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| Journal of the New Zealand Medical Association,
31-March-2006, Vol 119 No 1231
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Treating claudication in 5 words (stop smoking and keep
walking) is no longer enough: an audit of risk factor management in patients
prescribed exercise therapy in New Zealand
Nadine Kuiper, Malcolm Gordon, Justin Roake, David
Lewis
Intermittent claudication is a common presentation of
peripheral occlusive arterial disease (POAD). The prevalence of POAD in the
general population is approximately 5%, and increases to 15% in those over 70
years old.1
Although intermittent claudication is unlikely to progress
to critical lower limb ischaemia, there is an increased morbidity and mortality
in this patient group resulting from the systemic atherosclerotic burden.2
The 5-year mortality rate in patients with intermittent
claudication is approximately 2.5 times that of an age-matched population, and
their leading causes of death are myocardial infarction and ischaemic stroke.2
Best medical therapy (BMT) in patients with POAD should reduce atherothrombotic
events in this patient group.
Best medical treatment of intermittent claudication may be
considered to include walking exercise therapy and diligent risk factor
management. Bypass surgery, angioplasty, or stenting are no longer considered
first-line treatments unless symptoms are severely lifestyle limiting. Studies
have shown that, after 2 years, exercise therapy is better than percutaneous
balloon angioplasty in terms of improved walking distance and quality of life.3
Exercise therapy should involve >30 minutes of walking at
least three times a week. This regime has been shown to increase pain-free
walking time by 180%.4
“Green Prescriptions”, a New Zealand concept,
offer patients written advice and ongoing support to become more physically
active. This programme has been shown to improve quality of life and it has also
been reported to be cost-effective.5,6
The risk factors for POAD are established as hypertension,
hyperlipidaemia, tobacco use, and diabetes mellitus. These factors also
predispose to coronary artery disease and ischaemic stroke. Management of
patients with atherosclerosis usually includes prescription of antiplatelet
therapy as well as optimising the risk factors mentioned above.
The aim of the current study was to review recording of risk
factors by GPs and the vascular surgical team in patients with intermittent
claudication enrolled in an exercise programme. Treatment of modifiable risk
factors was also documented.
MethodsHospital notes from patients referred to vascular
outpatients at Christchurch Hospital (Christchurch, New Zealand) with
intermittent claudication were reviewed (January–April 2005). All patients
had symptoms typical of intermittent claudication as well as objective evidence
of peripheral occlusive arterial disease (resting ankle/brachial pressure index
(ABPI) <0.8 and/or an exercise-induced fall in ABPI). All patients were given
a “Green Prescription” for exercise therapy.
Hospital notes for each patient were reviewed. Referral
letters, vascular outpatient letters, and vascular nurse notes were analysed for
presence and treatment of the following risk factors: hypertension, diabetes
mellitus, hyperlipidaemia, smoking, antiplatelet therapy, and coronary artery
disease.
Risk factors, treatments, and attempted modifications
were recorded as either ‘yes’, ‘no’, or ‘not
mentioned’. If more than one letter existed for a patient, and a risk
factor was mentioned in one letter but not in others, then a single mention of a
risk factor was recorded.
If risk factor status changed (e.g. smoking cessation),
then the most recent data was recorded. Positive documentation of the
corresponding risk factor was accepted if the patient was recorded to be taking
antihypertensives, lipid-lowering therapy, or diabetic medications.
Attempted modifications of risk factors included
ordering a blood test for glucose or lipid levels, starting a medication (e.g.
asprin or a statin), asking the GP to start a medication, documenting that
advice had been given, or asking the GP to give advice about smoking
cessation.
ResultsSixty patient notes were reviewed. The male:female ratio was
1.5:1 and the median age was 69 years (range 41–83 years). Seventy-eight
percent of patients complained of calf pain, 15% complained of thigh pain, and
15% complained of buttock pain. Fifty-eight percent had bilateral symptoms.
The median duration of symptoms was 3.4 years (range 6
weeks–15 years), and the median estimated walking distance was 206.6 m (5
m–2 km). Median ABPI (both legs) was 0.78 (0.29–1.31).
Eighty-one referral letters were reviewed, 66 from GPs, 4
from orthopaedic surgeons, 4 from cardiologists, 3 from physicians, 2 from
ophthalmologists, and 2 from podiatrists. Of the 60 patients, risk factor
documentation by the referrer is shown in Table 1. Of the 18 current smokers, 5
referral letters stated that the patient had been advised to stop smoking; 6
referral letters stated that blood tests for lipids and glucose had been
requested.
Table 1. Risk factor documentation by referrer (n=60
patients)
Fifty-eight patients were seen by vascular surgeons and 118
letters from vascular surgeons were reviewed, as well as handwritten notes made
during consultations. The mean number of letters per patient was 2.13
(0–7). Two patients were not seen by a vascular surgeon but instead they
were given Green Prescriptions after assessment by a vascular nurse specialist.
Risk factor documentation by vascular surgeons is shown in Table 2.
Table 2. Risk factor documentation by vascular surgeon
(n=58)
Twenty-five patients were noted to be taking antiplatelet
therapy when they attended the vascular clinic. Aspirin was prescribed by the
surgeon for 3 patients and the GP was asked to start aspirin in 9 patients. Of
34 patients noted to have a history of hyperlipidaemia, 28 were on lipid
lowering therapy.
After consultation with a vascular surgeon, the GPs of 11
patients were asked to commence the patient on lipid-lowering therapy. Of 19
current smokers, there was documentation showing that the vascular surgeon
advised 9 to stop smoking; and in one case, the GP was asked to do so and
provide necessary support. Documented risk factor modification by vascular
surgeons, in those patients identified as not having optimal management is shown
in Figure 1.
Figure 1. Risk factor modification by vascular surgeons
in patients recognised as having suboptimal medical management n=58
 Vascular nurses assessed 43 of the 60 patients, none of whom
were asked about use of antiplatelet therapy. Coronary artery disease was only
documented for 6 patients but all patients were asked about their smoking
status. In addition, all but one had documentation of high blood pressure,
hyperlipidaemia, and diabetes mellitus.
DiscussionA significant proportion of referral letters to the vascular
surgical outpatient clinic for patients with intermittent claudication did not
mention the presence or absence of modifiable risk factors for atherosclerosis.
In general, letters from vascular surgeons were more likely
to mention risk factors than the referral letter, however there was occasionally
no evidence that an attempt was made by the surgeon to modify a documented risk
factor. Vascular nurses documented risk factors within the scope of the local
protocol for a nurse-run assessment clinic. Antiplatelet therapy and coronary
artery disease were not included in the nurse assessment proforma, and this
oversight has now been rectified. Nurse assessments did not document attempts to
modify risk factors.
This current report, based on case note review, is open to
criticism because of the relatively small sample size and the retrospective
design. The size of the study is similar, however, to previous reports and is
probably a fair reflection of current practice.
Recording bias is possible because clinicians are more
likely to record a positive finding rather than a relevant negative finding
which may explain lack of documentation in some cases. This study has, however,
collated detailed information on risk factor documentation and modification from
a well-defined cohort of patients with proven POAD, and has resulted in a
practice change—modification of the vascular nurse assessment protocol.
Systems to improve risk factor testing, documentation, and modification are also
being explored.
Risk factor management in patients with intermittent
claudication is often reported to be poor. One recent Scottish study assessed
the management of secondary risk factors in 104 patients with intermittent
claudication.7 In that study, a questionnaire was sent to 336 GPs to compare
their proposed attitudes to the documented evidence regarding risk factor
management. Many GPs stated that their usual practice was to review and (if
appropriate) initiate treatment of risk factors, and to encourage smoking
cessation. However a review of patients referred to a vascular clinic in that
region showed less than half of patients remembered such intervention, although
nearly all recalled smoking cessation advice.
A large recent French multi-centre trial has also shown
doctors are much better at treating the atherosclerotic risk factors in patients
with coronary artery disease than in patients with ischaemic stroke or
POAD.8
In the current study, detail in referral letters from GPs
and other health professionals varied considerably. Some letters included a list
of past medical history which made it easier to assess which risk factors were
present; however, documentation showing that a risk factor has been investigated
(and found not to be present) is also useful information for a vascular
specialist.
In terms of modifying risk factors, only a minority of
letters mentioned ordering blood tests to assess plasma lipid and glucose levels
or whether smoking cessation advice had been given. We propose that GPs possibly
want a diagnosis of intermittent claudication/atherosclerosis to be confirmed
before initiating risk factor management.
Vascular surgeons are also reported to be poor at risk
factor documentation in elective and emergency patients.9,10 For example, one
published report from Birmingham, England commented that it was seen as easier
to refer a patient for an intervention rather than for lifestyle evaluation,
modification of risk factors, and institution of BMT.10 The current study
suggests suboptimal BMT in the patients attending our vascular clinics, although
our results compare favourably with other reported series.9,10
The role of vascular nurses depends upon the size and scope
of the centre in which they work as well as the education and support that they
receive. It has been suggested that the vascular nurse should have a role in
managing risk factors for patients with intermittent claudication,11 and the
current study confirms that documentation by nurses (filling in proformas and
running assessments according to agreed protocols) can provide very acceptable
results.
A specialist smoking cessation nurse has also been suggested
as well as a vascular nurse trained in behavioural therapy and the use of
nicotine replacement therapy.12 However any benefit (in terms of smoking
cessation and cost, compared to other treatment modalities) needs to be
documented before this suggestion can be recommended.
Vascular nurse assessment in our centre involves a checklist
so smoking history, hyperlipidaemia, hypertension, and diabetes mellitus are
consistently documented. However, the assessment form previously did not include
sections for coronary artery disease, antiplatelet therapy, or whether other
risk factors had been addressed. The checklist has been updated after viewing
the results of our study, and previous omissions are now included in the latest
form for assessment of claudicants.
Research regarding risk factor management in peripheral
vascular disease has increased in recent years. Recent evidence has expanded on
the editorial comment by Housley13 that intermittent claudication should be
treated in five words: “stop smoking and keep walking”.
Risk factor modification is now an integral part of the
management of patients with atherosclerosis.
Indeed, there is published evidence that patients with POAD
should:
Although the evidence
is less clear-cut regarding the management of diabetes mellitus, the UK
Prospective Diabetes Study showed that a reduction in HbA1c (a specific type of
haemoglobin) by 1% reduced the rate of myocardial infarction (MI) by 18%, stroke
by 15%, and episodes of POAD by 42%.19 The peripheral vascular clinic may be
useful in screening for previously undiagnosed glucose intolerance by employing
validated point-of-care testing.
Risk factor modification is an essential part of the
management of all patients with atherosclerosis. A multidisciplinary, team
approach (combining the skills of GPs, vascular surgeons, vascular nurses, and
other physicians interested in the management of this patient group) will help
optimise treatment regimens and hopefully improve the outcome in these
patients.
Author information:
Nadine F Kuiper, House Officer; Malcolm K Gordon, Justin A Roake, David R Lewis,
Consultant Vascular Surgeons; Christchurch Vascular Group, Department of
Surgery, Christchurch Hospital, Christchurch
Correspondence: Mr
DR Lewis, Consultant Surgeon, Christchurch Hospital, Private Bag 4710,
Christchurch. Fax: (03) 364 0352; email: david.lewis@cdhb.govt.nz
References:
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