (Hazard Ratio [HR] 11.55, 95%CI 4.600-29.004, p < 0.001; and HR 3.55, 95%CI 1.031-12.196, p = 0.045, respectively). However, only five out of 20 participants with ulceration returned to the clinic for re-examination. In conclusion, a 12-month evaluation showed there was a low incidence of diabetic foot ulcers. These results might suggest that patients with a diabetic foot ulcer history need to undergo at least an annual follow-up in order to further reduce diabetic foot ulcer incidence, although studies involving control groups needs to be conducted, in presenting these as evidence.

Incidence of and risk factors for self-load-related and medical device-related pressure injuries in critically ill patients: A prospective observational cohort study.

There are two types of pressure injuries: self-load-related pressure injuries (PIs) and medical device-related pressure injuries (MDRPIs), but the differences in risk factors between PIs and MDRPIs have not yet been clarified. If risk factors for PIs and MDRPIs differ, preventive interventions should take this into account. This is a prospective cohort study aimed to determine the cumulative incidence of PIs and MDRPIs in critically ill patients and to identify corresponding risk factors. The study included 1418 patients who were admitted to the critical care medical center of a single university hospital in Tokyo, Japan, between 1 December 2019 and 31 August 2020. The Kaplan-Meier method was used to calculate the cumulative incidence of PIs and MDRPIs. Furthermore, the Cox proportional hazards model was used to analyse the predictors in both the PI and MDRPI incidence and non-incidence groups. Predictors were based on data from the 0th disease day. The cumulative incidence of PIs and MDRPIs was 4.6/1000 person-days and 3.6/1000 person-days, respectively. Multivariate analysis using the Cox proportional hazards model showed that common risk factors for the occurrence of PIs and MDRPIs were possession of PI on admission, higher blood lactate, blood purification therapy, and positional restriction. The risk factors for PIs only were diabetes mellitus, septic shock, and a lower serum albumin level, while the risk factors for MDRPIs only were the D-dimer level and extracorporeal membranous oxygenation treatment. Therefore, prophylactic interventions need to consider these different risk factors.

Prevention of diabetic foot ulcers using a smartphone and mobile thermography: a case study.

OBJECTIVE: Early identification of pre-ulcerative pathology is important to preventing diabetic foot ulcers (DFU), but signs of inflammation are difficult to detect on the feet of patients with diabetic neuropathy due to decreased sensation. However, infrared thermography can objectively identify inflammation. Therefore, a device that allows patients to visualise thermograms of their feet might be an effective way to prevent DFU. We aimed to determine the effects of a novel self-monitoring device to prevent DFU using a thermograph attached to a smartphone. METHOD: A self-monitoring device comprising a mobile thermograph attached to a smartphone on a selfie stick was created, and its effects in two patients with diabetic neuropathy and foot calluses assessed. RESULTS: For one patient, he understood that walking too much increased the temperature in the skin of his feet (a sign of inflammation). The other patient could not detect high-risk findings, because the temperature of his skin did not increase during the study period. CONCLUSION: This device might provide self-care incentives to prevent DFU, although some issues, such as the automatic detection of high-risk thermographic changes, need to be improved.

Validity of DMIST for monitoring healing of diabetic foot ulcers.

A new diabetic foot evaluation scale was proposed, using the seven domains of depth, maceration, inflammation/infection, size, tissue type of the wound bed, type of wound edge, and tunneling/undermining. This scale was named "DMIST" as an acronym from the initials of the domains. The purpose of this study was to evaluate the validity of DMIST. Secondary analysis was conducted in three investigations performed using the diabetic foot ulcer assessment scale (DFUAS) in Japan and Indonesia. Secondary analysis was assessed using DMIST, PUSH, and DESIGN for 4 weeks based on DFUAS score and photographs of diabetic foot ulcers by researchers. Concurrent validity was determined from the correlation of total DMIST scores with PUSH and DESIGN scores. Construct validity was determined by comparisons between total DMIST score and grade of the Wagner classification. Predictive validity was determined by receiver operating characteristic curve analysis for wound non-healing 4 weeks later. Subjects comprised 35 Japanese patients and 118 Indonesian patients. Correlations of total DMIST score with PUSH and DESIGN scores were 0.831 and 0.822, respectively. Comparison of total DMIST scores with grade of the Wagner classification (Grade I vs. Grade II/III vs. Grade IV/V) was p < 0.001. Based on an area under the curve of 0.872, a DMIST score of 9 was selected as a cut-off, offering sensitivity of 0.855 and specificity of 0.786 for wound non-healing 4 weeks later. Our findings suggest that DMIST offers high validity.

Factors Associated with Callus Formation in the Plantar Region through Gait Measurement in Patients with Diabetic Neuropathy: An Observational Case-Control Study.

Callus has been identified as a risk factor leading to severe diabetic foot ulcer; thus, it is necessary to prevent its formation. Callus formation under the first, second, and fifth metatarsal heads (MTHs) is associated with external forces (pressure and shear stress) during walking. However, the gait factors increasing the external forces remain undetermined. Thus, this study aims to identify the factors increasing the external forces to prevent callus formation. In 59 patients with diabetic neuropathy wearing their usual shoes, the external forces, and the lower extremity joint angles were measured using MEMS force sensors and motion sensors. The external forces and their relationship with the lower extremity joint angles and footwear size were determined. Risk factors causing high external forces on the first MTH included small flexion of the knee joint (p = 0.015) and large ankle pronation motion (p = 0.034) to obtain propulsion. For the second MTH, wearing excessively long footwear was identified (p = 0.026). For the fifth MTH, high external force was related to tight width footwear (p = 0.005). An effective intervention for preventing callus formation for the first MTH would involve assisting the push-off foot motion using rocker-sole footwear or gait training. For the second and fifth MTHs, wearing appropriate size footwear would be effective.

Skin characteristics associated with foot callus in people with diabetes: A cross-sectional study focused on desmocollin1 in corneocytes.

AIM: The purpose of this study was to investigate the degradation of desmocollin-1 (DSC1), a member of the desmosomal cadherin family in patients with diabetes, as well as the factors associated with the suppression of DSC1 degradation. METHODS: This cross-sectional study included 60 cases of foot callus involving 30 patients with diabetes (DM) and 30 matched volunteers without diabetes (non-DM). DSC1 degradation in samples from debrided calluses was analysed using western blotting. Skin hydration, a factor reported to suppress DSC1 degradation, was measured using a mobile moisture device. RESULTS: Full-length DSC1 (approximately 100 kDa) was detected in six participants only in the DM group, and no relationship was found between the suppression of DSC1 degradation and decreased skin hydration in the DM group. There was no significant difference in skin hydration values between the DM and non-DM groups. CONCLUSION: DSC1 degradation was suppressed in the DM group. There was no relationship between the suppression of DSC1 degradation and decreased skin hydration in the DM group. Current external force callus care would not be sufficient. This study highlights the need to develop novel callus care to enhance the degradation of DSC1.

Differences Between Patient-Reported Versus Clinician-Observed Nonulcerative Signs and Symptoms of the Foot in Patients With Diabetes Mellitus.

PURPOSE: The primary aim of this study was to compare patient reported versus clinician-observed nonulcerative foot conditions in patients attending a diabetic foot clinic and deemed at risk for diabetic foot ulcers. DESIGN: Retrospective review of medical records. SUBJECTS AND SETTING: The medical records of 126 patients with diabetes mellitus and deemed at risk for developing diabetic foot ulcers were reviewed. All patients received care from a diabetic foot outpatient clinic in a university-based hospital in Tokyo, Japan, between November 2008 and October 2009. METHODS: We compared patients' self-identified foot complaints with clinically observable conditions affecting the feet of these individuals with diabetes mellitus. Patients' medical records were retrieved, and patient complaints and identified preulcerative signs of the foot were documented. All clinical observations were made by nurse specialists with knowledge of diabetic foot conditions. Nonulcerative diabetic foot conditions we observed included calluses, corns, abnormal nails, fissures, tinea pedis, and tinea unguium. Patient sensitivity to correctly identify these signs was calculated using the following formula: patient-reported foot signs divided by clinically identified preulcerative signs. RESULTS: Patient sensitivity for identifying nonulcerative signs varied based on the foot condition was 51.4% for calluses, 47.8% for pincer nails, 44.4% for corns, 33.3% for fissures, 19.4% for nail abnormalities, 3.9% for scales/maceration between the toes, 2.6% for interdigital tinea pedis, and 18.2% for tinea unguium. CONCLUSION: These findings suggest that persons with diabetes vary in their awareness of conditions affecting their feet and enhancing their risk for the development of diabetic foot ulcers. We recommend additional education on foot-related self-care including how often to observe their feet and how to recognize symptoms that may elevate their risk for diabetic foot ulcers.

The Association between Tinea Pedis and Feet-Washing Behavior in Patients with Diabetes: A Cross-sectional Study.

OBJECTIVES: To examine the correlations between elements of feet-washing behavior, presence of tinea pedis (TP), and patients' background characteristics in order to identify a concrete intervention method to prevent TP. DESIGN AND PARTICIPANTS: A cross-sectional study of 30 patients with diabetes (16 with TP) who were admitted to or visited the university hospital. MAIN OUTCOME MEASURES: The presence of TP was confirmed by the detection of dermatophytes by direct microscopy. Data on elements of feet-washing behavior, such as scrubbing between the toes, were collected by observing recorded videos of participants normally washing their feet as they do at home. The patients' background characteristics included demographic data; diabetes-related factors; patient knowledge regarding diabetes, foot problems, and TP prevention; purpose for feet washing; and any difficulties in feet washing. MAIN RESULTS: The number of times patients scrubbed between their toes while washing with soap was significantly lower in patients with TP (odds ratio, 0.95; P = .036; with a cutoff value of 35 times) and those who had difficulty in reaching their feet with their hands (B = -14.42, P = .041). CONCLUSIONS: An effective foot-washing protocol should include specific instructions for patients to scrub between their toes at least 35 times in all 8 spaces while washing with soap. Appropriate advice is also needed for individuals who have difficulty reaching their feet with their hands. Education about appropriate foot-washing behavior may potentially prevent TP.

Evaluation of validity of the new diabetic foot ulcer assessment scale in Indonesia.

We developed a new assessment tool for diabetic foot ulcers because no such tool specifically for diabetic foot ulcer exists. The diabetic foot ulcer assessment scale (DFUAS) has 11 domain items. The minimum and maximum scores on this scale are 0 and 98, respectively; higher scores indicate more severe wounds. The aim of this study was to evaluate the concurrent validity, construct validity and predictive validity of DFUAS in Indonesia. A prospective cohort study was conducted on patients with diabetic foot ulcer at Kitamura wound clinic in Indonesia. A total of 62 patients with 70 diabetic foot ulcers were assessed with DFUAS tool, Bates-Jensen wound assessment tool (BWAT), and pressure ulcer scale for healing (PUSH). Concurrent validity was determined by correlation of the DFUAS total score with the external criterion (BWAT, PUSH, and wound surface area). A comparison between the total DFUAS score and chronic wound status was made to determine construct validity. We also analyzed 41 wounds that were followed for 4 weeks to evaluate predictive validity. The correlation coefficient total scores of the DFUAS against the BWAT, PUSH, and wound surface area were 0.92, 0.87, and 0.82, respectively. The comparison of the total DFUAS score with chronic wound status was p < 0.001. The predictive validity test indicated that a DFUAS cutoff score of 12 produced the best balance of sensitivity, specificity, positive predictive value, and negative predictive value (89%, 71%, 86%, and 77%, respectively). In conclusion, the newly developed DFUAS is a valid tool for assessing diabetic foot ulcers.

Cost-utility analysis of an advanced pressure ulcer management protocol followed by trained wound, ostomy, and continence nurses.

The high prevalence of severe pressure ulcers (PUs) is an important issue that requires to be highlighted in Japan. In a previous study, we devised an advanced PU management protocol to enable early detection of and intervention for deep tissue injury and critical colonization. This protocol was effective for preventing more severe PUs. The present study aimed to compare the cost-effectiveness of the care provided using an advanced PU management protocol, from a medical provider's perspective, implemented by trained wound, ostomy, and continence nurses (WOCNs), with that of conventional care provided by a control group of WOCNs. A Markov model was constructed for a 1-year time horizon to determine the incremental cost-effectiveness ratio of advanced PU management compared with conventional care. The number of quality-adjusted life-years gained, and the cost in Japanese yen (¥) ($US1 = ¥120; 2015) was used as the outcome. Model inputs for clinical probabilities and related costs were based on our previous clinical trial results. Univariate sensitivity analyses were performed. Furthermore, a Bayesian multivariate probability sensitivity analysis was performed using Monte Carlo simulations with advanced PU management. Two different models were created for initial cohort distribution. For both models, the expected effectiveness for the intervention group using advanced PU management techniques was high, with a low expected cost value. The sensitivity analyses suggested that the results were robust. Intervention by WOCNs using advanced PU management techniques was more effective and cost-effective than conventional care.

Establishment of a novel rat model for deep tissue injury deterioration.

Deep tissue injuries (DTIs) can become significant problems because of their rapid deterioration into deep pressure ulcers. Presently, no animal model of DTI deterioration has been developed. By concentrating pressure and shear stress in deep tissues while minimising pressure and shear stress in the overlying skin, we produced an effective rat model of DTI deterioration. Two-dimensional finite element method (FEM) simulated the distribution of pressure and shear stress under several pressure-loading conditions. FEM showed that concentrated shear stress in deep tissue with minimum shear stress in the overlying skin could be created by using a prominence and a cushion, respectively. On the basis of the results of FEM analysis, we selected suitable conditions for testing the rat DTI deterioration model. The compressed area was macroscopically observed until day 13, and histopathologic analysis via haematoxylin and eosin (H&E) staining was performed on days 3, 7 and 13. H&E staining showed that the distribution of tissue damage was similar to the predicted FEM results. Deep ulceration and tissue damage extending from deep tissues to the overlying skin and surrounding tissues were observed in the DTI deterioration model, which are similar to the clinical manifestations of DTI deterioration. In conclusion, a representative DTI deterioration model was established by concentrating high shear stress in deep tissues while minimising shear stress in the overlying skin. This model will allow a better understanding of the mechanisms behind DTI deterioration and the development of preventative strategies.

Skin blotting: a noninvasive technique for evaluating physiological skin status.

OBJECTIVE: The skin performs important structural and physiological functions, and skin assessment represents an important step in identifying skin problems. Although noninvasive techniques for assessing skin status exist, no such techniques for monitoring its physiological status are available. This study aimed to develop a novel skin-assessment technique known as skin blotting, based on the leakage of secreted proteins from inside the skin following overhydration in mice. The applicability of this technique was further investigated in a clinical setting. DESIGN: Skin blotting involves 2 steps: collecting proteins by attaching a damp nitrocellulose membrane to the surface of the skin, and immunostaining the collected proteins. The authors implanted fluorescein-conjugated dextran (F-DEX)-containing agarose gels into mice and detected the tissue distribution of F-DEX under different blotting conditions. They also analyzed the correlations between inflammatory cytokine secretion and leakage following ultraviolet irradiation in mice and in relation to body mass index in humans. MAIN RESULTS: The F-DEX in mice was distributed in the deeper and shallower layers of skin and leaked through the transfollicular and transepidermal routes, respectively. Ultraviolet irradiation induced tumor necrosis factor secretion in the epidermis in mice, which was detected by skin blotting, whereas follicular tumor necrosis factor was associated with body mass index in obese human subjects. These results support the applicability of skin blotting for skin assessment. CONCLUSIONS: Skin blotting represents a noninvasive technique for assessing skin physiology and has potential as a predictive and diagnostic tool for skin disorders.

Differences in characteristics between first-ever foot ulcer and recurrent foot ulcer in patients with diabetes: Prospective observational study.

Background and Aims: More effective preventive care can potentially be provided if the characteristics of both the first ever and the recurrent foot ulcers can be clarified. The purpose of this study was to characterize first ever and recurrent foot ulcers in diabetic patients. Methods: This study was conducted as a secondary analysis of a prospective study that was entitled: "Factors associated with the discontinuation of wound care specialist clinic visits in patients with diabetic foot ulcers." In 73 diabetes-related foot ulcer patients who visited one wound clinic in Indonesia between August 2020 and February 2021, we investigated characteristics of the patients and wounds, healing period, and cost. Results: Trauma was shown to be the primary cause of the diabetic foot ulcer in both the first ever foot ulcer (n = 48) and recurrent foot ulcer (n = 25) patient groups (95.8% and 100.0%, respectively). The DMIST score for the first ever foot ulcer patients was significantly higher than the DMIST score for the recurrent foot ulcers. This was found to be especially the case in the first ever foot ulcer patients, as not only were there signs of inflammation (45.8%), but there were also signs of local infection (35.4%), or osteomyelitis and signs of local infection (14.6%) present. In the eight first ever foot ulcer patients and in the nine recurrent ulcer patients who were able to be followed through complete healing, the costs found for the first ever foot ulcer patients were significantly higher as compared to the costs for the recurrent foot ulcer patients. Conclusion: To avoid diabetes-related foot ulcers, specialized educational programs on trauma prevention need to be established. Moreover, patients without diabetes-related foot ulcer histories should be educated regarding the need to undergo early consultations before developing any infections.

Risk Factors of Recurrent Diabetic Foot Ulcers Based on the Delphi Method.

Background: The risk factors for recurrence are poorly understood. The purpose of study is to investigate the risk factors that contribute to the recurrence of diabetic foot ulcers. Materials and Methods: This is a cross-sectional study, and the two-phase Delphi method was used. A category was developed to investigate the risk factors of recurrent diabetic foot ulcers by experts. The recurrent items with risk factors were analyzed. Furthermore, the risk factor variables were clinically tested for inter-rater reliability agreement. Fourteen experts and two patients were included from February 15 to September 28, 2020, Indonesia. Results: There were 13 risk factors for recurrent diabetic foot ulcers. The mean authority coefficient was 0.71. The positive coefficients were 100% and 78%, respectively. The Kendall coordination coefficient was statistically significant (p < 0.01), and inter-rater reliability agreement was perfect (1.00). Conclusions: This study found some risk variables related with recurrent diabetic foot ulcers, which might serve as guidance to prevent future recurrences.

Effectiveness of management protocol for insulin balls in diabetics: a scoping review.

Aim: In order to achieve good glycemic control, the prevention and management of insulin balls is important for diabetic patients during insulin therapy. However, insulin balls still occur within the clinical setting. This review evaluated the effectiveness of programs designed to manage insulin balls. Methods: A scoping review was conducted based on the Japanese and English literature available from a systematic literature search conducted from January 1964 to March 2022. Three databases were searched: PubMed, CINAHL, and Ichushi-Web. Results: A total of 33 articles met the inclusion criteria, which consisted of 3 for prevention management of insulin balls and 30 for management after the occurrence of insulin balls. Findings for prevention management suggested that the insulin injection technique education (avoidance of repeated injections to the same site) and providing knowledge (about insulin balls) prevented the appearance of insulin balls. As for post-occurrence management, insulin injection technique education (avoidance of injections to the insulin ball, avoidance of repeated injections to the same site, and switching the injection site) improved blood glucose control. Hypoglycemia was observed in all studies that included an assessment of hypoglycemia. None of the studies evaluated long-term effects of either preventive or post-occurrence management. Conclusions: Providing insulin injection technique education is an effective management protocol for insulin balls. Moreover, education about hypoglycemia is important for patients with insulin balls. Further studies to investigate the long-term effects in the management of insulin balls are needed.