Introduction
Design and methods
Data analysis
Results
Participant characteristics
N | 307 | |
---|---|---|
Podiatry setting | NHS | 211 (68.7%) |
Private practice | 89 (29.0%) | |
Research/education | 4 (1.3%) | |
Other | 3 (1.0%) | |
Current primary caseload | High risk patients | 110 (35.8%) |
Low risk routine patients | 82 (19.5%) | |
Wound care | 60 (19.5%) | |
Musculoskeletal | 28 (9.1%) | |
Rheumatology | 2 (0.7%) | |
Nail surgery patients | 0 (0%) | |
Paediatric | 1 (0.3%) | |
Mixed/other | 22 (7.2%) | |
Place of practice | Town | 160 (52.1%) |
City | 98 (31.9%) | |
Rural | 49 (16.0%) | |
Country | England | 219 (71.3%) |
Scotland | 43 (14.0%) | |
Northern Ireland | 22 (7.2%) | |
Wales | 22 (7.2%) | |
Other | 1 (0.3%) | |
Education | Diploma | 17 (5.5%) |
Bachelor’s degree or graduate entry Master’s degree | 196 (63.8%) | |
Post graduate coursework | 76 (24.8) | |
Higher degree by research only | 15 (4.9) | |
Years practicing, mean (SD) | 16.6 (10.3) |
Vascular assessment characteristics
Number of comprehensive vascular assessments performed and documented in most recent work day | None | 26 (4.8%) |
1 | 85 (15.8%) | |
2 | 56 (10.4%) | |
3 | 42 (7.8%) | |
4 | 43 (8.0%) | |
5 | 14 (2.6%) | |
6 | 14 (2.6%) | |
7 | 4 (0.7%) | |
8 | 9 (1.7%) | |
9 | 4 (0.7%) | |
> 10 | 10 (1.9%) | |
Estimated time taken to perform a vascular assessmenta | 5 min | 78 (27.5%) |
10 min | 72 (25.4%) | |
15 min | 40 (14.1%) | |
20 min | 34 (12.0%) | |
25 min | 3 (1.1%) | |
30 min | 50 (17.6%) | |
40 min | 2 (0.7%) | |
45 min | 5 (1.8%) | |
Vascular assessment booking practicesb | As part of a routine visit | 194 (81.5%) |
As a separate booking | 45 (15.9%) | |
Dependent on patient and time required for specific assessments | 39 (13.8%) | |
Other | 5 (1.8%) | |
Barriers in performing a vascular assessment | Time constraints | 161 (52.4%) |
Lack of equipment | 130 (42.3%) | |
Lack of experience | 103 (33.6%) | |
Lack of post-graduate vascular training | 77 (25.1%) | |
There are no barriers | 59 (19.2%) | |
Vascular team not requesting specific vascular assessments | 50 (16.3%) | |
Lack of managerial support | 39 (12.7%) | |
No financial incentive | 24 (7.8%) | |
Lack of interest | 6 (2.0%) |
Reasons/indicators to perform a vascular assessment | Symptoms of claudication | 274 (89.3%) |
Rest pain | 264 (86.0%) | |
Diabetes | 262 (85.3%) | |
Active wound | 261 (84.7%) | |
New patient assessment | 252 (82.1%) | |
History of poor healing | 249 (81.1%) | |
Assessment for nail surgery eligibility | 221 (71.7%) | |
Discolouration of skin | 210 (68.4%) | |
Cold feet | 205 (66.8%) | |
Referral request | 183 (59.6%) | |
Night cramps | 183 (59.6%) | |
Raynaud’s phenomena | 176 (57.3%) | |
History of cardiovascular disease | 175 (57.0%) | |
Chilblains | 169 (55.0%) | |
Active smoking | 168 (54.7%) | |
Smoking history | 165 (53.7%) | |
Burning feet | 133 (43.3%) | |
History of cerebrovascular disease | 119 (38.8%) | |
Advanced age | 110 (35.8%) | |
Hypertension | 77 (25.1%) | |
Widespread anhidrosis | 76 (24.8%) | |
Dyslipidaemia | 67 (21.8%) | |
Other | 20 (6.5%) | |
Vascular assessment equipment available in clinic | Hand-held Doppler without visual waveform display | 265 (86.3%) |
Blood Pressure Cuff and sphygmomanometer | 166 (54.1%) | |
Stethoscope | 76 (24.8%) | |
Hand-held Doppler with visual waveform display | 67 (21.8%) | |
Toe pressure cuff | 50 (16.3%) | |
Automated ankle brachial index machine | 27 (8.8%) | |
Photoplethysmography probe | 19 (6.2%) | |
TcPO2 unit | 17 (5.5%) | |
Automated toe pressure unit | 12 (3.9%) | |
None of the above | 6 (2.0%) | |
Other | 10 (3.3%) | |
Diagnostic testing used during a vascular assessment | Hand-held Doppler (waveform and/or pulses) | 222 (72.3%) |
Pedal pulse palpation | 160 (52.1%) | |
Visual assessment of skin and/or nails | 98 (31.9%) | |
Ankle brachial index | 98 (31.9%) | |
Patient medical history/symptoms | 69 (22.5%) | |
Capillary refill time | 60 (19.5%) | |
Temperature gradient | 51 (16.6%) | |
Buerger’s test | 26 (8.5%) | |
Toe brachial index | 18 (5.9%) | |
Edinburgh Claudication Questionnaire | 13 (4.2%) | |
Toe systolic pressure | 9 (2.9%) | |
Brachial Blood pressure | 7 (2.3%) | |
Pole test | 5 (1.6%) | |
SpO2 | 2 (0.7%) | |
TcP02 | 1 (0.3%) | |
Heart rate | 1 (0.3%) |
Observation, Doppler and pressure (ref) (n = 49) | Observation alone (n = 29) | Doppler alone (n = 50) | Observation and Doppler (n = 97) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
N (%) | N (%) | OR (95% CI) |
P
| N (%) | OR (95% CI) |
P
| N (%) | OR (95% CI) |
P
| ||
Education level | Bachelor (ref) | 30 (61.2%) | 17 (58.6%) | 28 (56.0%) | 70 (72.1%) | ||||||
PG/Research | 16 (32.6%) | 9 (31.0%) | −.10 (.32, 2.54) | 0.85 | 18 (36.0%) | 0.19 (0.51, 2.89) | 0.65 | 24 (24.7%) | −0.47 (0.28, 1.37) | 0.24 | |
Diploma | 3 (6.2%) | 3 (10.4%) | 0.63 (0.34, 10.49) | 0.47 | 4 (8.0%) | 0.35 (0.29, 6.93) | 0.66 | 3 (3.1%) | −0.83 (0.08, 2.29) | 0.33 | |
Podiatry setting | Public (ref) | 33 (67.3%) | 17 (58.6%) | 34 (68.0%) | 64 (66.0%) | ||||||
Private | 16 (32.7%) | 12 (41.4%) | 0.44 (0.58, 4.14) | 0.38 | 16 (32.0%) | −0.05 (0.40, 2.26) | 0.906 | 33 (34.0%) | 0.12 (0.53, 2.39) | 0.75 |
Clinical indicators for vascular assessment and equipment
Diagnostic interpretation of vascular assessment practices
Ankle brachial pressure index cut-off value for peripheral arterial disease a | < 0.5 | 14 (4.6%) |
< 0.6 | 9 (2.9%) | |
< 0.7 | 28 (9.2%) | |
< 0.8 | 39 (12.7%) | |
< 0.9 | 85 (27.8%) | |
< 1.0 | 11 (3.6%) | |
< 1.2 | 1 (0.3%) | |
I don’t use ABPI | 119 (38.9%) | |
Absolute ankle pressure cut-off value used for peripheral arterial disease | < 30 mmHg | 3 (1.0%) |
< 40 mmHg | 5 (1.6%) | |
< 50 mmHg | 35 (11.4%) | |
< 60 mmHg | 12 (3.9%) | |
< 70 mmHg | 12 (3.9%) | |
< 80 mmHg | 8 (2.6%) | |
< 90 mmHg | 5 (1.6%) | |
< 100 mmHg | 7 (2.3%) | |
I don’t know | 61 (19.9%) | |
I do not measure/interpret absolute ankle pressures | 159 (51.8%) | |
Toe brachial pressure index cut-off value used for peripheral arterial disease b | < 0.50 | 13 (4.4%) |
< 0.55 | 8 (2.7%) | |
< 0.60 | 7 (2.4%) | |
< 0.65 | 9 (3.0%) | |
< 0.70 | 16 (5.4%) | |
< 0.75 | 2 (0.7%) | |
< 0.80 | 1 (0.3%) | |
< 0.90 | 1 (0.3%) | |
< 0.95 | 1 (0.3%) | |
< 1.00 | 1 (0.3%) | |
I don’t use TBPI | 236 (80.0%) | |
Absolute toe pressure cut-off value for Peripheral arterial disease | < 10 mmHg | 4 (1.3%) |
< 20 mmHg | 3 (1.0%) | |
< 30 mmHg | 15 (4.9%) | |
< 40 mmHg | 9 (2.9%) | |
< 50 mmHg | 8 (2.6%) | |
< 60 mmHg | 4 (1.3%) | |
< 70 mmHg | 6 (2.0%) | |
< 80 mmHg | 2 (0.7%) | |
< 90 mmHg | 1 (0.3%) | |
< 100 mmHg | 4 (1.3%) | |
I don’t know | 27 (8.8%) | |
I do not measure absolute toe pressure | 226 (73.6%) | |
Hand-held Doppler interpretation a | Audible output | 246 (80.4%) |
Visual output | 1 (0.3%) | |
Combination of audible and visual output | 51 (16.7%) | |
I do not use hand-held Doppler | 8 (2.6%) | |
When Audible and visual Doppler outputs are conflicting c | I place more emphasis on visual output | 11 (22.0%) |
I place more emphasis on audible output | 11 (22.0%) | |
I document both outputs separately | 23 (46.0%) | |
I place less emphasis on Doppler results overall | 5 (10.0%) | |
Doppler Audible output considered indicative of peripheral arterial disease | Monophasic sounds | 254 (82.7%) |
Weak biphasic sounds | 65 (21.2%) | |
Quiet or dampened sounds | 55 (17.9%) | |
“Whooshing” sounds | 41 (13.4%) | |
Absent sounds | 40 (13.0%) | |
Irregular or turbulent sounds | 30 (9.8%) | |
“Bounding” sounds | 20 (6.5%) | |
Sluggish or slow sounds | 11 (3.6%) | |
Sounds which are different between limbs | 4 (1.3%) |
Education and Management practices
Education topics discussed following vascular assessment a | Smoking cessation | 189 (69.5%) |
Exercise advice | 166 (61.0%) | |
Dietary advice | 67 (24.6%) | |
Diabetes control | 59 (21.7%) | |
Medication options | 55 (20.2%) | |
Interpretation of results of assessments | 49 (18.0%) | |
Lifestyle modifications | 46 (16.9%) | |
Referral options | 42 (15.4%) | |
Foot health self-care | 41 (15.1%) | |
Cardiovascular risk | 37 (13.6%) | |
Implications of reduced wound healing | 35 (12.9%) | |
Hypertension management | 27 (9.9%) | |
Pain management | 24 (8.8%) | |
Footwear advice | 23 (8.5%) | |
Weight management | 22 (8.1%) | |
Cholesterol lowering | 19 (7.0%) | |
Comorbidities | 17 (6.3%) | |
Alcohol reduction | 11 (4.0%) | |
Hosiery advice | 9 (3.3%) | |
Premature death | 9 (3.3%) | |
Family history | 7 (2.6%) | |
Keeping feet warm | 6 (2.2%) | |
Limb elevation | 5 (1.8%) | |
Moisturising skin | 4 (1.5%) | |
Limb compression | 2 (0.7%) | |
Adequate sleep | 2 (0.7%) | |
Stress reduction | 1 (0.4%) | |
Comfortable discussing premature vascular event due to PAD diagnosis b | Yes | 183 (64.4%) |
No | 52 (18.3%) | |
Unsure | 49 (16.9%) | |
Comfortable deciding on ongoing management of patient based on vascular assessment b | Yes | 205 (72.2%) |
No | 30 (10.6%) | |
Unsure | 49 (17.3%) | |
Initial referral following vascular assessment c | Vascular surgical team | 83 (28.3%) |
General practitioner | 158 (67.6%) | |
Vascular laboratory | 16 (5.5%) | |
Podiatry-led PAD team | 31 (10.6%) | |
Other | 14 (4.8%) |
Role of the podiatrist and cardiovascular health
“I feel we are in a privileged position of having more time with patients on a regular basis, having built up a rapport we are able to discuss problems/conditions in a way they feel comfortable which allows better understanding.”
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“I think we should be involved, but I need more education.”
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“Key role but lacking confidence/ training in addressing difficult conversations with patients”
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“Podiatrists can assist in identifying PAD and providing information and education to patients and making appropriate onward referrals”
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“There isn’t one - that’s the doctor’s job”
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“I don’t feel particularly comfortable with assisting with managing this but I have quite frequently referred the patient back to the GP and highlighted this to them.”
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“We are easily accessible for most of the population and i feel we should be more skilled in private practice at assessing vascular problems however due to cost of equipment I feel it will never happen.”
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“I think we need to do more in this area, we are in a prime position to be able to identify PAD and have discussions with patients around the cause.”
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“I feel all health professionals have a role in assisting patients to manage their cardiovascular health including podiatrists, however I think some health professionals are more qualified to do this than others. As a podiatrist I feel it is slightly out of my scope of practice to manage a patient’s cardiovascular health.”
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“Should be to be confident and competent to recognise CV problems and highlight and refer where needed.”
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“Important, but overlooked by other health care professionals.”
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“I understand it should be paramount in their podiatry experience however feel confidence in this field inhibits my delivery of this advice.”
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“It is part of our role but hard when we don’t always have access to information or enough time to assess.”
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