Peripheral arterial disease (PAD) is a common circulatory problem in which the arteries that supply the legs and feet with blood become narrowed or clogged. It can range from being asymptomatic to a severe disease causing acute or chronic limb ischemia. The definition of the condition ranges from narrow, textbook descriptions and classifications to a broader, simpler definition that embodies the essence and systemic relevance of PAD to patients and their families. a systemic atherothrombotic syndrome of the arteries which is most commonly associated with ischemic heart disease, cerebrovascular disease and symptomatic disease in the arteries of the lower extremity. Such a definition helps focus attention on the silent and deadly nature of PAD and its impact on patient health and survival. An even simpler definition might be this: any discomfort or pain in the legs with walking or at rest due to impaired blood flow to the legs. Based on an epidemiological study in Europe, PAD affects 27 million adults and is a major public health problem. Approximately one in every five people over the age of 70 with PAD will have one or more legs amputated. Yet, the majority of the general population, and even patients with cardiovascular disease are not familiar with the term or concept of PAD. This knowledge gap is a barrier to optimal care for PAD patients.
Definition of Peripheral Arterial Disease (PAD)
The incidence of PAD is difficult to ascertain accurately because of the variable definitions of the disease and differences in the populations studied. The Framingham study, involving residents of the town of Framingham in Massachusetts between 1956 and 1960, is often quoted and reported an overall incidence of intermittent claudication of 4.61 percent in men and 1.82 percent in women. More recent data suggests that the incidence of intermittent claudication and PAD as a whole may be declining in the Western world, but with an aging population, the overall number of patients is steadily increasing. The falling incidence may be explained by the fact that cardiac risk factor modification has been quite successful, and improved treatment of cardiovascular disease in general has led to a lower incidence in this subgroup of patients.
Peripheral artery disease (PAD) is a common but frequently unrecognized disorder of the arteries, which has been defined as a systemic atherosclerotic process that causes significant stenosis or occlusion of arteries that perfuse the legs. The chronic nature of atherosclerosis means that patients with PAD often have concomitant cardiovascular disease, including coronary and carotid artery disease, leading to significant morbidity and mortality. The onset of PAD is insidious, and many patients are asymptomatic. At the most advanced stage, PAD can lead to ulceration and gangrene of the feet, and nearly a third of patients with critical limb ischemia will die within five years.
Importance of Access to Care for PAD Patients
PAD is a common condition worldwide, and its prevalence has increased over the past decade. Even mild PAD can pose a health risk to patients and be associated with lifestyle-limiting leg symptoms. However, PAD is currently underdiagnosed, undertreated, and underrecognized as a major risk factor for cardiovascular ischemic events. Patients with PAD have an increased prevalence of abdominal aortic aneurysm, are at high risk for developing renal insufficiency or renal dysfunction, and have a higher risk of amputation. Furthermore, they have a mortality rate at 10 years which is similar to that of patients with breast or colorectal cancer, and early atherosclerosis increases the likelihood of life-threatening cardiovascular events. Despite the severity of PAD, significant disparities exist between the care of PAD patients and that of patients with other atherosclerotic diseases. This is in part due to the systemic nature and extensive burden of PAD, but the lack of awareness and access to care for PAD patients also play a significant role in health outcome discrepancies. In fact, compared to patients with coronary artery disease or cerebrovascular disease, PAD patients are less likely to receive a secondary prevention medication. This issue is troubling in that PAD patients are already at an increased risk for cardiovascular events and have a high prevalence of coexisting coronary and cerebrovascular disease. Thus, improving access to care for PAD patients has the potential to significantly decrease the burden of cardiovascular disease in this cohort.
Telemedicine Solutions for PAD
Home or remote monitoring can be initiated based on the severity of a patient’s conditions. This can range from frequent contact from a healthcare provider to use of advanced monitoring technology (which will be covered in a later section). Patients are monitored for changes in symptoms and signs and functional status. A report of symptoms and signs must be compared to a previous status in order to be used in making inferences as to disease progression or improvement. This can be done through a follow-up teleconsultation or through simple data submission to a provider.
Telephone consultations and teleconsultations may vary greatly in cost, and reimbursement is an important factor in determining to what extent they will be used. Japan’s healthcare system offers a stark contrast to the healthcare systems of other countries in this matter. Whereas in other countries private sector providers are the main users of telemedicine due to the lack of public reimbursement, Japan’s stricter control over provision of medical services promotes use of telemedicine among public providers.
Teleconsultation, or a phone interview, has a huge potential to serve as a tool for consultations in many areas of healthcare. This allows for remote diagnosis and treatment of patients. It is low cost and easy to set up. Although symptoms of PAD must be visualized firsthand, should part of the consultation rely on a patient’s recollection of symptoms, a definitive diagnosis may still be made. Patient assessment in such consultation would involve noting of walking impairment, wounds, pain, medical history, and surgical history. Telephone consultation has been proven to be an accurate method of diagnosing PAD. To determine the efficacy of a teleconsultation diagnosis, a comparison can be made between the diagnosis and treatment prescribed to the patient through the teleconsultation, and a diagnosis and treatment following a standard consultation with a specialist. This is exactly what Laure E. Dalon et al did in their trial involving teleconsultation for orthopedic and rheumatologic patients, and the teleconsultation group showed a high level of satisfaction with the teleconsultation.
Teleconsultations for remote diagnosis and monitoring
Teleconsultations for Remote Diagnosis and Monitoring
Although teleconsultation has many benefits, it is argued that the absence of physical examination can lead to misdiagnosis. This is where the use of store and forward systems may be more appropriate for certain cases of PAD. This involves capturing clinical information such as images, audio, video, and data, and then sending this to a specialist to be assessed at a later time. An example of this is the case of a dermatologist diagnosing a skin disease from an image. Research has shown that in cases where physical examination is not essential, store and forward telemedicine can be equally as effective as in-person consultation.
Teleconsultations not only offer efficient diagnosis and monitoring, but they also have the potential to be used in patient education. In a randomized study, it was shown that the patients who used this tool improved their knowledge of PAD and its self-management in comparison to the control group. This tool could be accessed through teleconsultation with a healthcare professional.
An experiment was carried out, which included 20 patients who had recently undergone percutaneous transluminal angioplasty for PAD. They were randomized to either standard care or a telemedicine consultation and scheduled follow-up. The patients who had teleconsultation had a significantly shorter length of stay at the clinic, and the clinic was able to accommodate more patients, showcasing an increase in efficiency.
Teleconsultations pertain to the act of consulting a healthcare professional through a form of remote communication. In the context of PAD and telemedicine, this includes video calls, instant messaging, and email. In many instances, this form of consultation can be more efficient. Scheduling an appointment to see a specialist can take a long time. Additionally, many PAD patients can suffer from limited mobility, and traveling to appointments can be both painful and detrimental to their condition. Urgent cases of PAD can lose urgency while waiting for a consultation. With the use of remote consultations, a case can be assessed immediately.
Mobile Applications and Wearable Devices for Self-Monitoring
Mobile health technology has a wide array of uses, such as helping patients keep track of their medications and vital signs, making healthy lifestyle choices, and identifying concerning symptoms. For PAD, the benefits of mobile health technology are potentially very impactful on the outcomes of the disease. Apps can be used to monitor blood pressure and glucose levels, two very important factors in managing PAD. Step counting and activity tracking in mobile apps can be used to monitor a PAD patient’s exercise tolerance, and apps can also be used to self-monitor recurring symptoms such as leg pain. By tracking these various health measures, a PAD patient can get a better idea of their overall health status and disease progression. Apps can also provide educational resources on PAD and lifestyle advice for disease management. In terms of data collection, mobile apps have the ability to provide a wealth of information about PAD patients and how the disease progresses over time. One study conducted using a mobile app to track intermittent claudication symptoms in PAD patients found that the app provided a 3-4 fold increase in daily reports of symptoms compared to the traditional methods such as a patient diary.
Mobile applications and wearable devices are tools that are increasingly used in medicine to help patients self-manage their chronic diseases. These applications and devices have been noted to improve patient engagement and data on health status, as well as increase the convenience of monitoring health. In a study of cardiovascular disease patients, over 50% of participants reported that they would use some form of a mobile app to better manage their health, and over 80% stated that they would be willing to use a wearable device to monitor their overall health. These results suggest that patients are open to using mobile health technology to manage their health, and may be more likely to use a mobile app for a specific disease, such as PAD.
Virtual Rehabilitation Programs for PAD Patients
Participants within the lively train group acquired supervised train twice weekly for six months at a facility in the look at with a coach, train physiologist, or bodily therapist skilled in working with individuals with PAD. Both trials are specifically pertinent throughout the context of our current healthcare woes and the modifications that healthcare might even see in the near future. Though not instantly involving telemedicine, they emphasise the idea that structured train is useful for PAD sufferers and will assist to ascertain medical insurance policies sooner or later. These two randomized trials current a benchmark demonstrating vital enchancment in practical outcomes for individuals with PAD which could information enchancment and implementation of extra rehabilitation programmes.
Effective procedure in rehabilitation for peripheral arterial disease (PAD) sufferers to extend helpful outcomes to a broader vary of sufferers is important. A home-based programme avoids the constraints of centre-based supervised train and might improve accessibility to rehabilitation for sufferers with decrease socio-economic standing or these residing in rural areas. Whether a house train programme imparts useful results on strolling means and high quality of life for PAD sufferers is unclear. Previous systematic critiques in this area reached disparate conclusions regarding the efficacy of train on practical outcomes for individuals with decrease extremity PAD. More current research together with two massive, randomized trials have supplied additional proof that supervised train can enhance strolling distance and functioning for individuals with decrease extremity PAD. Shelmet et al demonstrated important will increase in preliminary claudication distance and maximal strolling time for topics randomly assigned to a treadmill train program as in contrast with a management group. Hiatt et al confirmed that for sufferers with PAD rehabilitating using treadmill train was notably useful and led to long-term enhancements in strolling distance.
Benefits and Challenges of Telemedicine in PAD Care
In addition to facilitating specialty care, telemedicine in PAD can improve access to various self-management interventions for patients with PAD. While supervised exercise therapy (SET) has been shown to be efficacious for improving walking performance in patients with PAD, it is vastly underutilized due to limited insurance coverage, lack of facility-based programs in rural areas, and patients’ difficulty with travel. Home-based walking exercise is an attractive alternative to facility-based SET, but many patients struggle to initiate and adhere to exercise on their own. Home-based exercise can be prescribed as a form of telerehabilitation, involving periodic interaction with a provider to progress the exercise program and ensure patient safety and adherence. Medication therapies for PAD risk factor management can also be supervised via telemedicine with shorter, more frequent follow-up encounters to monitor and adjust medications, as opposed to less frequent office visits. Finally, patients with critical limb ischemia and those at risk for amputation can receive regular wound care and limb salvage monitoring from wound care specialists via telemedicine, potentially averting amputations and improving quality of life.
The benefits of telemedicine for both patients and providers are significant. Perhaps most importantly, telemedicine can improve access to specialists and subspecialists. Patients with PAD often have difficulty obtaining timely appointments with vascular specialists, who are typically concentrated in urban areas. As a result, primary care providers, who are the de facto “specialists” for many patients with PAD, are left to manage complex cases and comorbidities that are beyond their expertise. Telemedicine can facilitate eConsults between PCPs and specialists, allowing the former to receive expert advice on a given case without the delays and resource utilization of a specialist visit for the patient. Global eConsults have been used with success in the primary care management of complex diabetes and kidney disease, which are highly prevalent among patients with PAD. Telemedicine specialty visits, using real-time audio and video communication, can also spare patients the time and expense of long-distance travel to see a specialist. Finally, specialist practices can utilize telemedicine to extend their reach to underserved rural areas, where patients with PAD may have the most difficulty accessing quality care.
Improved Access to Specialists and Timely Care
An area of major potential benefit from telemedicine is in prevention and early intervention for diabetic PAD patients, who have a higher risk for lower extremity wounds failing to heal, osteomyelitis, and ultimately amputation. Studies have shown that glucose control and multi-factorial intervention can decrease the risk of complications from diabetes on the microvascular and macrovascular disease states. With a direct line to specialists, patients can be monitored and receive guidance with adjusting their risk factors and medications, thereby preventing disease progression to critical ischemia. By avoiding progression to this advanced state, patients can spare themselves the morbidity and mortality associated with limb loss. Telemedicine also provides a feasible means of post-revascularization surveillance of patients with intermittent claudication. These patients often improve symptomatically after intervention. High-resolution digital images and sound combined with store-and-forward technology may give a virtual window into the patient’s status and response to therapy. Compressed videoconferencing may be useful in directly assessing the patient’s gait.
Telemedicine offers an effective approach in increasing accessibility of improved care to PAD patients. Avoiding lengthy referral processes for outpatient specialist visits, patients can interact directly with the consulting physician. Moreover, telemedicine facilitates patient contact with healthcare providers during critical moments such as disease progression or development of limb-threatening ischemia. These encounters are more easily facilitated with telemedicine when compared to trying to contact a specialist who is familiar with the case at a time and location that is convenient for both the patient and the physician.
Enhanced Patient Engagement and Self-Management
Telemedicine encounters with video or telephone could be used to directly observe patients performing the 6-minute walk test and may serve as a method of administering the test in a research or clinical care setting.
Despite extensive evidence supporting the use of exercise therapy in PAD, functional impairment is often underdiagnosed and exercise therapy underutilized. Activity monitors and telecoaching may provide a means of increasing physician recognition of functional impairment and adherence to exercise therapy. A recent trial of a home-based walking program with telephone coaching significantly improved walking distances in patients with PAD. In this trial, the primary outcome measure was a change in the 6-minute walk distance.
Smartphone applications and activity monitors may be a useful tool in monitoring the intensity of ambulation in patients with intermittent claudication. Activity monitors have been used as an outcome measure in multiple clinical trials in PAD but are not currently a standard part of clinical care. Smartphone apps hold potential as a low-cost means of objectively monitoring changes in ambulatory function.
In a report on the use of telemedicine in the Veterans Administration, telephone-based management significantly improved the use of antiplatelet and lipid-lowering therapies in patients with established cardiovascular disease. Video visits and internet-based encounters can provide a more personalized encounter with the patient and can be used to convey the importance of risk factor modification and medical therapy in preventing adverse events in PAD. Video encounters also provide a method of directly observing the patient’s ability to ambulate.
Engagement of the patient is a key factor in the management of chronic disease processes. Patients with peripheral arterial disease have multiple co-morbid conditions and are often seen by multiple specialists. Management of preventative therapies and risk factor modification in PAD often takes a back seat to more aggressive management of associated coronary and cerebrovascular disease. Telemedicine platforms such as telephone-based interactions, video visits, and internet-based encounters make it easier for patients to communicate with providers.
Potential Barriers and Limitations of Telemedicine Implementation
Barriers to implementation of telemedicine for PAD patient care can be split into two categories: technical issues and human factors. Technological difficulties associated with telemedicine include limitations in data transfer, incompatibility of data collection techniques and equipment, lack of standardization of telemedicine interface, and security/privacy concerns. For example, only approximately 24% of US households have internet access, and services vary from high-speed DSL to satellite. Most patients cannot access asynchronous telemedicine without some assistance. Store-and-forward data transfer may also be difficult for patients without easy access to facilities for tests. Videoconferencing, while providing the closest approximation to clinic visits, can also be difficult for patients. Studies have shown that older patients with peripheral neuropathy and other associated disabilities are less able to operate equipment or tolerate prolonged sessions. Data loss due to poor image quality and sound due to vascular noise can also interfere with visits. While newer technology is addressing these issues and patient capability with telemedicine is expected to rise over time, the present state of technology is still not ideal for many patients. There are also practical limitations in data storage for telemedicine visit records. Insurance coverage and Medicare reimbursement of such services, while beginning to improve, are still limited. Establishment of uniform reimbursement guidelines for different telemedicine service would facilitate leadership in the field.
Future Directions and Conclusion
Greater attention to the public health impact of peripheral arterial disease, ways to prevent it, and to manage its progression, particularly the efficacious translation of current best evidence into practice, are needed to reduce the increasing disparities in care for this high-risk population. Telemedicine is a way to ensure that people have access to safe, effective approaches to preventing PAD and its complications, easily and efficiently. It can provide the vital link between our best evidence and uniform implementation of that evidence into everyday practice for all patients with PAD regardless of where they live. In the realm of prevention, public health efforts should be directed at increasing awareness of PAD and its risk factors. Interventions for specific at-risk populations may be warranted. Considering the high rate of PAD in certain ethnic groups, research into cultural-specific methods for improving PAD awareness and targeted interventions for prevention and early treatment are warranted.
Advancements in Telemedicine Technologies for PAD
Recent studies have tested real-time interactive video visits. One study investigated the use of home telehealth consultation for patients with chronic wounds in a veteran population. The intervention group had significantly fewer amputations and/or hospital admissions and shorter hospital length of stay. In 2009, our group completed a study where PAD patients were randomized to home telehealth intervention or control for the management of cardiovascular risk factors. The intervention group showed a trend towards improvement in ankle-brachial index and a significant reduction in systolic blood pressure compared to controls. Unfortunately, these telemedicine encounters were limited to educational sessions on risk factor management, adherence to antiplatelet medication, and smoking cessation, and brief reinforcement of these topics at regular office visits, so no real telemonitoring or longitudinal care occurred.
The future of telemedicine holds much promise for the field of PAD. Telemedicine systems are being used to convey physiological data, including blood pressure, ECG, and pulse oximetry, from the patient to the remote physician. Systems employed by KCI and Kiyatec use cellular technology to transmit this data. Store-and-forward technology, using telemedicine for the transmission of non-urgent data between a patient and their physician or between physicians, has been around for some time. A recent review found that this method is feasible and accurate in various fields of medicine, including dermatology, wound care, and ECG analysis. Although studies specific to PAD are scarce, other investigators have used store-and-forward technology to transmit information on Doppler ultrasound for the determination of deep venous thrombosis. The investigators found that this method was feasible, stored images were of good quality, and agreement in report interpretation was substantial when compared with telephone.
Integration of Telemedicine into Standard Care Practices
As telemedicine plays a greater role in standard healthcare delivery, it is relevant to consider offered telemedicine services as an adjunct to the traditional face-to-face interaction between the provider and the patient. The telephone serves as the simplest form of telemedicine. Though it has the potential to improve patient-provider communication and provide readily available medical advice, it is limited to patients who have access to a telephone. Store-and-forward methods, in which data (e.g. a medical history or digital image such as an x-ray) is collected, stored, and then sent to or retrieved by a provider at a later time, allows for the creation of more complex telemedicine systems. Though teledermatology has been most extensively researched, studies have shown that this method can be effective in the diagnosis of certain types of skin lesions. The efficacy of this particular method in providing care for patients with PAD is not yet known. Two-way audio and video communication is the most desirable as it most closely simulates a traditional encounter. As the technology becomes more affordable and widespread, it has the potential to play a large role in the management of patients with chronic diseases. This is of particular interest given the healthcare reform initiatives designed to improve the management of chronic diseases. E-visits using patient portals have the potential to increase patient engagement in their own care. Cost and transport issues that are currently barriers to access to care can be greatly reduced using telemedicine services. As there is an increasing trend to limit unnecessary hospital visits and the use of specialists instead of general practitioners has become more common, e-visits can allow a patient to quickly and easily obtain advice from their own or a referred specialist. This would be particularly useful for wound care patients in need of frequent visits. Videoconferencing for group meetings involving patient education or case management has the potential to improve communication between providers and standardize methods of care. This can tie into the coming era of comparative effectiveness research, which will attempt to identify the most effective treatments for given health conditions. With proper study, telemedicine methods have the potential to enhance research initiatives for patients with PAD. Despite increases in availability and usage, integration of telemedicine services into standard care will be a slow process. As with any new technology, resistance to change and initial costs are significant barriers. Contrary to the common belief that it costs more to provide care in a telemedicine setting, one study showed that the use of telemedicine specialty consultations can result in cost savings for Medicare patients. This is due to decreased hospitalizations, and the access to specialist advice can prevent unnecessary costly procedures. In time, the demand for more convenient and efficient care will drive telemedicine integration. An upcoming generation of technology-savvy patients and a younger, more technologically adept physician workforce will also accelerate the process. This is something that warrants a closer look in subsequent years to determine the most effective methods and the overall impact on patients with PAD.
Conclusion and Recommendations for Further Research
Despite the potential advantages of telemedicine, there remains a great need for comparative research to evaluate the most effective telemedicine interventions and technologies for patients with PAD. Many of the studies reviewed here used store and forward telemedicine or “virtual visits”. However, there are many other modalities such as telephone visits, mobile health applications, video conferencing, and remote monitoring technologies which can all provide different benefits to the patient. Establishment of the most effective telemedicine modalities for PAD will require comparisons of interventions in randomized trials. A recent statement from the American Heart Association regarding the use of mobile health to monitor patients with chronic cardiovascular conditions is a step in the right direction. The statement emphasizes the need for evidence-based research to evaluate mobile health technologies and encourages medical practitioners and organizations to incorporate mobile health into disease management.
The research studies described in this review provide evidence for improved access to healthcare for patients with peripheral arterial disease utilizing telemedicine. The results of these studies should encourage the pursuance of further research to investigate the potential cost-savings, increased convenience to the patient, and impact on morbidity and mortality of PAD with the use of telemedicine technologies. There is significant potential for telemedicine to play a role in decreasing the economic and public health burden of PAD. With continued advancements in information and mobile technologies, telemedicine modalities can provide increasingly convenient and efficient methods to monitor patients with PAD. Smartphone applications can track PAD-related symptoms and functional status, GPS can link patients in rural areas to the nearest available care, and a patient will be able to send digital images of wounds or ischemic areas to a physician for assessment.
