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Complications of the diabetic lower extremity (such as diabetic foot ulcers, DFUs) occur when monitoring is infrequent, and often result in serious sequelae like amputation or even death.
To evaluate the potential application of mobile health (mHealth) to diabetic foot monitoring. We surveyed the self-management routines of a group of diabetic patients, as well as patient and clinician opinions on the use of mHealth in this context.
Patients with DFUs in Toronto, Ontario, Canada completed a 25-item questionnaire addressing their foot care practices, mobile phone use, and views on mHealth. Wound care clinicians across Canada were also surveyed using a 9-item questionnaire.
Of the patients surveyed, 59/115 (51.3%) spend less than a minute checking their feet, and 17/115 (15%) of patients find it difficult to see their doctor or get to the hospital regularly. Mobile phone use was widespread in our patient cohort (93/115, 80.9%). Of mobile phone users, 68/93 (73.1%) would use a device on their mobile phone to help them check their feet. Of the clinicians who completed the questionnaire, only 7/202 (3.5%) were familiar with mHealth; however, 181/202 (92%) of clinicians expressed interest in using mHealth to monitor their patients between visits.
Patient education or motivation and clinician training were identified as the major barriers to mHealth use in the diabetic lower extremity, which may be a viable mechanism to improve DFU monitoring practices.
The burden of treatment in diabetes is high: patients must monitor their diet and blood glucose levels, take medication, refill prescriptions, travel to medical appointments, seek information, and keep records [
The concept of
To determine if an MDM-based mHealth intervention is needed for the diabetic lower extremity, we sought to characterize the daily self-management routines of diabetics at St. Michael’s Hospital (SMH) in Toronto, Ontario, Canada, and the attitudes towards mHealth among Canadian foot care clinicians. Our goal was to understand the barriers to implementing such a strategy from both sides of the patient-clinician continuum.
This was a descriptive study of patients with DFUs presenting to plastic surgery clinics at SMH in Toronto over a 6-month period in 2017. SMH is a large, tertiary, academic level-1 trauma centre located in the downtown core. This study was approved by the SMH Research Ethics Board (REB 17-023). The questionnaire was designed by clinicians who treat this patient population, but was not validated in any way.
Patients at SMH were approached by study investigators following clinic visits and informed about the study. Patients were given the opportunity to ask questions, and if they chose to participate, they signed informed consent.
The study investigators designed a questionnaire addressing multiple themes associated with patients with DFUs, including characteristics of patient health, mobile phone use, and views on mHealth (see
A 9-question survey (see
Of the 117 patients who were approached in plastic surgery and diabetes clinics at SMH, 115 agreed to be asked a series of qualitative questions describing their foot checking practices and comfort with mobile technology. The average age of participants was 54.8 years, and 60/115 (52.2%) of the participants were men (
When asked about their current foot checking practices, 89/115 (77.4%) of patients reported checking their feet regularly, although 59/115 (51.3%) reported spending less than a minute checking, and only 16/115 (13.9%) use a mirror to check the bottoms of their feet (
Summary of patient demographic data and survey (n=115).
Patient demographic or survey response | Responses | |
Age, mean (range) | 54.8 (18-84) | |
Male | 60 (52.2) | |
Female | 60 (52.2) | |
Unknown | 5 (4.4) | |
Body mass index (kg/m2), mean (SD) | 28.17 (7.91) | |
Administration or management | 8 (7.0) | |
Education | 7 (6.1) | |
Engineering or technology | 6 (5.2) | |
Finance or business | 21 (18.3) | |
Healthcare | 4 (3.5) | |
Labor | 4 (3.5) | |
Other | 17 (14.8) | |
Retired | 30 (26.1) | |
Student | 3 (2.6) | |
Unemployed | 13 (11.3) | |
No answer | 2 (1.7) | |
1 | 42 (36.5) | |
2 | 68 (59.1) | |
Not sure | 6 (5.2) | |
Yes | 91 (79.1) | |
No | 23 (20.0) | |
No answer | 1 (0.8) | |
Smoker | 12 (10.4) | |
Never smoker | 100 (87.0) | |
No answer | 3 (2.6) | |
Yes | 83 (72.2) | |
No | 32 (27.8) | |
Yes | 103 (89.6) | |
No | 8 (7.0) | |
No answer | 4 (3.5) | |
Yes | 11 (9.6) | |
No | 101 (87.8) | |
No answer | 3 (2.6) | |
Yes | 3 (2.6) | |
No | 112 (97.4) | |
No answer | 0 (0) | |
Importance of being in control of their own healtha, mean (SD) | 8.28 (2.37) | |
Yes | 17 (14.8) | |
No | 95 (82.6) | |
No answer | 3 (2.6) | |
Ambulance | 1 (0.9) | |
Car | 25 (21.7) | |
Electric scooter | 1 (0.9) | |
Family member or friend | 3 (2.6) | |
Public transportation | 47 (40.9) | |
Taxi | 4 (3.5) | |
Walk | 9 (7.8) | |
Other | 2 (1.7) | |
Multiple methods | 21 (18.3) | |
No answer | 2 (1.7) | |
Never | 23 (20) | |
Less than 1 minute | 59 (51.3) | |
More than 1 minute | 30 (26.1) | |
No answer | 3 (3) | |
Yes | 16 (13.9) | |
No | 99 (86) | |
Every week | 1 (0.8) | |
Every month | 5 (4.3) | |
A few times a year | 61 (53) | |
Only when I am sick | 32 (27.8) | |
Never | 13 (11.3) | |
No answer | 3 (2.6) | |
Yes | 108 (93.9) | |
No | 7 (6.1) | |
Yes | 94 (81.7) | |
No | 21 (18.2) | |
Yes | 86 (74.7) | |
No | 29 (25.2) |
aMeasured on a scale of 1 to 10, where 10 is considered very important.
Although most of the study respondents (95/115, 82.6%) visit their doctor a few times a year, 17/115 (14.8%) of patients reported that it was difficult to get to the hospital or to see their doctor. Interestingly, 43/115 (37.4%) respondents said that they were retired or unemployed. We found that the occupations of our survey respondents were primarily in “white collar” sectors—46/115 (40.1%) of respondents listed their career as one of “Finance or business,” “Administration or management,” “Education,” “Engineering or technology” or “Healthcare”—and only 4/155 (3.5%) of respondents considered their occupation to be “General labor.” Mobile phone ownership was widespread (93/115, 80.4%) as was glucometer usage (108/115, 94%). Of the patients surveyed, 68/115 (73.1%) would use a device on their phone to help them check their feet (
Responses to the clinician survey were mostly from wound care nurses or nurse practitioners (149/202; 73.8%) and chiropodist or podiatrists (20/202, 10.0%) who have been in practice for more than 5 years (
Summary of responses by clinicians surveyed (N=202).
Demographic | Responses, n (%) | |
Nurse or nurse practitioner | 149 (73.8) | |
Chiropodist or podiatrist | 20 (9.9) | |
Family physician | 5 (2.5) | |
Internal medicine | 2 (1.0) | |
Surgeon (plastic, orthopaedic, vascular) | 0 (0) | |
Other | 26 (12.9) | |
Less than 10% | 43 (21.3) | |
10-50% | 111 (55.0) | |
Greater than 50% | 48 (23.8) | |
Less than 1 year | 5 (2.5) | |
1-5 years | 33 (16.3) | |
5+ years | 164 (81.2) | |
Using mHealth within practice | 7 (3.5) | |
Familiar, but not using mHealth | 50 (24.8) | |
Not familiar with mHealth | 145 (71.8) | |
Would use mHealth to supplement care/monitor between visits | 88 (43.6) | |
Would not change current practice, but would use mHealth as a supplement | 93 (46) | |
Have concerns about using mHealth | 17 (8.4) | |
Patient barriers | 41 (20.3) | |
Provider barriers | 22 (10.9) | |
Combination of barriers | 115 (56.9) | |
Other | 24 (11.9) |
Diabetics carry a heavy burden of illness that requires significant healthcare “work,” including diet and lifestyle planning and tracking, medication adherence, doctor’s appointments, and self-monitoring. In a large cohort study recently completed in Alberta, only 14% of respondents reported checking their feet 6 days a week or more, and only 41% and 34% had their feet checked regularly by a clinician for ulcers or sensory loss, respectively [
While the average lifetime incidence of DFUs among Canadian diabetics is 15% [
Diabetics are a technology-oriented patient population, as 108/115 (94%) of our study population reported using a glucometer to monitor their disease. The Canadian population as a whole is becoming increasingly oriented towards mobile phones: 85.6% of the population owned a mobile phone in 2016, up from 62.9% in 2006 [
Our patient survey suggests mHealth may be useful from a patient’s perspective, but we were also interested in the perspective of wound care clinicians. The results of our clinician survey suggest that approximately 1 in 3 patients are only being seen by a clinician once they have already developed a problem. Reasons cited by clinicians for this lack of care are not due to systemic barriers like wait times, but are largely a matter of patient education and engagement. Clinicians also cited financial barriers to mobile phone ownership and lack of comfort with technology among their patient populations, which are barriers that must be considered when developing future mHealth strategies. It could be argued, however, that the cost of ulcer prevention versus amputation should be considered from a public policy making perspective, and that the economics of mHealth are attractive in a publicly-funded healthcare system [
Despite their willingness however, clinicians did express concern about the reliability of using patient-generated data and relying on pictures alone for wound care (eg, no information on parameters such as wound smell). Furthermore, clinical adoption of mHealth would require the development of fee structures for billing, and mechanisms to ensure patients could be called into the clinic quickly if their condition deteriorated. Regulating technology that is used in healthcare would also require substantial oversight at the national level and on a hospital-by-hospital basis, as there are already many companies vying for space in this potentially lucrative market, some of which have a better understanding of wound care than others. Although work remains to be done before mHealth is ready for widespread use in wound care, in our opinion, these challenges are not insurmountable.
To the authors’ knowledge, this is the largest study evaluating the opinion of patients with DFU on mHealth, albeit in a single hospital population. We also surveyed both sides of the patient-care continuum; both patients and healthcare providers are willing to use mHealth for monitoring of the diabetic lower extremity. Weaknesses of our study include the fact that our patient population was drawn from a single plastic surgery wound clinic. It is unknown what proportion of diabetic foot patients ever present to clinics like this, and thus the external validity of the study may only be applicable to a small subset of patients.
In conclusion, we must find ways to increase foot monitoring frequency and effectiveness in diabetic patients. Using unconventional strategies like mHealth may be feasible but should incorporate educational campaigns to motivate patients and clinicians alike, and should move beyond simply taking a picture of a wound and instead build upon evidence-based outcome measures for foot health like tissue oxygenation, perfusion, and free-radical accumulation.
Supplementary figures.
diabetic foot ulcer
minimally disruptive medicine
St. Michael’s Hospital
This work was funded by a grant from the Translational Innovation Fund at St. Michael's Hospital to KC.
KC has equity interest in a small start-up company developing mHealth solutions for the diabetic lower extremity.