| 摘要: | 研究背景：糖尿病足潰瘍是糖尿病嚴重併發症之一，長期傷口照護視為預防感染、避免截肢甚至死亡的重要課題，然而仍有許多病患因就醫不便而疏於潰瘍傷口照護。過去研究發現遠距醫療或遠距照護可改善慢性傷口的癒合率及截肢率，也能提高糖尿病患的自我效能，但遠距傷口照護對糖尿病足潰瘍傷口照護及就醫成本的成效尚無定論。
研究目的：以系統性文獻回顧及統合分析探討遠距照護對糖尿病足潰瘍傷口癒合率、傷口癒合時間、截肢率、死亡率及就醫成本等指標之成效。
研究方法：本研究以系統性文獻回顧方式，透過中英文8個資料庫蒐集至2024年02月相關臨床研究之文獻以進行統合分析。研究對象為所有糖尿病足有潰瘍傷口患者，遠距傷口照護為介入措施，對照組則採常規門診護理治療，成效指標為潰瘍傷口癒合率、潰瘍傷口癒合時間、截肢率、死亡率、就醫成本，納入文獻為隨機對照實驗及非隨機對照實驗。隨機對照實驗使用Revised Cochrane Risk-of-Bias Tool 2.0（RoB 2.0），作為文獻評讀之工具，非隨機對照試驗之文章使用ROBINS-I作為評讀工具。使用Comprehensive Meta-Analysis Software 統計軟體進行統合分析。類別的成效指標效果量（Effect size）以勝算比（odds ratio, OR）呈現，連續資料成效指標，則使用Hedges’ g和95％信賴區間（Confidence interval, CI）估計作為實驗組及對照組在介入措施前後改變量的差異性，皆以隨機效應模式計算效果量。考科藍Q值及I2做為合併文獻後的異質性評估（heterogeneity）再以進行敏感度分析證明研究的穩定度，Egger’s test 回歸分析檢定結果出版偏差，最後使用GRADE證據等級評比系統進行本研究證據等級及建議強度。
研究結果：共納入7篇臨床隨機及非隨機對照實驗試驗。結果顯示相較於常規門診照護，遠距照護對改善糖尿病足潰瘍的傷口癒合率、傷口癒合時間、截肢率及死亡率的勝算比或效果量均未達統計學上的顯著差異，統計結果分別如下：OR = 1.11（95% CI: 0.814 - 1.516, p = .509）、Hedges’ g = -0.031（95％CI: -0.264 - 0.202, p = .795）、OR = 0.657（95％CI: 0.414 - 1.043, p= .075）及OR = 2.278（95% CI: 0.292 - 17.749, p= .432）。遠距照護降低糖尿病足潰瘍傷口照護之就醫成本有大量的效果量且達統計意義，Hedges’ g = -4.298（95％CI: -6.256 - -2.341, p < .001）。敏感度分析發現，在傷口癒合率、傷口癒合時間、截肢率及就醫成本指標成效各方面，無論移除哪一篇研究都不影響本研究的效果量。Egger’s test 回歸分析檢定在就醫成本方面有出版偏差。針對截肢率，GRADE證據等級評比為中度，傷口癒合率，癒合時間、死亡率及就醫成本GRADE證據等級評比為低度至非常低度。
結論：遠距照護相較於常規門診照護可能可以降低糖尿病足潰瘍傷口照護之就醫成本，然而對其他指標的成效仍須更多研究證實。
Background: Diabetic foot ulcer is a serious complication of diabetes. Effective long-term wound care is crucial for preventing infection, amputations and death. Despite this, many patients still face challenges in accessing medical care. Previous studies have shown that telemedicine can enhance the healing rates and reduce amputations in chronic wounds, and boost diabetic patients’ self-efficacy. However, the effectiveness and cost-effectiveness of telemedicine for diabetic foot ulcer remain unclear.
Objective: This study aims to assess the effects of telecare on wound healing rates, healing times, amputation rates, mortality, and medical costs for diabetic foot ulcers through a systematic review and meta-analysis.
Method: We searched eight Chinese and English databases up to February 2024, focusing on patients with diabetic foot ulcers. The intervention group received telecare, while the control group received standard outpatient care. Outcomes measured included wound healing rates, healing times, amputation rates, mortality, and medical costs. Included studies were randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs). Quality assessments were performed using the Revised Cochrane Risk-of-Bias Tool 2.0 for RCTs and ROBINS-I for NRCTs. Data analysis was conducted using Comprehensive Meta-Analysis Software, with effect sizes presented in odds ratios (ORs) for categorical outcomes and Hedges’ g for continuous outcomes, both with 95% confidence intervals (CIs). Statistical heterogeneity was evaluated using the Cochrane Q value and I2 statistics. Sensitivity analysis tested the robustness of the findings, and publication bias was assessed using Egger’s test. The quality of evidence was rated using the GRADE system.
Results: The study included seven clinical trials (both RCTs and NRCTs). The effect size of telecare on wound healing rate, healing time, amputation rate and mortality rate were not statistically significant compared with standard outpatient care. The results of the effect estimates for healing rate, healing time, amputation rate, and mortality were, respectively, as follow: OR = 1.11 (95% CI: 0.814 - 1.516, p = .509); Hedges’ g = -0.031 (95％ CI: -0.264 - 0.202, p = .795; OR = 0.657 (95％ CI: 0.414 - 1.043, p = .075); and OR = 2.278 (95% CI: 0.292 - 17.749, p = .432). Telecare significantly reduced medical costs with a large effect size( Hedges’ g = -4.298, 95％ CI: -6.256 to -2.341, p < .001). Sensitivity analysis confirmed the robustness of these findings. Egger’s test indicated no publication bias for all outcomes, except medical costs. The quality of evidence was moderate for amputation rates and low to very low for wound healing rates, healing time, mortality and medical costs.
Conclusion: Compared with standard outpatient care, telecare for diabetic foot ulcers may have a small effect for reducing medical costs, though its effectiveness on other clinical outcomes requires further investigation. |
