Risk factors of skin tear in older persons: a protocol for systematic review and meta-analysis

Abstract

Introduction

Skin tear (ST) will prolong the hospitalisation time of an older person, increase the cost of medical expenses and the difficulty in care for nursing staff, and seriously affect the quality of life of the older person. Early identification and intervention of the elderly at risk of ST are key factors in preventing the occurrence of ST in older persons. At present, risk factors for ST in older persons have not been systematically evaluated, let alone summarised to analyse risk factors for ST in older persons. Therefore, this systematic review and meta-analysis aims to synthesise existing research on risk factors for ST in older populations.

Methods and analysis

The protocol is being reported by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. On 17 September 2023, we will start literature search in PubMed, Embase, Web of Science, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Medline, Chinese Scientific Journal Database, Wan Fang Data Knowledge Service Platform, China National Knowledge Infrastructure, and Chinese Biomedical Literature Database. The language of the included literature is Chinese or English. Using RevMan V.5.4 software, we will perform a systematic review and meta-analysis of the final set of included studies to synthesise the data and draw meaningful conclusions. The Newcastle-Ottawa Quality Assessment Scale and the Agency for Healthcare Research and Quality will be used to assess the quality of the literature. The I² test will be used to test heterogeneity.

Ethics and dissemination

Ethical approval is not needed for this systematic review, as the study will not directly use information from human participants, and the data we use will be extracted from original studies. This systematic review and meta-analysis has been registered at the International Prospective Register of Systematic Reviews (PROSPERO). Once the systematic review and meta-analysis have been completed, we will publish our study in an academic journal.

PROSPERO registration number

CRD42023460810.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study will synthesise the risk factors for skin tear (ST) in older persons and will draw more reliable conclusions through systematic review and meta-analysis.

• The included studies will be derived from global studies on risk factors for ST in older persons from various countries, and therefore the results obtained can be used for worldwide reference.

• This study will also evaluate some new and controversial risk factors. Although relatively little research has been done on these risk factors, they may give clues to the prevention of skin lacerations in older people.

• This systematic review and meta-analysis will only include studies in English and Chinese, and will not include studies published in other languages.

Introduction

The International Skin Tear Advisory Panel (ISTAP) updated the definition of a skin tear (ST) to ‘a traumatic wound caused by mechanical force, including the removal of a sticky dressing or tape, the severity of which varies by depth, but not the subcutaneous tissue’ in 2020.¹ Studies have found that infants, young children, older persons, critically ill patients or patients with chronic diseases are commonly susceptible to ST.^{2 3} In studying the epidemiological characteristics of ST in older persons, different countries and regions have different conclusions. A cross-sectional study of 314 elderly people in 17 long-term care facilities in Germany showed that the prevalence of ST was 10.5%.⁴ A cross-sectional study of 678 elderly people in four long-term care institutions in Canada showed that the prevalence of ST was 14.7%.³ A study of 410 older people in a long-term medical institution in Japan showed that the prevalence of ST was 3.9%.⁵ ST is one of the most common skin problems in older persons. We should pay more attention to ST in older persons.⁴

ST prolongs the hospitalisation time, increases the cost of medical expenses, adds to the difficulty of the nursing staff in caring for patients, and seriously affects the quality of life of older persons.⁶ Therefore, early identification of risk factors that can lead to ST in older persons is crucial. At present, studies have found that the inducing factors of ST in older persons include ecchymosis, senile purpura, haematoma, history of ST, malnutrition, skin oedema and changes in self-care ability.^{7 8} Although Serra et al⁸ systematically evaluated the risk factors of ST, there is no systematic evaluation of the risk factors of ST in older persons. To address the lack of research in this area, we will carry out a systematic review of the risk factors for ST in older persons.

Objectives

The purpose of this systematic review is to systematically collect the literature related to the risk factors of ST in older persons, comprehensively and systematically evaluate the risk factors related to ST in older persons, and provide an evidence-based basis for early identification and prevention of ST in older persons in clinical practice.

Methods

The protocol is being reported by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. The protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023460810).

Condition

The main variable of this study is ST. With the ISTAP classification system, ST can be classified into no skin/flap loss, partial skin/flap loss, and total skin/flap loss according to its characteristics and severity.¹ Many studies have shown that ST mainly occurs in the limbs.^{1 9}

Types of studies

We will include all observational studies (registries, cohorts, etc), experimental and epidemiological study designs, including case-control and cohort studies. However, We will exclude research related to animal testing. Full-text accessible studies from around the globe will be accepted. All included studies will be published in either Chinese or English.

Study population

This systematic review and meta-analysis will primarily focus on older persons with ST. According to the WHO and the United Nations reports, the definition of the elderly refers to people ≥60 years of age.¹⁰ We directly identified the age of the study population as >60 years.

Exposure

Exposure will include all the risk factors mentioned in the studies that are associated with ST in older persons.

Outcomes

The outcomes of our systematic review and meta-analysis are mainly the risk factors for ST in older persons. Information on the finally included studies and the results of quality assessment of the studies will be presented in tabular form. Data on risk factors for ST in older persons will be extracted and analysed using RevMan V.5.4 software and presented in graphical and textual forms.

Search strategy

After a consensual exploration by the team members, we set up a corresponding search method to identify these contents as accurately as possible: ‘skin tear* /skin laceration*’ ‘relevant factor* / influencing factor* / risk factor* / predictor* / related factor* / associated factor* / relative factor* / determinant*’ . We will also set a standard that the retrieved literature should be full-text literature. The initial stage of the search plan that will be applied to the PubMed database is shown in table 1.

Table 1. Search strategy for PubMed.

Search #	Search term
1	‘Risk Factors’(Mesh) OR risk factor*(Title/Abstract)OR influencing factor*(Title/Abstract)OR relevant factor*(Title/Abstract)OR predictor*(Title/Abstract)OR related factor*(Title/Abstract)OR associated factor*(Title/Abstract)OR relative factor*(Title/Abstract)OR determinant*(Title/Abstract)
2	‘Skin Tear’(Mesh) OR skin tear*(Title/Abstract)OR skin laceration*(Title/Abstract)
3	1 AND 2

First, a search will be conducted in the designated database, and then a preliminary search will be conducted in PubMed to evaluate the effectiveness of the search terms, strategies and selection criteria in identifying all applicable articles. Modifications will be made based on the results obtained. Computers will be used to search PubMed, Embase, Web of Science, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Medline, Chinese Scientific Journal Database, Wan Fang Data Knowledge Service Platform, China National Knowledge Infrastructure, and Chinese Biomedical Literature Database.

Inclusion criteria

1. The object of study in the literature should be an older person (age ≥60 years) diagnosed with ST.

2. This literature includes studies on the risk factors for ST in older persons.

3. Research is about observational (registries, cohorts, etc), experimental and epidemiological study designs, including case-control and cohort studies.

4. The language of publication is Chinese or English.

Exclusion criteria

1. The full text is not available.

2. Repeatedly published studies.

3. The data in the literature are incomplete or the author cannot be contacted to obtain the data.

4. The methodological quality evaluation score of the literature is low (Newcastle-Ottawa Quality Assessment Scale (NOS) Score＜4, Agency for Healthcare Research and Quality (AHRQ) Scale Score 0–3).

We will import the literature retrieved from each database into the Endnote V.X9 program for preliminary screening of the literature. Two independent researchers (NZ and HJ) will remove any repetitive literature, read the title and abstract of the literature in detail, and remove the literature that does not meet the inclusion criteria. If at least one researcher believes that the literature meets the inclusion criteria, it will be included, and if the two researchers disagree, a third researcher (SF) will be involved in the discussion. During the screening process of this literature, the reasons for the removal of the paper will be recorded in detail in Excel. The number of retrieved articles, the number of excluded articles and the number of papers finally included will be displayed in the form of a flow chart (figure 1).

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram of the identification, screening and eligibility of included articles.

Data extraction

The two researchers (JS and HL) will use the following criteria to collect data from related studies during the data extraction process: (1) Author information; (2) Date of publication; (3) Study design; (4) Research country or continent; (4) Data sources used; (6) Demographics and inclusion criteria of the study participants; (7) ‘Older person’ defined; (8) 'STs' diagnostic standards stated; (9) Main results; (10) Risk factors; (11) ORs and 95% CIs for the risk factors (multivariate regression analysis data are recommended).

Risk of bias and quality assessment

The two researchers (LC and NZ) will use the NOS to independently assess the risk of bias in cohort studies and case-control studies. NOS includes three parts: selection of the study population, comparability between groups and exposure/outcome evaluation. There are eight items in NOS with a total score of 9 points. When NOS is used to evaluate the literature，except for the component of comparability, which can be rated up to 2 points, the other components can only be rated up to 1 point. The higher the NOS Score, the higher the quality of the literature. An NOS Score ≥6 is high-quality literature.¹¹ We employ the appraisal criteria suggested by the AHRQ in USA for evaluating the quality of cross-sectional studies. These criteria consist of 11 items, each assigned scores based on ‘Yes’, ‘No’ or ‘Unclear’ answers. Studies receiving scores between 0 and 3 are deemed poor quality, those earning 4–7 points are moderately good, while scores of 8 and higher indicate excellent quality.¹²

Strategy for data synthesis

We will use RevMan V.5.4 statistical software for data analysis. Binary variable data will be expressed as OR. Mean difference will used for measurement data. Each effect will be expressed as a 95% CI. In order to judge the rationality of the combined analysis of each test, the χ2 test will used to test the heterogeneity between the tests. If there is no heterogeneity (I²≤50%, p>0.10), the fixed-effects model will be used for meta-analysis; if there is heterogeneity (p≤0.10 or I²≥50%), a random-effects model will be used for meta-analysis. Funnel plot and Egger’s test will be used for analysis of publication bias.

Subgroup analysis

If necessary, subgroup analysis will be performed on gender, ethnicity, country, etc.

Patient and public involvement

Patients will not be involved in this study.

Ethics and dissemination

No ethical approbation is necessary for this investigation since it does not entail the utilisation of personal details from participating individuals. The outcomes shall be divulged via peer-evaluated periodicals or conferences. Important protocol revisions will be documented and updated on PROSPERO.

Conclusion

The goal of our systematic review and meta-analysis will be to provide an evidence-based basis for preventing ST in the elderly. We will evaluate and analyse the finally included studies, summarise the risk factors for ST in the elderly and fully discuss the results. We will carry out this study in strict accordance with the content developed in this protocol and report the results obtained as a paper.