Peripheral arterial disease: still on the periphery?BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7551.1213 (Published 18 May 2006) Cite this as: BMJ 2006;332:1213
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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
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
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
1. Data on file. 1Management of secondary risk factors in patients
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
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.
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.
Competing interests: No competing interests
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
Competing interests: No competing interests