Determinants of invasive treatment in lower extremity peripheral arterial disease

Zitteren, Moniek van; Vriens, Patrick W.; Burger, D.H.; Fijter, W.M. de; Gerritsen, Gery; Heyligers, Jan M.M.; Nooren, Maria; Smolderen, Kim G.

doi:10.1016/j.jvs.2013.08.045

Cited by 6 publications

(9 citation statements)

References 28 publications

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“…A variety of treatment strategies were available at both enrolling centers, including non-invasive strategies: a formal supervised exercise therapy program supported by a regional network of certified physiotherapists; smoking cessation counseling; and optimal medical care (e.g., aspirin, anticoagulants, and statins). 6 Treatments were categorized for analytical purposes: if no hospital admissions for vascular reasons were documented within the first year following diagnosis, patients were considered to have had non-invasive treatment options only. Patients were assigned to the invasive treatment category if any invasive lower extremity procedure was documented in their medical records.…”

Section: Methodsmentioning

confidence: 99%

“…Patients were assigned to the invasive treatment category if any invasive lower extremity procedure was documented in their medical records. 6 Patients received care for their PAD at the vascular surgery department. In any case, medical management of cardiovascular risk factors was initiated or sustained for all patients, and exercise therapy was also made available, regardless of whether patients were referred for invasive therapy for their PAD symptoms.…”

Section: Methodsmentioning

confidence: 99%

“…1e5 Despite these objectives, patients' health status may not always be a decisive factor in referring patients for invasive treatment. 6 In addition, in large clinical trials, outcomes of interest were often focused on hemodynamic success rates, 7e 9 as opposed to clinically meaningful improvements in patients' health status.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

One Year Health Status Benefits Following Treatment for New Onset or Exacerbation of Peripheral Arterial Disease Symptoms: The Importance of Patients' Baseline Health Status

Zitteren

Denollet

Heyligers

et al. 2015

European Journal of Vascular and Endovascular Surgery

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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One Year Health Status Benefits Following Treatment for New Onset or Exacerbation of Peripheral Arterial Disease Symptoms: The Importance of Patients' Baseline Health Status

Zitteren

Denollet

Heyligers

et al. 2015

European Journal of Vascular and Endovascular Surgery

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“…One of the main arguments for early revascularisation is the location and extent of the atherosclerotic lesion. Excellent patency rates and procedural results of aortoiliac ER in clinical trials prompt some clinicians to employ more liberal indications to intervene first in these patients 16. However, three randomised controlled trials (RCTs) compared SET with ER for patients with IC due to an iliac artery obstruction and found no important differences regarding walking distance or QoL 3 5 17.…”

Section: Introductionmentioning

confidence: 99%

Protocol for a prospective, longitudinal cohort study on the effect of arterial disease level on the outcomes of supervised exercise in intermittent claudication: the ELECT Registry

et al. 2019

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IntroductionDespite guideline recommendations advocating conservative management before invasive treatment in intermittent claudication, early revascularisation remains widespread in patients with favourable anatomy. The aim of the Effect of Disease Level on Outcomes of Supervised Exercise in Intermittent Claudication Registry is to determine the effect of the location of stenosis on the outcomes of supervised exercise in patients with intermittent claudication due to peripheral arterial disease.Methods and analysisThis multicentre prospective cohort study aims to enrol 320 patients in 10 vascular centres across the Netherlands. All patients diagnosed with intermittent claudication (peripheral arterial disease: Fontaine II/Rutherford 1–3), who are considered candidates for supervised exercise therapy by their own physicians are appropriate to participate. Participants will receive standard care, meaning supervised exercise therapy first, with endovascular or open revascularisation in case of insufficient effect (at the discretion of patient and vascular surgeon). For the primary objectives, patients are grouped according to anatomical characteristics of disease (aortoiliac, femoropopliteal or multilevel disease) as apparent on the preferred imaging modality in the participating centre (either duplex, CT angiography or magnetic resonance angiography). Changes in walking performance (treadmill tests, 6 min walk test) and quality of life (QoL; Vascular QoL Questionnaire-6, WHO QoL Questionnaire-Bref) will be compared between groups, after multivariate adjustment for possible confounders. Freedom from revascularisation and major adverse cardiovascular disease events, and attainment of the treatment goal between anatomical groups will be compared using Kaplan-Meier survival curves.Ethics and disseminationThis study has been exempted from formal medical ethical approval by the Medical Research Ethics Committees United ‘MEC-U’ (W17.071). Results are intended for publication in peer-reviewed journals and for presentation to stakeholders nationally and internationally.Trial registration numberNTR7332; Pre-results.

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“…7 There has been a tremendous increase and variation in lower extremity vascular interventions over the past decade for patients with intermittent claudication, 8-10 but we have little direct evidence about how physicians make intervention decisions, although payment incentives might play a role. 8,11 Providers may not wish to spend their own or their staff's time on medication titration or may feel like it is the responsibility of another physician. 12 Several reviews also focused on how physicians' knowledge, attitudes, cognitive processes, and self-efficacy affect their use of evidence-based guidelines.…”

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confidence: 99%

Barriers to and Facilitators of Evidence-Based Decision Making at the Point of Care

O’Malley

Collins

Contreary

et al. 2016

MDM Policy & Practice

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Introduction: Physicians vary widely in how they treat some health conditions, despite strong evidence favoring certain treatments over others. We examined physicians’ perspectives on factors that support or hinder evidence-based decisions and the implications for delivery systems, payers, and policymakers. Methods: We used Choosing Wisely® recommendations to create four clinical vignettes for common types of decisions. We conducted semi-structured interviews with 36 specialists to identify factors that support or hinder evidence-based decisions. We examined these factors using a conceptual framework that includes six levels: patients, physicians, practice sites, organizations, networks and hospital affiliations, and the local market. In this model, population characteristics and payer and regulatory factors interact to influence decisions. Results: Patient openness to behavior modification and expectations, facilitated and hindered physicians in making evidence-based recommendations. Physicians’ communication skills were the most commonly mentioned facilitator. Practice site, organization, and hospital system barriers included measures of emergency department throughput, the order in which test options are listed in electronic health records (EHR), lack of relevant decision support in EHRs, and payment incentives that maximize billing and encourage procedures rather than medical management or counseling patients on behavior change. Factors from different levels interacted to undermine evidence-based care. Most physicians received billing feedback, but quality metrics on evidence-based service use were nonexistent for the four decisions in this study. Conclusions and Implications: Additional research and quality improvement may help to modify delivery systems to overcome barriers at multiple levels. Enhancing provider communication skills, improving decision support in EHRs, modifying workflows, and refining the design and interpretation of some quality metrics would help, particularly if combined with concurrent payment reform to realign financial incentives across stakeholders.

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Determinants of invasive treatment in lower extremity peripheral arterial disease

Cited by 6 publications

References 28 publications

One Year Health Status Benefits Following Treatment for New Onset or Exacerbation of Peripheral Arterial Disease Symptoms: The Importance of Patients' Baseline Health Status

One Year Health Status Benefits Following Treatment for New Onset or Exacerbation of Peripheral Arterial Disease Symptoms: The Importance of Patients' Baseline Health Status

Protocol for a prospective, longitudinal cohort study on the effect of arterial disease level on the outcomes of supervised exercise in intermittent claudication: the ELECT Registry

Barriers to and Facilitators of Evidence-Based Decision Making at the Point of Care

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