Peripheral Arterial Disease (PAD) Outcome measurements

2

Hirsch AT. Fam Pract Recertification. 2000;15(suppl):6-12.

Clinical Presentation PAD Patients

Critical ischemia

Acute Ischemia

Stabile

Claudication

Asymptomatic

PAD

3

30 34 38 50 55

CHF COPD

Average

Adult

Average

Well

Adult

Adapted from Ware JE. Ann Rev Pub Health. 1995;16:327-354.

Physical Component Score

SF-36 Physical Function Scores

36

Intermittent

Claudication

No. of

People

CLI

4

Greater risk cardiovascular events and death than amputation

Ouriel K. Lancet 2001; 358: 1257–64.

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10

Time (years)

Pati

en

ts (

%)

Survival

Myocardial Infarction

Intervention

Amputation

Causes of death:

• 55% coronary artery disease

• 10% cerebrovascular disease

• 25% non-vascular

• < 10% other vascular

5

Identify and treat systemic

atherosclerosis

Improve functional status and quality

of life

Preserve the limb

Prevent progression of atherosclerosis

PAD Therapeutic Goals

Treatment goals CI/PAD

Can we achieve these goals?

How do we measure them?

6

Results of Critical Ischemia revascularization in EZ Tilburg (n 106)

Nonambulatory (n=18)

P<0.03

Limb salvage (days)

Ambulatory (n=38)

Ambulatory (n=38)

Nonambulatory (n=30)

P=0.00

Patient survival (days)

Inclusion jan 2001 - jan 2003

Flu et al. J Vasc Surg 2010 Feb;51(2):360-71.e1.

7

Results of Critical Ischemia revascularization in EZ Tilburg (n 106)

Nonambulatory (n=18)

P<0.03

Ambulatory (n=38)

Ambulatory (n=38)

Nonambulatory (n=30)

P=0.00

Flu et al. J Vasc Surg 2010 Feb;51(2):360-71.e1.

8

Results of PTA (dotter) versus exercise

Spronk S, Bosch JL, Veen HF, den Hoed PT, Hunink MG. Intermittent claudication: functional capacity and quality of life after exercise

training or percutaneous transluminal angioplasty--systematic review. Radiology. 2005 Jun;235(3):833-42. Epub 2005 Apr 28. Review.

Pilot Outcome of PAD ACHMEA

Pilot Hospitals Netherlands (3 UMC, 6 Teaching):

• Comparing outcome data PAD

• Case mix (comorbidity)

• Trying to improve performance

Claudication (PAD 2):

• Walking distance: Walking Impairment Questionnaire (WIQ)

• “Quality of Life”: VascuQol

Critical Limb Ischemia (CLI) (PAD 3/4):

• Outcome of bypass

• Limb salvage

• Death

9

Positive aspects of this study

• Focus on outcome and quality of care

• Patient: centrally

• Goal: good outcome parameters on quality of care and

can be registered

• Central guidance of process

But there are some points of concern

10

PROMS (patient recorded outcome measurements)

No one PROM was identified as a

'gold standard' for assessing HRQOL

in diabetes-related foot disease

12

QoL versus Health Status (SF-36)

Health status:

evaluates health related limitations of

disease

Quality of Life:

Evalusates functional lmitations and relates

with personal perception of the patient on

sickness and treatment (social factors)

Hamming JF, De Vries J. Measuring quality of life. Br J Surg. 2007 Aug;94(8):923-4.

Breek JC, de Vries J, van Heck GL, van Berge Henegouwen DP, Hamming JF. Assessment of disease impact in patients with

intermittent claudication: discrepancy between health status and quality of life. J Vasc Surg. 2005 Mar;41(3):443-50.

And futher……

Reduced QoL not only depends on level of

claudication, but merely on dependence on

medication: comorbidity

Also other functional limiting factors and diseases are

important (arthrosis)

QoL in PAD

2006;141:161-61

High level of stress has negative impact on walking

performance, health status and QoL in PAD

2005;96:996-1001

Type D personality (“tobberts”) is associated with reduced QoL

on top of the effect of PAD with high level of stress.

And more…

What should happen?

There is no easy fix!!!!

What should happen?

Questionnaires:

• Patient centered

• Better, more simple

• Shorter and webbased

Shared goal setting:

• Structured intake

• Evaluation setting

• Goal checking

“Portrait” study: the new PAD registry?

17

Patient centered Outcomes Related to Treatment practices in

Peripheral Arterial disease: an International Trajectory