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ABPI) in General Practice- a Mixed Methods Study

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ABPI) in General Practice- a Mixed Methods Study The Use of the Ankle Brachial Pressure Index (ABPI) in General Practice- A Mixed Methods Study Thomas Ding A thesis submitted for the degree of Bachelor of Medical Science with Honours At the University of Otago Dunedin, New Zealand 2015 Abstract Background Peripheral Arterial Disease (PAD) is an increasingly prevalent long-term illness globally. The Ankle Brachial Pressure Index (ABPI) is a well-established, simple, relatively quick, inexpensive and non-invasive assessment useful in diagnosing and quantifying PAD. International guidelines have supported its use in both secondary and primary care, stating that it has a critical role in assessment and management of patients with PAD. Though many theoretical benefits exist, ABPIs are underutilised in general practice. No extensive literature has investigated its longitudinal usefulness in this setting. Aims The aims were to describe why and how ABPIs are being used at Mosgiel Health Centre (MHC) and to assess whether ABPI use is associated with a change in clinical management. The study also aimed to explore perspectives of health professionals on the role of the ABPI. Methods This study used quantitative and qualitative methods. The quantitative arm used ten years of electronic practice data from MHC. The qualitative arm analysed one-to-one interviews with health care professionals, mainly General Practitioners (GPs), on their experience and view of the usefulness of the ABPI in general practice. Results The quantitative arm assessed patients who had ABPIs at MHC between 2006 and 2015. This is the longest international retrospective study of ABPI patients followed-up in general practice. Of all 379 ABPIs, over half were completed to investigate patient eligibility for compression therapy for venous disease and just under half were completed to investigate perceived arterial-related symptoms. Between 21.6-24.5% of all ABPI values indicated PAD leading to 23.2% of patients being reassured of having no PAD, 16.9% of patients managed as having PAD, and 17.7% requiring additional management or investigation. Approximately 73% of ABPI patients were not referred to secondary care. The qualitative arm showed that most GPs are aware of the main benefits of performing ABPIs in primary care; including to rule in or out PAD to aid management choices, to aid referral and for triage purposes. Many practical barriers to use were discussed, including cost, time and ii low patient need. When considered together, barriers outweighed benefits for many GPs when determining whether ABPI was justified for use. However, both primary and secondary care health professionals agreed that there was a role for ABPI use in the community if barriers were overcome. Most interviewees agreed that having a ‘specialised’ professional to complete ABPIs would be most beneficial for patients in the community. Conclusions 1. Common indications for ABPI use at MHC included to guide management of venous disease, and to investigate suspected arterial symptoms. 2. Of the 379 patients having ABPIs tests, 26.39% were referred to the secondary care vascular department. ABPI use prevented inappropriate referrals in over 70% of cases. 3. There was consensus among GPs that ABPI use is beneficial. 4. Many GPs named similar, practical barriers for why ABPIs are not more commonly done. 5. There is a role for ABPIs in primary care, although it may be more practical if it became a specialised tool for an individual clinician to complete for a community. iii Presentations What do health professionals think about the Use of the Ankle Brachial Pressure Index (ABPI) in Primary Care? T Ding, S Dovey, H Lloyd. Presented at the National Primary Care Research Weekend in Cromwell, New Zealand, on 13th September 2015. The Use of the Ankle Brachial Pressure Index (ABPI) in General Practice. T Ding, S Dovey, H Lloyd. Presented at the Department of General Practice and Rural Health Conference Seminar Series in Dunedin, New Zealand, on 22nd November 2015. iv Acknowledgements An incredible year would not have been an incredible year without the incredible people who have helped to make it one of the best I’ve had yet. You all have not only gotten me to the finish line, but have shaped, motivated and inspired me, and for that I am truly grateful. Firstly to the dedication and approachability of my two amazing supervisors. Prof Susan Dovey for the tireless efforts in mentoring me through the research journey, for refining and remodelling my written word (no poetry and no ‘whilsts’, ‘it’s’, and ‘hences’!), for insights into future pathways and connecting me with the Robert Graham Centre in Washington DC earlier this year. Dr Hywel Lloyd for the clinical and statistical savvy, reassurance that R would not ruin my life, teaching me about research and computer systems, and allowing me to see research as just a story through Bruegel’s 1565 Hunters in the Snow. You both have shown me much more than just how to do research. To the astounding bunch at the Department of General Practice and Rural Health who have been the friendliest and most supportive colleagues to work with. Your sincere words, expertise, interesting discussions at our all-important morning teas and caring natures made it an absolute treat to come into the office, even on those rare sunny days outside. The mighty PhD students in our combined postgrad office- Sherrema Bower and Claudia Ammann. Here’s to all our brilliant, heartening, boosting as well as strange conversations had. It has been a pleasure putting the minds together from all our different backgrounds. I have learnt much from you both. I will watch the cat video some time. Keep in touch. To the statistics 101 help I received from the super Brenton Twist and Kevin Jia (often at a distance from Stewart Island and Auckland respectively). When I was at my most frustrated with open access statistical software, you both managed to figure out codes I would have spent the year trying to find. Library and thesis support by Sarah Gallagher was much appreciated. That kick-start in thesis planning at the beginning and ongoing questions answered (at the flick of an email) made the whole process more stress-free. Thank you also to the generosity of BPAC and Maurice and Phyllis Paykel Trust for gifting me with your scholarships and financial assistance. Without this (and the sushi, grapes and snacks it provided me), I would not have been able to sustain myself through the long days and nights of writing. v To the staff, students and friends at the Department of Anatomy (my second departmental home)- cheers for the laughs, the questions, the brilliant coffee breaks (which I always looked forward to) and helping me to rekindle my love of learning anatomy as well as to develop a passion for teaching. It was interesting having a second go at ELM. To my family, Ma, Ba and Carol, who kept me in check and reminded me to keep eating when I had papers to review or chapters to edit. Thank you for your never-ending support, food parcels, our much needed catch-ups, advice and steadfast love. My flatmates and friends- though I may have seen more of the office than yourselves during October, those best moments we had throughout the year really saw me to the end. In particular to: Jeriel “Jerry” Tan for those damn good steaks, doing some referencing for me for fun and being that person I could just go to if I felt I needed a research break. Mari “Mars” Fernandez- your snaps and messages kept me laughing through the day. Andrew “Chief” Tan for keeping the home in check and making the year so easy. Anabel “Ruuude” Chow for chats midday, midnight and just whenever really. Finally, to Vimal “Vims” Patel, this year would not have been as enjoyable, fruitful and hilarious without you. Your insights into (and care for) my niche project and thoughtful criticisms kept me on the nose. Thanks for doubling as my personalised ITS computer technician (you definitely deserved that Hikari), as my external analyst (with great power comes great responsibility), and for making my most colourful graph. Cheers for all the times we wanted to do the thesis and not, the money we spent at Golden and being my right hand man. To all these incredible people. vi Table of Contents Abstract ................................................................................................................... ii Presentations ......................................................................................................... iv Acknowledgements ................................................................................................. v Table of Contents .................................................................................................. vii List of Tables .......................................................................................................... xv List of Figures ....................................................................................................... xvii List of Abbreviations .............................................................................................. xix Chapter 1: Introduction to Thesis ......................................................................... 1 Chapter 2: Literature Review ................................................................................ 3 2.1 Introduction to Literature Review ........................................................................ 3 2.2 Search Strategy, Search Scope .............................................................................. 3 2.3 Peripheral
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