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Computerized Dynamic Posturography for Postural Control Assessment in Patients with Intermittent Claudication
Published on: December 11, 2013
Variations in the Management of Claudication in a Tertiary Care Center
Cassius Iyad Ochoa Chaar1, Navid Gholitabar1, Mara Detrani1
1Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT.
Insights
Vascular surgeons showed better adherence to guidelines for claudication treatment before lower extremity revascularization (LER) than other specialists, but overall adherence remains low. Improved institutional protocols are needed to ensure consistent application of care standards.
Area of Science:
- Vascular Surgery
- Patient Management
- Clinical Guidelines
Background:
- Societal guidelines recommend medical optimization and exercise therapy before lower extremity revascularization (LER) for claudication.
- The practical application of these guidelines by healthcare providers is not well understood.
- This study hypothesized that vascular surgeons (VS) adhere more closely to guidelines than non-VS providers for claudication management.
Purpose of the Study:
- To assess and compare the adherence to established guidelines for claudication management prior to LER between vascular surgeons and non-vascular surgeons.
- To identify disparities in the application of conservative therapies, including exercise and smoking cessation, before revascularization procedures.
Main Methods:
- A retrospective review of 187 patients undergoing LER for claudication was conducted.
- Adherence to guidelines was assessed by documenting the use of conservative therapies such as quality of life assessment, ankle-brachial index (ABI) measurement, supervised walking exercise, and smoking cessation.
- Patients were categorized based on whether they were treated by VS or non-VS.
Main Results:
- Vascular surgeons were more likely to assess claudication symptoms and obtain ABIs, and more likely to recommend walking exercises and smoking cessation.
- Despite recommendations, only a minority of patients received the guideline-recommended 3-month trial of conservative therapy.
- Overall conservative therapy rates were low (12.3% for VS, 3.3% for non-VS), though significantly higher for VS.
Conclusions:
- Adherence to guidelines for medical management of vascular claudication before LER was higher among vascular surgeons compared to non-VS providers.
- Overall adherence rates to conservative management strategies remain low across all providers.
- Implementation of stricter institutional protocols and interdisciplinary oversight is recommended to improve adherence to standards of care.
Background:
Multiple societal guidelines recommend medical optimization and exercise therapy for patients with claudication prior to lower extremity revascularization (LER). However, the application of those guidelines in practice remains unknown. Our hypothesis is that vascular surgeons (VS) are more adherent to guidelines compared to non-VS treating claudication.
Methods:
The records of patients undergoing LER for claudication in a single center were reviewed, and adherence to guidelines prior to LER was assessed. Patients received conservative therapy if the impact of claudication on quality of life was documented, ankle-brachial index (ABI) was obtained, and patients were treated with at least 3 months of walking exercise and smoking cessation when indicated.
Results:
There were 187 patients treated for claudication (VS = 65, non-VS = 122). There were 161 patients who underwent endovascular intervention, 19 patients had an open revascularization, and 7 patients had a hybrid procedure. Patients treated by VS were younger and more likely to be African American. Patients treated by non-VS were more likely to have hyperlipidemia, coronary artery disease, smoke, and be on antiplatelet and statin medications. VS was more likely to assess pattern of symptoms with claudication and obtain ABIs compared to non-VS, although the mean ABIs were no different. VS was more likely to use walking exercises and smoking cessation when indicated before LER. Even though 70.8% and 31.1% of patients treated by VS and non-VS respectively were recommended walking exercises, only 33.8% and 18.0% were given a period of 3 months to benefit from it prior to LER. Conservative therapy was significantly higher among VS compared to non-VS but was overall low (VS = 12.3%, non-VS = 3.3%, P = 0.016). After a mean follow-up of 3.1 ± 1.3 years, there was no difference in mortality or major amputation.
Conclusions:
Although adherence to guidelines in the medical management of vascular claudication prior to LER was higher among VS compared with non-VS, overall rates of adherence were low. Stricter institutional protocols and oversight across specialties are needed to reinforce the application of the established standards of care.
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