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LETTERS: Jill Belch and Gerry Stansby Peripheral arterial disease: still on the periphery? BMJ 2006; 332: 1213 [Full text]

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Evidence on Peripheral Vascular Disease Care?

Neal C Jolly   (27 May 2006)

Re: Evidence on Peripheral Vascular Disease Care?

Jill JF BELCH, Brittenden Julie, Stansby Gerry   (5 June 2006)

Evidence on Peripheral Vascular Disease Care? 27 May 2006
Neal C Jolly, GP principal Huddersfield HD8 0HH Send response to journal: Re: Evidence on Peripheral Vascular Disease Care?	By calling for Peripheral Vascular Disease(PVD) to be added to the quality and outcomes framework(QOF) Belch and Stansby (letters vol 332 20th May) seem to assume that GPs will only start to look after these patients with coercion. Do they have any evidence that General Practioners(GPs) are NOT treating these patients in the same way as those with other establish vascular diseases that ARE included in the QOF? In many practices that were involved with the primary care collaborative on vascular disease(whose remit was to deliver the national service framework on vascular disease) patients with PVD were included in the target group for secondary prevention and as such there risk factors dealt with in the same way as if they had established ischaemic heart disease or cerebrovascular disease. This has been going on for many years, for the good of the patient and continues despite its lack of inclusion in QOF. I am sure we in GP would be happy for this work to be recognised and rewarded. Competing interests: None declared
Re: Evidence on Peripheral Vascular Disease Care? 5 June 2006
Jill JF BELCH, Professor of Vascular Medicine University of Dundee DD1 9SY, Brittenden Julie, Stansby Gerry Send response to journal: Re: Re: Evidence on Peripheral Vascular Disease Care?	Editor - In response to Dr Jolly's request for evidence regarding the undertreatment of PAD compared to other established vascular diseases, we are pleased to share a number of the key results from two recent surveys. The first surveyed1 all the GPs (336) within the referral area of a regional vascular unit, which was cross referenced to the risk factor of new patients with claudication attending the vascular clinic. A 73% GP response rate was obtained. It was found that 28% of patients with PAD were on no antiplatelet therapy, one in seven GPs did not check their serum cholesterol, only 41% of GPs would treat PAD patients with cholesterol above 5.5mmol/l with cholesterol lowering therapy and only 18% of smokers had been given any further help to stop smoking. In the second study2 equal numbers of General Practitioners and relevant Hospital doctors (n=400) were surveyed, and their antiplatelet therapy prescribing measured for Coronary Heart Disease (CHD) patients and PAD patients. For CHD the figures were excellent with 95% and 93% of patients attending hospital and primary care doctors, respectively, being given antiplatelet therapy. For PAD, however only 71% of hospital patients and 65% of primary care patients received antiplatelet therapy. Interestingly when the doctors were questioned about their patients they believed that 85% (hospital based) or 72% (primary care) of their patients received this therapy. This discrepancy in actual and perceived prescribing is important in the context of Dr Jolly’s letter. By contrast, the treatment of other established vascular diseases such as CHD and stroke is incentivised by the GMS contract. For example, maximum QOF points are awarded when 90% of CHD patients and 90% of stroke patients are: treated with antiplatelets; have their total cholesterol recorded and when their total cholesterol is below 5mmol/l. Also, maximum points are received when 90% of CHD and stroke patients who smoke are offered further help to stop smoking. While we appreciate the first survey was carried out in one locality and that huge variation exists across the country, clearly the undermanagement of PAD needs to be urgently addressed to reduce the morbidity and mortality from vascular disease, with inclusion in the GMS contract offering an obvious solution. Furthermore, this message is reinforced with data from the PREPARED- UK study3, which demonstrates that patients with claudication and evidence of CHD appear to receive more evidence-based treatments than non-CHD patients and that overall patients with claudication referred from primary care in the UK are not receiving optimal medical risk factor management. Jill Belch, Gerry Stansby & Julie Brittenden (on behalf of Target PAD) 1. Data on file. 1Management of secondary risk factors in patients with intermittent claudication. K Cassar et al. 2006. 2. Hospital and Primary care prescribing for the patient with peripheral arterial disease J Belch & P Stonebridge, 2006. 3. Coronary heart disease (CHD) in patients with intermittent claudication. Mister, R et al. Heart 2004; 90:081. The Target PAD group is supported by an educational grant from sanofi -aventis and Bristol-Myers Squibb. The views expressed within the article are those of the authors. Competing interests: Jill Belch has received educational funds from sanofi-aventis to cover travel costs to attend a scientific meeting, to speak at a further meeting and an educational grant for a PAD database. Gerry Stansby has received funding from sanofi-aventis for research projects, speakers fees and to support a member of his staff. Julie Brittenden has received part-funding from sanofi-aventis for research projects and funding for a meeting. Also consultancy fees from AstraZeneca and Otsuka.