Diagnostics and Treatment of Pad in Primary Health Care: Limited Adherence to a Dutch Guideline

Abstract

Introduction - The Dutch general practitioner (GP) has a key role in the treatment of patients with peripheral arterial disease (PAD). The Dutch GPs guideline on PAD recommends measurement of the ankle-brachial index (ABI) and supervised exercise therapy (SET) for patients with intermittent claudication (IC). Antiplatelet drugs and statins should be prescribed as part of cardiovascular risk management (CVRM). Aim of this study was to evaluate the reliability of ABI measurements in primary health care and to determine the compliance to the national PAD guideline. Methods - All patients suspected of PAD referred to our vascular surgery outpatient clinic by GPs in 2015 were evaluated based on three criteria as recommended in the Dutch GPs guideline on PAD: ABI measurement, prescription of CVRM medication and referral for SET. Primary care ABI measurements were compared to values as measured in the vascular laboratory of our hospital and were depicted in a Bland-Altman plot. The leg with the lowest ABI was used for analysis. Results - In 2015, 476 patients suspected of PAD (259 men, 54%; age 70±12 years) were referred and 167 had a history of PAD. Of 309 de novo patients, just 58% (n=180) had indeed undergone an ABI measured by their GP. The primary care ABI was 0.73±0.23 compared to 0.79±0.28 as measured in the vascular laboratory (P=0.038). A large variation was observed between the two measurements. The Pearson correlation coefficient (r) was 0.64 (‘good’, r>0.75). Moreover, the intraclass correlation coefficient (ICC) was 0.62 (‘good’, ICC>0.75), whereas the coefficient of variation (CV) was 0.16 (‘good’, CV<0.15), see Fig. Just 56% (n=72) with an abnormal primary care ABI used antiplatelet drugs or coumarin derivatives whereas a mere 48% (n=61) used statins. Only 11 of the 113 (10%) de novo patients with IC symptoms and an abnormal primary care ABI were referred for SET by their GP. Conclusion - Dutch GPs do not sufficiently adhere to their PAD guideline. The technique of an ABI measurement as well as the decision-making process of prescribing CVRM medication and referring for SET need improvement. Collaboration between primary and secondary care should be optimized and a training program for GPs is necessary to enhance compliance to the national PAD guideline.