Symptoms, quality of life, important for management of peripheral artery disease (PAD)

With an estimated 8.5 million people in the U.S. living with peripheral artery disease (PAD—pronounced PAD), which is a narrowing or blockage of the arteries in the legs, treatment decisions and success criteria should be guided by their symptoms and self-reported quality of life , according to a new scientific statement from the American Heart Association published today in the association’s top peer-reviewed journal Circulation. The American Heart Association scientific statement is an expert review of current research and may inform future treatment recommendations.

The statement “Coming diseases of peripheral arteries quality of care and patient-reported outcomes state of health evaluation’, highlights how managing PAD based on a person’s experience of symptoms can lead to more patient-centered care and outcomes, with an emphasis on high-value care, compared to relying on clinical measurements such as leg blood velocity or arterial diameter.

“The person living with peripheral artery disease is the authority on how it affects their daily life. Our treatment must be informed by their life experience and go beyond clinical measures of how well the blood flows through the arteries.” said vice chair and lead author of the statement’s writing team Kim G. Smolderen, Ph.D., a clinical psychologist and associate professor of medicine and psychiatry and co-director of the Vascular Medicine Outcomes Study (VAMOS) Laboratory at Yale University in New Haven, CT. “We’ve spent years developing and testing standardized tools to reliably and sensitively capture people’s experiences. We are now at a point where we can begin to integrate this information into real-world care through pilot programs that can develop quality benchmarks for different phenotypes of PAD patients and the types of treatment they receive from their perspective.”

Painful legs and other patient experiences

While most people living with peripheral artery disease are over 40, PAD also occurs in younger people. People with PPA experience blockages in the arteries that supply blood to the legs and feet, often causing pain, cramping, or weakness when walking, forcing them to stop and rest temporarily until the pain subsides. Some people experience no symptoms; however, many patients can remain pain-free simply because they limit their activities. Research shows that it also affects their health and functioning. People with severely restricted blood flow to the legs (called critical limb ischemia) may experience pain even at rest, fail to heal if the wound is treated early, or develop gangrene that can lead to amputation. PAD is also a risk factor for heart attack or stroke.

“All of these manifestations have a huge impact on people’s daily functioning and quality of life, with a greater impact as disease severity increases. Other health conditions common among people with PPA, such as type 2 diabetes, coronary artery disease, kidney dysfunction, or mental illness, also affect the results. health conditions like depression or stress-related disorders,” Smolderen said.

Patient-led treatment

When the health care team has increased awareness and recognition of the burden of disease on quality of life, coordination of treatment of risk factors and patient concerns come to the fore. The statement advocates improving and individualizing care for people with blocked arteries in their legs by gathering feedback from their experiences throughout treatment.

Patient-reported outcome measures (PROMs) are systematic and validated ways of asking patients to directly rate how their disease affects their symptoms, their functioning (physical, social, and emotional), and their quality of life. Feedback through PROMs can more reliably and objectively assess the quality of care for people with PAP.

The main advantages of using PROM are:

• improving understanding of the PAD patient’s lived experience;
• improving patient self-management of symptoms and medical needs;
• standardizing performance quality measures for practices caring for people with PAD; and
• providing appropriate feedback to determine treatment changes or needs.

Engaging patients as a first-hand expert requires greater focus on quality-of-life or cardiovascular issues risk factors, which can help clinicians think beyond a specific intervention. This perspective can lead to conversations that change treatment or connect patients to other resources, such as behavioral health services, wound care, or smoking cessation. Patient-centered care can also improve self-management and shared decision-making between patients and clinicians.

All of these benefits are possible if patient-reported outcomes are assessed using instruments that are understandable to the patient, regardless of literacy, language barriers, or cultural norms. It is also important that PROMs are conducted by experts who have the skills and understanding to administer the tools, interpret the results, and connect patients to additional resources. The statement includes examples of PROMs to measure leg pain and function (including gait impairment), PAD-specific health status, general health status, and depressive symptoms.

Performance measures to improve the quality of care

PROMs can also be an integral part of assessing whether programs are providing quality care for people with PAD. Pushed by the Centers for Medicare and Medicaid Services and the National Quality Forum, PROMs are increasingly being integrated into the definition of what it means to provide patient-centered, high-quality clinical care, and PROM scores can directly affect reimbursement. To evaluate programs, PROMs are translated into patient-reported outcome measures (PRO-PMs).

Using PRO-PM can:

• set measurable goals for service improvement programs;
• encourage the development of training and expertise for health systems to administer, interpret, and ethically use PRO-PM to improve patient care;
• reduce disparities in care and promote health equity; and
• helping to establish national standards for the quality of medical care.

“This roadmap highlights a paradigm shift that puts the patient experience first, which is a departure from the status quo. It now puts the lived experience of the disease at the forefront, engaging people with PAD with information that keeps health systems and clinicians- practitioners are responsible for whether quality care was provided, in addition to evaluating the safe and effective delivery of current, evidence-based treatments,” Smolderen said.

This scientific statement was prepared by a volunteer writing team on behalf of the American Heart Association’s Council on Peripheral Vascular Disease and the Council on Lifestyle and Cardiometabolic Health. The writing team includes a patient advocate and experts in clinical psychology, outcomes research, nursing, cardiology, vascular surgery, and vascular medicine. It was important to ensure that this statement embodies the interdisciplinary nature of PAD treatment and the commitment to vascular innovation across the various vascular specialties. This meant including experts with expertise in both PRO research and PAD clinical experience, as well as pioneers in patient-reported outcomes for cardiovascular populations and direct involvement of patient advocates.

Scientific statements from the American Heart Association promote awareness of cardiovascular disease and stroke and help make informed health care decisions. Scientific statements describe what is currently known about a topic and what areas require further research. While scientific statements inform the development of guidelines, they do not provide treatment recommendations. The American Heart Association guidelines provide the Association’s official guidelines for clinical practice.

Co-authors are Chair Carol Decker, PhD, RN; Olamide Alabi, MD; Tracy K. Collins, MD, MPH, MS; Bernard P. Dennis, BA; Philip P. Goodney, MD; Carlos Meno-Hurtada, MD; and John A. Spertus, MD, MPH