Quality statement 1: Identification and assessment of peripheral arterial disease

Quality statement

People who have symptoms of, or who are at risk of developing, peripheral arterial disease (PAD) are offered a clinical assessment and ankle brachial pressure index (ABPI) measurement.

Rationale

Early identification of both asymptomatic and symptomatic PAD means that treatment can begin earlier, potentially slowing disease progression and improving quality of life through better mobility and reduced pain. Early identification and treatment of PAD and its risk factors may also reduce the risk of cardiovascular morbidity and mortality, and the need for lower limb amputation. A comprehensive assessment should include both a clinical assessment with structured history taking, and ABPI measurement with a hand-held doppler ultrasound scan to ensure an accurate diagnosis and quantification of disease severity.

Quality measures

Structure

(a) Evidence of local arrangements to ensure that health and social care practitioners receive training to recognise the symptoms of PAD.

Data source: Local data collection.

(b) Evidence of local arrangements to ensure that people who have symptoms of, or who are at risk of developing, PAD are offered a clinical assessment and ABPI measurement.

Data source: Local data collection.

(c) Evidence of local arrangements to ensure that all healthcare practitioners undertaking hand-held doppler ultrasound assessment of ABPI are appropriately trained.

Data source: Local data collection.

Process

(a) Proportion of people who have symptoms of PAD who receive a clinical assessment and ABPI measurement.

Numerator – the number of people in the denominator receiving a clinical assessment and ABPI measurement.

Denominator – the number of people who have symptoms of PAD.

Data source: Local data collection.

(b) Proportion of people who are at risk of developing PAD who receive a clinical assessment and ABPI measurement.

Numerator – the number of people in the denominator receiving a clinical assessment and ABPI measurement.

Denominator – the number of people at risk of developing PAD.

Data source: Local data collection.

Outcome

Disease severity at diagnosis.

Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that hand-held doppler ultrasounds are adequately available; that staff are trained to recognise the symptoms of PAD; and that people who have symptoms of PAD or who are at risk of developing it are offered a clinical assessment and ABPI measurement.

Health and social care practitioners ensure that they are aware of the symptoms of PAD and the need to have these symptoms assessed; that they are aware of the risk factors for PAD; and that healthcare practitioners ensure that they offer a clinical assessment and ABPI measurement to people who have symptoms of PAD or who are at risk of developing it.

Commissioners ensure that they commission services that have an adequate supply of hand-held doppler ultrasounds, and have staff trained to carry out clinical assessments and ABPI measurements in people who have symptoms of PAD or who are at risk of developing it.

What the quality statement means for patients, service users and carers

People with possible peripheral arterial disease, and people who are at risk of developing peripheral arterial disease receive a thorough assessment to find out whether or not they have it, in which they are asked about their symptoms, their legs and feet are examined, their pulses are checked, and the blood pressures in their arms and ankles are compared.

Source guidance

Definitions of terms used in this quality statement

Symptoms of PAD include:

  • non-healing wounds on the legs or feet

  • unexplained leg pain

  • pain in the leg when walking that resolves when stopping (intermittent claudication), pain in the foot at rest, often made worse by elevation (for example, in bed at night disturbing sleep and relieved by hanging the foot down)

  • tissue loss (ulceration and/or gangrene).

[Adapted from NICE clinical guideline 147]

People at risk of PAD include those who:

  • have diabetes or

  • are being considered for interventions to the leg or foot (for example, podiatric and orthopaedic foot surgery and chiropody) or

  • need to use compression hosiery.

[Adapted from NICE clinical guideline 147, recommendation 1.3.1]

A clinical assessment should include:

  • asking about the presence and severity of possible symptoms of intermittent claudication and critical limb ischaemia using a structured questionnaire

  • examining the legs and feet for evidence of critical limb ischaemia, for example, tissue loss (ulceration and/or gangrene)

  • examining the femoral, popliteal and foot pulses.

[Adapted from NICE clinical guideline 147, recommendation 1.3.2]

ABPI measurement:

Recommendation 1.3.3 in NICE clinical guideline 147 provides guidance on how this should be done.