Performance Measures for Peripheral Artery Disease: Implications for Primary Care

Recently published evidence- based guidelines for peripheral artery disease (PAD) highlight some disturbing facts about the prevalence and complications resulting from this disease.¹ For instance, the rate of myocardial infarcts, strokes, and heart disease is higher among patients with PAD than among those with coronary artery disease.² As a result, patients with PAD have a 6 times greater risk of dying from associated heart disease compared with agematched controls. Thus, recent guidelines not only address the ischemic leg symptoms consequent to PAD, but also suggest interventions to simultaneously lower the incidence of myocardial infarction, strokes, and cardiovascular deaths common to this high-risk cohort.

DIAGNOSIS AND TREATMENT RECOMMENDATIONS

It goes without saying that the diagnosis of PAD has to come first. PAD is not uncommon—the prevalence in the adult population is 12%. This figure may comprise 8 million persons in the United States. In those over 70 years of age, a rapidly growing demographic, the incidence increases to 20%.¹ The guidelines provide a list of predisposing conditions for PAD. The committee recommends that anklebrachial index (ABI) measurements be performed on all persons at risk. The problem with this recommendation is that reimbursement remains an issue, and the additional screening “add(s) a burden to busy primary care physicians.”² An ABI measurement of less than 0.9 is diagnostic of PAD (the guidelines provide additional logistical information on office performance of ABI). After diagnosis, the guidelines stress treatment to mitigate potentially fatal risks in organs outside the lower extremity (especially the heart and brain) as well as for claudication. These recommendations include²:

• Statin therapy with a target low-density lipoprotein level below 100 mg/dL.
• Smoking cessation.
• Antiplatelet therapy with either aspirin or clopidogrel.
• Supervised exercise for patients with claudication.
• Monitoring of any potential abdominal aortic aneurysms or previously placed lower extremity bypass grafts.

IGNORANCE MAY PROVE EXPENSIVE
There is another side to the guidelines. The authors predict that the content will be utilized by the Centers for Medicare and Medicaid Services as well as other thirdparty payers to assess physician performance and quality of care. Ignorance of the guidelines can cost primary care physicians money.

A REFERENCE TO KEEP HANDY
For those who want more detail, the original paper runs 34 pages.¹ It has the added benefit of specifics and supporting literature, including the following sections: selection of measures for inclusion in the performance measure set, potential measures considered but not included in that set, and some information addressing concurrent diseases such as chronic kidney disease, hypertension, diabetes, and screening for abdominal aortic aneurysms (some of these were excluded from the guideline’s purview and final recommendations, however). I saved a copy on my hard drive to use as a reference in the future. Since PAD will become a sentinel disease for performance outcomes and since the evidence demonstrates that cardiovascular-targeted treatment saves lives, the guideline should become an integral part of primary care.