Abstract
Purpose
The aim of this semi-experimental study was the determination of collaborative care model training on diabetic foot ulcer patients’ quality of life.
Methods
Demographic characteristics and life’s quality questionnaires were used, and to implement the collaborative model that included (including four steps of motivation, preparation, engagement, and evaluation), 60 patients divided into two “experiment” and “control” groups. For the experimental group, the program was done by face to face education and pamphlet through one hour in seven sessions. Data were analyzed by descriptive and inferential statistical methods. SPSS 24 was used for data analysis.
Results
Findings showed the differences of the scores of life’s quality dimensions (except the economic situation), which was significant between both groups after the implementation of the collaborative care model (p < 0.001).
Conclusion
The implementation of collaborative care model can be effective to improve diabetic foot ulcer patients’ quality of life.
Keywords: Collaborative care, Life’s quality, Diabetic foot ulcer
Introduction
Diabetes is one of the most prevalent diseases which increased through the past several years [1, 2]. By 2035, its global outbreaks will increase to 600 million. It is estimated that 80% of diabetic patients live in developing countries. They have many problems such as damage to their small blood vessels and peripheral nerves endings, in addition to abnormalities due to motor nerve disorders [3, 4]. Neuropathy causes patients not to experience heat and pain or feeling the shoe pressure on their toes that leads to deformity. Feet ulcers can develop cellulitis, fasciitis, infectious arthritis, myositis, abscess, tendinitis and osteomyelitis [5]. It is estimated that lower extremities will be cut off every 20 s among diabetic patients [6]. Positive effect of education in improving many dimensions of quality of life has been proved in patients who are taught by health providers in hospitals and awareness of them about diet and medication through may be very effective. [7]. In addition to their hospital-borne costs of diabetes, the patients with diabetic foot ulcers are at higher risk of death than others and that promote patients’ self-concept and provide an appropriate training care models may reduce their problems [8].
On the other hand, patients’ training can be considered as one of the methods for making patients to take care of themselves. This goal can be accomplished by involving the individuals in group processes. So, collaborative care educational model was established to participate the patients in their chronic disease management and improve their quality of life, include 4 different phases. [9].
Nurses play a main role in the prevention, care, and education of patients of diabetic foot complications. Therefore, the use of new methods to improve the survival rate, quality of care, and outcomes of patients has become one of the main foci of nursing. This model of collaborative nursing has been widely used, achieving high-standard therapeutic results across various clinical specialties [10].
Collaborative care is a systematic and logical process of communicating between the patient and the healthcare providers to a better understanding and cognition of the needs, problems and expectations in the process of disease control, to motivate and engage the patients’ responsibility, to improve and maintain the health, awareness and self-care [11]. Since, the collaborative care model may be effective to improve the diabetic patients’ quality of life and reducing their problems. Regarding the increasing number of diabetic patients and other non-communicable diseases, using this method seems necessary. Due to the limited number of studies about this method, the aim of this study was the determination of collaborative care model training effects on life’s quality of diabetic foot ulcer patients who were referred to treatment and educational centers, Urmia city, Iran.
Methodology
In a semi-experimental study, 60 diabetic foot ulcer patients selected through convenience sampling were studied. Through 95% confidence, the test power was 95%, the minimum sample size required was 50. As an estimated 20% drop, the number was increased to 60 and divided into two groups: “experiment” and “control”.
Simple sampling from patients who referred to diabetes wards for diabetic foot and also had the inclusion criteria was carried out. Then, using the table of random numbers, the participants randomly allocated into two groups; they were blind about their group allocation.
Data collection tools were demographic characteristics and DFS (Diabetic Foot Scale) questionnaire. The latter consists of 58 items grouped into 11 domains: physical health, leisure, daily activities, noncompliance, family, emotions, friends, treatment, satisfaction, positive attitude and financial. This questionnaire was validated by measuring the correlation coefficient: Cronbach’s alpha estimated at 0.98% [12]. After the questionnaire completion in pre-test, the participants were divided into six subgroups of 5 members [13]. Then, a collaborative care model with four stages: motivation, preparation, involvement and evaluation was implemented. The content of the training included the chronic disease, threats and complications; then, an appropriate dietary regime, exercise and physical activity, massage of foot to promote quick recovery and aid the physical exercise to preserve anatomical function drug consumption and side effects were explained. In the last sessions, the educational materials were discussed between the researcher and participants and an agreement was reached; then, the final program was performed by patients’ opinion.
The community health center was located in the center of ten federally designated health professional shortage census tracts.18 In 2012, the community health center served 10,782 unduplicated patients for a total of 27,963 patient visits. Of those 10,782 patients, 81% were Hispanic and 69% of them were uninsured. At least 65% of the patients in 2012 lived below poverty level.
All instructions were done by a face-to-face method and the control group received routine care. After the collaboration sessions, the patients were followed up for three months through phone calls to answer their questions and problems. On the other hand, after finishing the sseessions, the educational booklet was given to the control group or their family members, too.
Three months after the collaboration care program, SF-36 questionnaire was completed by the participants of the intervention and control groups again.
Three months after the completion of the program, both groups completed the DFS questionnaire again. They were followed by telephone contacts and their probable questions were answered. Data were analyzed by descriptive statistics (mean, standard deviation, frequency and percentage), independent t-test and chi-square test to compare the qualitative variables between two groups; also, to compare the quality of life among them after the experiment. Covariance analysis was used for both. Data were analyzed by SPSS 24. The normality of the data distribution was evaluated by Kolmogorov-Smirnov test; in the absence of data normality, appropriate transformations or equivalent parametric tests were used.
Data distribution normality was measured by Kolmogorov Smirnov test. If the normal distribution of variables is not established, non-parametric tests and in other cases, parametric tests were used.
Findings
Most of the participants were men, 75% with the age of 54 to 90, 65% married and 55% unemployed. The income status of them (46.7%) was normal. Twenty-four (80%) were male and 6 (20%) were female in control group, and 30 patients were in the experimental group, that 21(70%) were men and 9 (30%) women. Most of them (95%) had non-academic education and 63.3% lived at a private home. The majority of them, in both groups, were unemployed.
Regarding the level of education in control group, 9 people (30%) were illiterate, eleven (36.7%) had primary school degree, 4 (13.3%) had secondary school degree, 4 (13.3%) diploma and 2 (6.7%) had a bachelor’s degree. In the experimental group, 13 people (43.3%) were illiterate, 14 (46.7%) had elementary school degree, 2 (6.7%) had high school degree and one person (3.3%) had a bachelor’s degree. In general, it can be said that there was no significant difference between the two groups in terms of distribution of education level based on Fisher’s exact test (p value = 0.0191).
Regarding the distribution of marital status of patients, it can be said that out of 30 patients in the control group, two people (6.7%) were single, twenty (66.7%) were married and eight of them (26.7%) were widow. In the (experimental group), 19(63.3%) were married, 4 people (13.3%) divorced, 5 (16.7%) widowed and 2 (6.7%) were polygamous. In general, it can be said that the majority of members of the control group and the experiment group were married; there was no significant difference between them in terms of distribution of marital status based on Fisher’s exact test (p = 0.059).
Describing the job status among the two groups indicated that out of a total of 30 patients in the control group regarding the job status, 4 people (13.3%) were housewives, 16 (53.3%) employed, 7 (23.3%) unemployed and 3 (10%) retired. In (experiment group), 6 people (20%) were housewives, 11 (36.7%) employed, 6 (20%) unemployed and 7 (23.3%) retired. In general, it can be said that there was no significant difference between them in terms of distribution of job status based on Chi-square test (p = 0.391). In terms of financial status in the control group, 13 people (43.3%) said it is insufficient, 12 (40%) had adequate life expectancy, 5 (16.7%) had adequate expression. In the next (experimental group), 10 people (33.3%) said it is insufficient, 16 (53.3%) had a life expectancy and 4 (13.3%) had a sufficient expression. In general, it can be said that there was no significant difference between them in terms of financial situation distribution based on Fisher’s exact test (p value = 0.685). Among the control group, 13 people (43.3%) were smokers and 17 (56.7%) non-smokers. In the experiment group, fifteen (50%) were smokers and 15 (50%) were non-smokers. In general, there was no significant difference between them in terms of the distribution of smoking status based on the chi-square test (p = 0.605). There was no significant difference between the both groups in terms of demographic variables (p value ≤0.05). Table 1.
Table 1.
Demographic variables among Control and Experimental groups in pre-test and post-test
| Variables | Experimental Group | Control Group | *P value | |||
|---|---|---|---|---|---|---|
| No | (%) | No | (%) | |||
| Gender | Male | 70 | 21 | 24 | 80 | 0.371 |
| Female | 30 | 9 | 6 | 20 | ||
| Level of Education | Ilitarate | 43.3 | 13 | 9 | 30 | 0.091 |
| Primary School | 46.7 | 14 | 11 | 36.7 | ||
| Guidance School | 6.7 | 2 | 4 | 13.3 | ||
| Highschool | 0 | 0 | 4 | 13.3 | ||
| University | 3.3 | 1 | 2 | 6.7 | ||
| Marital Status | Single | 0 | 0 | 2 | 6.7 | 0.059 |
| Married | 63.3 | 19 | 20 | 66.7 | ||
| Widow | 13.3 | 4 | 8 | 26.7 | ||
| polygamy | 2 | 6.7 | 0 | 0 | ||
| Employment Status | Housekeeper | 20 | 6 | 4 | 13.3 | 0.391 |
| Employed | 36.7 | 11 | 16 | 53.3 | ||
| Unemployed | 20 | 6 | 7 | 23.3 | ||
| Retired | 23.3 | 7 | 3 | 10 | ||
| Financial status | Good | 33.3 | 10 | 13 | 43.3 | 0.685 |
| Moderate | 53.3 | 16 | 12 | 40 | ||
| Bad | 13.3 | 4 | 5 | 16.7 | ||
| Cigarette Smoking | Yes | 50 | 15 | 13 | 43.3 | 0.605 |
| No | 50 | 15 | 17 | 56.7 | ||
*p < 0.05: Statistical
Most of patients (95%) had type 1 diabetes and 56.7% had normal BMI; 46.7% had a history of smoking. The location of the foot ulcers among the majority of them was 45% in the heel. 50% had two ulcers. Also, 53.3% had more than one month of diabetes. 60% of patients participating in the study had a family history of diabetes. The mean of fasting blood glucose in the study was 193.33 mg / dl and the mean of non-fasting blood glucose was 263.77 mg / dl. Data were analyzed by Kolmogorov-Smirnov test. Significance level (α = 0.05) was used in pre-test and post-test results; parametric and non-parametric tests were used.
In Table 2, after examining post-test scores of life quality and its dimensions among two groups except economic component in all other cases, significant difference was observed statistically (P ≥ 0.01). In general, it can be claimed (with 99% confidence) that the training of collaborative care model among those with diabetic foot ulcer improved their life quality.
Table 2.
Results on quality of life in two groups of experimental and control after training collaborative care model
| Quality of Life and its dimensions (Post-test scores) | Groups | Statistical Results | ||
|---|---|---|---|---|
| Experimental | Control | |||
| X ± SD **** | T* / U** | X ± SD | P | |
| Enjoying the life | 87.63 ± 73.5 | 67.50 ± 54.6 | 12.22 *- | 0.001 |
| Physical health | 60.79 ± 63.5 | 80.07 ± 52.6 | 95.50 ** | 0.001 |
| Daily activity | 33.95 ± 62.5 | 55.03 ± 50.5 | 8.28 *- | 0.001 |
| Emotions | 26.94 ± 58.4 | 15.04 ± 39.5 | 14.84 *- | 0.001 |
| Treatment Adherence | 33.04 ± 84.11 | 33.79 ± 75.12 | 268** | 0.006 |
| Family Relationships | 60.02 ± 59.8 | 13.22 ± 48.13 | 4.06 *- | 0.001 |
| Friend Relationships | 60.49 ± 63.8 | 47.02 ± 39.7 | 20 ** | 0.001 |
| Foot ulcer care | 52.14 ± 7 | 50.84 ± 33.6 | 31 ** | 0.001 |
| Life satisfaction | 74.02 ± 13 | 60.74 ± 11 | 197.50 ** | 0.001 |
| Life Attitude | 93.35 ± 66.7 | 87.13 ± 55.9 | 5.17 * | 0.001 |
| Economic situation | 67.88 ± 46.16 | 67.7 ± 44.18 | 411.50 ** | 0.548 |
| Quality of life (TS)*** | 64.33 ± 3.0 | 38.94 ± 50.3 | 14.58*- | 0.001 |
*Independent t-test
** Man Whitney Utest
*** Total Scores
**** Mean ± Standard Deviation
p < 0.05: Statistical
Table 3 presents the results of the hypothesis “Quality of life and its dimensions among diabetic foot ulcer patients who referred to treatment educational centers, within the experimental and control group before and after training in the implementation of collaborative care model”.
Table 3.
In-group comparisons of the paired regarding the quality of life of the control and experimental groups before and after the collaborative care program training
| Life Quality and its dimensions (Cona and Expb scores) | Stage | Statistical Results | ||||||
|---|---|---|---|---|---|---|---|---|
| Pre-test | Post test | |||||||
| X ± SD**** | X ± SD | T* /W** | P | |||||
| groups | Cona | Expb | Cona | Expb | Cona | Expb | Cona | Expb |
| Enjoying the life | 50.71 ± 8 | 47.68 ± 45.10 | 67.50 ± 54.6 | 87.63 ± 73.5 | 2.036-** | 12.37*- | 0.042 | 0.001 |
| Physical health | 48.66 ± 10 | 50.28 ± 10 | 80.07 ± 52.6 | 60.79 ± 63.5 | 2.090 * | 4.216**- | 0.045 | 0.001 |
| Daily activity | 89.11 ± 48.9 | 56.62 ± 58.9 | 55.03 ± 50.5 | 33.95 ± 62.5 | −0.796* | 1.71*- | 0.433 | 0.098 |
| Emotions | 63.52 ± 31.5 | 93.96 ± 35.5 | 15.04 ± 39.5 | 94/4 ± 26/58 | 6.34-* | 18.24*- | 0.001 | 0.001 |
| Treatment Adherence | 67.50 ± 69.14 | 33.61 ± 73.10 | 33.79 ± 75.12 | 33.04 ± 84.11 | 1.39-* | 3.35**- | 0.176 | 0.001 |
| Family relationships | 27.99 ± 52.12 | 60.04 ± 49.14 | 13.22 ± 48.13 | 60.02 ± 59.8 | 1.01* | 3.40*- | 0.321 | 0.002 |
| Friend relationships | 33.88 ± 37.7 | 20.25 ± 49.10 | 47.02 ± 39.7 | 60.49 ± 63.8 | 1.07-* | 4.32**- | 0.290 | 0.001 |
| Foot ulcer care | 50.44 ± 31.7 | 33.64 ± 36.9 | 50.84 ± 33.6 | 52.14 ± 7 | 0.869 -** | 4.322**- | 0.385 | 0.001 |
| Life satisfaction | 33.58 ± 51.13 | 68.07 ± 20 | 60.74 ± 11 | 74.02 ± 13 | 2.707 -** | 1.392**- | 0.007 | 0.164 |
| Life Attitude | 60.13 ± 47.12 | 20.69 ± 53.9 | 87.13 ± 55.9 | 93.35 ± 66.7 | 3.31 -* | 5.61*- | 0.003 | 0.001 |
| Economic situation | 33.57 ± 37.12 | 46.99 ± 14 | 67.70 ± 44.18 | 67.88 ± 46.16 | 1.876-** | 0.276**- | 0.061 | 0.782 |
| Quality of life (TS)*** | 96.89 ± 45.4 | 42.09 ± 51.5 | 38.94 ± 50.3 | 11.33 ± 64.3 | 3.30 -* | 10.848*- | 0.003 | 0.001 |
aControl
bExperimental
*Correlated t-test
**Wilcoxon test
***Total Scores,
****Mean ± Standard Deviation
p < 0.05: Statistical
The data results from the t-test and Wilcoxon test results in Table 3 indicated in most of the studied components, life quality among the experimental group, before and after training in the implementation of collaborative care model, except in the activity components, were statistically significant differences between daily life satisfaction and economic situation (P value ≥0001). The results of correlated t-test and Wilcoxon that the life’s quality of control group did not show a significant difference (P < 0.05) in most components.
Discussion and conclusion
The results showed a significant difference between life’s quality scores among those who had diabetic foot ulcer in the control and experimental groups after training the collaborative care model. The average score of experimental group was high (64), which confirmed the first hypothesis of the study. The results of this hypothesis are similar to the results of Bojadzievski ans Gabbay (2011), Lin et al. (2012), Huang et al. (2013), Hua et al. (2017), Jiang and Ehya (2020), because their studies indicated a positive effect of this model and other educational programs on improving the life’s quality [11, 14–17]. Also, regarding the quality of life, the results confirmed the components of life satisfaction, daily activity, emotions, family relationships, attitude, physical health, adherence to treatment, friend relationships, life satisfaction; also, rejecting the economic situation. This confirms a statistically significant difference in all aspects of life’s quality (except the economic component) in the control and experimental groups after the study. The results of research by Hua et al. (2017), among those who had chronic heart failure [14] and the results of research by Anaya et al. (2008), among diabetic patients treatment after training of this model [15] were similar to our study. Nemcová et al. showed that significant negative correlations between demographic characteristics such as duration of diabetes mellitus, age, duration of diabetic ulceration treatment and a lower quality of life in diabetic patients [16]. Therefore, this model can increase the ability of patients to manage their disease and reduce hospitalization duration, costs and ultimately to achieve the highest level of community health. Funnell et al. (2009) also emphasized the seventh principle of the eleven standards for the development of self-care in diabetes, individual assessment and participatory training to make behavioral changes among patients and the effectiveness of education [17]. The results showed the mean scores of patients’ quality of life were different before and after the collaborative care model training (P value≥0.001). So, the mean quality of life after training of this model improved significantly compared to pre-test. This result indicated that by educating and implementing this model, the patients will increase their understanding of the concept of quality health care and quality of life. Also, there was a significant difference in all dimensions of life’s quality (except daily activity components, life satisfaction and economic situation) among the experimental group before and after training.
Solli et al. (2010) also emphasized a variety of interventions can improve life’s quality dimensions among diabetic adults, but the effectiveness varied with the interventions. It seems interventions are capable of capturing the consequences of diabetes complications that may have substantial impact on life’s quality dimensions such as ischemic heart disease, stroke and neuropathy [18].
Acute shortage of trained professionals and the overworked medical practitioner were the main limitations of quality healthcare delivery. Our findings emphasized the need to develop a trained team of health professionals to solve the problem of diabetic foot ulcer patients, associated vulnerabilities and economic, familial and consequents [19].
Based on the results, we can conclude:
According to the findings of this study, diabetic foot ulcer situation is not optimized and diabetic foot ulcer patients and all the same patients had a low quality of life in the region. The improvement of their life’s quality seems to be necessary.
This hypothesis that “ life’s quality and its dimensions among diabetic foot ulcer patients who referred to treatment educational centers is different between the experiment and control groups after the implementation of participatory care model “ is confirmed. Also, this hypothesis that demensions of quality of life improve among diabetic foot ulcer patients referred to treatment educational centers within the experimental group before and after training collaborative care model“is also confirmed. In general, it can be claimed (with 99% confidence) that the training of collaborative care model among diabetic foot ulcer patients improved their life’s quality. The method can be usefully applied in educational planning for diabetic foot ulcer patients in other countries.
Limitations
In our study, patients were recruited from two centers. Designing a multi-centric study will improve the quality of the study. In addition, the relatively shorter duration of the study made conclusion about the method impact on patients’ quality of life not feasible. On the other hand, the patients’ quality of life is affected by some genetic differences that were out of control and we couldn’t follow up patients until complete healing. Finally, small patients’ population may create a low power of statistical analysis. Despite these limitations, the proposed intervention appears to provide an effective approach to enhance patients’ quality of life.
Ethical considerations
This study is the result of a Master’s Thesis in Nursing, with the Ethics Committee of Urmia University of Medical Sciences Code: ir.umsu.rec1396–277-1396 / 8/17, IRCT20160220026662N4.
After ethical approval, the aims of study were described for all of the participants, and consent part was filled by them. The control group was permitted to participate in program when the study was finished. Data were collected and recorded in a manner that protected the anonymity of the participants. The participants could withdraw from the study at any time; they were not expected to pay for anything.
Acknowledgments
We would like to acknowledge of diabetic foot ulcer patients, their families and hospital staff in selected educational and treatment centers of Urmia city participating in this study for their devotional corporation.
Compliance with ethical standards
Conflict of interest
The authors declared that they have no conflict of interest.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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