Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral

Objective: Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeon s and IMPs include early identification of peripheral arterial disease (PAD ), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might cont ribute to suboptimal care form the basis for this report. Methods: An anonymous survey was mailed to all IMPs (n = 843) in the centra l and southern parts of Illinois. Questions concerned IMP demographics, app roach to diagnostic testing, referral patterns, perception of adequacy of e ducation of PAD, and boar often parts of the history and physical examinati on for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50 %, 50%-75%, and 75%-100% of the time completed). Results: There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locat ions for IMPs returning the questionnaire included rural (36%), suburban (2 2%), and urban (40%). Practice types included academic (7%), solo private ( 29%), group private (53%), and other (14%). A history of cardiac disease wa s obtained most of the time by 92% of IMPs (75%-100% answer category). Hist ories for pulmonary disease, diabetes mellitus, stroke, and smoking were ob tained most of the time with similar frequencies (85%, 86%, 73%, and 96%, r espectively). In contrast, only 37% obtained a history for claudication, an d 26% obtained a history for foot ulceration 75% to 100% of the time (P < . 05, all comparisons). Examination of the heart (95%) and lungs (96%) occurr ed most of the time (75%-100% answer category) compared with each part of t he pulse examination (range, 34%-60% P < .05, all comparisons) and aortic a neurysm palpation (39%; P < .05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist re ferral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and ton e r extremity PAD (86% vs 14%). Initial referral patterns were made to vascul ar surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), c ardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis. Conclusions: Deficiencies may exist in the identification of PAD by IMPs th at could adversely affect diagnosis, time to referral, health care costs, a nd ultimately, patient outcome. Improvements in medical school education an d IMP training in the diagnosis of PAD are needed.