Process of Care and Outcomes in Patients with Peripheral Arterial Disease
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We investigated the association of process of care measures with adverse limb and systemic events in patients with peripheral arterial disease (PAD).
We conducted a retrospective cohort study of patients with PAD, as defined by an ankle-brachial index (ABI) <0.9. The index date was defined as the date, during 1995 to 1998, when the patient was seen in the Michael E. DeBakey VA Medical Center noninvasive vascular laboratory and found to have PAD. We conducted a chart review for process of care variables starting 3 years before the index date and ending at the time of the first event or the final visit (December 31, 2001), whichever occurred first. We examined the association between PAD process of care measures, including risk factor control, and prescribing of medication, with time of the patient’s first major limb event or death.
Of the 796 patients (mean age, 65 ± 9.9 years), 230 (28.9% experienced an adverse limb event (136 lower-extremity bypass, 94 lower-extremity amputation), and 354 (44.5%) died. Of the patients who died, 247 died without a preceding limb event. Glucose control was protective against death or a limb event with a hazard ratio (HR) of 0.74 (95% confidence limits [CL] 0.60, 0.91, P = 0.004). African Americans were at 2.8 (95% CL 1.7, 4.5) times the risk of Whites or Hispanics for an adverse limb event. However, this risk was no longer significant if their glucose was controlled. For process measures, the dispensing of PAD specific medication (HR 1.4, 95% CL 1.1, 1.7) was associated an increased risk for an adverse outcome.
Our data suggest that glucose control is key to reducing the risk for adverse outcomes, particularly limb events in African Americans. Certain process of care measures, as markers of disease severity and disease management, are associated with poor outcomes in patients with PAD. Further work is needed to determine the role of early disease intervention to reduce poor outcomes in patients with PAD.
- Collins T, Petersen N, Suarez-Almazor M, Ashton C. The prevalence of peripheral arterial disease in a racially diverse population. Arch Intern Med. 2003;163:1469–74.
- Hirsch A, Criqui M, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317–24.
- Newman A, Sutton-Tyrrell K, Kuller L. Lower-extremity arterial disease in older hypertensive adults. Arterioscler Thromb. 1993;13(4):555–62.
- Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44:166–206.
- Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006;113(11):e463–654.
- Morise AP, McDowell DE, Savrin RA, et al. The prediction of cardiac risk in patients undergoing vascular surgery. Am J Med Sci. 1987;293(3):150–8.
- Cheng SW, Ting AC, Lau H, Wong J. Survival in patients with chronic lower extremity ischemia: a risk factor analysis. Ann Vasc Surg. 2000;14(2):158–65.
- Harness N, Pinzur MS. Health related quality of life in patients with dysvascular transtibial amputation. Clin Orthop Relat Res. 2001;(383):204–7.
- Mackey WC, McCullough JL, Conlon TP, et al. The costs of surgery for limb-threatening ischemia. Surgery. 1986;99:26–35.
- Raviola C, Nichter L, Baker J, Busuttil R, Machleder H, Moore W. Cost of treating advanced leg ischemia: bpass graft vs. primary amputation. Arch Surg. 1988;123:495–6.
- Weiss GN, Gorton TA, Read RC, Neal LA. Outcomes of lower extremity amputations. J Am Geriatr Soc. 1990;38(8):877–83.
- National Institutes of Health: National Heart, Lung, and Blood Institute. National High Blood Pressure Education Program. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997;157–46.
- Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285(19):2486–97.
- American Diabetes Association Consensus Statement: Peripheral arterial disease in people with diabetes. Diabetes Care. 2003;26(12):3333–41.
- McAlister AL, Rabius V, Geiger A, Glynn TJ, Huang P, Todd R. Telephone assistance for smoking cessation: one year cost effectiveness estimations. Tob Control. 2004;13(1):85–6.
- Stevenson RB. American Cancer Society and smoking cessation. J Am Dent Assoc. 1989;118(3):274.
- Collins T, Johnson M, Henderson W, Khuri S, Daley J. Lower extremity non-traumatic amputation among veterans with peripheral arterial disease: is race an independent factor. Med Care. 2002;40(Suppl):I-106–16.
- Criqui M, Langer R, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381–6. CrossRef
- Leng G, Fowkes F, Lee A, Dunbar J, Housley E, Ruckley C. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. Br Med J. 1996;313:1440–4.
- McDermott M, Criqui M, Liu K, et al. Lower ankle/brachial index, as calculated by averaging the dorsalis pedis and posterior tibial arterial pressures, and association with leg functioning in peripheral arterial disease. J Vasc Surg. 2000;32:1164–71.
- McDermott M, Greenland P, Liu K, et al. The ankle-brachial index is associated with leg function and physical activity: The Walking and Leg Circulation Study. Ann Intern Med. 2002;136:873–83.
- Rajagopalan S, Dellegrottaglie S, Furniss AL, et al. Peripheral arterial disease in patients with end-stage renal disease: observations from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Circulation. 2006;114:1914–22.
- Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Concensus (TASC). J Vasc Surg. 2000;31(1 Pt 2):S1–296.
- Dawson DL, Cutler BS, Meissner MH, Strandness DE, Jr. Cilostazol has beneficial effects in treatment of intermittent claudication: results from a multicenter, randomized, prospective, double-blind trial. Circulation. 1998;98:678–86.
- Money SR, Herd JA, Isaacsohn JL, et al. Effect of cilostazol on walking distances in patients with intermittent claudication caused by peripheral vascular disease. J Vasc Surg. 1998;27:267–74.
- Ernst E. Pentoxifylline for intermittent claudication: a critical review. Angiology. 1994;45:339–45. CrossRef
- Girolami B, Bernardi E, Prins MH, et al. Treatment of intermittent claudication with physical training, smoking cessation, pentoxifylline, or nafronyl: a meta-analysis. Arch Intern Med. 1999;159:337–45.
- Hood SC, Moher D, Barber GG. Management of intermittent claudication with pentoxifylline: meta-analysis of randomized controlled trials. CMAJ. 1996;155:1053–59.
- Lindgarde F, Jelnes R, Bjorkman H, et al. Conservative drug treatment in patients with moderately severe chronic occlusive peripheral arterial disease. Circulation. 1989;80:1549–56.
- Porter JM, Cutler BS, Lee BY, et al. Pentoxifylline efficacy in the treatment of intermittent claudication: multicenter controlled double-blind trial with objective assessment of chronic occlusive arterial disease patients. Am Heart J. 1982;104:66–72.
- Radack K, Wyderski RJ. Conservative management of intermittent claudication. Ann Intern Med. 1990;113(2):135–46.
- McDermott M, Mehta S, Liu K, et al. Leg symptoms, the ankle-brachial index, and walking ability in patients with peripheral arterial disease. J Gen Intern Med. 1999;14(3):173–81.
- McDermott M, Hahn E, Greenland P, et al. Atherosclerotic risk factor reduction in peripheral arterial disease: results of a national physician survey. J Gen Intern Med. 2002;17(895):904.
- Banta MR, Ma F, Bravata DM, Kirsner RS, Federman DG. Incidence of and factors associated with achieving target lipid levels in patients with peripheral arterial disease. J Gen Intern Med. 2006;21(7):711–4.
- Hernan MA, Brumback B, Robins JM. Marginal structural models to estimate the causal effect of zidovudine on the survival of HIV-positive men. Epidemiology. 2000;11(5):561–70.
- Process of Care and Outcomes in Patients with Peripheral Arterial Disease
Journal of General Internal Medicine
Volume 22, Issue 7 , pp 942-948
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- peripheral arterial disease
- process of care
- glucose control
- atherosclerosis risk factors
- Industry Sectors
- Author Affiliations
- 1. Department of Medicine, Division of General Internal Medicine, The University of Minnesota, 420 Delaware St., S.E. MMC 451, Minneapolis, Minnesota, USA
- 2. Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- 3. Section of Health Services Research, Baylor College of Medicine, Houston, Texas, USA
- 4. Department of Aging and Geriatrics, North Florida/South Georgia Veterans Health System, Rehabilitation and Outcomes Research Center, Geriatric Research, Education and Clinical Center, The University of Florida, Gainesville, Florida, USA
- 5. Minneapolis VA Medical Center, Center for Chronic Disease Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
- 6. MD Anderson Cancer Center, University of Texas, Houston, TX, USA
- 7. Department of Surgery, Texas A&M University Health Sciences Center, Temple, TX, USA
- 8. Department of Epidemiology and Community Health, University of Minnesota School of Public Health and the Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
- 9. Professor of Medicine, University of Alabama School of Medicine, Birmingham, Alabama, USA