PAD Patients Often Don't Receive Evidence-Based Care From Specialty Clinics

By Marilynn Larkin

February 10, 2020

NEW YORK (Reuters Health) - Patients with peripheral artery disease (PAD) attending specialty clinics do not always receive evidence-based care, and supervised exercise therapy (SET), in particular, is often missed, an international registry study suggests.

Guideline-directed therapy includes antiplatelet therapy, statin prescription, smoking cessation support, and referral to SET, Dr. Kim Smolderen of the University of Missouri-Kansas City School of Medicine told Reuters Health by email.

The current study found that "only one in five patients presenting to a PAD specialty clinic for new or worsening of PAD symptoms received all eligible evidence-based medical management quality measures for PAD, with high variability across institutions," she noted.

"While individual medication prescriptions were relatively high, rates for smoking cessation support and referral to SET were highly variable and overall low," she said. "Especially, a lack of referral to SET stands out in the U.S. context versus European specialty care settings."

"The study collected data before Centers for Medicare and Medicaid Services approved the reimbursement of SET, and this may explain the lower referral rates in the U.S., along with a less developed infrastructure to deliver SET - i.e., specialized centers, training," she added. "Other current important barriers from the patient side are the distance they need to travel to get to a center and out-of-pocket costs to attend a program."

The 16-center PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry enrolled 1,275 patients with new PAD or an exacerbation in the United States, the Netherlands, and Australia from 2011 to 2015. Patients with a resting ankle brachial index 0.90 or less or drop in post-exercise ankle pressure of 20 mm Hg or greater were eligible for inclusion.

The analysis, published in the Journal of the American Heart Association, revealed that 89% patients were taking antiplatelets, 83% were on statins, and only 23% had been referred to SET. Among current smokers, 72% received smoking cessation therapy/counseling.

Overall, 77.2% of patients received two quality measures - i.e., referral for both statin and antiplatelet medications - and 19.7% received all four quality measures." The median odds ratio for receiving two quality measures was 2.13, and for four quality measures, 5.43.

Variability in guideline adherence was not explained by country, except for referral to SET. The odds for SET referral in the Netherlands (70% referral rate) was nearly 100 times greater than in the U.S. (2% referral rate).

Dr. Jose Wiley, Director, Endovascular Interventions at Montefiore Einstein Center for Heart and Vascular Care in New York City, commented by email, "PAD performance measures, particularly non-pharmacological ones such as SET or smoking cessation, should intuitively be easier to implement and adhere to than pharmacological ones."

"However, there are barriers that limit its application in the U.S., including limited availability of specialized SET centers, unawareness of current guidelines and recommendations, and the fact that until 2017, CMS did not reimburse SET," he told Reuters Health.

"In the CLEVER trial, SET improved treadmill walking performance significantly more than endovascular revascularization," he noted. ( "Furthermore, (another study) reported that SET is also a more cost-effective primary treatment for intermittent claudication than endovascular revascularization." (

"In the era of value-based care, provider payment is based on outcomes such as those achieved with SET, not on the number of visits or procedures performed," he added. "SETs are best performed in specialized PAD clinics that focus on both primary and secondary prevention. Patients and providers need to be educated on the latest PAD guidelines as well as insurance coverage and reimbursement guidelines."

SOURCE: Journal of the American Heart Association, online January 24, 2020.