How German vascular surgeons and angiologists judge walking exercise for patients with PAD
Results from a nationwide survey amongst 743 members of two major scientific societies
Abstract
Summary:Background: To determine the physician’s perspective and perception on walking exercise as well as barriers in guideline-directed best medical treatment of patients with lower extremity peripheral arterial disease (PAD). Patients and methods: All members of the German Society for Vascular Surgery and Vascular Medicine and of the German Society for Angiology – Society for Vascular Medicine with valid email address were invited to participate in an electronic survey on walking exercise for treatment of intermittent claudication that was developed by the authors. Results: Amongst 3910 invited participants, 743 (19%) provided valid responses (33% females, 84% vascular surgery, 15% angiology). Thereof, 65% were employed by non-university hospitals, 16% by university institutions, and 18% by outpatient facilities. A mean of 14 minutes were spent per patient to counsel and educate, while only 53% responded they had enough time in everyday clinical practice. While 98% were aware of the beneficial impact of structured exercise training (SET) on pain free walking distance and 90% advise their patients to adhere to SET, only 44% provided useful guidance to patients to find local SET programmes and merely 42% knew how to prescribe SET as service that can be reimbursed by medical insurances. Approximately 35% knew a local SET programme and appropriate contact person. Health-related quality of life was assessed in a structured way by only 11%. Forty-seven percent responded that medical insurances should be responsible to implement and maintain SET programmes, while only 4% held hospital physicians responsible to achieve this task. Conclusions: This nationwide survey study amongst vascular specialists illustrates the current insufficient utilisation of SET as an evidence-based therapeutic cornerstone in patients with lower extremity PAD in Germany. The study also identified several barriers and flaws from the physician’s perspectives which should be addressed collectively by all health care providers aiming to increase the SET use and eventually its’ impact on patients with PAD.
Introduction
With a prevalence of almost 24% amongst European populations and approximately 237 million affected people worldwide, lower extremity peripheral arterial disease (PAD) counts as both common and important target population of several medical specialties [1, 2]. Thereby, the proportion of symptomatic patients who underwent invasive revascularisation for intermittent claudication vs. chronic limb-threatening ischaemia increased rapidly during the past decade [3, 4]. For patients suffering from intermittent claudication, all clinical practice guidelines emphasised the comparative effectiveness of walking exercise either as structured exercise training (SET) or home-based exercise training (HET) [5, 6, 7, 8].
Moreover, while intermittent claudication is known to being directly associated with impaired quality of life, a structured approach to measure the complex concept of lifestyle limiting claudication was only just recommended on consensual agreement amongst international experts [5, 6, 7, 8, 9]. However, valid clinical practice guidelines still lack clear definitions for the construct of lifestyle limitation through intermittent claudication and how to ponder realistic treatment goals with complementing treatment strategies.
Most recently, two survey studies from the United States and Germany revealed that participation in SET was strikingly low, and that missed opportunities in the patient-physician communication may have driven this situation [10, 11]. Unfortunately, the complex interactions between patients and physicians in the primary care and hospital sector were hardly illuminated by previous research. Numerous factors may ultimately lead to insufficient adherence to guideline-directed care. While few previous studies focused on the patient perspective, the impact of physicians appears likewise important.
Hence, the current survey study aimed to determine the perspective and perception of physicians who are active in vascular care on walking exercise. We further aimed to generate hypotheses and targets for both future research and actions to improve the insufficient participation in guideline-based exercise.
Patients and methods
This was a prospective questionnaire-based electronic survey study of the German Institute for Vascular Research (DIGG gGmbH). The questions included in the survey were developed in a focus group of experts involving the authors of the current study. German language was used.
We invited all registered members of the German Society for Vascular Surgery and Vascular Medicine (DGG) and the German Society for Angiology – Society for Vascular Medicine (DGA) with an electronic mail address (e-mail) to participate.
The study protocol was written a priori and circulated along with the electronic survey amongst the coordinators (Electronic supplementary material [ESM] 1). The leading board of both societies approved the study.
The invitation to participate in the electronic survey (via Surveymonkey®, Momentive Europe UC, Ireland) was sent via e-mail by the office of the DGG as well as of the DGA on 12 January 2023. An electronic reminder was sent on 30 January 2023, and the survey was closed on 16 February 2023. The invitation was delivered to 2716 (DGG) and 1194 (DGA) members.
Ethical considerations
Due to the anonymised nature of the study data, no ethical approval was necessary.
Statistical analysis
The de-identified survey data was collected digitally by the last author in the coordinating centre (Hamburg). We summarised the baseline information with medians and interquartile ranges (IQR) and with percentages and 95% confidence interval (CI) for discrete variables. The agreement rate (Figure 1) was calculated by adding agreement and strong agreement from the four point Likert scale and dividing it through the number of valid responses. Missing data (<0.2%) were handled by exclusion.
Data processing was performed with SPSS version 28 (IBM Corporation, New York, USA), visualization was performed with software Adobe Illustrator version 24.1.2 (Adobe, California, USA).
Results
During study duration of 35 days, a total of 743 (19%) valid responses were collected electronically. The baseline characteristics of the survey are presented in Table I. Amongst all participants, 33.1% (95% CI: 29.7–36.6) were females and 80.0% (95% CI: 76.9–82.8) were between 30 and 59 years of age.
In regard to the medical specialty of the participants, 84.2% (95% CI: 81.4–86.8) were vascular surgeons, and 15.1% (95% CI: 12.6–17.9) were angiologists.
A total of 88.2% (95% CI: 85.6–90.4) had finished their board exam while 9.3% (95% CI: 7.3–11.6) responded they were still in training.
Most participants worked at non-university hospitals (65.1%, 95% CI: 61.6–68.6) while 18.2% (95% CI: 15.5–21.1) were from outpatient care institutions and 15.6% (95% CI: 13.1–18.4) were employed by university hospitals. The proportion of participants from outpatient facilities was different between vascular surgery (13.1%) vs. angiology (45.5%).
All participants were asked if they were regularly involved in the most common non-invasive and invasive branches of vascular medicine: 95.8% were involved in patient consultation, 90.9% in wound therapy, 90.4% in stepwise diagnostics, 77.5% in endovascular revascularisation, 73.2% in open-surgical revascularisation, and 9.4% in rehabilitation.
Adherence to walking exercise, period of consultations, and transferal practices
The participants estimated that in mean 12.3% (SD=14.47) of their patients would attend any SET. When being asked about the mean period of consultations per capita, the participants estimated 13.5 minutes (SD=13.21). Thereby, 32.7% (95% CI: 29.1–36.6) of the vascular surgeons and 48.2% (95% CI: 38.7–57.9) of the angiologists were aware of a specific local SET programme and appropriate contact persons.
Rehabilitation and walking exercise
An established referral practice to a rehabilitation facility was declared by 25.1% (95% CI: 22.0–28.4), while 35.4% (95% CI: 32.0–39.0) were not aware of any appropriate rehabilitation facility. In total, 55.1% (95% CI: 51.4–58.7) rated a rehabilitation with SET programme highly, while most (65.3%, 95% CI: 61.7–68.7) participants declared they would refer their patients to specialised rehabilitation institutions in their region (Figure 1).
Likert scale
Results from the seven-question 4-point Likert matrix are presented in Figure 1. Approximately 90% of the participants responded that they advice all patients with intermittent claudication to attend a SET and 98% agreed that SET may improve the pain free walking distance, while 89% responded that they do not collect health related quality of life in a structured way.
Discussion
In the current survey study amongst 743 members of two major scientific societies in the vascular field in Germany, the perceptions of physicians on walking exercise are illuminated. Thereby, this survey provides an insight into the diverse cross-sectional non-invasive treatment of patients with intermittent claudication in this country.
Interestingly, while most participants rated SET superior to invasive therapy and predominantly declared that they advice and counsel SET in everyday clinical practice, their sobering appraisal of patients’ adherence was close to a recent survey amongst patients. In that previous survey, only 11% of patients with intermittent claudication participated in SET which clearly emphasised a missed opportunity [11, 12].
Another interesting finding of the current survey may additionally underline the inherent gap between guideline recommendations and treatment reality in everyday clinical practice [5, 6, 7, 8]. Most guidelines used the vague concept of lifestyle limitation due to intermittent claudication [5, 6, 7, 8]. Numerous heterogeneous tools exist to approximate to this concept as an important part of health-related quality of life. Most recently, an international group of experts suggested the use of the VascuQoL-6 as a pragmatic approach while guidelines still lack clear recommendations for collecting quality of life [9, 13]. The surprising fact that only 11% of the participants responded that they even collect health-related quality of life in a structured way underlines that there is a long way to go.
The comparative effectiveness of SET or HET for patients with intermittent claudication is beyond dispute [14, 15, 16, 17, 18, 19]. That said, if both patients and physicians were profoundly convinced by the existing evidence base, what are the main barriers responsible for the disillusioning reality and lack of guideline-directed care?
The availability of time for counselling and patient care appears to be a critical factor in so-called patient-centred decision making. Less than 14 minutes are available for each patient in everyday clinical care which seems insufficient in light of the importance of this topic. Thereby, the setting and reimbursement factors vary widely between countries, limiting the applicability of evidence from one system to another [20]. In Germany, where almost 700 centres provide invasive therapies to this target population [21], the reimbursement system does not offer incentives for counselling or any educational efforts. This may also explain why almost 50% of the participants responded that medical insurance funds are responsible for the implementation and maintenance of SET programmes. Another important window of opportunity may lie with vascular rehabilitation programmes where patients can experience walking exercise and its importance for walking impairment.
However, even if physicians manage to get through to the patient and assure adherence to this important pillar of complementary care, the lack of awareness about appropriate regional activities forestall any efforts. Only 35% knew contact details of local or regional SET programmes, but 65% did not. This also leads to another challenge especially in rural living areas. In a previous survey, the minority of patients responded that they would travel more than 30 minutes to reach a SET programme; a major problem and clear target for societal activities [11].
The main question remains how we – as multidisciplinary teams in different care sectors – can improve this situation with low adherence to SET. There are almost 4,000 members registered with these two societies, who should focus better on best medical therapies and adherence to guideline-directed care beyond hospital discharge. Although we still carry the main burden in terms of patient education and awareness as physicians, the inherent contact between patients and medical insurance funds may introduce further interesting opportunities.
Limitations
Although we used the complete membership databases of two major scientific societies to reach as many physicians as possible, only 19% of all invited members participated, therefore a selection bias with impact on the generalisability cannot be ruled out. Also, not all members of both societies provided valid e-mail addresses. A large proportion of patients with PAD are managed by non-vascular physicians such as general practitioners and internal specialists. The perception of SET and the frequency of its implementation in those physicians and patients might be different than shown in the current study. Medical societies may have the ultimate opportunity to improve this situation not only by implementing joint awareness campaigns but also by offering a structured certification for nationwide walking exercise programmes.
Conclusions
In this nationwide survey amongst members of the two major scientific societies, the pattern of opinions on walking exercise for patients with intermittent claudication was obtained. Limited time for counselling, lack of knowledge of local programmes, and insufficient focus on the structured collection of quality of life may be suitable starting points, while almost 50% saw medical insurance funds mainly responsible.
Electronic supplementary material
The electronic supplementary material (ESM) is available with the online version of the article at https://doi.org/10.1024/0301-1526/a001071
The authors appreciate the time and efforts made by all colleagues who answered to this survey study.
References
1 Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis. Lancet Glob Health. 2019;7:e1020–e30.
2 Editor’s Choice – Prevalence of peripheral arterial disease, abdominal aortic aneurysm, and risk factors in the Hamburg City Health Study: A Cross-Sectional Analysis. Eur J Vasc Endovasc Surg. 2023;S1078-5884(23)00004-7.
3 Editor’s choice – Comorbidity patterns among patients with peripheral arterial occlusive disease in Germany: a trend analysis of health insurance claims data. Eur J Vasc Endovasc Surg. 2020;59:59–66.
4 Editor’s choice – International variations and sex disparities in the treatment of peripheral arterial occlusive disease: a report from VASCUNET and the International Consortium of Vascular Registries. Eur J Vasc Endovasc Surg. 2020;60:873–80.
5 Editor’s choice – 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55:305–68.
6 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation. 2017;135:e726–e79.
7 ESVM Guideline on peripheral arterial disease. Vasa. 2019;48:1–79.
8 . German guideline on the diagnosis and treatment of peripheral artery disease – a comprehensive update 2016. Vasa. 2017;46:79–86.
9 A delphi consensus on patient reported outcomes for registries and trials including patients with intermittent claudication: recommendations and reporting standard. Eur J Vasc Endovasc Surg. 2022;64:526–33.
10 Barriers to participation in supervised exercise therapy reported by people with peripheral artery disease. J Vasc Surg. 2023;77:506–14.
11 A prospective survey study on the education and awareness about walking exercise amongst inpatients with symptomatic peripheral arterial disease in Germany. Vasa. 2023. Online ahead of print. https://doi.org/10.1024/0301-1526/a001057
12 Distribution of mobile health applications amongst patients with symptomatic peripheral arterial disease in Germany: a cross-sectional survey study. J Clin Med. 2022;11:498.
13 . Patient reported outcomes: the missing link in symptomatic vascular disease outcome assessment. Eur J Vasc Endovasc Surg. 2022;63(3):464.
14 Exercise training for intermittent claudication: a narrative review and summary of guidelines for practitioners. BMJ Open Sport Exerc Med. 2020;6:e000897.
15 . Exercise for intermittent claudication. Cochrane Database Syst Rev. 2017;12:CD000990.
16 Supervised walking therapy in patients with intermittent claudication. J Vasc Surg. 2012;56:1132–42.
17 . Gait changes after supervised exercise training in patients with symptomatic lower extremity peripheral artery disease. Vasc Med. 2021;26:259–66.
18 . Exercise training for health-related quality of life in peripheral artery disease: a systematic review and meta-analysis. Vasc Med. 2015;20:30–40.
19 . Exercise training for management of peripheral arterial disease: a systematic review and meta-analysis. Sports Med. 2015;45:231–44.
20 International variations and gender disparities in the treatment of peripheral arterial occlusive disease – a report from VASCUNET and the International Consortium of Vascular Registries. Eur J Vasc Endovasc Surg. 2020;60(6):873–80.
21 . The relationship between hospital procedure volume and outcomes after endovascular or open surgical revascularisation for peripheral arterial disease: an analysis of health insurance claims data. Eur J Vasc Endovasc Surg. 2023;65(3):370–8.
