Identifying the presence and extent of peripheral arterial disease (PAD) through accurate lower limb vascular assessment is essential for reducing morbidity and mortality associated with the disease [
1]. Through early identification of PAD, complications such as ulceration, gangrene and amputation can be reduced or avoided using aggressive risk factor modification, provision of ongoing foot care and foot care education [
2‐
4]. It has been estimated that up to 90% of amputations are preventable [
2‐
4] with adequate foot screening including vascular assessment playing a vital role in reducing complications and improving clinical outcomes [
1]. Accurate and effective vascular assessment requires a complex reasoning process which takes into account a patient’s vascular risk factors as well as an awareness of the effect of co-morbidities on the clinical efficacy of assessments techniques, and, subsequent interpretation of results to formulate an evidence-based management plan.
Podiatrists play a central role in conducting non-invasive lower limb vascular assessments in the general population. We have recently demonstrated that on average, podiatrists perform two vascular assessments per day, however, the type of the testing that is conducted during the assessments is extremely varied and, potentially inadequate for accurate PAD screening [
2]. There are several available international guidelines for performing screening for PAD, including National Institute of Health and Care Excellence (NICE) guidelines and the American Heart Association (AHA) guidelines. Both of these guidelines recommend the use of ABI as a primary screening tool for populations at risk of PAD [
3,
4]. However the uptake of these recommendations into clinical practice appears to be inconsistent [
2]. Time required to perform recommended objective testing, particularly the ankle-brachial index (ABI) is the most widely nominated barrier to conducting appropriate vascular assessment, [
2,
5] with clinicians often relying on more quickly applied assessments including continuous wave Doppler (CWD) and pulse palpation. In addition there is growing evidence of the reduced accuracy of the ABI for detecting PAD in specific populations including those at risk of medial arterial calcification (MAC), particularly when co-existing with PAD and of a more distal distribution of atherosclerotic lesions including diabetes, renal disease, and older aged cohorts [
6]. In such populations further alternate testing including the toe brachial index (TBI) is frequently required, adding to the time to complete an assessment. Our recent research suggests more quickly applied vascular assessment techniques such as the TBI and CWD may be suitable for use as first line assessment techniques for PAD assessment, particularly in older people and those with diabetes [
7,
8]. The aim of this study was to determine if a targeted version of current guidelines in which the TBI was used initially in patient populations in which the ABI is known to be problematic could achieve similar diagnostic accuracy to testing protocols where the ABI is used as the primary objective testing method for all people at risk of PAD.