Vascular assessment techniques of podiatrists in Australia and New Zealand: a web-based survey

Podiatrists play a central role in conducting non-invasive vascular assessment in the lower extremity. This involves screening for signs and symptoms of peripheral arterial disease (PAD) and ongoing monitoring of the condition following diagnosis [1]. Given that people with PAD are not only at higher risk of wounds and limb loss, but are at far greater risk of cardiovascular events and death [2], effective routine vascular assessment and subsequent accurate diagnosis of PAD is integral to improving clinical outcomes and to facilitate effective intervention and ongoing monitoring [3].

A number of tests are currently used for lower limb vascular assessment including pulse palpation, systolic toe pressures, toe-brachial index (TBI), ankle-brachial index (ABI) and Doppler examination. While generally these tests have been shown to have high reliability and diagnostic accuracy [4‐12], there has been little investigation of the frequency of use and practicality of performing these assessments in clinical practice generally, with most evidence relating to the most widely recommended test, the ABI [13].

In general medical practice, time constraints and lack of financial reimbursement have been reported to contribute to reduced utility of the ABI for vascular screening [14] with general medical practitioners also reporting a lack of confidence in ability to perform the measurement [15]. Only 32% of general medical practitioners are reported to perform ABI on a regular basis most commonly prior to the application of compression bandaging and for determining the aetiology of chronic wounds [14]. Podiatrists also have reported time constraints and lack of financial reimbursement as barriers in performing ABI, with approximately half of practitioners reporting using ABI regularly [16]. However the clinical indicators used by clinicians to complete this assessment or conduct other forms of lower limb vascular assessment including the TBI and Doppler waveform assessment have not been investigated [15, 16].

The primary aim of this study was to determine current practices in performing lower limb vascular assessments of Podiatrists in Australia and New Zealand. The secondary aims of this study were to investigate factors influencing lower limb vascular assessment practices including levels of clinical experience and education, practice location and resources and to establish perceived barriers to performing lower limb vascular assessments Podiatry practice.

This was a cross-sectional observational study performed using a web –based, secure anonymous self-administered survey reading lower limb vascular assessment techniques of Podiatrists from Australia and New Zealand that was conducted between 1 April and 31 July 2013.

Recruitment of participants was via their affiliated professional body—The Australian Podiatry Association or PodiatryNZ. Invitations to participate were sent via e-mail advertising in the weekly bulletin or a small advertisement in the paper based bulletin with a link to the survey. External clinical supervisors participating in the University of Newcastle external placement program were also invited to take part via email invitation containing a survey overview with a hyperlink to the survey. Inclusion criteria were Podiatrists registered and currently practicing in Australia and New Zealand. Ethical approval was obtained from the University of Newcastle Human Research Ethics Committee (Ethics approval: H-2012-0384). All participants provided informed consent prior to participation in this study.

The survey was delivered online via the online survey software Survey Monkey®. The questions examined clinician’s regular practices in vascular assessment, factors prompting performance of an assessment and availability of equipment (Additional file 1). The first seven questions elicited demographic and descriptive data from the participants. Questions eight to 15 related to clinicians vascular assessment habits and 16 and 17 related to provision of patient education. The majority of questions were closed with three open ended questions, which related to time spent in practice and topics covered in education provision. A mix of nominal polytomous, ordinal polytomous and dichotomous questions were used. Pilot testing of the survey was performed at a University of Newcastle continuing professional development event attended by a mix of 35 private and public sector podiatrists. Based on feedback from podiatrists some small amendments were made to some of the questioning methods from open ended to ordered polytomous and phrasing of the questions was slightly altered to allow for further clarity.

This is the first study to investigate the clinical indicators that podiatrists use to undertake lower limb vascular assessment and to establish the current clinical examination techniques most commonly used by podiatrists in Australia and New Zealand. We have demonstrated that pedal pulse palpation and use of Doppler were the most commonly utilised assessment methods, and that practice setting and experience had the most significant influence on performance of assessment and what type of assessment methods were utilised. This study suggests that in Australian and New Zealand podiatrists there is a reliance on subjective vascular assessment testing methods such as pedal pulses palpation and Doppler examination, and a lack of use of objective measurement such as the ABI and TBI. As objective measurements not only help to identify the presence of PAD but provide indication of severity of disease, when used in combination with signs and symptoms these tests play an essential role in guiding patient management and assessing risk status. This reliance on more subjective testing methods was more evident in private practitioners than public practitioners. This may be due to a number of different factors. The patients seen in each clinical setting tend to differ, generally with more high risk, diabetes and complex vascular pathology patients seen in public practice [17] who require more extensive investigation, which may account for some of the differences reported. In private practice, no financial incentives currently exist to complete vascular assessment and time is more limited, so practitioners may not perform the more time consuming testing such as pressure measurement.

The overall number of podiatrists reporting using the ABI on a regular basis was lower than previously reported [16] and podiatrists participating in this study reported they were more likely to use the clinical signs and symptoms of PAD present in the lower limb, as a clinical indicator to perform vascular assessment. Systemic factors, such as advanced age, smoking, cardiovascular disease and stroke, which are well-established risk factors for PAD, were much less frequently reported to be used as clinical indicators to perform such an assessment. Given that the signs and symptoms of PAD are frequently unrecognised or even absent [18], it may be likely that relying on subjective testing methods will result in missed or late diagnosis of PAD, and/or an inaccurate diagnosis of disease severity. Objective pressure measurements add another important dimension to lower limb vascular assessment, allowing for ongoing monitoring of PAD from year to year. This is particularly important for conditions such as Diabetes where changes can occur quickly and action needs to be undertaken to prevent complications such as wounds, ulceration and gangrene.

This study highlights that a large proportion of reported practices in lower limb vascular assessment being undertaken by podiatrists in Australia and New Zealand do not follow international guidelines [19] for PAD screening. However, it is likely that podiatrists are unaware of this broad guideline which recommends the use of objective pressure measurement, mainly the ABI when performing vascular assessment in populations deemed at risk of PAD. Our findings suggest the need for a podiatry specific summary of these broad international guidelines to assist podiatrists in their daily practice or increased awareness of the international guideline through continuing education.

The barriers to performing vascular assessment reported in this present study were consistent with previous studies [14, 16], with time constraints and lack of equipment most frequently cited. Uncertainty of technique was identified as a barrier to complete an assessment mainly in rural podiatrists, suggests that continuing education provision may be particularly beneficial in rural areas. A lack of equipment was identified as a major barrier in New Zealand podiatrists, however, there are differences in service provision in New Zealand compared to Australia, which may have an influence on the equipment required most frequently in daily clinical practice. Limited ability to obtain financial remuneration for vascular assessments was also a reported barrier in a quarter of all respondents. Given the importance of the task lower limb vascular assessment and it’s role in preventative care, future lobbying for health fund and/or medicare rebates may be of use to remove this barrier for podiatrists to more regularly screen for PAD in their patients who are considered at risk.

Although our study only included a small proportion of practicing podiatrists in Australia and New Zealand, our findings suggest there is a lack of consistency in the profession regarding our approach to lower limb vascular assessment. Our results indicate there is greater scope for use of objective assessment techniques within the profession. Assessment methods employed by podiatrists appear to be guided by practice setting, practitioner experience and geographical location, rather than diagnostic utility of testing methods. There is a need for continuing education for podiatrists in the area of lower limb vascular assessment to increase awareness of accurate and appropriate vascular assessment requirements for populations at risk of PAD.