Low Adherence to Guideline-Recommended Therapies at PAD Specialty Clinics

Treadmill exercise
Treadmill exercise
Only one-fifth of patients with new peripheral artery disease or exacerbated lower limb symptoms consulting a specialty clinic were found to be offered all 4 guideline-recommended therapeutic measures.

Only one-fifth of patients with new peripheral artery disease (PAD) or exacerbated lower limb symptoms consulting a specialty clinic were found to be offered all 4 guideline-recommended therapeutic measures, according to a study published in the Journal of the American Heart Association.

The investigators sought to evaluate the use of therapies recommended for the management of PAD in patients treated at specialty clinics in the United States (US), Australia, and The Netherlands.

In this multicenter prospective Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories study, 1275 patients with symptomatic PAD (mean age, 67.6±9.4 years; 37.9% women) were enrolled between 2011 and 2015. The study’s primary outcome was the rate of adherence to the 4 noninvasive interventions recommended for the management of PAD in the 2016 American College of Cardiology/American Heart Association guidelines: statin therapy, antiplatelet therapy, smoking cessation counseling, and supervised exercise therapy (SET). Outcomes were categorized in terms of the achievement of 2 or 4 quality measures, which indicated adherence to antiplatelet and statin therapies or to all 4 measures (or 3 in non-smokers), respectively.

A median odds ratio (MOR) was used to calculate variability in the achievement of the outcomes across sites and indicated the likelihood of patients with comparable characteristics receiving a given treatment at different clinics.

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In this cohort, 1104 patients (89.0%) were prescribed antiplatelet medications, 1055 (82.7%) received statin prescriptions and 280 (23.3%) were referred to a supervised exercise program. Of the 455 participants (35.7%) who were current smokers, 342 (75.2%) received counseling for smoking cessation. The MORs for individual therapies were all high: antiplatelet medications, 2.93 (95% CI, 1.94-6.17; P <.0001; prescribing rate range, 63-100%); statin medications, 2.11 (95% CI, 1.57-3.63; P <.0001); smoking cessation therapy, 3.06 (95% CI, 1.90-7.06; P <.001); and SET, 4.98 (95% CI, 2.73-15.46; P <.0001).

A total of 984 participants (77.2%) achieved 2 quality measures (MOR, 2.13; 95% CI, 1.61-3.56; P <.001), and 251 patients (19.7%) fulfilled all 4 quality measures (MOR, 5.43; 95% CI, 2.84-17.91; P <.001). Adherence rates for 2 quality measures were comparable in patients treated in the US, Australia, and The Netherlands (77.9%, 68.4%, and 77.8%, respectively; P =.107), but not for adherence to 4 quality measures (4.6%, 16.8%, and 51.7%, respectively; P <.001).

The SET referral rates in The Netherlands (70%) and Australia (24%) were considerably higher than in the US (2%), with a significant difference between rates in The Netherlands and the US (odds ratio, 97.42; 95% CI, 9.79-969.59; P =.001).

Study limitations include differences in healthcare policies and organizations between the 3 countries and uncertainty regarding the impact of a changing SET reimbursement policies in the US.

“Structural barriers for realizing optimal quality PAD care in the specialty setting need to be explored and addressed, as without realizing optimal quality care, patients suffering from PAD remain disadvantaged in their ability to manage their PAD and cardiovascular risk,” noted the authors.

Disclosures: Research reported in this article was partially funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (IP2 PI000753-01; CE-1304-6677), The Netherlands Organization for Scientific Research (VENI Grant No. 916.11.179), and an unrestricted grant from W. L. Gore & Associates, Inc (Flagstaff, Arizona).

Dr Smolderen is supported by an unrestricted research grant from Terumo, Boston Scientific, and Abbott Vascular. Dr Patel is supported by an unrestricted research grant from AstraZeneca, Bayer, Janssen and serves on the advisory board of Bayer and Janssen. Dr Mena-Hurtado is a consultant for Abbott, Cardinal Health, Cook, Medtronic, Boston Scientific, Bard. The remaining authors have no disclosures to report.


Saxon JT, Safley DM, Mena‐Hurtado C, et al. Adherence to guideline‐recommended therapy—including supervised exercise therapy referral—across peripheral artery disease specialty clinics: insights from the international PORTRAIT registry. J Am Heart Assoc. 2020;9(3):1-9. doi:10.1161/jaha.119.012541