ChoosingWisely NLPeripheral ArteryDisease

Practice Points•Approximately 12% of adults in Newfoundland and Labrador have Peripheral Artery Disease (PAD).

•Usually, patients with PAD DO NOT need a test or revascularization procedure.

•There are simple and safe ways to improve PAD symptoms through home management.

•Choosing Wisely Canada guideline: Do not suggest a test that will not change the patient’s clinical course.

•Do peripheral vascular testing in those who could potentially benefit from a revascularization procedure.

Who needsa test?

•Rest pain: Pain in feet, especially when legs are elevated in bed

•Extremity ulcer: Sores on toes or feet that won't heal

•Gangrene: Toe that looks blue or black and may hurt

•Severe Claudication: Leg pain during exercise severe enough to limit lifestyle or ability to work

Refer patients for peripheral vascular testing if they have any of the following:

Who needs a test and who doesn’t? Only refer patients with “Good

Indicators” for PAD testing:

Good Indicators Poor Indicators

Rest Pain (pain in feet, especially when legs are elevated in bed)

Tissue Loss (ulcers/sores on the feet that will not heal or a toe that is blue or black and may hurt)

Severe Claudication (leg pain while walking severe enough to limit lifestyle or work)

Mild claudication (mild leg pain during exercise that stops when at rest)

Leg cramps

Raynaud's

Digital cyanosis

Absent peripheral pulses

Family history with no symptoms

What’s happening in Newfoundland?Percentage of testing by indication (St. Clare’s 2007-2015, N = 17 683)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Testindication

Percen

tageoftests

Inappropriate /nosymptoms49%

Followuppostrevascularization11%

Appropriate symptoms, testindicated40%

What’s happening in Newfoundland?

Over 2500 PAD tests are conducted each year at St. Clare’s Vascular Lab

Over 90% of the people tested do not need a revascularization procedure

51% Normal Test Result

41% Early signs of PAD

8% May need a procedure

What’s happening in NL?Proportion of tests analyzed by indication and by presence of PVD: (excluding testing in patients with a previous limb revascularization procedure)

Normal Mild Moderate Severe Total

Indicated 1983(28%)

1543(22%)

2194(32%)

1238(18%)

6958(44%total tests)

Notindicated

7493(84%)

718(8%)

527(6%)

162(<2%)

8900(56%totaltests)

15858Normal

NormalMild

Mild

Moderate

Moderate

Severe

Severe

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Indicated Notindicated

Num

bero

ftests Volume of tests at St. Clare’s (2007-2015)

How can we improve?

Our objective is to test patients with symptoms of vascular disease that may need revascularization quickly, and not test patients unless they have symptoms indicative of disease requiring surgical intervention.

Unnecessary tests increase wait times for all patients.

What you can do…

For patients with symptoms of mild to moderate PAD, a home management plan is the best way to manage and reduce symptoms.

Discuss lifestyle options with these patients and provide them with a pamphlet.

Home management plans may include:Quitting smoking Regular exercise (walk daily)Aspirin and/or PlavixDiabetic management

Blood Pressure control (with ACE)Proper foot careCholesterol control (with Statin)

Patient Pamphlet: Blocked Leg Arteries -CWNL

Tools to help your practice

Contact Choosing Wisely NL at choosingwiselynl.ca for printed copies of pamphlets or prescription pads to be mailed to your practice

OR

Download printer friendly copies of the patient pamphlet and prescription pad and view our video at the links below…

Video: Blocked Leg Arteries - CWNL

Prescription Pad: Blocked Leg Arteries - CWNL

Personal dataClick the PDF link below¹ to access aggregate data for Peripheral Artery testing at St Clare’s Mercy Hospital from 2007-2015 and analysis of your personal practice² by indication and by diagnosis of peripheral artery disease.

¹ Not every physician will have personal data available due to limitations in data entry, duration of practice, and volume of referrals.

² Personal data is anonymous and only data on your own personal utilization will be provided to you.