Peripheral Arterial Disease: Challenges in Rural Healthcare Settings

The management of PAD involves lifestyle modifications, control of aggravating systemic factors, relief of symptoms, prevention of cardiovascular events, and where possible, cure of the disease. This is achieved in a step-wise approach. Unfortunately for many, successful management of PAD involves a fair amount of healthcare with disease progression and symptomatic states often requiring more medical attention. Revascularization procedures and major amputations are avoided. In the US, the treatment of PAD has been estimated to cost over 21 billion dollars per year, with 2 billion spent on pharmaceuticals and 4 billion for inpatient care. With these numbers, it is clear that the management of PAD is not insignificant. The prevention of cardiovascular events and death in patients with symptomatic PAD is the main goal, and with the high rate of CAD and cerebrovascular disease in these patients, it is also the benefit of treating other manifestations of atherosclerosis.

African-Americans are at higher risk for PAD with a higher prevalence of 17.6% compared to 6.4% in Caucasians. In addition, people with diabetes, hypertension, hyperlipidemia, and systemic vascular disease have a greatly increased risk of developing PAD. Most patients with PAD are asymptomatic or have atypical leg symptoms. Critical leg ischemia, the most severe manifestation of PAD, occurs in its minority. PAD is also associated with a high incidence of cardiovascular events including myocardial infarction and stroke with rates of 20-30% in patients over 5 years. PAD patients also have a significantly higher cardiovascular mortality compared to the general population with a mortality rate of 8-12%.

Peripheral arterial disease (PAD) is a chronic illness that affects approximately 8 million Americans. Over the age of 40, the incidence of PAD increases to approximately 12-20% of the population. It is caused by atherosclerosis, which is the narrowing and hardening of the arteries due to a buildup of plaque.

Challenges in Diagnosing Peripheral Arterial Disease in Rural Areas

An article has summarized the reasons that PAD frequently may be misdiagnosed or underdiagnosed; these lessons can be applied particularly to primary care physicians in rural settings. lists the following common misconceptions about PAD among healthcare providers: attributing leg symptoms to aging, arthritis, spinal stenosis, or neurological intermittency; considering any pulse in the feet to indicate that there is no significant arterial obstruction; failing to check leg pulses in patients with systemic atherosclerosis; limiting the diagnosis of claudication to only those patients who cannot walk and who have significant functional impairment. These are all manifestations of lack of information or education about the disease. This lack of knowledge and adequate clinical suspicion of PAD is a hindrance to diagnosing it.

The process of diagnosing PAD is complex and is not necessarily made easier when evaluating patients in rural areas. This is in part due to the fact that many individuals practicing in rural communities are not specialized in diseases of the circulatory system. Instead, many are general practitioner physicians, who may only see PAD presented in its most severe form as chronic wounds, gangrene, or amputation. Often, the disease is not on the radar for these primary care physicians as it is not taught as a large part of the curriculum in medical school. This lack of awareness by patients and healthcare providers is a major obstacle in diagnosing PAD early in its course. Even in cases where a physician has knowledge of the disease, diagnoses are often missed due to the subtle nature of early symptoms of claudication.

Lack of Access to Specialized Medical Facilities

There are many potential explanations for the disparity between the high prevalence and disease burden of PAD and the relatively low utilization of health care services by affected individuals. Epidemiological studies have consistently demonstrated that patients with PAD have a high prevalence of coexisting cardiovascular risk factors and diseases. The majority of individuals with PAD are over the age of 65, and nearly 60% are women. Smokers have a two- to eightfold increased risk of PAD, and the cessation of smoking is associated with a lower rate of disease progression. These and other traditional risk factors for atherosclerosis are highly prevalent in patients with PAD. PAD patients also frequently have other manifestations of systemic atherosclerosis, such as coronary or carotid artery disease, and thus may be seeing physicians for these conditions rather than for their leg symptoms. High rates of comorbidity and the involvement of multiple organ systems can make it difficult for physicians to recognize PAD in patients who present with atypical leg symptoms. PAD patients frequently receive aggressive medical management for cardiovascular risk factors and diseases. The Aspirin for Asymptomatic Atherosclerosis Trial demonstrated that over 80% of patients with known lower extremity PAD were already taking aspirin. Because the trial required asymptomatic patients to discontinue or initiate aspirin therapy, it reflects a high background use of aspirin among PAD patients. There was relatively little increase in statin and antihypertensive medication use in the PAD cohort, a finding that is consistent with the observation that PAD is a stronger predictor of antiplatelet and anticoagulant medication use than of other pharmacological treatments for atherosclerosis. The low rate of medication initiation may partly reflect a belief by physicians that the initiation of cardiovascular risk factor management is not indicated in PAD patients who are asymptomatic or have mild symptoms. Devic’s qualitative study found that physicians were less likely to prescribe aspirin therapy to patients with intermittent claudication than to patients with coronary artery or cerebrovascular disease. The high use of antiplatelet and anticoagulant medications is likely related to the fact that these are proven therapies for the prevention of symptomatic and asymptomatic cardiovascular and cerebrovascular events in patients with PAD. Still, the association of PAD with high cardiovascular morbidity and mortality suggests that more aggressive risk factor management is warranted. This management requires recognition of PAD and an understanding of its impact on functional status and health-related quality of life.

Peripheral artery disease (PAD) is characterized by a narrowing of the arteries that supply the lower extremities with blood. It is a manifestation of systemic atherosclerosis and is associated with a high risk for cardiovascular disease. Although PAD affects Americans from all ethnic groups, the prevalence of symptomatic PAD is estimated to be 4-12% in the population over 60 years of age. Most individuals with PAD are asymptomatic or have atypical leg symptoms, and fewer than 25% seek medical attention because of functional limitations. The discrepancy between the prevalence of PAD and the utilization of health care services by affected individuals is particularly striking. Patients with PAD are also at higher risk of coronary artery disease, carotid artery disease, and adverse cardiovascular events. Symptomatic PAD represents only the “tip of the iceberg” in a population whose overall atherosclerotic burden increases the demand for health care services. Yet, the disease has been dubbed a “silent killer” because of its association with high cardiovascular morbidity and mortality even among those without claudication. Despite the growing recognition of PAD as a major health problem, patients with PAD are less likely to receive aggressive cardiovascular risk factor management and may have higher rates of underdiagnosed and undertreated coronary and cerebrovascular disease than patients without PAD.

Limited Availability of Diagnostic Tools

A major barrier to accurately diagnosing PAD in the rural healthcare setting is the limited availability of diagnostic technology. To confirm a diagnosis of PAD, measurement of the ankle brachial index is recommended but often cannot be carried out in rural areas due to lack of availability of the necessary equipment. Although Doppler ultrasound can also be used to measure the ankle brachial index and is more readily available, there is evidence to suggest that it is often not utilized to its full potential in rural areas. A study by Collins et al. utilized data from the North Carolina Medicaid database to compare use of non-invasive vascular tests in urban and rural areas. They found that urban residents were more likely to undergo non-invasive vascular testing than rural residents, despite there being no difference in the rate of hospitalization for PAD. This suggests that there is disparity in access to diagnostic tests for PAD between urban and rural residents. As for the use of angiography to detect stenoses and occlusions in the arteries of the lower extremities, it is often difficult to access this service in remote areas. This can result in patients being forced to travel long distances and incur significant expense, or be referred to specialist services in urban centers. The latter option is often complicated by long waiting times, during which the patients’ symptoms may progress to the stage of critical limb ischemia. In the same way that a lack of access to treatment can result in adverse outcomes for patients with CLI, delays in receiving services to diagnose PAD can lead to poorer health for patients in rural areas.

Insufficient Healthcare Professionals with Expertise in Peripheral Arterial Disease

Due to a lack of time and financial incentives, physicians often do not perform a complete assessment of a patient with leg symptoms. Patient complaints of leg pain may be misattributed to arthritis or other musculoskeletal disorders. Undertreatment of cardiovascular risk factors and leg symptoms in patients with known atherosclerosis is also common. Many physicians assume that the patient’s leg symptoms are due to a systemic process that cannot be effectively treated by interventions directed at improving limb perfusion. Awareness

Making a clinical diagnosis of PAD when not using stress testing or angiography is often difficult. The patient’s symptoms may be atypical, or the physician may fail to ask the right questions or to perform a thorough examination. In addition, many primary care physicians and nurse practitioners do not routinely palpate pulses, and the significance of absent or decreased pulses may not be appreciated. Thus, many patients with PAD are not even suspected of having the disease. A recent study showed that only 40% of patients with some criteria for possible PAD had a diagnosis of PAD documented in their medical records, and only 35% of these patients had a diagnosis of PAD noted in the problem list of the record. A lack of awareness of PAD may not only delay the diagnosis but also contribute to less aggressive treatment of the disease. High-risk patients, such as those with diabetes, cardiac, or cerebrovascular disease and those with a history of smoking, may have multiple reasons for leg symptoms and may not have a correct diagnosis made if consideration is not given to all possible diagnoses.

Difficulties in Treating Peripheral Arterial Disease in Rural Settings

Peripheral arterial disease results in complications that range in severity from claudication to limb-threatening ischemia. Comprehensive management of PAD must involve recognition of the disease process, medical therapy to modify risk factors and symptoms, aggressive interventional therapies when warranted, and in some instances, surgical revascularization. Optimal secondary prevention treatments to reduce the risk of MI, stroke, and cardiovascular death in PAD patients as well as critical limb ischemia require effective collaboration with other medical disciplines, particularly cardiology and interventional radiology or vascular surgery. In rural areas, limited availability of specialists to treat PAD makes effective collaboration difficult. Since many patients with PAD are managed initially by their primary care physician, efforts to increase awareness and education of the disease process are paramount. Randomized trials have substantiated the benefits of education and supervised exercise programs in improving symptoms and quality of life in PAD patients with intermittent claudication. Unfortunately, access to supervised exercise programs and claudication services is quite limited in many rural areas. Patients in these areas often have higher functional impairment at baseline compared with urban patients, thus benefiting even more from aggressively treating risk factors and symptoms. This discrepancy in care is a clear example of how rurality can exacerbate healthcare disparities.

Limited Treatment Options in Remote Areas

Treatment options for PAD are based on the control of cardiovascular risk factors and lifestyle changes, such as regular exercise and proper nutrition. In rural areas where PAD is common, these changes may be difficult to implement, and medications may be missed due to limited access to pharmacies and reliance on sample medications frequently distributed by drug representatives. Another issue in rural areas is the high prevalence of uncontrolled cardiovascular risk factors, such as smoking, diabetes, and uncontrolled hypertension. These risk factors exacerbate PAD and may result in the inability to work and loss of independence, which is especially traumatic for individuals who have spent their lives working on farms or in manual labor. When this stage is reached, invasive procedures may be the only option to regain the ability to walk and work. In rural areas, the lack of local vascular specialists or availability of minimally invasive angioplasty procedures is a major issue. This results in increased morbidity from attempts to treat with antiplatelet or antithrombotic medications and a higher incidence of major limb amputation. Among the Medicare population, the rate of lower extremity bypass surgery to treat PAD has decreased in recent years. This data suggests that patients in rural areas are not being offered revascularization procedures, which may be the most effective way to relieve claudication and prevent progression to critical limb ischemia. These concerning findings among rural PAD patients represent a significant loss in functional status, autonomy, and ability to work. An understanding of the rural implications of PAD is important for policymakers and government organizations in order to allocate resources and develop programs in areas where they are most needed.

Lack of Follow-up Care and Rehabilitation Services

Although the benefit of exercise therapy for claudication has been established over the last decade, the nature of the therapy and the type of claudicants that may benefit the most continue to be explored. One common mode of exercise is treadmill walking 3-5 times per week for 30-45 minutes at a pace that induces claudication pain. Although this method has been shown to be beneficial, claudicants often find it difficult to exercise in this manner on their own, and adherence is often poor. Supervised exercise is an effective means of increasing adherence to an exercise program. Several randomized trials have shown that compared to unsupervised exercise and control groups, supervised exercise significantly increases pain-free and maximal walking distances in patients with claudication. Unfortunately, however, there is limited availability of supervised exercise programs for claudicants, and it is probable that lack of availability restricts the access of this service to the patients who may benefit from it the most. In terms of more advanced therapies, those patients with severe claudication or critical limb ischemia may go on to require revascularization or surgical procedures. Several studies have shown that regardless of the type of revascularization procedure, patients with PAD have a substantially higher functional status post-procedure if they go on to receive comprehensive rehabilitation as opposed to standard care. Unfortunately, it is well known that patients with PAD represent a small proportion of patients referred to rehabilitation services, due to a lack of awareness about the benefits of rehabilitation and limited availability of rehabilitation services.

Strategies for Overcoming Challenges in Rural Healthcare Settings

Recent studies carried out a randomized control trial in the Scottish Highlands to evaluate the benefits of telemedicine in the management of chronic heart failure. While the trial showed no difference in the primary composite endpoint, there were significant reductions in the mortality rate and number of bed days in those who received telemedicine intervention. This points towards promising results, however, it could be argued that the medical conditions being managed may determine the success of telemedicine.

The feasibility and success of telemedicine and remote consultations are highly reliant on the patient having internet access, therefore with our previous point in mind, it’s important that services are not solely reliant on applications that may be directed at smartphone users. Telephone consultations could still provide an effective means of communication between practitioners and patients.

Telemedicine and remote consultations could play a significant role in rural areas where patients have difficulties in accessing services. Providing more convenient access to healthcare would pull through the patients that otherwise would not seek care. It would also enable early intervention, where in certain cases, an individual may not feel it necessary to see a practitioner in person but would seek advice at an earlier date.

Telemedicine and Remote Consultations

While there is an assumption that rural physicians may have more knowledge and a higher rate of PAD diagnoses because it is more common in the rural population, literature suggests otherwise. Despite rural populations having a higher prevalence of PAD, physician knowledge specific to PAD is less than urban physicians. Rural physicians had fewer specialist consultations, which could be a possible reason why PAD patients have less access to specialists. A large proportion of specialist consultations come from urban areas; it is reported that 71% of specialist consultations in Canada were conducted in urban centers. PAD patients referred to specialists are generally older and have multimorbidity; these patients may prefer a consultant within their own community as traveling can pose difficulties. This preference for a local consultant can be accommodated through telemedicine and may result in more PAD patients seeking specialist consultations. Given that rural physicians on average consult medical journals for 30 minutes per week, it is not practical to improve PAD knowledge through recent literature. This can be improved through the availability of PAD education and management courses specifically targeting rural physicians and making specialist consultations more available through telemedicine.

In pursuance of tackling the disparities with peripheral arterial disease (PAD) patient care and management between rural and urban communities, strategies need to be implemented to help bridge the gap. Medical therapies and treatment modalities have advanced in the care of PAD; however, this is not uniform between rural and urban communities. The disparities in healthcare infrastructure, access to care, and knowledge base are challenges that rural healthcare providers face when managing patients with PAD. In overcoming these disparities in care and knowledge, it is essential to make PAD education more available and to develop strategies enhancing the link between rural healthcare providers and urban specialists.

Enhancing Healthcare Infrastructure in Rural Areas

Geographical isolation is considered the major issue linked with healthcare delivery in rural areas. This isolation occurs due to poor transportation, less technology, and fewer resources. In order to improve healthcare delivery in rural areas, first, we need to improve the basic infrastructure or we can say the basic platform which can lead to a more efficient healthcare system. We need to develop a new model of the healthcare system where we need to improve transportation facilities, communication system, internet connectivity, and all-weather road. This is a very crucial issue for any of the rural people to go to a nearby healthcare center, as during the time of emergency or at night time it’s very difficult for the patient to find the transport. So the person must have his own vehicle or we can have the facility of an ambulance. The communication system is also very important as to keep in touch with the healthcare provider, the patient must have telephone connectivity and the toll-free number to get the information about various services provided by the healthcare provider in that area. With the advancement in technology, internet connectivity is also very much crucial to get various information in healthcare. All-weather road is also very important as during the rainy season and winter season, roads become so much muddy and slippery that it’s very difficult to go to a nearby healthcare center. In a nutshell, if we can improve the basic infrastructure in rural areas, the patient-physician interaction will be more effective, which can lead to better health outcomes for rural residents.

Training and Educating Rural Healthcare Providers

The effect of medical education location on practice location is well documented. More medical students who trained in rural medical schools are likely to work in rural areas. Yet this does not necessarily mean that those medical students are from rural areas, in fact, most of them are not. One-fourth of the medical students who are currently in rural medical schools are from rural areas. At the present time, there is not a sufficient number of rural medical programs to produce the needed amount of rural physicians. Incentive programs are one way to encourage medical students and residents to practice in rural areas, though these have been met with limited success. High income is not a priority or prerequisite for all physicians. Yet, it is known that those from rural areas who practice medicine tend to have lower income expectations than their urban counterparts. This would be due to the rural-urban income gap.

The shortage of healthcare providers in rural areas is well known. The origin of this problem is complex and multifaceted. One problem is that healthcare professionals who originated from areas of rurality are more likely to set up and work in rural areas. This “rural background factor” is not as strong as it was but still plays a significant role. On average, health professionals from urban areas are less likely to practice in rural areas. Although over the course of recent years, there has been an increase in the rate of those from urban areas choosing to practice in rural areas.

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