Choosing Wisely NL Peripheral Artery Disease
Practice Points • Approximately 12% of adults in Newfoundland and Labrador have Peripheral Artery Disease (PAD). • Usually, patients with PAD DO NOT need a test or revascularization procedure. • There are simple and safe ways to improve PAD symptoms through home management. • Choosing Wisely Canada guideline: Do not suggest a test that will not change the patient’s clinical course. • Do peripheral vascular testing in those who could potentially benefit from a revascularization procedure.
Who needs a test? Refer patients for peripheral vascular testing if they have any of the following: • Rest pain: Pain in feet, especially when legs are elevated in bed • Extremity ulcer: Sores on toes or feet that won't heal • Gangrene: Toe that looks blue or black and may hurt • Severe Claudication: Leg pain during exercise severe enough to limit lifestyle or ability to work
Who needs a test and who doesn’t? Only refer patients with “Good Indicators” for PAD testing: Good Indicators Poor Indicators Mild claudication (mild leg pain during Rest Pain (pain in feet, especially when exercise that stops when at rest) legs are elevated in bed) Leg cramps Tissue Loss (ulcers/sores on the feet that will not heal or a toe that is blue or Raynaud's black and may hurt) Digital cyanosis Severe Claudication (leg pain while walking severe enough to limit lifestyle Absent peripheral pulses or work) Family history with no symptoms
What’s happening in Newfoundland? Percentage of testing by indication (St. Clare’s 2007-2015, N = 17 683) 100% Follow up post revascularization 11% 90% 80% Percentage of tests 70% Inappropriate / no symptoms 49% 60% 50% 40% 30% 20% Appropriate symptoms, test indicated 40% 10% 0% Test indication
What’s happening in Newfoundland? Over 2500 PAD tests are 51% Normal Test Result conducted each year at St. Clare’s Vascular Lab 41% Early signs of PAD Over 90% of the people 8% May need a tested do not need a procedure revascularization procedure
What’s happening in NL? Proportion of tests analyzed by indication and by presence of PVD: (excluding testing in patients with a previous limb revascularization procedure) 9000 Severe Moderate 8000 Mild 7000 Volume of tests at St. Clare’s (2007-2015) Number of tests Severe 6000 Normal Mild Moderate Severe Total 5000 Moderate Indicated 1983 1543 2194 1238 6958 (44% 4000 Normal total tests) (28%) (22%) (32%) (18%) 3000 Mild Not 7493 718 527 162 8900 (56% 2000 indicated total tests) (84%) (8%) (6%) (<2%) Normal 1000 15858 0 Indicated Not indicated
How can we improve? Our objective is to test patients with symptoms of vascular disease that may need revascularization quickly, and not test patients unless they have symptoms indicative of disease requiring surgical intervention. Unnecessary tests increase wait times for all patients.
What you can do… For patients with symptoms of mild to moderate PAD, a home management plan is the best way to manage and reduce symptoms. Discuss lifestyle options with these patients and provide them with a pamphlet. Blood Pressure control (with ACE) Home management plans may include: Proper foot care Quitting smoking Cholesterol control (with Statin) Regular exercise (walk daily) Aspirin and/or Plavix Diabetic management
Tools to help your practice Contact Choosing Wisely NL at choosingwiselynl.ca for printed copies of pamphlets or prescription pads to be mailed to your practice OR Download printer friendly copies of the patient pamphlet and prescription pad and view our video at the links below… Patient Pamphlet: Prescription Pad: Video: Blocked Leg Blocked Leg Arteries - Blocked Leg Arteries Arteries - CWNL CWNL - CWNL
Personal data Click the PDF link below ¹ to access aggregate data for Peripheral Artery testing at St Clare’s Mercy Hospital from 2007-2015 and analysis of your personal practice ² by indication and by diagnosis of peripheral artery disease. ¹ Not every physician will have personal data available due to limitations in data entry, duration of practice, and volume of referrals. ² Personal data is anonymous and only data on your own personal utilization will be provided to you.
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