Quality standard


This quality standard covers the diagnosis and management of lower limb peripheral arterial disease in adults aged 18 years and over. It does not cover acute ischaemia of the lower limb. For more information, see the topic overview.

Why this quality standard is needed

Peripheral arterial disease (PAD) is a condition in which the arteries that carry blood to the limbs are narrowed or blocked by a build-up of fatty deposits (called atheroma).

The most common initial symptom of PAD is leg pain (usually in the calf) while walking. This is known as intermittent claudication. In most people with intermittent claudication, the symptoms remain stable. Approximately 10–20% of people may develop increasingly severe symptoms and 5–10% may develop critical limb ischaemia. Critical limb ischaemia is characterised by severely diminished circulation, ischaemic pain at rest and tissue loss (ulceration and/or gangrene). Overall, approximately 1–2% of people with intermittent claudication will eventually undergo lower limb amputation, although the risk is higher (about 5%) in people with diabetes.

The incidence of PAD increases with age, and about 20% of people over 60 years have some form of PAD. Smoking is the most important risk factor for PAD; other risk factors include diabetes, high cholesterol and high blood pressure.

PAD is also a marker for an increased risk (3–4 fold) of other cardiovascular morbidity and mortality (heart attack and ischaemic stroke), even if it is asymptomatic. Symptomatic PAD significantly impairs quality of life through reduced mobility, severe pain and tissue loss (ulceration and/or gangrene). It is the largest single cause of lower limb amputation in the UK.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measureable quality improvements within a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2014–15


Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential years of life lost (PYLL) from causes considered amenable to healthcare i) Adults

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease*

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition**

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care i) GP services

4b Patient experience of hospital care

Alignment across the health and social care system

* Indicator shared

** Indicator complementary

Table 2 Public health outcomes framework for England, 2013–2016


Objectives and indicators

4 Healthcare public health and preventing premature mortality


Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities


4.4 Mortality from all cardiovascular diseases (including heart disease and stroke)*

Alignment across the health and social care system

* Indicator shared

Coordinated services

The quality standard for PAD specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole PAD care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to people with PAD.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality PAD service are listed in Related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health and social care practitioners involved in assessing, caring for and treating people with PAD should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting people with PAD. If appropriate, health and social care practitioners should ensure that family members and carers are involved in the decision-making process about investigations, treatment and care.