Ankle brachial index measurement in primary care setting: how long does it take?

Provider ankle brachial index and wound classification teaching as part of a comprehensive limb preservation outreach program

OBJECTIVE

Utilization of evidence-based specialty guidelines is low in primary care settings. Early use of ankle-brachial index (ABI) testing and a validated wound classification system allows prompt referral of patients for specialty care. We implemented a program to teach providers ABI testing and the use of the Wound, Ischemia, and foot Infection (WIfI) classification tool. Here, we report program outcomes and provider perceptions.

METHODS

Physicians and non-physicians from wound care centers, nursing and physician education programs, primary care offices, and federally qualified health centers were invited to participate in the educational program teaching ABI testing and the use of the WIfI tool. Pretest and posttest responses and intention to use content in the future were assessed with descriptive statistics.

RESULTS

A total of 101 subjects completed the ABI module, and 84 indicated their occupation (59 physicians, 25 non-physicians). Seventy-nine subjects completed the WIfI module, and 89% indicated their occupation (50 physicians, 20 non-physicians). Physicians had lower pre-test knowledge scores for the ABI module than non-physicians (mean scores of 7.9 and 8.2, respectively). Both groups had improved knowledge scores on the post-test (physicians, 13.4; non-physicians, 13.8; P < .001). Non-physicians in practice longer than 10 years at wound care centers had the lowest baseline knowledge scores, whereas physicians in practice for over 10 years had the highest. In the ABI module, the largest knowledge gap included accurately calculating the ABI, followed by the correct use of the Doppler, and management of incompressible vessels. For the WIfI module, providers struggled to accurately score patients based on wound classification. The greatest barriers to the implementation of ABI testing were the availability of trained personnel, followed by limited time for testing. Barriers to the use of the WIfI tool for physicians included lack of time and national guideline support. For non-physicians, the most notable barrier was a lack of training.

CONCLUSIONS

Provider understanding of ABI and WIfI tools are limited in wound care centers, primary care offices, and federally qualified health centers. Further barriers include a lack of training in the use of tools, limited potential for point-of-care testing reimbursement, and insufficient dissemination of WIfI guidelines. Such barriers discourage widespread adoption and result in delayed diagnosis of arterial insufficiency.

The LEADER trial in type 2 diabetes: Were the characteristics and outcomes of the participants representative?

AIMS

To compare the characteristics and outcomes of people with type 2 diabetes recruited to the LEADER trial to those of participants in the contemporaneous community-based Fremantle Diabetes Study Phase II (FDS2) who fulfilled LEADER entry criteria.

METHODS

Baseline characteristics of LEADER and LEADER-eligible FDS2 participants were compared using bivariate methods. Incidence rates of the primary (nonfatal myocardial infarction, nonfatal stroke, cardiovascular disease (CVD) death) and other outcomes in the LEADER placebo group were compared with those in LEADER-eligible FDS2 participants during 3.8 years after entry, the median LEADER follow-up.

RESULTS

Of 1551 FDS2 type 2 participants, 323 (20.8%) were LEADER-eligible. Compared with the LEADER sample, they were an average 6 years older, and were less likely to be male, obese and to have prior CVD. There were 3.9 and 2.9 primary outcomes/100 patient-years in LEADER placebo-treated and FDS2 LEADER-eligible patients, respectively. Incidence rates for first myocardial infarction and stroke were 1.9 and 2.1 events/100 patient-years and 1.1 and 1.0 events/100 patient-years, respectively. FDS2 LEADER-eligible patients had a lower CVD death rate of 0.8 versus 1.6/100 patient-years in the LEADER placebo group, but their non-CVD mortality was greater (2.1 versus 1.0/100 patient-years).

CONCLUSIONS

These data suggest recruitment bias in type 2 diabetes CVD outcome trials.

Prevalence of peripheral arterial disease among diabetic patients in Santo Domingo, Dominican Republic and associated risk factors

Introduction

Peripheral arterial disease (PAD) is a major risk factor of coronary artery disease and a major complication of atherosclerosis. Peripheral arterial disease can be diagnosed with simple and low cost techniques. There are major risk factors of PAD that have been studied for different countries. However, no such study has been done for the Dominican Republic. We conducted a cross-sectional study to determine the prevalence of PAD and the risk factors among patients with diabetes in Santo Domingo, Dominican Republic.

Material and methods

Six hundred randomly chosen patients with previously diagnosed diabetes were enrolled in our study. Their blood pressure and ankle brachial index were calculated and a questionnaire was provided to gather information regarding gender, age, weight, ethnicity, known duration of diabetes along with any history of smoking, hypertension and hyperlipidemia. A physical examination was also done to assess for any active diabetic ulcers, previous foot ulcers and non-traumatic amputation. A microfilament test was conducted to check for peripheral neuropathy.

Results

Eighty-four diabetic patients were diagnosed with PAD with a prevalence of 14% in Santo Domingo, Dominican Republic. Statistically significant associations (p < 0.05) was found for female gender, presence of active foot ulcers, history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia and peripheral neuropathy. Glycated hemoglobin (HbA_1c), age and smoking were not statistically significant in our study.

Conclusions

Diabetic patients who are either female, have active foot ulcers, a history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia or peripheral neuropathy are more at risk of developing PAD.

A systematic review of the effect of pre-test rest duration on toe and ankle systolic blood pressure measurements

Background

Measurement of toe and ankle blood pressure is commonly used to evaluate peripheral vascular status, yet the pre-test rest period is inconsistent in published studies and among practitioners, and could affect results. The aim of this systematic review is to evaluate all research that has investigated the effect of different periods of pre-test rest on toe and ankle systolic blood pressure.

Methods

The following databases were searched up to April 2012: Medline (from 1946), EMBASE (from 1947), CINAHL (from 1937), and Cochrane Central Register of Controlled Trials (CENTRAL) (from 1800). No language or publication restrictions were applied. Eighty-eight content experts and researchers in the field were contacted by email to assist in the identification of published, unpublished, and ongoing studies. Studies evaluating the effect of two or more pre-test rest durations on toe or ankle systolic blood pressure were eligible for inclusion. No restrictions were placed on participant characteristics or the method of blood pressure measurement. Outcomes included toe or ankle systolic blood pressure and adverse effects. Abstracts identified from the search terms were independently assessed by two reviewers for potential inclusion.

Results

1658 abstracts were identified by electronic searching. Of the 88 content experts and researchers in the field contacted by email a total of 33 replied and identified five potentially relevant studies. No studies were eligible for inclusion.

Conclusions

There is no evidence of the effect of different periods of pre-test rest duration on toe and ankle systolic blood pressure measurements. Rigorous trials evaluating the effect of different durations of pre-test rest are required to direct clinical practice and research.

Training to Measure Ankle–Brachial Index at the Undergraduate Level

We examined the effectiveness of teaching ankle–brachial index (ABI) measurement to medical students. ABI was estimated in 28 lower limbs by an experienced vascular surgeon. After a 2-week training course, 5 fourth-year students repeated the estimations and their results were compared with that of the trainer’s. There was no difference in ABI values between trainees and trainer for subjects with mild-to-moderate peripheral arterial disease (PAD; 0.77 ± 0.22 vs 0.77 ± 0.19, respectively, P = .95). In the 4 normal limbs, ABI was 1.37 ± 0.12 and 1.16 ± 0.11, as measured by the trainer and the trainees, respectively ( P < .00001). In subjects with severe PAD, trainees tended to overestimate ABI ( P = .0002) in the beginning of the educational process, but this was no longer the case at a later stage of the training with no difference in ABI values between the 2 examiner groups ( P = .09). In conclusion, training of medical students in ABI measurement can be helpful toward accurate estimation of PAD and merits further practice.

Resting Doppler ankle brachial pressure index measurement: a literature review

Peripheral vascular disease (PVD) is under-diagnosed in primary and acute settings. The use of Doppler ankle brachial pressure index (ABPI) is effective in diagnosing PVD , aid in determining aetiology of leg ulcers and is cost efficient in reducing the effects of atherosclerosis and cardiovascular events. The aim of this literature review was to review practitioners' experience in using Doppler ABPI, different skills used to measure ABPI and to examine practitioners' confidence in ABPI. The findings identified variation in method for Doppler measurement: including position of the artery, arm measurement, resting period and type of equipment for measuring blood pressure, variations in practitioners' training and experience have demonstrated variability in ABPI results. Although limited in number, the studies have demonstrated knowledge gap, and the need for training among health professionals.

Prevalence of peripheral arterial disease and related risk factors in Turkish elders

Background

It is known that prevalence of peripheral arterial disease being a widespread atherosclerotic vascular disease increases by age. On the other hand, no comprehensive study showing the prevalence of peripheral arterial disease in Turkish elders is seen. In this study, it is aimed to assess prevalence of peripheral arterial disease and related risk factors in Turkish elders in primary health center.

Methods

507 elderly staying at Narlidere Geriatric Care Center and Residential Home and accepting to participate in the study were included in the study. Epidemiological data for diagnosis of peripheral arterial disease, risk factors, findings of physical examination and ankle brachial index measurements were assessed in the study. Data were analyzed in terms of prevalence of peripheral arterial disease, age and gender relation and other cardiovascular risk factors.

Results

Of the participants, 317 (62.5%) were female. The mean age was 77.61 ± 6.93 years (62-102). The most wide-spread chronic diseases in elderly included hypertension, coronary artery disease, hyperlipidemia and Type 2 DM, respectively. On the other hand, only 7 (1.4%) elderly were diagnosed with peripheral arterial disease. The number of elderly ABI of whom was measured as < 0.90 and sent to cardiovascular surgery polyclinic with the diagnosis of peripheral arterial disease was assessed as 30 (5.9%). Intermittent claudication was seen in about half of these patients.

Conclusions

Peripheral arterial disease is expected to be seen prevailing in elderly. However, it was determined at very low rate before the study due to the fact that the disease cannot be diagnosed clinically especially in early-period. Peripheral arterial disease determined in the study is lower than expected as per the age group. This can be associated with practices of geriatrics nursing and family practice including continuous care to reduce cardiovascular risk factors of patients staying at the unit.

Peripheral artery disease assessed by ankle-brachial index in patients with established cardiovascular disease or at least one risk factor for atherothrombosis--CAREFUL study: a national, multi-center, cross-sectional observational study

BACKGROUND

To investigate the presence of peripheral artery disease (PAD) via the ankle brachial index (ABI) in patients with known cardiovascular and/or cerebrovascular diseases or with at least one risk factor for atherothrombosis.

METHODS

Patients with a history of atherothrombotic events, or aged 50-69 years with at least one cardiovascular risk factor, or > = 70 years of age were included in this multicenter, cross-sectional, non-interventional study (DIREGL04074). Demographics, medical history, physical examination findings, and physician awareness of PAD were analyzed. The number of patients with low ABI (< = 0.90) was analyzed.

RESULTS

A total of 530 patients (mean age, 63.4 ± 8.7 years; 50.2% female) were enrolled. Hypertension and dyslipidemia were present in 88.7% and 65.5% of patients, respectively. PAD-related symptoms were evident in about one-third of the patients, and at least one of the pedal pulses was negative in 6.5% of patients. The frequency of low ABI was 20.0% in the whole study population and 30% for patients older than 70 years. Older age, greater number of total risk factors, and presence of PAD-related physical findings were associated with increased likelihood of low ABI (p < 0.001). There was no gender difference in the prevalence of low ABI, PAD symptoms, or total number of risk factors. Exercise (33.6%) was the most common non-pharmacological option recommended by physicians, and acetylsalicylic acid (ASA) (45.4%) was the most frequently prescribed medication for PAD.

CONCLUSION

Our results indicate that advanced age, greater number of total risk factors and presence of PAD-related physical findings were associated with increased likelihood of low ABI. These findings are similar to those reported in similar studies of different populations, and document a fairly high prevalence of PAD in a Mediterranean country.