Journal of General Internal Medicine

, Volume 22, Issue 7, pp 942–948 | Cite as

Process of Care and Outcomes in Patients with Peripheral Arterial Disease

  • Tracie C. Collins
  • Rebecca J. Beyth
  • David B. Nelson
  • Nancy J. Petersen
  • Maria E. Suarez-Almazor
  • Ruth L. Bush
  • Alan T. Hirsch
  • Carol M. Ashton
Original Article



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.


peripheral arterial disease process of care glucose control surgery atherosclerosis risk factors 



This work was supported by an Investigator-Initiated Grant (#01-180-1; Principal Investigator, Dr. Tracie C. Collins) from the Department of Veterans Affairs, Health Services Research and Development, along with resources from the Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey Veterans Affairs Medical Center. Dr. Collins was a recipient of the Department of Veterans Affairs Advanced Clinical Research Career Development Award. Dr. Beyth was a recipient of the Department of Veterans Affairs HSR&D Advanced Research Career Development Award during data collection for this work. We acknowledge and are very grateful for the excellent study support by Patricia N. Krueger, Meei Ku-Goto, and Diana Urbauer.

Conflicts of Interest

The following were reported by the authors: Dr. Collins is a consultant (Data and Safety Monitoring Committee) for Synteract. Dr. Hirsch has grants from AstraZeneca, Biomedix, Bristol-Myers Squibb-Synthelabo, Omron, PreMD, and SonoSite. He is a consultant for Pfizer. Dr. Bush is a consultant for Guidant, Abbott and Endologix.


  1. 1.
    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.PubMedGoogle Scholar
  2. 2.
    Hirsch A, Criqui M, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317–24.PubMedGoogle Scholar
  3. 3.
    Newman A, Sutton-Tyrrell K, Kuller L. Lower-extremity arterial disease in older hypertensive adults. Arterioscler Thromb. 1993;13(4):555–62.PubMedGoogle Scholar
  4. 4.
    Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44:166–206.PubMedGoogle Scholar
  5. 5.
    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.PubMedGoogle Scholar
  6. 6.
    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.PubMedGoogle Scholar
  7. 7.
    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.PubMedGoogle Scholar
  8. 8.
    Harness N, Pinzur MS. Health related quality of life in patients with dysvascular transtibial amputation. Clin Orthop Relat Res. 2001;(383):204–7.Google Scholar
  9. 9.
    Mackey WC, McCullough JL, Conlon TP, et al. The costs of surgery for limb-threatening ischemia. Surgery. 1986;99:26–35.PubMedGoogle Scholar
  10. 10.
    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.PubMedGoogle Scholar
  11. 11.
    Weiss GN, Gorton TA, Read RC, Neal LA. Outcomes of lower extremity amputations. J Am Geriatr Soc. 1990;38(8):877–83.PubMedGoogle Scholar
  12. 12.
    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.Google Scholar
  13. 13.
    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.Google Scholar
  14. 14.
    American Diabetes Association Consensus Statement: Peripheral arterial disease in people with diabetes. Diabetes Care. 2003;26(12):3333–41.Google Scholar
  15. 15.
    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.PubMedGoogle Scholar
  16. 16.
    Stevenson RB. American Cancer Society and smoking cessation. J Am Dent Assoc. 1989;118(3):274.PubMedGoogle Scholar
  17. 17.
    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.Google Scholar
  18. 18.
    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.PubMedCrossRefGoogle Scholar
  19. 19.
    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.Google Scholar
  20. 20.
    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.PubMedGoogle Scholar
  21. 21.
    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.PubMedGoogle Scholar
  22. 22.
    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.PubMedGoogle Scholar
  23. 23.
    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.PubMedGoogle Scholar
  24. 24.
    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.PubMedGoogle Scholar
  25. 25.
    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.PubMedGoogle Scholar
  26. 26.
    Ernst E. Pentoxifylline for intermittent claudication: a critical review. Angiology. 1994;45:339–45.PubMedCrossRefGoogle Scholar
  27. 27.
    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.PubMedGoogle Scholar
  28. 28.
    Hood SC, Moher D, Barber GG. Management of intermittent claudication with pentoxifylline: meta-analysis of randomized controlled trials. CMAJ. 1996;155:1053–59.PubMedGoogle Scholar
  29. 29.
    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.PubMedGoogle Scholar
  30. 30.
    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.PubMedGoogle Scholar
  31. 31.
    Radack K, Wyderski RJ. Conservative management of intermittent claudication. Ann Intern Med. 1990;113(2):135–46.PubMedGoogle Scholar
  32. 32.
    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.PubMedGoogle Scholar
  33. 33.
    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.Google Scholar
  34. 34.
    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.PubMedGoogle Scholar
  35. 35.
    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.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Tracie C. Collins
    • 1
    • 2
    • 3
  • Rebecca J. Beyth
    • 4
  • David B. Nelson
    • 5
  • Nancy J. Petersen
    • 2
    • 3
  • Maria E. Suarez-Almazor
    • 6
  • Ruth L. Bush
    • 7
  • Alan T. Hirsch
    • 8
  • Carol M. Ashton
    • 9
  1. 1.Department of Medicine, Division of General Internal MedicineThe University of MinnesotaMinneapolisUSA
  2. 2.Houston Center for Quality of Care and Utilization StudiesMichael E. DeBakey VA Medical CenterHoustonUSA
  3. 3.Section of Health Services ResearchBaylor College of MedicineHoustonUSA
  4. 4.Department of Aging and Geriatrics, North Florida/South Georgia Veterans Health System, Rehabilitation and Outcomes Research Center, Geriatric Research, Education and Clinical CenterThe University of FloridaGainesvilleUSA
  5. 5.Minneapolis VA Medical Center, Center for Chronic Disease Outcomes ResearchUniversity of MinnesotaMinneapolisUSA
  6. 6.MD Anderson Cancer CenterUniversity of TexasHoustonUSA
  7. 7.Department of SurgeryTexas A&M University Health Sciences CenterTempleUSA
  8. 8.Department of Epidemiology and Community HealthUniversity of Minnesota School of Public Health and the Minneapolis Heart Institute FoundationMinneapolisUSA
  9. 9.Professor of MedicineUniversity of Alabama School of MedicineBirminghamUSA

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