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Ibeggazene S, Stirrup A, Pymer S, Palmer J, Cai PL, Smith GE, Chetter IC. The Edinburgh Claudication Questionnaire has poor diagnostic accuracy in people with intermittent claudication. Vascular 2023; 31:115-121. [PMID: 35143731 PMCID: PMC9936437 DOI: 10.1177/17085381211059665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The screening and diagnosis of intermittent claudication is a challenging process and often relies on the expertise of specialist vascular clinicians. We sought to investigate the diagnostic performance of the Edinburgh Claudication Questionnaire (ECQ) as a screening tool for referrals of suspected intermittent claudication from primary to secondary care. METHOD Prospectively, 100 referrals from primary care with a stated diagnosis or query regarding intermittent claudication were recruited. All participants who completed the ECQ, underwent an anklebrachial pressure index (ABPI) assessment and treadmill exercise testing. Outcomes of the ECQ were compared to clinical diagnoses of intermittent claudication. RESULTS The ECQ had a sensitivity of 46.8% (95% CI: 27-65%), specificity of 63.2% (95% CI: 43-82%) and accuracy of 53.0% (95% CI: 43-63%). The diagnostic performance was not changed by combining the ECQ with a positive ABPI or post-exercise ABPI outcome for PAD. CONCLUSION The ECQ had a poor diagnostic performance in this cohort. Considering the results found here and in other recent studies, the utility of the ECQ as a screening tool and epidemiological survey tool must be questioned. Novel, low-resource diagnostic tools are needed in this population.
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Affiliation(s)
- Saïd Ibeggazene
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK,College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK,Saïd Ibeggazene, Allied Health Professionals, Sheffield Hallam University, Parkholme Building College of Health, Wellbeing and Life Sciences, Sheffield S1 1WB UK.
| | - Andrew Stirrup
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Sean Pymer
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Joanne Palmer
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Paris L Cai
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - George E Smith
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
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Boylan L, Nesbitt C, Wilson L, Allen J, Sims A, Guri I, Mawson P, Oates C, Stansby G, Investigators OBOTN. Reliability of the Edinburgh Claudication Questionnaire for Identifying Symptomatic PAD in General Practice. Angiology 2021; 72:474-479. [PMID: 33401955 DOI: 10.1177/0003319720984882] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Edinburgh Claudication Questionnaire (ECQ) was developed to help identify peripheral arterial disease (PAD) in the general population but has not been validated against diagnostic arterial imaging methods such as Duplex Vascular Ultrasound Scanning (DUS). In the present study, we assessed the accuracy of the ECQ for diagnosis using DUS. As part of a National Institute of Health Research funded project looking at novel diagnostic methods, 250 patients were studied from 15 general practices across North East England from May 2015 and November 2016. Practices identified those with a PAD diagnosis from their registers as well as age- and sex-matched controls. All the ECQs were recorded by a vascular specialist nurse. Duplex vascular ultrasound scanning was used as a reference standard for the diagnosis of occlusive PAD. The ECQ had a sensitivity of 52.5% (95% CI: 42.3%-62.5%), specificity of 87.1% (95% CI: 80.6%-92.0%), positive likelihood ratio of 4.06 (95% CI: 2.57-6.42), and negative likelihood ratio of 0.55 (95% CI: 0.44-0.68) compared with reference standard DUS. The ECQ has relatively poor overall diagnostic test accuracy in isolation. It may be helpful in ruling out PAD or as a supplementary test to improve diagnosis of symptomatic disease in General Practice.
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Affiliation(s)
- Luke Boylan
- Northern Vascular Centre, Freeman Hospital, 5983The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom.,12186Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Craig Nesbitt
- 12186Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lesley Wilson
- Northern Vascular Centre, Freeman Hospital, 5983The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - John Allen
- 12186Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Northern Medical Physics and Clinical Engineering, Freeman Hospital, 5983The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew Sims
- 12186Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Northern Medical Physics and Clinical Engineering, Freeman Hospital, 5983The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ina Guri
- 12186Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Northern Medical Physics and Clinical Engineering, Freeman Hospital, 5983The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Philip Mawson
- Newcastle Joint Research Office, Gosforth, Newcastle upon Tyne, United Kingdom
| | - Crispian Oates
- Northern Medical Physics and Clinical Engineering, Freeman Hospital, 5983The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Gerard Stansby
- Northern Vascular Centre, Freeman Hospital, 5983The Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, United Kingdom.,12186Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
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Shinkunas LA, Klipowicz CJ, Carlisle EM. Inappropriate referrals in pediatric surgery. J Pediatr Surg 2020; 55:2596-2601. [PMID: 32660777 DOI: 10.1016/j.jpedsurg.2020.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/29/2020] [Accepted: 06/09/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inappropriate referrals consume a significant amount of health-system resources. To optimize referral patterns, organizations such as the American Academy of Pediatrics provide policy statements regarding appropriate surgical referrals. Here, we identify the volume/characteristics of inappropriate referrals to pediatric surgeons. METHODS Retrospective chart review of new patients evaluated in the Pediatric Surgery Clinic at a university-based, tertiary-care Children's Hospital over 12-months. Demographics, insurance, referring provider/surgeon diagnosis, and referring provider specialty were abstracted and coded as appropriate/inappropriate. RESULTS Five hundred nine referrals were identified; 19% were inappropriate. Inappropriate referrals were more common from mid-level providers (OR = 1.97, p = 0.02) and non-pediatric providers (OR = 1.94, p = 0.01) compared to physicians and pediatric providers. Female patients (OR = 1.65, p = 0.03) and younger patients (OR = 0.94, p = 0.002) were more likely to have an inappropriate referral than their older, male peers. Umbilical hernia, chest wall deformity, and GI complaint were the diagnoses most frequently given to inappropriately referred patients. Average distance traveled by patients for an inappropriate referral was 57.8 miles with significant difference in average distance traveled for rural (78 miles; range = 12-199) and urban (42 miles; range = 0-125) patients (p < 0.01). CONCLUSIONS Despite guidelines on appropriate referral patterns, 19% of pediatric surgery referrals are inappropriate. Increased supervision of mid-level providers, training in pediatrics, or referral to a local pediatrician prior to surgical consultation may decrease the rate of inappropriate referrals. TYPE OF STUDY Prognosis. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Laura A Shinkunas
- University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, IA, USA
| | | | - Erica M Carlisle
- University of Iowa Hospitals and Clinics, Department of Surgery, Iowa City, IA, USA.
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Lewis JE, Williams P, Davies JH. Non-invasive assessment of peripheral arterial disease: Automated ankle brachial index measurement and pulse volume analysis compared to duplex scan. SAGE Open Med 2016; 4:2050312116659088. [PMID: 27493755 PMCID: PMC4959301 DOI: 10.1177/2050312116659088] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/14/2016] [Indexed: 11/17/2022] Open
Abstract
Objectives: This cross-sectional study aimed to individually and cumulatively compare sensitivity and specificity of the (1) ankle brachial index and (2) pulse volume waveform analysis recorded by the same automated device, with the presence or absence of peripheral arterial disease being verified by ultrasound duplex scan. Methods: Patients (n=205) referred for lower limb arterial assessment underwent ankle brachial index measurement and pulse volume waveform recording using volume plethysmography, followed by ultrasound duplex scan. The presence of peripheral arterial disease was recorded if ankle brachial index <0.9; pulse volume waveform was graded as 2, 3 or 4; or if haemodynamically significant stenosis >50% was evident with ultrasound duplex scan. Outcome measure was agreement between the measured ankle brachial index and interpretation of pulse volume waveform for peripheral arterial disease diagnosis, using ultrasound duplex scan as the reference standard. Results: Sensitivity of ankle brachial index was 79%, specificity 91% and overall accuracy 88%. Pulse volume waveform sensitivity was 97%, specificity 81% and overall accuracy 85%. The combined sensitivity of ankle brachial index and pulse volume waveform was 100%, specificity 76% and overall accuracy 85%. Conclusion: Combining these two diagnostic modalities within one device provided a highly accurate method of ruling out peripheral arterial disease, which could be utilised in primary care to safely reduce unnecessary secondary care referrals.
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Affiliation(s)
- Jane Ea Lewis
- Cardiff School of Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Paul Williams
- Department of Medical Physics, University Hospital of Wales, Cardiff, UK
| | - Jane H Davies
- South East Wales Trials Unit, Cardiff University, Cardiff, UK
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Oesterling C, Kalia A, Chetcuti T, Walker S. Atypical leg symptoms: does routine measurement of the ankle brachial pressure index (ABPI) in primary care benefit patients? LONDON JOURNAL OF PRIMARY CARE 2015; 7:97-102. [PMID: 26681981 PMCID: PMC4673507 DOI: 10.1080/17571472.2015.1082345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Background : Managing patients with atypical leg symptoms in primary care can be problematic. Determining the ankle brachial pressure index (ABPI) may be readily performed to help diagnose peripheral arterial disease, but is often omitted where signs and symptoms are unclear. Question: Does routine measurement of ABPI in patients with atypical leg symptoms aid management increase satisfaction and safely reduce hospital referral? Methodology: Patients with atypical leg symptoms but no skin changes or neurological symptoms underwent clinical review and Doppler ABPI measurement (suspicious finding ≤ 1.0). Testing was performed by the same doctor (study period: 30 months). Patient outcomes were determined from practice records, hospital letters and a telephone survey. Results : The study comprised 35 consecutive patients (males: N = 15), mean age 64 years (range: 39-88). Presentation included pain, cold feet, cramps, irritation and concerns regarding circulation. Prior to ABPI measurement, referral was considered necessary in 10, not required in 22 and unclear in 3. ABPI changed the referral decision in 10 (29%) and confirmed the decision in 25 (71%). During the study, 10 (29%) patients were referred (9 vascular, 1 neurology). Amongst the vascular referrals, significant peripheral arterial disease has been confirmed in six patients. A further two patients are under review and one did not attend. To date, lack of referral in patients with atypical leg symptoms but a normal ABPI has not increased morbidity. Current status was assessed by telephone review in 16/35 (46% contact rate; mean 18 months, range 2-28). Fifteen patients (94%) appreciated that their symptoms had been quickly and conveniently assessed, 8/11 (73%) with a normal ABPI were reassured by their result and in 8/11 symptoms have resolved. Discussion/Conclusion: APBI conveniently aids management of atypical leg symptoms by detecting unexpected peripheral arterial disease, avoids /confirms the need for referral, reassures patients and guides reassessment. This study suggests ABPI should be used more widely.
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Affiliation(s)
| | - Amun Kalia
- Kingston Hospital NHS Trust , Kingston upon Thames , UK
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Griffin JL, Clarke GA, Roake JA, Lewis DR. A nurse-run clinic for patients with incidentally discovered small abdominal aortic aneurysms is feasible and cost-effective. Vascular 2014; 23:138-43. [PMID: 24875184 DOI: 10.1177/1708538114537049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Patients with incidentally discovered small abdominal aortic aneurysms (AAA) require assessment by a vascular surgery department for possible enrollment in a surveillance programme. Our unit implemented a vascular nurse-run AAA clinic in October 2010. The aim of this study was to assess the feasibility of a specialist nurse-run small AAA clinic. METHODS Demographic and clinical data were collected prospectively for all patients seen in the new vascular nurse clinic between October 2010 and November 2012. A validated AAA operative mortality score was used to aid decision making by the vascular nurse. RESULTS Some 250 patients were seen in the clinic. 198 (79.2%) patients were enrolled in surveillance, 40 (16%) declined enrollment and 12 (4.8%) were referred to a consultant clinic for further assessment. The majority of patients were male and the mean age was 73.7 years. Co-morbidities included hypertension, a history of cardiovascular disease, and hyperlipidaemia. The majority of referrals were considered to be low operative risk. No aneurysms ruptured whilst under surveillance. CONCLUSIONS A nurse-run clinic that assesses patients with incidentally discovered small AAAs for inclusion in AAA surveillance is a feasible alternative to assessment of these patients in a consultant-run clinic.
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Affiliation(s)
- J L Griffin
- Department of General Surgery, Perth Royal Infirmary, UK
| | - G A Clarke
- Department of Vascular Surgery, Christchurch Public Hospital, New Zealand
| | - J A Roake
- Department of Vascular Surgery, Christchurch Public Hospital, New Zealand
| | - D R Lewis
- Department of Vascular Surgery, Royal Infirmary of Edinburgh, UK
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