Post on 10-Jan-2022
ChoosingWisely NLPeripheral ArteryDisease
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 needsa test?
•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
Refer patients for peripheral vascular testing if they have any of the following:
Who needs a test and who doesn’t? Only refer patients with “Good
Indicators” for PAD testing:
Good Indicators Poor Indicators
Rest Pain (pain in feet, especially when legs are elevated in bed)
Tissue Loss (ulcers/sores on the feet that will not heal or a toe that is blue or black and may hurt)
Severe Claudication (leg pain while walking severe enough to limit lifestyle or work)
Mild claudication (mild leg pain during exercise that stops when at rest)
Leg cramps
Raynaud's
Digital cyanosis
Absent peripheral pulses
Family history with no symptoms
What’s happening in Newfoundland?Percentage of testing by indication (St. Clare’s 2007-2015, N = 17 683)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Testindication
Percen
tageoftests
Inappropriate /nosymptoms49%
Followuppostrevascularization11%
Appropriate symptoms, testindicated40%
What’s happening in Newfoundland?
Over 2500 PAD tests are conducted each year at St. Clare’s Vascular Lab
Over 90% of the people tested do not need a revascularization procedure
51% Normal Test Result
41% Early signs of PAD
8% May need a 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)
Normal Mild Moderate Severe Total
Indicated 1983(28%)
1543(22%)
2194(32%)
1238(18%)
6958(44%total tests)
Notindicated
7493(84%)
718(8%)
527(6%)
162(<2%)
8900(56%totaltests)
15858Normal
NormalMild
Mild
Moderate
Moderate
Severe
Severe
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Indicated Notindicated
Num
bero
ftests Volume of tests at St. Clare’s (2007-2015)
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.
Home management plans may include:Quitting smoking Regular exercise (walk daily)Aspirin and/or PlavixDiabetic management
Blood Pressure control (with ACE)Proper foot careCholesterol control (with Statin)
Patient Pamphlet: Blocked Leg Arteries -CWNL
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…
Video: Blocked Leg Arteries - CWNL
Prescription Pad: Blocked Leg Arteries - CWNL
Personal dataClick the PDF link below¹ to access aggregate data for Peripheral Artery testing at St Clare’s Mercy Hospital from 2007-2015 and analysis of your personal practice² 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.