What is the Relationship Between Caregiver Attendance at Wound Clinic Visits and Wound Healing in Patients With Diabetes?

Not unlike other chronic diseases, clinicians and family members observe that people with diabetes often cannot manage, or have difficulty managing, the condition alone.^1-3 As witnessed by the author and supported by a qualitative vascular study by Zamani and colleagues, patients with diabetes-associated wounds often related feeling overwhelmed.⁴ Additionally, these patients may have compromised mobility, be physically unable to reach the lower limb to apply wound dressings, or unable to drive.⁵ Loss of visual acuity, common to diabetes, can impair wound dressing techniques and all aspects of diabetes self-care.⁶

Patients and families often find that a caregiver becomes necessary in these complex scenarios. In a retrospective descriptive study conducted over one year, recently published in Wound Management & Prevention,⁷ the author sought to determine whether a correlation exists between regular caregiver attendance at wound care appointments for patients with diabetes and the resultant outcomes. Data retrieval took place from the hospital-owned electronic health record (EHR) for all eligible patients assigned to the principal investigator at 3 outpatient hospital-based wound center locations.

The study identified 126 total patients; of these, 15 became excluded due to hospice enrollment (n = 2) or ABI below threshold (n = 13). Of the remaining 111 patients, 26 became lost to follow-up. A total of 85 patients remained. Of those, 30 had caregiver accompaniment greater than 50 percent of the time (Accompanied cohort), and 55 were accompanied less than 50 percent of the time (Unaccompanied cohort). Age and race were the only statistically significant differences evident in the demographics. The Accompanied group was older, had higher rates of tobacco use, and had a slightly higher proportion of wounds healed. Differences in HbA1c, healing rates, initial wound size, and percent reduction in wound size were not significantly different between the two groups.⁷

The Unaccompanied group was younger (mean, 59 years) and more racially diverse, with members spanning all identified racial groups, the majority of whom were black (49 percent). While this group displayed several clinical features known to favor wound healing, these patients had the unexpected finding of unfavorable wound healing outcome metrics across the board. Notably, the total visit count (14.09, P = .04) and weeks in service (22.6, P = .05) during the study interval were significantly more than that of the Accompanied group, culminating in an overall lower wound healed rate (73 versus 77 percent).⁷

Persons accompanied greater than 50 percent of the time had significantly more accompanied visits, a lower visit count, and fewer weeks in service than persons accompanied less than 50 percent of the time. The Accompanied group had a higher rate of wound size reduced percent (83 versus 54 percent), but the difference was not statistically significant.⁷

Essentially, Accompanied patients, though older and with higher rates of tobacco use, demonstrated higher rates of wound size reduction and overall healing, with fewer visits and half the weeks in consecutive time with an open wound. However, one should note that their wounds were smaller than those in the Unaccompanied group.⁷

An unexpected finding was the range of the percent accompanied in the Unaccompanied group. This range spanned from 0 to 29 percent, demonstrating none were near the cut-off point, contributing to clarity between groups. Of those in the Unaccompanied group who occasionally did have a caregiver present, the accompanying caregiver attended, at most, fewer than one-third of their total visits. The percentage of accompanied visits in the Accompanied group spanned from 52 to 100 percent, nearly the entire range. Of note, the mean difference in percent accompanied between these 2 groups was extremely large and statistically significant, with caregivers attending only 5 percent of visits in the Unaccompanied group versus 87 percent of those in the Accompanied group.⁷

There were no statistically significant differences noted between the Accompanied and Unaccompanied groups in the comparisons of body mass index (BMI), HbA1c, wound healing, wound size, and size reduced. Although a weak association, patients accompanied by their caregiver more frequently had a higher wound healing percentage. The study also found that the higher the percentage of clinic visits that included a caregiver in the Accompanied group, the more the reduction in corresponding visit count. The Unaccompanied group revealed the exact opposite, with the same variable but a reversed and lesser magnitude, indicating a weak positive correlation.⁷

What Does Previous Evidence Reveal About Caregiver Impact on Patient Care?

Chronic wounds are burdensome on the patient, the health care system, and the family alike. However, wide gaps exist in the literature related to the roles and benefits of caregivers to wound care.^8-11 In a literature review, Pittman outlined ample studies supporting the impact of wound care on the individual, but there is a paucity of literature on the chronic wound and its effect on the family or caregivers.¹² In an editorial examining a National Family Caregivers Association survey published in 2001, the author reports an estimated 54 million Americans involved in caregiving in the previous 12 months but, “in wound care, we have not done much to factor in the contributions of lay caregivers.”¹³ This author also cites the paucity of peer-reviewed literature and substantiates the need for wound care professionals to establish relationships with lay caregivers and patients.¹³

A randomized, unblinded, controlled pilot study by Shields and team¹⁴ examined patient-centered communication in a family medicine clinic serving elderly patients. This study randomly assigned patients to accompanied or unaccompanied-type visits and found that companions facilitated patient-physician discussions by bringing up new topics for the physician to explore. The physician spoke more words during accompanied visits, and they found that a companion’s presence did not divert the provider’s attention away from the patient. These authors also mentioned the lack of clinical trials in the literature, noting this was the first randomized study to examine the effect of a third person being present during the medical visit.¹⁴

To the author’s knowledge, the study recently published in Wound Management & Prevention is the first to examine the characteristics of patients attending a wound clinic accompanied versus unaccompanied and whether a correlation existed in their respective wound healing outcomes. There were no exclusions for uncontrolled glucose, Charcot deformity, previous amputations, current tobacco use, uninsured status, dialysis participation, or any history of osteomyelitis in order to capture real-world clinical presentations and patient complexity.

These exclusion exceptions are consistent with a prospective, multicenter, open-label clinical trial by Frykberg and colleagues¹⁵ that examined placental membrane allograft response in participants with complex wounds (N = 27) frequently eliminated from studies. The Frykberg study highlighted the crucial nature of rapid closure of complex diabetic wounds to avoid amputation and the need to study the characteristics of the population present in the clinics.

Not surprisingly, caregivers play essential roles in many other areas of managing serious chronic disease. In its peer-reviewed Physician Data Query (PDQ) database, the National Cancer Institute describes the caregiver role as a “critical ingredient” to effective cancer management, inclusive of decision-making, treatment planning, and care implementation.² The agency enlists caregiver cooperation at the onset of treatment as part of the “unit” of care spanning physical, psychosocial, and spiritual domains.²

In a 2013 seizure clinic correlation study by Robson and colleagues (N = 48),¹⁶ the authors found that companions facilitated physician-patient discussions by providing additional information, so they now routinely invite patients to bring a seizure witness to visits. In addition, companions provided essential diagnostic information, tracked patient symptoms, asked more questions, and assisted the patient with understanding explanations.¹⁶ The Work Group on Alzheimer’s Disease and Other Dementias clinical guideline defines caregivers and family members as a critical source of information and vital to implementing treatment plans.¹³ The treatment paradigm then shifts to a patient–caregiver systematic approach, encouraging clinicians to form an alliance with the family.¹

Concluding Thoughts

The study results previously published in Wound Management & Prevention demonstrated favorable findings for patients who attended wound clinic visits with a caregiver. This included higher healing rates, a reduced number of visits, less time with an open wound, and increased wound size reduction.⁷ Although, as with many studies, this investigation had certain limitations, the results of this study may encourage additional investigations. More research is necessary to expand the body of evidence to determine caregiver impact on wound healing outcomes and their role in future determinations of wound care guidelines. 

Ms. Jessee is a medical student at Oceania School of Medicine, and a nurse practitioner in Pinehurst, NC.

This article references research that originally appeared in Wound Management & Prevention in its December 2021 issue. It is adapted with permission. The original article can be found at https://tinyurl.com/yckkryf3 .

1. Practice Guideline for the Treatment of Patients With Alzheimer’s Disease and Other Dementias. 2nd ed. American Psychiatric Association; 2007. https://psychiatryonline.org/ pb/assets/raw/sitewide/practice_guidelines/ guidelines/alzheimers.pdf

2. PDQ Supportive and Palliative Care Editorial Board. Informal Caregivers in Cancer: Roles, Burden, and Support (PDQ^®): Health Professional Version. 2021 Nov 12. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK65845/

3.Galvin J. The importance of family and care- giver in the care and management of people with Alzheimer’s disease. Poster presented at: Alzheimer’s Association International Conference 2013. Primary Care Preconference: PC: Alzheimer’s Disease in Primary Care Settings: Management. Vol 9. 2013:P1-P2. https://alz-journals.onlinelibrary.wiley.com/ doi/epdf/10.1016/j.jalz.2013.04.012

4.Zamani N, Chung J, Evans-Hudnall G, et al. Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers. J Vasc Surg. 2020;73(4):1388–1395. doi:10.1016/j.jvs.2020.08.127

5.Kim PJ, Steinberg JS. Complications of the diabetic foot. Endocrinol Metab Clin North Am. 2013;42(4):833–847. doi:10.1016/j. ecl.2013.08.002

6.American Diabetes Association. Comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes. Diabetes Care. 2020;43(suppl 1):S37–S47. doi:10.2337/dc20-S004

7.Jessee C. Relationship between caregiver attendance at wound clinic visits and wound healing in patients with diabetes: a retrospective multicenter evaluation. Wound Manag Prev. 2021;67(12):16–24 doi:10.25270/wmp.2021.12.1624

8.Regulski MJ. Cellular senescence: what, why, and how. Wounds. 2017;29(6):168– 174.

9.Tricco AC, Antony J, Vafaei A, et al. Seek- ing effective interventions to treat complex wounds: An overview of systematic reviews. BMC Med. 2015;13:89. doi:10.1186/s12916- 015-0288-5

10.Monteiro-Soares M, Martins-Mendes D, Vaz-Carneiro A, Sampaio S, Dinis-Ribeiro M. Classification systems for lower extremity amputation prediction in subjects with active diabetic foot ulcer: a systematic review and meta-analysis. Diabetes Metab Res Rev. 2014;30(7):610–622. doi:10.1002/dmrr.2535

11.American Diabetes Association. Diabetes technology: standards of medical care in diabetes-2019. Diabetes Care. 2019;42(suppl 1):S71–S80. doi:10.2337/dc19-S007

12.Pittman J. The chronic wound and the family. Ostomy Wound Manage. 2003;49(2):38–46.

13.Salcido RS. It takes a village: The caregiver’s role in wound care. Adv Skin Wound Care. 2001;14(5):220–222.

14.Shields CG, Epstein RM, Fiscella K, Mallinger JB. Influence of accompanied encounters on patient-centeredness with older patients. J Am Board Fam Pract. 2005;18(5):344–354.

15.Frykberg RG, Gibbons GW, Walters JL, Wukich DK, Milstein FC. A prospective, multicentre, open-label, single-arm clinical trial for treatment of chronic complex diabetic foot wounds with exposed tendon and/or bone: positive clinical outcomes of viable cryopreserved human placental membrane. Int Wound J. 2017;14(3):569–577. doi:10.1111/ iwj.12649

16.Robson C, Drew P, Reuber M. Duration and structure of  unaccompanied  (dyadic)  and   accompanied (triadic) initial outpatient consultations in a specialist seizure clinic. Epilepsy Behav. 2013;27(3):449–454. doi:10.1016/j.ye- beh.2013.03.008