In our prior blog Prior Belief Systems, Placebos, Nocebos, and Wound Healing we talked about various belief systems in regard to wound care. However, there is another elephant in the room that we have not mentioned and that is the frequency that a patient visits a clinic; in research parlance this would be visit frequency. The late Dr. Bob Warriner, Jim Wilcox, and I published a short study on visit frequency a few years ago Adv Skin Wound Care. 2012 Nov;25(11):494-501 and concluded that for patients with diabetic foot ulcers (DFUs) or venous leg ulcers, more frequent visits were likely to be beneficial.
However, the sample size in that study was fairly small (N=421) and thus I did not know how generalizable this result was to other populations. More recently, I have completed a much larger study of patients with DFUs in which visit frequency was the variable in terms of effect size compared to the many other significant variables in a Cox regression adjusted for time-varying covariates. This really surprised me. I will be reporting on the results at several conferences in 2015 (including SAWC) and hope to submit the results for peer-reviewed publication later in 2015 also.
In controlled trials it is thought that the frequency of visits is not a factor because all arms of trials have the same visit frequency with some fairly tight windows. But the truth is we don’t know because it has never been examined. We know even less about the elements responsible for better outcomes when clinic visits are more frequent but we could speculate:
· More opportunities for clinic staff to catch wound infection in the early stages
· Positive staff-patient interactions could benefit patients in terms of raising expectations of healing; this might affect healing beliefs
· Opportunities for more frequent debridement accompanied by better outcomes although we should remember that over-debridement can be detrimental for a variety of reasons and is a judgment call by the treating wound care clinician
· For some patients the opportunity for more social interaction at the clinic might be beneficial, remembering that for some patients the wound itself can cause social isolation
· Better tracking of wound healing (wound measurements and assessment)
· Opportunities to see if elements of basic wound care or adjunct therapy are working (also a function of patient compliance)
I’ve diagrammed these factors into a figure so we can see how some of these interactions might interact.
Interactions can be divided into two parts: increased wound tracking (measurements and assessment) and increased patient interactions.
The former could lead to several benefits, including earlier assessment of wound infection, basic wound care, and adjunct therapies, more frequent debridement, and perhaps an alert to clinic staff that the patient is not being compliant in regard to basic wound care (for example, ignoring prescribed offloading).
More frequent dressing changes and faster response to potential complications could speed wound healing as well as understanding the wound-healing trajectory itself. Increased patient interactions could lead to increased wound healing expectations by the patient via a variety of pathways.
It is well know that many patients with chronic experience a sense of social isolation and perhaps interaction with people at the clinic could elevate their mood and expectations. Also social exchange with other patients can have positive benefits as exemplified by the Lindsay Leg Club model in Australia.
We make the assumption that all these elements are positive but in fact we do not know which are the most important, and which might consistently have positive benefits.
I will be talking about these points (amongst other things) at a lecture I will give at SAWC in New Orleans.